324
Journal of Religion and Health
Induced Abortion i n Contemporary Medical Practice
IRVIN
M. C U S H N E R
It is obviously fitting that a discussion of induced abortion be included in a publication that addresses itself to the intertwining of medical practice and societal ethics. In an era of rapidly changing moral values, among our more trying and impelling areas of concern is that dealing with human sexuality-its meaning, its function, its consequences. Those disciplines that deal with the human individual and his environment have expended much thought and and action on sex education, family life, contraception, population control, and other issues broadly related to sexuality. The most controversial of these has to do with the philosophies and practices regarding induced abortion. The intent of this paper is to outline the role of induced abortion in the clinical practice of medicine--the currently accepted indications and methodology as practiced in hospitals, the problems related to the illegal practice of abortion outside hospitals, the legal restrictions, and the hospital administrative requirements. Finally, the paper will also include a brief consideration of the ethical issues surrounding this procedure.
Clinical and sociologic aspects Nomenclature. An abortion is a termination of pregnancy, as are spontaneous The substance of this paper was presented at one of the Conversations in Medical Ethics conducted for students of six medical schools in the Philadelphia area at the University of Pennsylvania under the auspices of the Academy, October 10, 1967.
Induced Abor~on
325
labor and delivery, induced labor, and cesarean section. The distinguishing feature in abortion is the termination of pregnancy prior to viability (i.e., prior to that time in gestation when the fetus is capable of survival in an extrauterine environment). As currently defined, this capability begins when the fetus weighs 400 grams (15 ounces) or more at birth. Thus, when such a fetus is delivered, a birth (or stillbirth) certificate must be filed with the local and national offices of vital statistics. Contrariwise, if the fetus weighs less than 400 grams at birth, no such certificate is required, since a "birth" is not considered to have occurred; rather, it was an "abortion." In terms of duration of pregnancy, this fetal weight is usually reached at 20-24 weeks following the beginning of the last menstrual period. Actually, these criteria are based upon a single recorded instance of a fetus that weighed 397 grams at birth and survived. In more practical terms, the fetus is considered "practically viable," with a 50 per cent chance of survival, at a birth weight of about 1500 grams (3-31/z pounds), which occurs at about 26-28 weeks of gestation. A spontaneous abortion is one that occurs as a result of natural cause. An induced abortion, on the other hand, is one that is artificially caused by medicinal or mechanical agents. As will be discussed subsequently, induced abortion is prohibited by all states in this country (as well as by most other countries) except under certain circumstances. By virtue of these exceptions allowed by law, induced abortions are either legal or illegal, depending on whether or not they are performed by licensed physicians, in licensed hospitals, and for legally acceptable indications. Since legal abortions are those considered to be part of the management of a clinical problem, they have often been referred to as "therapeutic" or "medical" abortions. Those otherwise done are, then, illegal and have also been referred to as "criminal" abortion. Legal (medical, therapeutic) abortion. The magnitude of these procedures can be viewed in several different ways. The number performed annually in this country has been estimated as 8,000-10,000. With the annual number of births approaching 4,000,000, the incidence of legal abortion here is about one abortion for every 400-500 births. A more realistic picture of legal abortion in the United States must include variations in incidence among population groups.
326
Journal of Religion and Health
Thus, the incidence per 1,000 deliveries among hospitals in New York City in 1958 varied from 5.2 in privately-owned hospitals to 0.4 in municipally-operated hospitals; in 1952, at the Los Angeles County Hospital, it was 1: 8000.1 In order to point out the impact of legal restrictions upon the incidence of legal abortion, the experience in two countries where abortion is legal, at the request of the patient, is noteworthy. In 1961, the number of abortions performed in Japan was 843,000, amounting to 46 abortions per 100 births; in Hungary during the same year, 180,000 abortions were performed, while 133,000 live births occurredd The indications for hospital-performed abortions reflect contemporary medical knowledge at any given point in time. A generation ago, abortions were performed primarily to prevent the aggravation by pregnancy and delivery of a serious physical disease (e.g., heart disease, tuberculosis, vascularrenal disease) or of a psychiatric illness in which continuation of the pregnancy was associated with a significant risk of suicide. Currently, the threat of impairment-of physical health by pregnancy is indeed minimal, as a result of the medical advances that have occurred; however, in about 1-2 per cent of legal abortions, this represents the indication and now includes heart disease, malignancy of the breast or reproductive organs, hypertensive vascular-renal disease, and certain neurologic illnesses. On the basis of accumulated medical knowledge and experience, therapeutic abortion is currently considered justifiable for the following additional indications.: 1. Threatened impairment of mental health. This includes the entire spectrum of psychologic and psychiatric sequelae to pregnancy, from suicide risk and psychosis to emotional disturbance severe enough to render the patient unable to function in her normal manner. Some eases of pregnancy resulting from rape have been aborted on this basis. 2. Threatened birth of a child with serious congenital deformity or mental retardation. This indication is based on the now predictable teratogenic effect of certain viruses and drugs and excessive doses of irradiation upon the early intrauterine fetus. Thus abortions are deemed justified, when requested
Induced Abortion
327
by the parents, after they are informed of the fetal risk involved. The known teratogens at present include the rubella virus, thalidomide, and excessive doses of ionizing irradiation. Other viruses and drugs are suspect and under investigation. In cases of pregnancy resulting from incest, abortion has been deemed justified on the basis of genetic factors with an increased risk of fetal anomaly, as well as on the basis of probable impairment of mental health. The methods used in inducing abortion vary with the duration of pregnancy at the time of operation. This is so because of certain inherent hazards in performing these procedures in the enlarged and softened pregnant uterus. The operative procedures now being utilized are as follows: 1. Dilation and curettage (D & C) consists of dilation of the cervix and evacuation of the uterine contents by gentle scraping of the wall of the uterus. This is applicable only in the first trimester of pregnancy and is never performed beyond the 10th-12th week. A recent innovation in this technique that has been introduced by Soviet workers in this field consists of evacuation of the uterine contents by aspiration ~with suction apparatus. It is likewise limited to the first 12 weeks, but it is associated with less blood loss, less operating time and less operative trauma. 2. When the pregnancy has progressed beyond the 12th week, abortion is induced by the injection of hypertonic saline solution into the uterine cavity via a needle inserted through the abdominal wall. This is followed, in 24-48 hours, by a sequence of events entirely similar to a late spontaneous abortion, namely, uterine contractions, rupture of membranes, and evacuation of the uterus. This is most safely done when the uterine cavity is sufficiently enlarged to allow for easy transabdominal insertion of the needle, i.e., at about 16 weeks. 3. Abdominal hysterotomy is actually a "miniature cesarean section," with all that this implies--a major abdominal operation, longer hospkal stay and home care, increased medical costs, and a permanent uterine sear. It can be used to induce abortion at any time; however, it is usually reserved for the rare failure of saline injection, or when there is to be concomitant sterilization requiring an abdominal approach.
328
Journal o{ Religion and Health
It is quite probable that the future will bring an effective and safe pharmacologic abortifacient that will induce abortion by the administration of a drug. Such methods are currently being studied. Complications following induced abortion, even in capable hands and in adequate hospitals, are known to occur. They are quite rare. The major problems associated with "D & C" are postabortal hemorrhage and accidental perforation of the softened uterus with damage to adjacent structures. In the early usage of intrauterine injections, severe cases of infection and of hypotension with cardiac arrest occurred. However, refinements in technique, improved selection of cases, and discontinuance of the use of hypertonic glucose have virtually eliminated these dangers. Obviously, the greatest danger is death. It is well established, on the basis of American and European experience, that the risk of death from abortion performed by competent operators in hospitals is negligible in fact, very much lower than the maternal mortality rate associated with term pregnancy. Illegal (criminal) abortion. For obvious reasons, it is impossible to determine accurately the number of abortions performed annually in this country. It has been estimated as approaching one million. Most of these are done by physicians who perform a "D & C" or who insert a catheter into the uterus through the cervix; these are carried out in their offices or in other facilities. Some are performed by nonphysician abortionists with or without some background in health services. Others are self-induced by the patient, who attempts to introduce a foreign body and/or an irritant chemical through the cervix. Based only upon data derived from women who admit to having had an illegal abortion, it would appear that most of these procedures are performed upon married women between 25 and 35 years of age who have 2 or 3 children. The medical and sociomedical problems associated with illegal abortion have to do with the resultant complications. The risk of severe complication is, of course, related to the competence of the operator and the availability of aseptic precautions. The risk is greatest among the self-induced abortions and those performed by nonphysician abortionists. The most severe problems are infection, hemorrhage, and uterine perforation. In this country,
Induced Abortion
329
one critical index of the degree of this problem is the number of deaths that follow illegal abortion. This figure has been previously exaggerated; however, there are probably 500 to 1,000 such deaths annually. In some communities, infected criminal abortion has become the most common cause of maternal death. New York and Baltimore have experienced this situation in recent years. The death rate, however, is but one index; another is the number of hospital admissions for septic abortion. In some Latin-American countries, as many as 25 per cent of all hospital beds at any given time are occupied by patients suffering from a complication of illegal abortion. Those patients fortunate enough to survive frequently suffer a long illness and are rendered permanently sterile, either by the infection itself or by the treatment, which may include hysterectomy. Another complication of induced abortion, both legal and illegal, that is a source of concern is the psychologic sequelae. These are caused by feelings of remorse and guilt, with self-recrimination and depression. There are no accurate data on the incidence of this problem. However, it seems reasonably clear that the occurrence of serious psychiatric illness requiring therapy or hospitalization is, indeed, uncommon.
Medical-legal and administrative aspects Legal restrictions. All of the states prohibit induced abortion. Prior to 1967, when the nationwide movement to reform abortion laws began, 45 states allowed abortion only when the mother's physical life was endangered; 4 states allowed it if her life, health, or safety were at risk; 2 states allowed for no exceptions? Even in those states with more liberal laws, legal abortion is infrequently done because of restrictive policies promulgated from within the medical profession (hospital by-laws, local medical society policy, etc.). In 1962, the American Law Institute (A.L.I.) advised that the "ideal" abortion law would allow licensed physicians in licensed hospitals to perform induced abortion for those reasons considered justified by contemporary medical thought and practice, namely, when the pregnancy threatened the moth-
330
]ournal of Religion and Health
er's physical or mental health, or if there was an increased risk of fetal abnormality, or if the pregnancy resulted from rape or incest. In 1967, abortion legislation embodying these recommendations was introduced for consideration by 30 state legislatures. Revised laws were enacted in California, Colorado, and North Carolina; the California law, however, continues to prohibit abortion for possible fetal defect. In 1968, Maryland and Georgia revised their abortion laws. The law in Maryland was revised after a legislature subcommittee on abortion law studied the various laws, the recommended revisions, and the new (1967) policy statements of the American Medical Association and the Medical and Chirurgical Faculty of Maryland. This subcommittee actually found that there was no need for an abortion law, since the medical profession could adequately control abortion practices, as in the case of other surgical procedures. It, therefore, recommended that the existing law be repealed and that the Board of Medical Examiners be empowered to revoke the license of any physician who performed an abortion in other than an accredited hospital; the nonphysician would be liable under the already existing law prohibiting the illegal practice of medicine. This recommendation was all the more significant by virtue of the composition of the subcommittee, which consisted primarily of legislators with community representation. The broad and strong community support for this bill was offset by very strenuous opposition. The net result was a series of amendments that made the finally enacted law fall short of the original bill. However, it is, indeed a more realistic law than its predecessor, and it will allow for contemporary medical practice with the dignity of legality. Hospital administrative aspects. It remains the responsibility of the hospital to assure that all abortions performed within its confines meet the legal requirements. This results in two basic rules prevailing in all hospitals that allow induced abortions to be performed. First, the obstetrician must obtain competent consultation prior to the procedure. This is part and parcel of good medical practice, since the indications for abortion are, for the most part, nonobstetrical and, therefore, not within his expertise. Secondly, the hospital
Induced Abortion
331
requires prior approval by an abortion review authority. This usually consists of a committee of physicians, who must agree by majority or unanimously that the abortion falls within the framework of the existing state law. In other hospitals, the approving authority is the department head in obstetricsgynecology. Ethical considerations
Eastman4 has succinctly reviewed the ethical philosophies held by the proponents and the opponents to a more liberal role for abortion in medical practice and in our society. These attitudes fall into two categories of ethical theory: 1. "Utilitarian." This opinion would hold that the end justifies the means; that that which is most beneficial for most people is right; that the will of the majority must prevail. All published public opinion polls on this subject indicate that this is the favored view. Among physicians, according to Modern Medicine, 87 per cent of over 40,000 physicians who returned a questionnaire favored more liberal abortion laws. 5 2. "Intuitional." This philosophy holds that, all other factors notwithstanding, all induced abortions are immoral, based upon the view that the product of the union of spermatozoon and ovum is, from the moment of that union, a human life in the full sense of the term. Thus, fetal life is inviolate and abortion is murder. Although this opinion, in its purest form, is included in Roman Catholic doctrine, philosophies very close to it in degree are shared by more non-Catholics than is generally appreciated (e.g., the Orthodox Jewish rabbinate and many Protestant ministers). Comment
It is clear that the use of induced abortion in ethical medical practice has been heretofore severely limited by legal restrictions, by hospital administrative restrictions, and by the markedly conservative views of physicians advising
332
Journal of Religion and Health
patients, legislators, and hospital governing boards. It is likewise clear t h a t an increasingly vociferous citizenry is desirous of a more liberal view and of an increased usage of this procedure, when indicated, by competent physicians in hospitals. Such changes have started to occur, and it seems inevitable that they will eventually encompass most of the nation. As regards the ethical question, the fact that there exist two opposing philosophies becomes irrelevant. It does remain within the right and conscience of each individual person to choose freely whichever philosophy he finds appropriate to his background and orientation. If, therefore, a physician, his patient, his consultant, and his hospital feel that an induced abortion is necessary and desirable, they have the right to carry out this therapy. Contrariwise, no person should be forced, against his will, to perform, or to participate in, an induced abortion. This is nothing less than ethical and moral. It may some day be necessary to resort to public referenda or to an appeal before the United States Supreme Court to afford this right to all our citizens. References
1. Guttmacher, A. F., Babies by Choice or Chance. New York, Doubleday and Co., Inc., 1959. 2. Havemann, E., Birth Control. New York, Time, Inc., 1967. 3. George, B. J., Jr., "Current Abortion Laws: Proposals and Movements for Reform." In Smith, D. T., ed., Abortion and the Law. Cleveland, The Press of Western Reserve University, 1967. 4. Eastman, N. J., "Induced Abortion and Contraception: A Consideration of Ethical Philosophy," Obst. r GynecoL Survey, 1967, 22, 3-11. 5. "Abortion: The Doctor's Dilemma," Modern Medicine, 1967, 5J'~ 12-32.
Journal of Religion and Health
Induced Abortion i n Contemporary Medical Practice
IRVIN
M. C U S H N E R
It is obviously fitting that a discussion of induced abortion be included in a publication that addresses itself to the intertwining of medical practice and societal ethics. In an era of rapidly changing moral values, among our more trying and impelling areas of concern is that dealing with human sexuality-its meaning, its function, its consequences. Those disciplines that deal with the human individual and his environment have expended much thought and and action on sex education, family life, contraception, population control, and other issues broadly related to sexuality. The most controversial of these has to do with the philosophies and practices regarding induced abortion. The intent of this paper is to outline the role of induced abortion in the clinical practice of medicine--the currently accepted indications and methodology as practiced in hospitals, the problems related to the illegal practice of abortion outside hospitals, the legal restrictions, and the hospital administrative requirements. Finally, the paper will also include a brief consideration of the ethical issues surrounding this procedure.
Clinical and sociologic aspects Nomenclature. An abortion is a termination of pregnancy, as are spontaneous The substance of this paper was presented at one of the Conversations in Medical Ethics conducted for students of six medical schools in the Philadelphia area at the University of Pennsylvania under the auspices of the Academy, October 10, 1967.
Induced Abor~on
325
labor and delivery, induced labor, and cesarean section. The distinguishing feature in abortion is the termination of pregnancy prior to viability (i.e., prior to that time in gestation when the fetus is capable of survival in an extrauterine environment). As currently defined, this capability begins when the fetus weighs 400 grams (15 ounces) or more at birth. Thus, when such a fetus is delivered, a birth (or stillbirth) certificate must be filed with the local and national offices of vital statistics. Contrariwise, if the fetus weighs less than 400 grams at birth, no such certificate is required, since a "birth" is not considered to have occurred; rather, it was an "abortion." In terms of duration of pregnancy, this fetal weight is usually reached at 20-24 weeks following the beginning of the last menstrual period. Actually, these criteria are based upon a single recorded instance of a fetus that weighed 397 grams at birth and survived. In more practical terms, the fetus is considered "practically viable," with a 50 per cent chance of survival, at a birth weight of about 1500 grams (3-31/z pounds), which occurs at about 26-28 weeks of gestation. A spontaneous abortion is one that occurs as a result of natural cause. An induced abortion, on the other hand, is one that is artificially caused by medicinal or mechanical agents. As will be discussed subsequently, induced abortion is prohibited by all states in this country (as well as by most other countries) except under certain circumstances. By virtue of these exceptions allowed by law, induced abortions are either legal or illegal, depending on whether or not they are performed by licensed physicians, in licensed hospitals, and for legally acceptable indications. Since legal abortions are those considered to be part of the management of a clinical problem, they have often been referred to as "therapeutic" or "medical" abortions. Those otherwise done are, then, illegal and have also been referred to as "criminal" abortion. Legal (medical, therapeutic) abortion. The magnitude of these procedures can be viewed in several different ways. The number performed annually in this country has been estimated as 8,000-10,000. With the annual number of births approaching 4,000,000, the incidence of legal abortion here is about one abortion for every 400-500 births. A more realistic picture of legal abortion in the United States must include variations in incidence among population groups.
326
Journal of Religion and Health
Thus, the incidence per 1,000 deliveries among hospitals in New York City in 1958 varied from 5.2 in privately-owned hospitals to 0.4 in municipally-operated hospitals; in 1952, at the Los Angeles County Hospital, it was 1: 8000.1 In order to point out the impact of legal restrictions upon the incidence of legal abortion, the experience in two countries where abortion is legal, at the request of the patient, is noteworthy. In 1961, the number of abortions performed in Japan was 843,000, amounting to 46 abortions per 100 births; in Hungary during the same year, 180,000 abortions were performed, while 133,000 live births occurredd The indications for hospital-performed abortions reflect contemporary medical knowledge at any given point in time. A generation ago, abortions were performed primarily to prevent the aggravation by pregnancy and delivery of a serious physical disease (e.g., heart disease, tuberculosis, vascularrenal disease) or of a psychiatric illness in which continuation of the pregnancy was associated with a significant risk of suicide. Currently, the threat of impairment-of physical health by pregnancy is indeed minimal, as a result of the medical advances that have occurred; however, in about 1-2 per cent of legal abortions, this represents the indication and now includes heart disease, malignancy of the breast or reproductive organs, hypertensive vascular-renal disease, and certain neurologic illnesses. On the basis of accumulated medical knowledge and experience, therapeutic abortion is currently considered justifiable for the following additional indications.: 1. Threatened impairment of mental health. This includes the entire spectrum of psychologic and psychiatric sequelae to pregnancy, from suicide risk and psychosis to emotional disturbance severe enough to render the patient unable to function in her normal manner. Some eases of pregnancy resulting from rape have been aborted on this basis. 2. Threatened birth of a child with serious congenital deformity or mental retardation. This indication is based on the now predictable teratogenic effect of certain viruses and drugs and excessive doses of irradiation upon the early intrauterine fetus. Thus abortions are deemed justified, when requested
Induced Abortion
327
by the parents, after they are informed of the fetal risk involved. The known teratogens at present include the rubella virus, thalidomide, and excessive doses of ionizing irradiation. Other viruses and drugs are suspect and under investigation. In cases of pregnancy resulting from incest, abortion has been deemed justified on the basis of genetic factors with an increased risk of fetal anomaly, as well as on the basis of probable impairment of mental health. The methods used in inducing abortion vary with the duration of pregnancy at the time of operation. This is so because of certain inherent hazards in performing these procedures in the enlarged and softened pregnant uterus. The operative procedures now being utilized are as follows: 1. Dilation and curettage (D & C) consists of dilation of the cervix and evacuation of the uterine contents by gentle scraping of the wall of the uterus. This is applicable only in the first trimester of pregnancy and is never performed beyond the 10th-12th week. A recent innovation in this technique that has been introduced by Soviet workers in this field consists of evacuation of the uterine contents by aspiration ~with suction apparatus. It is likewise limited to the first 12 weeks, but it is associated with less blood loss, less operating time and less operative trauma. 2. When the pregnancy has progressed beyond the 12th week, abortion is induced by the injection of hypertonic saline solution into the uterine cavity via a needle inserted through the abdominal wall. This is followed, in 24-48 hours, by a sequence of events entirely similar to a late spontaneous abortion, namely, uterine contractions, rupture of membranes, and evacuation of the uterus. This is most safely done when the uterine cavity is sufficiently enlarged to allow for easy transabdominal insertion of the needle, i.e., at about 16 weeks. 3. Abdominal hysterotomy is actually a "miniature cesarean section," with all that this implies--a major abdominal operation, longer hospkal stay and home care, increased medical costs, and a permanent uterine sear. It can be used to induce abortion at any time; however, it is usually reserved for the rare failure of saline injection, or when there is to be concomitant sterilization requiring an abdominal approach.
328
Journal o{ Religion and Health
It is quite probable that the future will bring an effective and safe pharmacologic abortifacient that will induce abortion by the administration of a drug. Such methods are currently being studied. Complications following induced abortion, even in capable hands and in adequate hospitals, are known to occur. They are quite rare. The major problems associated with "D & C" are postabortal hemorrhage and accidental perforation of the softened uterus with damage to adjacent structures. In the early usage of intrauterine injections, severe cases of infection and of hypotension with cardiac arrest occurred. However, refinements in technique, improved selection of cases, and discontinuance of the use of hypertonic glucose have virtually eliminated these dangers. Obviously, the greatest danger is death. It is well established, on the basis of American and European experience, that the risk of death from abortion performed by competent operators in hospitals is negligible in fact, very much lower than the maternal mortality rate associated with term pregnancy. Illegal (criminal) abortion. For obvious reasons, it is impossible to determine accurately the number of abortions performed annually in this country. It has been estimated as approaching one million. Most of these are done by physicians who perform a "D & C" or who insert a catheter into the uterus through the cervix; these are carried out in their offices or in other facilities. Some are performed by nonphysician abortionists with or without some background in health services. Others are self-induced by the patient, who attempts to introduce a foreign body and/or an irritant chemical through the cervix. Based only upon data derived from women who admit to having had an illegal abortion, it would appear that most of these procedures are performed upon married women between 25 and 35 years of age who have 2 or 3 children. The medical and sociomedical problems associated with illegal abortion have to do with the resultant complications. The risk of severe complication is, of course, related to the competence of the operator and the availability of aseptic precautions. The risk is greatest among the self-induced abortions and those performed by nonphysician abortionists. The most severe problems are infection, hemorrhage, and uterine perforation. In this country,
Induced Abortion
329
one critical index of the degree of this problem is the number of deaths that follow illegal abortion. This figure has been previously exaggerated; however, there are probably 500 to 1,000 such deaths annually. In some communities, infected criminal abortion has become the most common cause of maternal death. New York and Baltimore have experienced this situation in recent years. The death rate, however, is but one index; another is the number of hospital admissions for septic abortion. In some Latin-American countries, as many as 25 per cent of all hospital beds at any given time are occupied by patients suffering from a complication of illegal abortion. Those patients fortunate enough to survive frequently suffer a long illness and are rendered permanently sterile, either by the infection itself or by the treatment, which may include hysterectomy. Another complication of induced abortion, both legal and illegal, that is a source of concern is the psychologic sequelae. These are caused by feelings of remorse and guilt, with self-recrimination and depression. There are no accurate data on the incidence of this problem. However, it seems reasonably clear that the occurrence of serious psychiatric illness requiring therapy or hospitalization is, indeed, uncommon.
Medical-legal and administrative aspects Legal restrictions. All of the states prohibit induced abortion. Prior to 1967, when the nationwide movement to reform abortion laws began, 45 states allowed abortion only when the mother's physical life was endangered; 4 states allowed it if her life, health, or safety were at risk; 2 states allowed for no exceptions? Even in those states with more liberal laws, legal abortion is infrequently done because of restrictive policies promulgated from within the medical profession (hospital by-laws, local medical society policy, etc.). In 1962, the American Law Institute (A.L.I.) advised that the "ideal" abortion law would allow licensed physicians in licensed hospitals to perform induced abortion for those reasons considered justified by contemporary medical thought and practice, namely, when the pregnancy threatened the moth-
330
]ournal of Religion and Health
er's physical or mental health, or if there was an increased risk of fetal abnormality, or if the pregnancy resulted from rape or incest. In 1967, abortion legislation embodying these recommendations was introduced for consideration by 30 state legislatures. Revised laws were enacted in California, Colorado, and North Carolina; the California law, however, continues to prohibit abortion for possible fetal defect. In 1968, Maryland and Georgia revised their abortion laws. The law in Maryland was revised after a legislature subcommittee on abortion law studied the various laws, the recommended revisions, and the new (1967) policy statements of the American Medical Association and the Medical and Chirurgical Faculty of Maryland. This subcommittee actually found that there was no need for an abortion law, since the medical profession could adequately control abortion practices, as in the case of other surgical procedures. It, therefore, recommended that the existing law be repealed and that the Board of Medical Examiners be empowered to revoke the license of any physician who performed an abortion in other than an accredited hospital; the nonphysician would be liable under the already existing law prohibiting the illegal practice of medicine. This recommendation was all the more significant by virtue of the composition of the subcommittee, which consisted primarily of legislators with community representation. The broad and strong community support for this bill was offset by very strenuous opposition. The net result was a series of amendments that made the finally enacted law fall short of the original bill. However, it is, indeed a more realistic law than its predecessor, and it will allow for contemporary medical practice with the dignity of legality. Hospital administrative aspects. It remains the responsibility of the hospital to assure that all abortions performed within its confines meet the legal requirements. This results in two basic rules prevailing in all hospitals that allow induced abortions to be performed. First, the obstetrician must obtain competent consultation prior to the procedure. This is part and parcel of good medical practice, since the indications for abortion are, for the most part, nonobstetrical and, therefore, not within his expertise. Secondly, the hospital
Induced Abortion
331
requires prior approval by an abortion review authority. This usually consists of a committee of physicians, who must agree by majority or unanimously that the abortion falls within the framework of the existing state law. In other hospitals, the approving authority is the department head in obstetricsgynecology. Ethical considerations
Eastman4 has succinctly reviewed the ethical philosophies held by the proponents and the opponents to a more liberal role for abortion in medical practice and in our society. These attitudes fall into two categories of ethical theory: 1. "Utilitarian." This opinion would hold that the end justifies the means; that that which is most beneficial for most people is right; that the will of the majority must prevail. All published public opinion polls on this subject indicate that this is the favored view. Among physicians, according to Modern Medicine, 87 per cent of over 40,000 physicians who returned a questionnaire favored more liberal abortion laws. 5 2. "Intuitional." This philosophy holds that, all other factors notwithstanding, all induced abortions are immoral, based upon the view that the product of the union of spermatozoon and ovum is, from the moment of that union, a human life in the full sense of the term. Thus, fetal life is inviolate and abortion is murder. Although this opinion, in its purest form, is included in Roman Catholic doctrine, philosophies very close to it in degree are shared by more non-Catholics than is generally appreciated (e.g., the Orthodox Jewish rabbinate and many Protestant ministers). Comment
It is clear that the use of induced abortion in ethical medical practice has been heretofore severely limited by legal restrictions, by hospital administrative restrictions, and by the markedly conservative views of physicians advising
332
Journal of Religion and Health
patients, legislators, and hospital governing boards. It is likewise clear t h a t an increasingly vociferous citizenry is desirous of a more liberal view and of an increased usage of this procedure, when indicated, by competent physicians in hospitals. Such changes have started to occur, and it seems inevitable that they will eventually encompass most of the nation. As regards the ethical question, the fact that there exist two opposing philosophies becomes irrelevant. It does remain within the right and conscience of each individual person to choose freely whichever philosophy he finds appropriate to his background and orientation. If, therefore, a physician, his patient, his consultant, and his hospital feel that an induced abortion is necessary and desirable, they have the right to carry out this therapy. Contrariwise, no person should be forced, against his will, to perform, or to participate in, an induced abortion. This is nothing less than ethical and moral. It may some day be necessary to resort to public referenda or to an appeal before the United States Supreme Court to afford this right to all our citizens. References
1. Guttmacher, A. F., Babies by Choice or Chance. New York, Doubleday and Co., Inc., 1959. 2. Havemann, E., Birth Control. New York, Time, Inc., 1967. 3. George, B. J., Jr., "Current Abortion Laws: Proposals and Movements for Reform." In Smith, D. T., ed., Abortion and the Law. Cleveland, The Press of Western Reserve University, 1967. 4. Eastman, N. J., "Induced Abortion and Contraception: A Consideration of Ethical Philosophy," Obst. r GynecoL Survey, 1967, 22, 3-11. 5. "Abortion: The Doctor's Dilemma," Modern Medicine, 1967, 5J'~ 12-32.
