When I started medical school and pictured my future as a physician, abortion could not have been further from my mind. I remember receiving mass emails inviting members of our class to join our school's Medical Students for Choice group, reading them with some interest, but eventually letting them fade to the bottom of my inbox. I knew where I stood ideologically, and how I would vote if given the opportunity, but I had not begun to sort out how my professional duty toward my patients and my personal beliefs might relate to one another.
Flash forward nearly four years, and much has changed. In two short months I will graduate from medical school and embark on my career as an obstetrician-gynecologist. Though I still have many formative years of training ahead of me, I do know one thing for certain about the type of OB-GYN I will be. I will always support and advocate for my patient's right to choose, and I will be trained to help her safely exercise that right.
I know this in part because over the past several years I have been deeply affected by the many women I have met who seek abortion care. The right to choose is no longer a matter of personal ideology for me. It feels like a matter of professional and ethical responsibility.
To understand and support a patient in her decision is one thing. To be faced firsthand with the physical implications of that decision is another.
In medical school we were taught relatively little about abortion. We received one lecture on the subject, descriptive and appropriately devoid of ideology in the way most of our lectures were. Later that month, two speakers addressed our class: One was a rural family practice doctor who chose not to provide abortions; the other was an OB-GYN who provided abortions. Rather than debating one another, they each told their respective stories and left it at that. For me it was the beginning of a long process of reflection on my role as a future doctor.
Hearing the perspective a doctor who objected to providing abortions on religious grounds was both thought-provoking and troubling to me. He explained that it was against his conscience not only to perform abortions but also to even refer a patient to an abortion provider. He would tell his patients seeking to end their pregnancies that he could not take this path with them (his words as I recall them) and refer them to a colleague, who in turn would refer them to an actual provider of this service.
I looked around the lecture hall and saw some of my classmates nodding their heads that this seemed reasonable, while others seemed disquieted. I was in the latter group. Why was I so bothered? He seemed like a nice enough man who was entitled to his personal beliefs and expressed them respectfully, but the more I pondered his prioritization of those beliefs over what I felt was his professional obligation to his patients, the more certain I became that this choice could harm patients.
We all have personal convictions, but to expose patients to the unavoidable sense of judgment that had to accompany these encounters seemed wrong, as did the burden of seeing an additional provider.
I wondered if afterward, once a patient was finally able to access the services she needed, could she really go back to this doctor? How could a positive and trusting physician-patient relationship endure after all of this?
Soon, my reflections on abortion went from theoretical to practical. In my third year of medical school I spent six weeks immersed in the world of obstetrics and gynecology. I had a patient who underwent a surgical abortion — the first I had ever seen. My patient was a mother of two healthy children, pregnant with her third child, but this pregnancy had gone horribly awry. Her fetus had a severe anomaly diagnosed in the second trimester of pregnancy. This anomaly was so severe that her fetus was likely to die in the womb or very soon after birth. After learning about this prognosis, she made the decision to end her pregnancy.
The procedure was not a gentle introduction to the practice of abortion. In a way I'm glad it wasn't, because it challenged my ideology for the first time, pitting my immediate emotional reaction to the procedure itself against my deeply felt duty to the patient before me.
To understand and support a patient in her decision is one thing. To be faced firsthand with the physical implications of that decision is another. There is a reason that opponents of abortion often use images of second-trimester procedures like the one I observed to advance their cause. The fetus has, at this point in pregnancy, developed into something with discrete and recognizable human features.
I felt for the first time the gravity of what had previously been only theoretical. I was forced, in those minutes in the operating room and for many days thereafter, to reconcile my grief with something quite the opposite. It was a strong and enduring sense that we had done something therapeutic and right, that we had lifted a small part of her burden of suffering and, with time, set the patient on the path to healing from a terrible situation.
As I continued working with patients, I found that most abortions are not like this. Most women who have abortions — upward of 90 percent — do so within the first 12 weeks of pregnancy, and only about 1 percent have one after 20 weeks. Despite common stereotypes, women who have abortions are a racially diverse group, many from disadvantaged backgrounds and unstable social situations and others from relative privilege. Their reasons for choosing to end their pregnancies are varied and often complex. Many of the patients I saw were either married or in otherwise very committed relationships with their partners. Statistics tell us that more than 60 percent already have a child.
Some patients I met had confidently known their choice and their reasons from the moment the test came back positive, while others had taken a more circuitous path to a nonetheless resolute decision. Some were at peace, and some were conflicted on the day of their procedure, still grieving the fact that they were pregnant when they did not want to be.
I will never forget a patient telling me that the only thing worse for her than getting an abortion that day would be leaving the clinic still pregnant. This sense of being caught between the proverbial rock and a hard place was common, but as another patient once explained, there was some comfort and empowerment in at least having the choice.
As a doctor, when faced with an ethical or clinical dilemma, one simple question often provides amazing clarity: Is what I am doing in service of my patient?
We live in a country where roughly half of all pregnancies are unplanned, so there are, unsurprisingly, many women who become pregnant and choose not to give birth. We know that about one in three women will have an abortion by age 45. Is this number, as some have argued, too high? In the 1990s, the Clinton administration popularized the notion that abortion ought to be "safe, legal, and rare." I understand this sentiment, but I think this misses the point. There are a great number of ways to reduce abortion rates. Some of which, as I would argue we have seen in the past couple of decades, do not promote the health and reproductive autonomy of women.
Moreover, insisting single-mindedly that abortion should be "rare" further stigmatizes the one in three women who will make this decision. From a public health perspective, the end-all objective should not be to reduce abortion rates, but instead to further empower more women to make informed reproductive choices.
This may seem like a trivial distinction, but it is the difference between an agenda that conforms women's health to socially accepted standards and an agenda that truly promotes the health of women.
As a doctor, when faced with an ethical or clinical dilemma, one simple question often provides amazing clarity: Is what I am doing in service of my patient? The answer to this question is always "yes" when I support my patient's right to choose. Forced childbirth is never in the best interests or in service of a woman. Even under the best of circumstances, pregnancy is not, medically speaking, a benign state. The risk of death when a pregnancy is continued to birth is about 14 times as great as the risk of death from safe induced abortion.
But for me, this consideration is only a starting point. As a physician I will be charged with promoting the health of my patients, and there is so much more to this endeavor than just caring for the body. This is especially true when it comes to reproductive health, which has profound emotional and social significance to patients. In this sense, access to abortion is a matter of dignity and of a fundamental level of autonomy over the body.
The harm in denying this autonomy is real. One only has to go back a short time in history to realize that at a policy level we do not have a choice between legal abortion and no abortion. Instead, we have a choice between safe and unsafe abortion.
Many anti-abortion activists deny that women who lack access to a safe, legal abortion would choose an unsafe abortion. Yet in the past they have, in large numbers, and the health consequences for women were tragic. Estimates of the number of illegal abortions in the 1950s and '60s range from at least 200,000 to more than 1 million. These illegal abortions were dangerous — they accounted for nearly 20 percent of all pregnancy-related deaths during those decades.
Now nearly all deaths that result from abortion occur in developing countries where services are illegal or otherwise difficult to access. Returning the US to a similar situation would be a frightening blow to the health and welfare of women.
There is no achievable middle ground when it comes to pregnancy. Though a woman can ultimately choose adoption over parenthood, the burden of pregnancy and childbirth and the long-lasting consequences of both are hers to shoulder alone and completely.
This inherent inability to compromise gets to the heart of why abortion is so publicly contentious. There is no easy answer, but I believe there is a right one. It ultimately boils down to whether we, as a society, are willing to accept a world in which a woman's physical ability to grow and deliver a child is tantamount to an imperative to do so. Are we are willing to accept unsafe and illegal abortion over safe and legal abortion in the name of enforcing this imperative? To this, as a future physician charged with the health care of women, I say no.
I am a pro-choice medical student, and soon I will be a pro-choice physician committed to learning, among a vast many other things, to provide safe abortion care and advocate on my patients' behalf. It feels especially important for doctors to engage in this conversation in our current political climate. In recent years, anti-abortion advocates seem to have taken up the mantle of protecting women's health insofar as it is used as a justification for increased regulation of legal abortion.
For a procedure as safe as abortion, the amount of regulation surrounding it is unheard of. As of January 2014, more than half of states have enacted regulations on abortion that limit access at both patient and provider levels. Both the American Medical Association and the American College of Obstetricians and Gynecologists oppose these regulations because they do not meaningfully increase the safety of abortion and instead jeopardize women's health by limiting their ability to access this service.
The legality of abortion means relatively little if access to these services is not there. The number of abortion providers is decreasing, as is the number of clinics providing abortion services. As of 2011, an alarming 90 percent of counties in the US lacked an abortion clinic, despite the fact that 38 percent of all US women reside in these counties.
Mandated counseling and burdensome waiting periods designed to dissuade women from their decision do nothing to increase the safety of this already very safe procedure. Some states are limiting women's access to abortion by effectively forcing clinics to shut down because they do not meet facility standards irrelevant to the provision of safe care. This may lower rates of safe abortions, but it will not promote the health of women.
Doctors in many states are required by law to read inaccurate information about the risks of abortion to patients before the procedure. This erodes the sacred trust that should exist between a woman and her health care provider and interferes with a doctor's oath to do no harm. Abortion may be a hot-button political issue, but it is at its core a health issue, just like pregnancy itself.
Regardless of your moral position on abortion, the politicization of women's health should concern us all, because when it comes to abortion regulation it is health, not ideology, that is at stake. Advocating for a woman's ability to access a safe abortion is one way that I fulfill my duty to promote the health of my future patients.
Susan Brinckerhoff is a medical student in Chicago.