Perspectives on Abortion from Sixty Years of Medical Practice

 

We start with a summary of the events followed by personal annotations.

Chronology of abortion policy in USA

1) Boys get souls 40 days after conception,                           16th century theology

 girls in 80 days.                                                            

 

2) No prosecutions for abortions before  quickening              17th & 18th  century British Common Law                   

                                                                                      

3) Abortion banned except to save the mother’s life              19th century, Connecticut  1st 1821

 

4) Comstock Law banned information about                         1873 (and banned much else)

 contraception by US mail.

 

5) Many thousands of women harmed by illegal                    1880-1973

 abortions with 5000 deaths per year in the US.

 

6) Margaret Sanger’s conviction for mailing                          1915 “because it could be used

 contraceptive information reversed                                       to prevent disease”  (condoms) 

 

7) Federal Appeals Court ruled that the US                           1936 case entitled: US vs One           

 government could not interfere with                                     package of Japanese pessaries     

 physicians providing contraception.                                      (end of Comstock Laws)                

 

8) Judge August Hand lifted ban on birth control                 1938

 

9)  The Vatican has a split vote on contraception                   1954 possibly a reliable rumor

 

10) Colorado legalizes abortion for rape, incest,                    1967, 13 more states before 1970,           

 health of mother                                                                     Tinkering with exceptions to illegality

occurred in many states for years.

                                                                                           

11) New York State legalized elective abortion                     1970, 4 more states by 1973

  in the first trimester of pregnancy.

 

12) US Supreme Court established the right of                      1972, Eisenstadt vs  Baird

  unmarried people to use contraception.

                                                              

13) Roe vs Wade permitted elective abortion in                    1973

  the first trimester of pregnancy in all states.

 

14) Violent crime down in all US jurisdictions                      1990-2000, 50% due to the absent cohort 

of potential  criminals, & many more in jail

15) FDA approves RU486 (mifipristone) for                         2000

   nonsurgical abortions.

16) The concept of the fourth trimester of pregnancy            2010

 

Personal Annotations:

1) Obtaining souls. This one is from the majority opinion of the Roe vs Wade Supreme Court decision.  We can only speculate why four century old theology was included in the 31 page opinion.  Personally, I thought it was funny enough to “make the team.”  The question when does human life begin has become very pertinent.  Read on beyond annotation 16).

2) British common law apparently thought that human life begins after quickening or at birth.

3 & 5) Banning abortion. By the nineteenth century it had become apparent that full term childbirth was much less danger of death to a mother than induced abortion.  The germ theory of disease was a hundred years away.  For example, although there are no firm statistics, expert opinion tells us that in the last decade of the twentieth century, about 70,000 women died annually worldwide from induced abortions with 5,000,000 more disabled.  It is worthy of emphasis that about 50% of all pregnancies result in spontaneous abortion, many so early that they pass for a late menstrual period.  In these cases, infection is not a risk as it is in induced abortion (even with modern sterile precautions).  Most very early spontaneous abortions are due to chromosome abnormalities and are best regarded as good riddance. (Down’s syndrome is unusual among chromosome abnormalities as it is compatible with prolonged post natal survival, although with disability.)

Another interesting worldwide statistic: annual abortions of about 45,500,000 in 1995 dropped by 3,500,000 per year during the next decade due to improved availability of birth control worldwide.  Even more interesting: a greater percentage of Catholic women have abortions than the percentage having abortions from the rest of the population,  Some of these have later turned up as protesters at Planned Parenthood clinics. This is why the signed permit form for obtaining an abortion from a Planned Parenthood facility contains a rider permitting Planned Parenthood to make public the fact that you had an abortion if you are found among such protesters.

4) Comstock laws were an early and unsuccessful attempt to eliminate obscenity with prolonged unintended adverse effects on women’s health (and population control).  5)-8) need no explanation.

9) The College of Cardinals had a split vote about permitting contraception.  I heard this in 1954 from the dean of the Missouri Bible College, in his capacity as volunteer leader of the Unitarian Fellowship in Columbia.  I can’t remember his name and couldn’t find it---a  rare Google failure.  At the time I scarcely believed the accuracy of the report.  Subsequent events have indicated that this man must have had a mole at the Vatican (he was that sort of a guy).  So be prepared for unexpected help from high places.

10) Fetal  indications for abortion.  Most, if not all states, had not prohibited abortion for life-threatening maternal illness. During my medical residency at the University of Colorado Medical Center, the head of the obstetrics department, E. Stewart Taylor, MD, repeatedly emphasized that the Colorado abortion law was defective in not having a provision for fetal indications for abortion such as in the case of a pregnant woman getting rubella (German measles) during early pregnancy.  He considered it unethical not to provide this service stating that if we, as physicians, were ever prosecuted in such a case, he would testify at his expense in our defense at any trial.  For more see: Amazing Teacher #6 on www.frantzmd.info.  11)-12) need no explanation.

13) The suddenness of the  Roe vs Wade decision upset me.  My solution: I obtained the entire majority opinion from the local library’s back copies of the New York Times—they publish all Supreme Court opinions.  It was an epiphany for me.  All my concerns about the problems I had seen of complications from botched illegal abortions would not recur.  Shrill objections to contraception would die down. Sexual activity could achieve its rightful place as one of the glues of society.  Mankind could emulate bonobos in this regard.  (Bonobos are close to us evolutionarily and use sex more positively than either humans or chimpanzees.)

14) From reading the Roe vs Wade decision in 1973, I said to myself, “Remember to look for a fall in crime rates in about twenty years.”  I did remember.  Violent crime rates in all US jurisdictions declined about 10% (homicides in our 25 largest cities 18-75%) throughout the 1990s.  I sought interpretation from experts.  Their consensus: a reduced population of criminals; about half from higher jail populations—fewer of them out and around thereby unable to offend, and the other half from the absent cohort of less adequately reared, (nonexistent) children.  You don’t need to look up the specialist literature.  One of them wrote a popular book about it, as I was informed  by a friend—the book Freakonomics by Steven D. Levitt. 

15)  RU486 is becoming the most satisfactory medical (nonsurgical) inducer of abortion.  Antimetabolites  also  used  for  cancer  chemotherapy  such as  methotrexate  have occasionally been  used with some success, but seldom since RU486 was approved.  All require a surgical team on standby in case the abortion is incomplete.  There follows an interesting paragraph about much weaker abortfacient herbs that are unlikely to be significant agents under modern conditions.  It is included because of the interesting cultural bias depicted.  It is also apparent that women, whether primitive or modern, prefer no more children than they can adequately care for.

I came across the word agnotology in 2008 and wondered about its origin.  From Google I found what must have been a very early use of the new word agnotology, if not its coining, in an article by Linda Schiebinger titled Agnotology and Exotic Abortifacients: The Cultural Production of Ignorance in the Eighteenth Century Atlantic World.  The most recent of its 55 references is from 2004. The article emphasizes the work of Maria Sibylla Merian from 1699 to 1701 in Surinam, then Dutch Guiana. She was the only one of many naturalists and anthropologists active among the indigenous peoples in Africa and the Americas who mentioned extensive use of abortifacients for “menstrual regulation” (population control) that were widely known among these aborigines. The silence of the others had to be self-censorship imposed by no authority, but by a rather universal cultural bias.  I did not find agnotology in any dictionary including the most recent Oxford English Dictionary.  I, personally, look forward to a long and constructive relationship with agnotology (as a “worthy [?] opponent”).  In any event the word must be quite new even though the behavior it defines must be almost as old as spoken language.  (The tobacco industry has fostered the most adept of modern agnotologists.)

                          *                       *                        *                      *                      *

My next decade’s question became that of the medieval theologians, “When does life as a human begin?” I have suspected the answer is, “Human life begins when a human infant, or fetus, makes a connection with human caregivers capable of transmitting human culture to it during a constructive childhood.”  The preferred expert to answer the question is Melvin Konner, MD, author of  The Evolution of Childhood: Relationships, Emotion, Mind Belknap Press of Harvard University 2010.  He is also an ethnologist and ethologist (studies animal behavior).

Page 564.  Vast domains of human child rearing…..are largely shared with apes and monkeys and to a lesser extent with other species.  What we think of as the essence of humanity is often not that at all, but a suite of capacities much older than we are.

Page 580.  Efforts  by skeptics to test claims for animal culture are valuable, but some scoffing has been defensive and shrill.  The bar can always be raised and definitions changed so that the latest and most culturelike [sic] animal capability remains just shy of a mark, revised ad hoc to protect human uniqueness.  Skeptics as well as proponents of animal culture can miss the point: this is a search for the rudiments of culture, for something that natural selection might have started with, in the brain function and social life of a nonhuman species, to build a true capacity for culture.  Whether we call these phenomena rudimentary or (as I prefer) proto-culture is of little consequence as long as we understand them……….but it serves little purpose to truncate debate by fiat---defining culture as inherently human.

In other words inadequately reared children may suffer an irremediable handicap almost as if they had been reared by animals.  This demonstrates that having a thoroughly human genotype and phenotype does not make us thoroughly human.  So when does human life begin?  Even the structure of the brain of socially deprived apes differs from that of those not so deprived.  Why should we be spared these anatomical and social deficits?

Page 582 & 591.  All agree that the artistic creations of the people who lived in Southwestern Europe 30,000 years ago qualify as culture [this refers, no doubt, to ancient cave art in France].  But these humans could have been living 300,000 years after the evolution of Homo sapiens; that conclusion does not help with… the problem of non human-human boundaries.….Only humans, among primates, teach; only humans create and build culture cumulatively.  Only humans are suspended in a web of significance we ourselves have spun.  [Cheetah mothers do teach their young  how to hunt.]

Page 123  The meaning of these works is unknown [the cave art], but speculation has focused on the small size of the hand prints that occur in many places, perhaps the paintings were made with the help of children……so it has been proposed that the caves may have been part of a kind of ritual theatre……This novel art required no new advance in brain function, but it was predicated on the existence of a fully modern human brain…..it entailed a cultural level that took even homo sapiens many thousands of years to arrive at……This was also, perhaps, a level at which teaching children important life lessons had become central to their development and worthy of great art, among the most precious of resources.

Human life was beginning in prehistory, and it depended on culture.  Medieval theologians don’t have modern answers.  Supreme Court Justices are an improvement.  We are facing problems that are new to our times.  There are some bright spots.  For example, economists have gotten over the dogma that requires continuous economic growth.  We must get over the dogma that continuous growth of food supply solves the population problem.  Just because Malthus was not proven wrong promptly, does not mean that we should ignore his warning until he is proven correct.  Enormous harms deserve corrective action before they are beyond repair with available means.  Here is another  lesson from Melvin Konner’s book about the !Kung culture of the Kalahari desert of Africa.  He had studied the !Kung extensively.  The following is food for thought even if we don’t have an answer any more than I knew the answer to violent crime rates a generation after R v Wade.  Konner told us that about 1% of !Kung infants die of premeditated neglect mostly when a mother delivers a baby while she is still nursing her previous offspring of less than two years---!Kung children are normally weaned after four or five years of breast feeding.  Do we similarly need to look ahead to see which of limited investment opportunities are going to pay off?  Konner does not present this information until he has provided ample information that infant relationships and mutual commitment are not solid for several months after birth in all human cultures.  Evolution can only build on what already exists.  I may not live to understand fully nor may our authority figures.  Let us help each other to choose wisely.

16) The Fourth Trimester of pregnancy. In this context I want to say more about Melvin Konner’s concept of the “fourth trimester of pregnancy”--the first two or three months of early infancy in full term babies.  By this bemusing term, the author of The Evolution of Childhood chose to emphasize that we humans have evolved to be born prematurely to permit our baby’s heads to pass through the maternal pelvis before brain development has made the head too large.  Delayed parent-child bonding and excessive crying in early infancy may have been inevitable consequences according to Konner, who has stated that rare neglect of full term infants may result. 

Western neonatologists ponder ethical dilemmas concerning prematurity and early infancy (the fourth trimester again) because of late, serious sequels of prematurity that defy effective remedies.  Physicians have long been aware that humans are borne prematurely for the reason that Dr. Konner states---the need for extensive postpartum growth of the brain (and head).  Neonatologists and other pediatricians have also been aware that formula feeding cannot fully replace breast feeding of infants because human milk is unique in containing special lipids essential for optimum brain development in early infancy.  This is especially vital for babies borne prematurely.  A British study of a few years ago comparing intelligence in breast fed premature babies with matched bottle fed ones, showed an average of 8 IQ points improvement in intelligence quotient when tested in late childhood (age 8-10).

These cogent questions ensue: 1) Does the concept of the fourth trimester of pregnancy minimize the moral problem with third trimester abortions?  The chief medical problem with elective third trimester abortions is increased maternal risk. 2) Does infanticide in early infancy become morally acceptable?  3) Why do we agonize so over these questions before assuring that every child is wanted by parents (or parent surrogates)?  4) Should not supporting (if not trying to guarantee) every child’s right to the kinds of experiences necessary for personal growth?  5) Have I avoided overemphasizing these questions? 

The realization that human life begins as late as the “fourth trimester” of pregnancy may come after some delay like the unexpected reduction in crime in the 1990s with probable incremental further benefits.    

While Homo erectus and Homo sapiens were evolving cooperative breeding in their communities, which was crucially helpful to mothers, evolving menopause was creating surviving infertile grandmothers to foster the helpful endeavor---menopause is unique to humans.  Neglected children simply did not survive in paleolithic times.  Neglect of infant apes didn’t occur in our ape ancestors.  Ape mothers don’t let other apes hold their infants for the entire first year or so of life.  Even in the middle ages childhood mortality was over 50%.  Now 99% of newborns in western society survive to age five (Sarah Hrdy).  Our modern obligation increasingly becomes not to create neglected children with their inadequate socialization and more frequent criminality as adults. Modern public health and social support systems rightfully care for these children thus increasing our obligation to avoid unwanted children in the first place.

Thinking about when does human life begin, integrates well with thinking about enhancing early and later childhood.  Another book Mothers and Others, The Evolutionary Origins of Mutual Understanding by Sarah Hrdy, Belknap Press of Harvard University, 2009 has something to contribute to this discussion.   Here are some quotations:

Pages 130-131. ……Overall children seemed to do best when they have three secure relationships---that is, three relationships that send the clear message, “You will be cared for no matter what.”……the most powerful predictor of later socioemotional development involves the quality of the [child’s] entire attachment network……                                                                                                                                      
……….Infants [in Israeli kibbutzim] who spent the night in communal nurseries tended to be less securely attached to their mothers, and less securely attached to caretakers generally. It is tempting to interpret the greater sense of security derived from sleeping near the mother in line with  the comparative evidence across primate and foraging [human] societies.                                                                                        
……….Mother-infant co-sleeping may be as close to a primate universal in child care as can be found…...The existence of this near-universal suggests human infants who find it distressing to be put alone in a dark room at night, or who find bedtime especially stressful when away from home are well within what we might call their “primate rights.”                                                                       
…….infants  securely attached to their meteplot [Hebrew for “caregiver”] were also more self-confident and socially sophisticated several years later when they entered kindergarten…..The strongest predictor of empathy,…….. independence, and achievement-orientation often turned out to be a strong attachment to a nonparental caretaker. 

What do these quotations have to do with abortion?  Much.  Enhancing human experience depends on enhancing human relationships for all of us.  This goal is greatly advanced by insightful analysis of many topics including adjusting abortion policy to promote universal human values.

I say, “Thank you US Supreme Court for your masterful Roe vs Wade majority opinion.”  Reading it and absorbing it was a very positive turning point in my life and thinking.

John A. Frantz, MD
December 14, 2010, revised January 6, 2012.

 

References:

1) www.allaboutpopularissues.org/history

2) www.feminist.com/resources/ourbodies/abortion.html  both accessed November 30, 2010

Human beings are not born with human nature—they develop it.  [Human beings are born with] potentialities for being human……but being human is something one learns; it is not a status with which one is born.  To earn the status of being human, one must earn it; otherwise one can never play the role of a human being.      Ashley Montagu, 1962

Those who cannot remember the past are condemned to repeat it.   George Santayana

 

Addendum to Perspectives on Abortion from 60 Years of Medical Practice

I read in Free Inquiry recently that Martin Luther King, Jr. and Coretta Scott King had been Unitarians early in their marriage and switched to Southern Baptist before thoroughly establishing themselves in their career of abolishing apartheid in the United States in order to gain a “bully pulpit” (so far I have not found my source in Free Inquiry for April/May 2011 (where I thought I saw it).

Even if this story is not true (I don’t really believe that), overnight it became a useful allegory for me for the following reason: while I was submitting my article about abortion, one editor was quite interested in it and suggested that I pursue the implication of the concept of the fourth trimester of pregnancy (mentioned in the article) because it might justify infanticide in early infancy by logic similar to that justifying abortion.  I had noticed this implication of “fourth trimester” but strongly felt that its emphasis would unnecessarily detract from much of the even liberal public receiving my main message—we need ordinary legal abortion for many reasons (Number 1: The availability of abortion make contraception acceptable to many who would otherwise oppose it.)

Here is another useful allegory that I know to be true to further illustrate the point.  About fifteen years ago on an Elderhostel hiking trip in Patagonia, I became acquainted with a former president of one of our state universities.  After a number of interesting conversations, I asked him, “Do you suppose there is any president of a public university in the United States who never had a run-in with the athletic department?”  A yes or no question, but he replied:

“Let me tell you a story.  I found out on Thursday evening before the homecoming football game that the star fullback had not been to class all fall.  So I scheduled a meeting for Monday with all those who must have known and did not tell me. I fired the lot of them except for the coach who had tenure, but that did not mean that he had to be retained as coach.  The next day the headline came in the newspaper ‘THE PRESIDENT OF THE UNIVERSITY IS STILL IN CHARGE’.”

From this story I learned that one should stay calm and choose one’s battles.  The key point was waiting until Monday and not unnecessarily spoiling the big alumni weekend.  Sometimes when I am having a bad day, I worry about missing an opportunity to ask an appropriately (im)pertinent question.

Allegories may be valid even without always being true stories, and I think that the former university president knew me well enough to realize that the final result of his run-in with the athletic department might contribute to my personality and future (even if the Kings had always been Baptists).