I was

always against it, but...

Elliott Emanuel,

md

For many of us the work of other tion to develop with less stress than physicians is a closed book, the pages might otherwise be felt. The Quebec briefly glimpsed through gossip in the Health Insurance Board pays for the staff room of the hospital. In the pres¬ consultations and the operation. Re¬ ent furore of discussion about abortion ferrals come mostly from our own it may be worth setting down just how catchment area, and almost all our the present law is working in a sub- operations are done in the 1st trimester. urban hospital of 145 beds on the Patients generally come to us within 6 weeks of the missed period, and their Island of Montreal. Without any official arrangement applications are processed quickly. A one gynecologist has interested himself pregnant uterus can be a time bomb. Canadian law permits abortion in another in this and work, especially replaces him at times. Other members public hospitals when sanctioned by of his department prefer not to per¬ an abortion committee on the grounds form the operation but are open- that continuation of the pregnancy minded enough to refer patients to would probably be dangerous to the those who do. The great majority of mental or physical health of the moth¬ er. Some would say that any unwanted women seek abortion for psychosocial reasons, and because of my own in¬ pregnancy is dangerous to the health terest and availability almost all are by that very fact; others would draw examined by me, even when there is the line with great stringency, accepta physical health problem. The abor¬ ing only patients with severe cardiac tion committee meets weekly. We serve or renal insufficiency. Most presum¬ a mixed population, and the neighbourably try to steer a middle course. A healthy married woman of 24 ing hospitals are a French-speaking hospital at which no abortions are per¬ with a child of 2 and a stable marriage. formed, and a bilingual hospital at may talk of the cost of living, but I which very few are done. In Montreal find it impossible to say that her health itself there are teaching hospitals, is threatened. I tell her the Canadian whose abortion facilities are, I believe, law and recommend (if she wishes) overloaded, and 130 km away, in New sterilization at term. Perhaps she then York State, abortion can be obtained goes to New York State, as is her on demand for a substantial fee, and right. On the other hand, in my opinion busloads of Montrealers go there daily that is, a mar¬ for this purpose, "like cattle" one wom¬ a shotgun marriage an told me. You could say that these riage forced against the wishes of clinics act as an overflow for patients either party by the mere fact of preg¬ is itself harmful to a girl's who would not be eligible under Cana¬ nancy dian law, just as the Montreal teaching health. I know that fine children have hospitals act as an overflow for pa¬ been raised in stable marriages on this tients who live in parts of the province basis, but it is a serious gamble, espe¬ where there are no abortion commit¬ cially at lower ages, and I would not tees. The arrangement is perhaps il- want one of my sons or daughters to logical, but life is illogical, and these enter marriage like this. And for most safety valves are making it possible girls to carry a pregnancy to term with for changing attitudes towards abor- the sole purpose of giving the child up for adoption is also emotionally da¬ Reprint requests to: Dr. Elliott Emanuel. 352 Dorval Ave., Ste. 201, Dorval, PQ H9S 3H8 maging. The third option, to raise the

child alone or have the grandmother raise it, is chosen by a few girls, but it presents great hardship. Most minor children have told at least one parent about the pregnancy and I advise the others to do so. It is too great a burden to carry alone, and the lying and concealment make a bad situation worse. A common answer is "If I told my mother it would kill her." None of the mothers who participated in the deci¬ sion opposed abortion and most favoured it. Another important group is formed by the separated women who conceive either in half-hearted attempts at reconciliation with their husbands or in other relationships that have no pros¬ pect of permanence. The position of the separated woman on her own, usu¬ ally with one or more children, is hard enough without this added burden. The woman in her 40s in a stable marriage whose youngest child is in his teens can hardly go through a new preg¬ nancy without harm to her mental and physical health. There are a few cases of severe mental illness severe schizoid or

sociopathic personality, severe depres¬ sion, or mental deficiency in which the woman is incapable of raising a child and becomes more ill in the at¬ tempt; often this has already been de¬ monstrated by her failure to raise the children she has, and her reliance on relatives and social agencies. Some people say that abortion should never be needed because per¬ fect contraception is always possible. On the contrary, no method of contra¬ ception, not even sterilization, is per¬ fectly effective. My material contains cases of tubal ligation performed a few days after conception, "tubal ligation" that left a tube patent, "vasectomy" after which sperms never disappeared,

and vasectomy after which pregnancy CMA JOURNAL/OCTOBER 18, 1975/VOL. 113 723

occurred when sperms were absent. This last, of course, was particularly disturbing to the wife's mental health and she stoutly denied infidelity. One woman conceived at the age of 38 near the start of an extramarital affair after two sterile marriages. It is quite common for a girl to conceive while waiting for her period before taking an anovulant, and foam seems to give a false sense of security. There have been a few cases in which the girl has seemed to me to seek abortion less for her own sake than for that of her parents or her partner's parents, and I have tried to help her see this. In all cases the consultation should be a true exploration of the woman's feelings and of the various options open to her, and should never be a perfunctory formality. I try to save the fetus, as divorce lawyers try to save the marriage, but at this stage most have made up their minds. Even so, I believe that a review of the whole situation with a professional is helpful. Though their situation is standardized, one is struck by the individuality of each case. Many women have said to me "I was always against abortion, but there is no other way." Some say that there is always another way, even though at great emotional cost. If you count this cost as nothing against an embryonic life, then it must be paid, but more and more people, with all kinds of religious training, have come to feel that the emotional cost to the mother has some value, perhaps great value, and must be set in the balance. This is the central fact. Embryonic life must be valued, but so must the mother's health and feelings. Moreover, the quality of life that awaits the embryo may be so poor - mentally, physically and socially - as to be likely to affect the mother's future health. My statistics are not very meaningful because the patients are selected from an unknown pool. The criteria with which we work quickly became known. Women in stable marriages, coming mainly from countries where abortion is a form of contraception, were no longer referred after one or two rejections. They probably turn up in someone else's statistics. We see about 60 women a year and other solutions are found for a half dozen. Our youngest patient had just turned 14 and the oldest was 42. Meaningful statistics must come from those who deal with large numbers of unselected patients. The report of the National Academy of Sciences shows that in New York the easy availability of abortion halved the number of admissions for septic and incomplete abortion between 1969 and 1973 and reduced the number of associated maternal deaths from

128 in 1970 to 47 in 1973. In the 1st year of legalized abortion some 70% of those legally aborted said they would have sought illegal abortion if legal abortion had not been available (Lancet' 1:1418, 1975). The committee usually meets on Tuesdays, the patient has a chest radiograph, hemogram and urinalysis on the Thursday, suction curettage is done under general anesthesia on Friday morning, and she goes home in the afternoon. It is physically an easy procedure for the patient and most report a great sense of relief. A few are depressed, some seriously, but I believe rarely from guilt; more often it is because the experience has revealed the emptiness or lack of future prospects of the relationship that led to the pregnancy. Because this work is inherently destructive, and because all of us have, in varying degree, a reverence for life, it is distasteful, and only a few care to be involved in it. For the surgeon the procedure in the 1st trimester is so easy as to be boring; only the human aspect is endlessly fascinating, as one is carried at once deep into the centre of a woman's life. But this work is necessary: a review of our cases shows how much human suffering would have resulted had this service not been available, or how much illegal backstreet butchery would have been wrought on desperate women. The existing Canadian law is workable, although it is interpreted variously across the country. This is its strength. I believe that the way it is applied will evolve, and that physicians and patients alike in areas where there are no abortion committees will revolt against the hypocrisy of sending the patient elsewhere. Is it right that a hospital supported almost wholly by taxation should deny a legal procedure to those who need it? On the other hand, no one should be forced against his principles to participate in any way. I would not even ask a secretary to type my reports if she found them offensive. We have entered an era when sexuality is much more open and honest. Everyone runs the risk of an unwanted pregnancy at one time or another, and pregnancy cannot be thought of as a punishment or a price for sexual intercourse. For these women it was an accident, but an accident for which they alone, and not their partners, must suffer severely. People expose themselves to other risks in life, and we repair the damage without hesitation if things go wrong. So it should be here. I am against abortion, but... it is sometimes necessary. U

724 CMA JOURNAL/OCTOBER 18, 1975/VOL. 113

Garamycin* Injectable I.J/IV GARAMYCIN Injectable (40 mg (base)/ml) GARAMYCIN Pediatric Injectable (10 mg (base)/ml) INDICATIONS: GARAMYCIN is indicated in the treatment ot serious intections caused by proven susceptible organisms. In suspected or documented gram-negative septicemia, particularly when shock or hypotension are present, GARAMYCIN should be considered tor initial antimicrobial therapy. In staphylococcal intections. GARAMYCIN should be considered when conventional antimicrobial therapy is inappropriate or when susceptibility testing and clinical judgment indicate its use. ADMINISTRATION AND DOSAGE: INTRAMUSCULAR/INTRAVENOUSttADMINISTRATION: A. Urinary Tract Infections: The usual dosage in lower urinary tract intections is 0.8-1.2 mg/kg/day in two or three equally divided doses tor seven to ten days. For increased antibacterial activity it may be advantageous to alkalinize the urine. Infections of the upper urinary tract, such as pyelonephritis, should be treated according to one ot the schedules tor systemic intections. B. Systemic Infections - Normal Renal Function: The treatment ot systemic intections in patients with normal renal tunction requires a dosage 01 3 mg/kg/day in the three equally divided doses. A course of seven to ten days ot treatment will usually clear an infection due to a susceptible organism. In patients with lifethreatening intections, dosages up to 5 mg/kg/day should be administered in three or tour equally divided doses. This dosage should be reduced to 3 mg/kg/day as soon as clinically indicated. C. Patients with Impaired Renal Function: In patients with diminished renal function or those undergoing intermittant hemodialysis, the dosage has to be adjusted depending on the degree of renal impairment. For detailed information consult the product monograph or the Schering Representative. ftINTRA VENOUS ADMINISTRATION: The usual effective dosage 01 GARAMYCIN Injectable administered intravenously is 3 mg/kg/day in three equally divided doses. For intravenous administration, a single dose (1 mg/ kg) 01 GARAMYCIN Injectable is diluted in 100-200 ml 01 sterile normal saline or 5% dextrose. The solution is infused over a period of one to two hours and repeated two to three times a day. The usual duration 01 treatment is seven to ten days. PRECAUTIONS: Ototoxicity: Gentamicin, like other aminoglycosides, has produced ototoxicity in experimental animals and man, It is manifested by damage to vestibular function and may be delayed in onset. Damage has occurred in patients who were uremic, had renal dysfunction, had prior therapy with ototoxic drugs or received higher doses or longer therapy than those recommended. The concomitant use of ethacrynic acid and furosemide should be avoided. The physician should strongly consider discontinuing the drug if the patient complains of tinnitus, dizziness or loss of hearing. Serum GARAMYCIN levels in excess 0112 .g/ml should be avoided. Nephrotoxicity: Nephrotoxicity manifested by an elevated BUN or serum creatinine level or a decrease in the creatinine clearance has been reported with GARAMYCIN. In most cases these changes have been reversible. Neuromuscular Blocking Action: Neuromuscular blockage and respiratory paralysis have been reported in animals. The possibility of this occurring in man should be kept in mind particularly in those patients receiving neuromuscular blocking agents. ADVERSE REACTIONS: Among other adverse reactions reported infrequently and possibly related to GARAMYCIN are elevated SGOT, increased serum bilirubin, granulocytopenia and urticaria. Reactions reported rarely and possibly related to GARAMYCIN include drug fever, hypotension, hypertension, itching, hepatomegaly and splenomegaly. OVERDOSAGE: Peritoneal or hemodialysis will aid in the removal of GARAMYCIN from the blood. SUPPLIED: Each ml of aqueous parenteral solution at pH 4.5 contains: 40 mg or 10 mg (pediatric) of gentamicin base. Preservatives, methylparaben U.S.P., propylparaben U.S.P., sodium bisulfite U.S.P., disodium edetate U.S.P. Available in 2 ml multipledose vials and 1.5 ml Unidose* ampoules containing 60 mg gentamicin base/1.5 ml. Also available in 2 ml and 1.5 ml pre-filled disposable syringes containing 40 mg gentamicin base per ml. Solutions are heat stable and do not require refrigeration. Product monograph available on request trom Schering Corporation Limited Pointe Claire, Quebec. H9R 184

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* Reg. TM.

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I was always against it, but.

I was always against it, but... Elliott Emanuel, md For many of us the work of other tion to develop with less stress than physicians is a closed...
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