A Scientific Critique Of Abortion As A Medical Procedure
Psychiatric Annal - 2:9
Everyone is entitled to the philosophical orientation of his choice, but those who advocate a technique as a medical procedure should provide a rationale documented by scientific evidence that goes beyond clinical impressions or philosophical preferences. In the absence of such scientific evidence, the technique as a medical procedure must be regarded as unethical, in accordance with sections 2 and 3 of the Principles of Medical Ethics of the American Medical Association. That is, all methods of healing should be founded on a scientific basis with clinical investigation limited to a systematic, competently designed research program producing valid and significant data.
To argue that abortion, or any technique for that matter, is a person's right begs the scientific question since this is really no more than an assertion of one's philosophy or emotional bent. Any medical technique is a right if it is indicated in accordance with scientifically sound medicine. If abortion is to be defended as a medical procedure, its value must be scientifically demonstrated.
Most articles opposing abortion as a medical procedure are in fact philosophical discussions of the nature of the fetus and the time when life begins. Most articles supporting abortion as a medical procedure are pseudoscientific disquisitions about indications, benefits and absence of complications, pseudo-scientific chiefly because scientific criticism is not applied. This present article opposes abortion by applying scientific criticism to many studies on which the abortion movement relies. This will not be a complete review of the abortion literature, but the criticisms offered may be universally applicable. Philosophical issues will be avoided, but they cannot be ignored completely because they are the reason for the emotional skew of abortion studies.
THE EMOTIONAL SKEW
This is evident in two ways: the need to call abortion "therapeutic" and the need to deny complications.
Bartemeier has been very direct about the word therapeutic: "...the term 'therapeutic abortion' is a misnomer; it appears to have been devised to circumvent the laws of the states. No carefully conducted clinical investigations have demonstrated the therapeutic value of these surgically induced procedures."
Even abortion proponents will occasionally confirm this:
"This phrase [therapeutic abortion] compounds the ethical confusion and intellectual dishonesty which are characteristic of popular and professional attitudes and notions about abortion. Obviously abortion is not a treatment for anything unless pregnancy is considered a disease, and if it were that, it is the only disease which is 100 per cent curable by abortion or delivery at term."
Therapeutic efficacy for abortion was claimed by Ford et al. in a study with such elementary deficiencies that the competence of the editorial board of JAMA, ultimately responsible for its publication, was in question before the judicial council of the American Medical Association.
THE LIST OF COMPLICATIONS
This tendency to claim therapeutic value may indicate that unconscious mental processes or conscious philosophical issues are influencing those studying abortion to justify it by abusing the scientific method. In addition, these same mental processes that find therapeutic value may also be influencing abortion proponents to underestimate the complications. Nevertheless, the list of known complications has grown quite long. The socialist countries of Central and Eastern Europe, which permit abortion, stress the necessity of warning the pregnant woman about the grave risks of abortion, and in some instances anti-abortion efforts have even required government sponsorship.
Even in Western countries, the evidence is growing concerning the adverse medical and surgical consequences of induced abortions. Stallworthy, Moolgoaker and Walsh detail the complications of over 1,000 abortions in a teaching hospital in England. They state clearly that abortion as a surgical procedure is neither simple nor safe even when performed in the early weeks.
In summary, it is important to remember that an underlying emotional skew exists among those studying abortion. Because most studies are done by abortion proponents, this emotional skew causes the studies on the therapeutic value to be highly suspect. Thus, good scientific methodology is needed to offset the emotional skew that makes claims of therapeutic value where none exists and understated morbidity, conclusions which are contradicted by counter-abortion efforts and trends in the more experienced countries.
ABORTION STUDIES AND SCIENTIFIC METHODOLOGY
As of this writing, two generalizations are justified: first, abortion studies are generally deficient in research design, sampling techniques and methods of evaluation. Second, abortion data is inadequate for meaningful statistical analysis both in terms of efficacy and adverse consequences. Simon and Senturia described these deficiencies in the 28 major abortion studies conducted prior to 1965, all of which were found repeatedly to suffer from situational research problems that rendered inconclusive the data about the effects of induced abortions.
Little has changed. One recent example is a study by Meyerowitz, Satloff and Romano. Its faults are several and basic. The major defect is obvious from their statement:
"...most of our information is not primarily derived from direct contact with the patient. However, our own experience and the reports of others suggest a poor yield when patients are contacted directly for a follow-up interview or for completion of a questionnaire."
The follow-up information for this study was therefore obtained primarily from the patients' physicians, such second-hand information suggesting that these authors regard hearsay as a basis for valid follow-up. They try to offset this by stating that they "were impressed throughout by the magnitude and detail of the information obtainable from physicians who have followed some of these patients for years since the unwanted pregnancy." One's scientific curiosity is prompted to ask what sort of problems brought these patients into such unusually close contact with their doctors and what the psychological components were of those relationships. Ignoring these questions makes superficiality to be a basic deficiency of this study.
Another factor worthy of note is the lack of reflection of what is implied by the admitted poor yield for follow-up studies. One obvious conclusion is that many women do not want to talk about this supposedly beneficial, emotionally stabilizing surgical procedure. This resistance to talking about it suggests a large amount of psychic energy may be tied up in repressing, suppressing or working through this procedure. Such energy would then be unavailable for more egosyntonic or constructive activity.
Finally, almost one-third of the study's aborted women were lost to follow-up, contrasted to only nine per cent lost to follow-up of those women who were refused abortion and carried to term. It would appear fair to conclude that the incompleteness of the data on those aborted and the hearsay nature of the information obtained both undermine the scientific credibility of this study.
Studies which purport to show the absence of adverse psychological reactions in patients who obtain legal abortions are superficial and nonobjective, regardless of claims to the contrary. For example, Osofsky and Osofsky's immediate postabortion data is obtained by an interviewer who is supposed to provide the aborted woman with emotional support as well as determine mood and, among other things, quantify "smiling." To provide support and be an objective observer may not be irreconcilable tasks, but it would appear obvious that only a double-blind survey could avoid the methodological objections that the interviewer or observer was instrumental in arranging the abortion or providing emotional support after it, was asking leading questions or was conveying subliminal cues to desired responses.
Studies which claim therapeutic value are typified by Ford et al. wherein, among other deficiencies, a woman who had a spontaneous abortion was included in the detailed analysis of women who had induced abortions. The greatest deficiency of all in these studies which claim therapeutic value is the probability that any therapeutic value of abortion is due to a human interactional encounter with other people, rather than to the actual abortion procedure.
THE INDICATIONS FOR ABORTION
Most abortion proponents (at least those not involved in public efforts to promote their cause) admit that elective removal of the fetus is without psychiatric or medical justification. The fetus has not been shown to be a direct cause of any emotional disorder, and present medical capabilities make almost all pregnancies safe. Even Sloane, a proponent of abortion, has candidly clarified the question of indications for abortion:
"There are no clear-cut psychiatric indications for therapeutic abortion. The risk of precipitation or exacerbation of an existing psychosis is small and unpredictable, and suicide is rare... There is no medical indication for a termination of a new pregnancy...."
Recognizing that there is no scientific basis for abortion on psychiatric or medical grounds, he, like many others, would justify abortion on what he calls a key issue of unwillingness to continue the pregnancy. Scientifically, "unwillingness" is neither a diagnosis nor an easily measured variable; it has not been studied, but efforts have produced studies on "unwantedness," which perhaps is close enough.
It is amply documented that parental attitudes such as unwantedness can affect a child, but postpartum parental attitudes cannot be predicted in the prepartum interval. Assessing genuine attitudes is difficult in the first place, and what these attitudes actually mean in terms of actions and outcome is something else again.
Ferreira found evidence of newborn babies' deviancy in the nursery correlating with their mothers have obtained high prepartum scores on a Fear-of-Having-A-Baby Scale but not on a Rejection-of-Pregnancy Scale. He also found no relationship between unplanned pregnancies and newborn deviant behavior; in fact, there were more deviant babies of mothers who had planned their pregnancy than of those who had not. Zemlick and Watson conclusively demonstrated a spontaneous change from prepartum rejection to postpartum acceptance of their children by a group of mothers.
THE DIFFICULTY OF ANALYSIS
Pregnant women, new mothers and newborn infants are in short puzzles which tend to defy hard scientific analysis. However, efforts have been made to study unwantedness. Proponents of abortion typically ignore these studies even though they use unwantedness as a crucial indication for abortion, and they have made many unwarranted and unjustified statements about the conjectured but undocumented adverse effects of an unwanted pregnancy on mother and child. The evidence is rather to the contrary.
An excerpt from the summary of Pohlman's review of the literature on the effects of unwanted conceptions will clarify the situation:
"There is a contention that unwanted conceptions tend to have undesirable effects...the direct evidence of such a relationship is almost completely lacking, except for a few fragments of retrospective evidence....It was the hope of this article to find more convincing systematic research evidence and to give some idea of the amount of relationship between unwanted conception and undesirable effects. This hope has been disappointed."
Of especial interest because it is not included in Pohlman's review is Forssman and Thuwe's study of 120 children born after the mothers' requests for abortion had been refused. This study is popular with abortion proponents, so much so that it has tempted many to misuse it in a most unscientific manner. These 120 children were followed for 21 years, and it was clear that they had been born into a worse situation, with greater risks of social and mental handicaps, than had peer controls. Yet the outcome was far from a disaster. No significant difference was found between subjects and controls in regard to criminal behavior, drunken misconduct, educational subnormality, the number taking university entrance examinations, the number who entered the university, the fitness of the boys for military service and the number married before age 21. Overall, the subject group had a lesser number of individuals who were free from all the defects studied, but this difference was not significant if the subjects were raised by their real parents until age 15. All comparisons, however, pale before the overriding fact that 48.3 per cent, almost half, of the subject group had complete "freedom from defects in all respects studied." While it is not entirely clear what it means to have been "unwanted but unaborted," it seems at least to mean that such an individual has an almost fifty-fifty chance of turning out satisfactorily despite having had to face more than the usual problems in growing up.
How does one account for "unwantedness of pregnancy" being unrelated to later adverse problems? This may be explained by the remarkable finding of Klaus et al. that a sensitive period exists in human mothers shortly after delivery of full-term infants, and contacts between mothers and offspring during this period greatly foster the development of adequate mother-offspring interaction. The researchers found that affectional bonding between mother and child was greatly enhanced by nothing more than exposure of the mother to her child for one hour in the first three hours after birth and also for five extra hours each afternoon of the three days following delivery. The standardization of this early exposure as routine policy for hospitals may have profound mental health-fostering effects and make the concept of unwantedness of pregnancy more irrelevant than it has already been shown to be.
In summary, "unwantedness of pregnancy" is a condition with unknown implications for the future outcome of an unborn child and the mother; it does not carry automatic adverse consequences, and it does not require surgery to be changed. Unwantedness is a symptom that rises from problems in the society and in the parents.
THE REAL PROBLEM
Why does a woman not want her child? Helper et al. have studied the acceptance of pregnancy and life events, and found that a woman has the greatest difficulty in accepting a pregnancy when she faces circumstances that represent a major rejection of the pregnancy by society as a whole or by the father of the child. These observations seem to be confirmed by contemporary circumstances.
First, society as a whole is creating unwantedness in pregnancies by the newest psychosocial disease, population hysteria. This refers to the emotionality and emotional conclusions that accompany population statistics and figures. It is a disease for a number of reasons:
It can be studied in the same manner as any other well-defined social attitude or anti-life syndrome (polio, paranoid schizophrenia or prejudice).
It has certain noxious stimuli that can be identifiable as etiological factors.
It has a primary symptom of misanthropy, which is a psychological tetrad of human antipathy, resistance to unforeseen change, pessimistic preoccupation with present technological difficulties and an inability to trust life. Such misanthropy enables the mental detachment necessary to dehumanize people by enumerating them as if they were nonpersons in much the same manner as the military analysts estimate nuclear war casualties.
It is mediated by the central nervous system's ability to respond by external social rejection as well as by internal biological anxiety.
Its pathogenesis involves environment and object relationships with people.
Population hysteria makes people forget that the world has had population problems as far back as history records; that population has always outrun the technological means to provide for it; and that the eventual solutions of major problems have almost always been unforeseeable for any given generation. But as a psychosocial disease, it is new and appears to have afflicted many persons: scientists, physicians and parents. Its main symptom, misanthropy, is a cause of pregnancies being unwanted and probably has something to do with the willingness of physicians to perform abortions.
The second external circumstance is less characteristically contemporary but more accessible to direct intervention. This is the father's rejection of his unborn child. Certainly no remedy will be found for the father who causes both the pregnancy and the unwantedness unless efforts are made to promote paternal behavior as a way of life for men in society.
Evidence is growing that failures in fathering play a critical role in psychosocial problems. For example, Bigner notes that the father's absence (relative or absolute) produces behavior problems and has deleterious effects on intellectual and personality development. Even when the father is present, paternal behavior has qualitative importance. O'Neal et al. demonstrate how a picture of a generalized antisocial behavior in the father was related to sociopathic personality in the child.
In general, data on fathering is somewhat more firm than data on unwantedness, and helping fathers by paternal training seems a constructive course. Finding men for whom paternal training is warranted (for the benefit of themselves, their partners and their children) would appear relatively simple: find the unwanted pregnancies. Efforts to retrain a father appear at least on the surface to be crucial in solving the fundamental problems that underlie an unwanted pregnancy.
When both society and the father reject a pregnancy, it is little wonder that the potential mother finds it hard not to join in the general negativism, especially when her physician knows of no alternative to abortion.
ALTERNATIVES TO ABORTION
The physician rarely considers the alternatives to abortion when he acquiesces in the gross manipulation of himself that usually underlies such statements as, "If I don't have an abortion, I will kill myself." This sort of situation, in fact, is probably detrimental to the physician, besides being antitherapeutic for the patient, since to be consciously a party to a patient's manipulation represents the worst sort of doctor-patient interaction. What if someone asked for penicillin, a new car or a mammoplasty in the same way, and the physician went along with it? It is not surprising when this patient later denies problems to the physician and perhaps refuses to return. In such cases, the manipulable physician has simply lost his patient's confidence.
MANIPULATIVE EXCLAMATIONS AND UNDERLYING PROBLEMS
To find alternatives to abortion, physicians must look past manipulative exclamations and depressive histrionics; more importantly, they must look beyond unwantedness to its causes. The fact that a pregnancy is unwanted is a symptom of underlying problems that deserve attention. The average physician, however, is ill equipped, both in training and time, to delve into the underlying causes of unwantedness. Misanthropy numbs the senses, making it difficult to say "no" to an abortion request or to communicate positive feelings about pregnancy and help the expectant woman understand why she does not want her child. Finally, the provisions of suggestions for remedy and the enlistment of support from society become time-consuming chores for the busy physician.
Nevertheless, these broad therapeutic measures are feasible. Gordon and Gordon describe how emotional upset after pregnancy may be associated with and proportional to social stress. Helpful in such cases were brief psychotherapy, social assistance and advise with the enlistment of support from others, especially the child's father and an older woman experienced with infants.
Another example of nonsurgical therapy is Babikian and Goldman's description of efforts to develop ego and superego that can be offered to pregnant teenagers by prenatal and postnatal instruction, child care discussions and vocational counseling. Such efforts certainly need not be confined to teenagers nor even limited to mothers-to-be for the involvement of the father may have far-reaching beneficial effects in terms of marital and paternal attitudes.
PREGNANCY AS STRESS
In addition, when the salutary effects of the newborn on the mother are considered, then such group therapy efforts and social assistance would appear to offer more permanent therapeutic efficacy than would a quick abortion with the woman sent back whence she came with little more than contraceptive advice.
Finally, it is helpful to recognize that pregnancy is normally a stressful situation anyway. Bibring and her colleagues feel that pregnancy is a normative crisis similar to puberty. They describe the normal transitory crisis features of pregnancy which were resolved by the salutary effects of presenting a "positive attitude... towards the patient's pregnancy." Pregnancy, they think can be a maturing and growth experience whether the woman is married or unmarried, whether the child is wanted or unwanted and whether society is approving or disapproving. Most important is their finding that women will often respond to the positive attitudes of others towards a pregnancy with positive attitudes of their own.
Emotions, which science as a method is capable of bypassing, have overwhelmed scientists everywhere in their attitudes towards abortion. It is highly questionable that a medical procedure should be accepted without being subjected to the rigors of the scientific method. After looking at the scientific data on abortion, on the lack of therapeutic value and legitimate indications, on unwantedness in pregnancy, on the real underlying problems such as population hysteria and nonpaternal attitudes of fathers and on pregnancy being a normal developmental crisis, it should be obvious that the alternative to abortion is the practice of scientifically sound medicine applied to the whole patient. In order to practice medicine ethically (which means on a scientific basis), the physician will have to learn to say no to an abortion request and to offer psychosocial help to both the mother and father to be.
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