Abortion Care as Moral Work: Ethical Considerations of Maternal and Fetal Bodies

Introduction

Providing Abortion Care

Women of all backgrounds have experienced unwanted pregnancies, and many of them sought an abortion even when the procedure was illegal. In 1966, journalist Lawrence Lader investigated the consequences of illegal abortion. In the mid-1950s, estimates of the number of illegal abortions ranged anywhere from 200,000 to 1.2 million a year. Among urban White, educated women, one-fifth to one-fourth of all pregnancies ended in abortion, but only about 8,000 abortions annually took place inside a hospital, constituting a fraction of the number of abortions performed each year.¹ Women without resources, Lader noted, were forced to enter a world of underground abortions where care was frequently humiliating and the procedures dangerous. Its practitioners, preying mainly on poor and ignorant women, rarely have a medical degree, Lader cautioned—many had occupations as clerks, barbers, and salesmen.² Before the mid-1960s, the estimated mortality rate from illegal abortion stood at 1,000 to 8,000 deaths per year. Almost 80 percent of all abortion deaths occurred among non-White women.³ Women with resources could visit a skilled abortion provider or travel to foreign locations for abortions; those without were the most likely to die of a botched abortion.

On January 22, 1973, the U.S. Supreme Court legalized abortion with its Roe v. Wade and Doe v. Bolton decisions.⁴ The decisions overturned nearly all state abortion regulations existing at the time and expanded the fundamental right of privacy to include abortion. With the legalization of abortion and the simultaneous introduction of vacuum aspiration machines to perform first trimester abortions, a previously clandestine and dangerous procedure became safe, quick, and inexpensive almost overnight. As Americans witnessed the emergence of a growing network of abortion clinics, abortions that had previously been invisible, performed behind the curtains of private physicians’ offices or secretly by underground providers, became visible. The number of legal abortions climbed from 744,610 in 1973 to over a million in 1975, while the estimated number of illegal abortions declined.

These developments had a dramatic impact on abortion mortality. The mortality rate due to abortion had hovered between sixty and eighty deaths per 100,000 cases in the decades prior to legalization, but it sank to 1.3 by 1976–1977. Legal abortion before sixteen weeks’ gestation, the authors of a study on morbidity and mortality of abortion concluded, had become safer than any other alternative available to the pregnant woman, including continued pregnancy and childbirth.⁵

Many physicians interested in providing abortions had cared for women suffering from the complications of illegal abortion and had seen their patients die. They recalled their despair as they tried to save women’s lives before they bled to death or died of overwhelming infections. We had a ward of patients who we admitted during the weekend, one physician remembers of his time as an obstetrics and gynecology (ob-gyn) intern and resident. You’d go up there and it would smell. They’d have a tomato soup discharge. I remember one patient and as fast as we’d put the blood in, it would run and fill up your shoes.⁶ In addition, many physicians had been frustrated with a system in which women with money and connections could obtain a safe abortion from their private physicians while women without such resources ended up in the emergency department with complications from illegal procedures. The poor pulled the innards out or got soap shot up inside them, a St. Louis physician commented.⁷ Now these physicians hoped to establish services that offered safe and affordable abortions to all women.

And many of the women who found their way into the emerging field of legal abortion in the early 1970s had themselves experienced an illegal abortion, participated in underground abortion services while abortion was illegal, referred others to those services, or had friends or relatives with such experiences. Inspired by the emerging women’s movement and frustrated with traditional medical care, which they viewed as patriarchal and paternalistic, they looked to the field of abortion care as an opportunity to shape a more feminist future in medicine. Both groups came together in the early 1970s to establish a new system of abortion care. At times uneasy allies—male physicians found young feminist women challenging and demanding while young women found male physicians patronizing and dismissive of their concerns—they nevertheless negotiated over different aspects of abortion care and established a broad network of abortion clinics that influences abortion services to this very day.⁸

The very ease and speed with which patients gained access to abortions after legalization was tied to the invention of vacuum aspiration. Vacuum aspiration machines, imported in the late 1960s from England, shaped the emerging field of abortion care and meant that the procedure became a simple and safe outpatient procedure. In the course of the mid-1970s, a diverse group of physicians, feminists, and business people established freestanding abortion clinics to cater to women who could now access the legal procedure. The number of physicians performing legal abortions climbed by 76 percent, from 1,550 in 1973 to 2,734 in 1979.⁹ It also led to the emergence of freestanding clinics. In 1973, of 1,550 providers who performed more than five abortions per year, 81 percent practiced in a hospital setting and 19 percent in a nonhospital setting. By 1979, of 2,734 abortion providers, 57 percent practiced in a hospital setting and 43 percent practiced in a nonhospital setting.¹⁰

The most widely used method of terminating second trimester abortions in the early 1970s was saline instillation in which the physician withdrew amniotic fluid and replaced it with a concentrated salt solution, leading to miscarriage within 24 to 36 hours. However, saline abortions could be performed only after the sixteenth week of pregnancy, when the uterine cavity contained enough amniotic fluid to allow for the procedure. In the 1970s, this left a window of four weeks during which women were usually unable to terminate unwanted pregnancies. By the end of the decade, however, abortion providers had begun to turn to dilation and evacuation (D&E), in which the fetus is removed, generally in parts, through the cervix and vagina.

Following the 1977 establishment of the National Abortion Federation (NAF), which provided abortion providers and clinic staff with a forum for support and information exchange, abortion providers turned their attention to the development and refinement of abortion procedures. Over the next decade they created a scientific discourse surrounding pregnancy termination procedures that included the comparison of different procedures and the development of support systems and counseling techniques for patients and clinic staff. NAF began to sponsor continuing education seminars to encourage abortion providers to switch from instillation procedures to D&E and to develop supportive services for abortion providers and staff involved in D&E procedures.

What kind of abortion services women were to receive and how they experienced legal abortion depended not only on the kind of abortion provider a woman visited but also on the philosophical orientation and organizational structures that shaped abortion services inside the clinic walls. The legalization of abortion and opening of abortion clinics had a profound impact on women seeking to control their reproduction, many of whom had had experiences with illegal abortion. Patients were grateful to have access to legal and safe abortion services, and their responses were overwhelmingly positive. The demand for services resulted in an explosive growth of clinics. By 1980, many clinics had grown from new offices with a small staff to large clinics that offered a wide variety of services and served an increasing number of patients.

But with the legalization of abortion, the country also saw the emergence of an antiabortion movement and almost immediate attempts to reverse the Roe decision. In April 1974, fifteen months after the legalization of abortion, Assistant District Attorney Newman Flanagan charged Boston ob-gyn resident Kenneth Edelin with manslaughter for performing a hysterotomy, a second trimester abortion procedure akin to a cesarean delivery. Critics held that the charges were racially motivated—Edelin was African American—and represented an attempt by the Boston Catholic community to undo the gains made under Roe v. Wade. Indeed, the Edelin case became the first test case surrounding legal abortion. The trial juxtaposed two very different narratives of abortion. The prosecution charged that Edelin’s action had killed a live baby. Edelin’s defense attorney contended that Edelin had performed a medical procedure that was sanctioned by good medical practice and the law.¹¹

Seeking to establish the fetus as a person, antiabortion activists constructed narratives that described the fetal experience of abortion and fetal death. As the antiabortion movement emerged in the early 1970s, antiabortion activists also began to disseminate fetal images. Combined with the fetal narratives, the images took center stage in the unfolding debate, drawing attention away from the pregnant woman and transforming the fetus into a baby. By 1975, these modern views of the fetus contributed to a jury verdict where feelings about an image trumped scientific understanding: after the prosecution in the Edelin trial introduced images of the fetus, Edelin was found guilty, although the judge later overturned his conviction.

Antiabortion activists spent the late 1970s and 1980s creating increasingly gruesome abortion narratives. The narratives described the abortion procedure as a heinous process that caused agony for the woman and an agonizing death for the fetus. They positioned the fetus as a baby who was being killed and the pregnant woman as a murderer. They produced a body of propaganda that was disseminated via prolife newsletters and magazines and in educational materials distributed on picket lines and at crisis pregnancy centers. The materials tapped into a store of narratives stretching back to the pre-Roe era that depicted abortion providers as greedy and unscrupulous murderers and women who chose to have an abortion as irresponsible and mentally deranged. Fetal images became a mainstay on picket lines and at marches. Protestors regularly brought preserved fetuses to antiabortion protests to confront women with the fetal bodies. These materials proved crucial to the recruitment of antiabortion activists, many of whom joined the movement in the 1980s after viewing the images and movies produced in the 1970s. And they served as a rallying cry to a growing number of militant antiabortion protestors who hoped to garner publicity and to provoke public action that might further discredit abortion.

Even as antiabortion narratives of pregnancy terminations were depicting abortion procedures in increasingly violent terms, protestors were escalating their aggressive strategies to intimidate patients and clinic staff. The picket lines in front of abortion clinics had been relatively small in the 1970s, but during the following decade they gradually grew, reaching into the hundreds after the rise of a new antiabortion group focused on direct action tactics: Operation Rescue founded by Randall Terry in 1986. Unlike their largely peaceful predecessors, demonstrators of the 1980s aggressively approached clinic staff and patients; armed with posters, plastic fetuses, and specimens in jars, they frequently screamed at patients and family members. They fetishized the fetus and systematically escalated antiabortion tactics.

In the early 1980s, antiabortion activists in Chicago developed a protest activity they termed sidewalk counseling. Initiated to present abortion patients with information that would make them change their minds before they entered the abortion clinic, the strategy won prominence with the publication of Joseph Scheidler’s 1985 book Closed: 99 Ways to Stop Abortion. Scheidler was an antiabortion leader who emerged in Chicago in the early 1980s; he was the executive director of Friends for Life and the founder of the Pro-Life Action League, a national antiabortion group based in Chicago. In the very first chapter of his book, Scheidler described sidewalk counseling as

the single most valuable activity that a pro-life person can engage in.… Counseling goes to the very heart of the abortion problem. The problem of abortion is the problem of killing babies. They are killed in abortion clinics or hospitals or doctor’s offices and pro-lifers go there to intercede for the baby’s life. The aim of the Pro Life Action League and other activists groups is to get more people out on the streets to stand between the killers and the victims.¹²

Such counseling was urgent—Schneider compared it to trying to physically stop someone who has rushed into your living room to kidnap your three-year-old child—and, he claimed, it was effective. In one thirty-day period, he insisted in his book, half a dozen sidewalk counselors at a few clinics had been able to stop ninety women from having abortions. While Schadler noted that the sidewalk counselor had to know something about human nature to understand why a woman might decide to have an abortion, he emphasized there was no one right way to engage in sidewalk counseling.¹³

By the middle of the 1980s, the line between sidewalk counseling and regular protest activities became impossible to draw. Encouraged to think of the rescue of a fetus as equivalent to the rescue of a baby or toddler, some sidewalk counselors did anything they could think of to discourage women from entering the clinic. They blocked clinic entrances, yelled at women seeking to enter clinics, and attempted to show women dead fetuses. We feel that it’s important to visualize and to educate and inform people, said Reverend Norman Stone, who regularly traveled with fetal remains to abortion clinics, at a 1985 demonstration in St. Louis. So, sometimes it takes this kind of demonstration to make that point.¹⁴ Antiabortion activists regularly intimidated women, trying to scare them away from the clinic. They started yelling at people to get their attention. They said hateful, hurtful things to people, a Planned Parenthood staff member recalled.¹⁵ One sidewalk counselor explained to a couple he had intercepted how God looked at abortion: Women who reject his gift, his children, he makes them barren, because women have become sterile out of abortion. That’s obvious, that happens all the time. He added, directed to the woman, "I just want to let you know that the consequences of your decision is [sic], before God you have now become a murderer."¹⁶

Protestors harassed patients, clinic staff, and abortion providers. They blocked entrances in an attempt to dissuade patients and employees from entering clinics, and they followed them into the building. They wrote down patients’ license plate numbers to contact them later, followed the patients home, or just showed up at the patients’ homes. Antiabortion activists terrorized the abortion providers day and night. They threatened staff, waited for abortion providers at airports, followed providers in their cars as they traveled to and from work, and showed up at the homes of clinic administrators and abortion providers. Protestors built human barriers to block access to clinics and to prevent abortion providers from leaving their homes. They physically accosted administrators and abortion providers. Employees and abortion providers regularly received hate mail and harassing phone calls at both their clinics and their private residencies. Protestors leafleted abortion providers’ home communities with Wanted for Murder posters and terrorized the providers themselves by sending daily letters describing how they would be tortured and killed.¹⁷

Along with sidewalk counseling, antiabortion activists also turned to the establishment of crisis pregnancy centers (CPCs) to educate women about the dangers of abortion and discourage them from terminating a pregnancy. Established to provide pregnancy options counseling in the early 1970s, these centers significantly increased in number in the early 1980s when antiabortion activists intensified their efforts to reach out to women seeking abortions. One estimate notes that at the end of 1984 there were at least 2,100 CPCs around the country, many of them established by conservative Christian foundations. They attracted potential patients with the promise of free walk-in pregnancy tests. During a thirty-minute wait for the test results, a staff member would show the woman a film or narrated slide presentation detailing the horrors of legal abortion. The CPC staff members drew on antiabortion narratives of women who now regretted their abortions and told stories of fetal death to convey the alleged dangers of abortion and scare clients away from abortion clinics. Narratives of agonizing pain and death—for the fetus and the pregnant woman—were a central part of this information.

CPCs sought to confuse women who were looking for an abortion clinic, and they were most likely to attract young women who found themselves pregnant for the first time. Most of these young women were determined not to let their parents find out that they were pregnant, and many of them sought an abortion alone or with the help of a boyfriend or girlfriend. Scared and intimidated by what lay ahead, they were an easy target for CPCs. They frequently did not realize that they had gone to the wrong place, failed to recognize that the counseling at CPCs was biased, and were too shy to just leave the fake clinic if they recognized their mistake. If patients were still determined to end their pregnancies after these scare tactics, the CPC staff tried to mislead and delay them by sending them to appointments with various prolife counselors and physicians.¹⁸ Indeed, delaying the procedure until women could no longer obtain a first trimester abortion was a common tactic at CPCs. Staff at CPCs also called women who had been to their clinic at their homes and sent clergy to their homes in hopes of changing their minds. Not only did experiences with CPCs leave these patients extremely disturbed, their emotional condition after visiting a CPC increased their risk of abortion complications.¹⁹

On March 10, 1993, antiabortion activist Michael F. Griffin shot and killed abortion provider David Gunn outside Pensacola Women’s Medical Services in Pensacola, Florida. The news of Gunn’s death shocked the abortion provider community. The killing of David Gunn led to an immediate escalation of personally targeted harassment and violence against abortion providers. That year, antiabortion violence spiked with two murders or attempted murders, thirteen bombings, arsons, or attempted arsons, and 415 incidences of clinic invasions, assaults, vandalism, death threats, burglaries, and stalking.²⁰ The following year, antiabortion protestor Paul Hill murdered Dr. John Britton and his bodyguard James Barrett, and John Salvi killed two receptionists at Planned Parenthood clinics in Brookline, Massachusetts. Seven others were wounded in the 1994 attacks.²¹ Since then, at least eleven people have been killed, including four doctors, two clinic employees, a security guard, a police officer, a clinic escort, and two civilians.

By the 1990s, the escalation of antiabortion protests and the protestors’ increasing use of violence had significantly stigmatized and isolated providers and clinic staff. The number of physicians willing to provide abortions had declined significantly. From a high in 1982, when the country counted 2,908 abortion providers, the number fell to 2,582 in 1988 and to 2,434 by 1991— a 16 percent decline in less than a decade. In the 1990s, the decline was even more drastic: 1,819 providers remained by 2000, a 37 percent decline from 1982.²² With the decline in providers, it also became more difficult for patients to access abortion services. This was further aggravated by legislators’ attempts to increase the barriers to women’s access to abortion.

Indeed, the Roe v. Wade decision also signified the beginning rather than the end of a protracted legislative and legal battle over access to abortion. As the antiabortion movement gained strength, activists set out to eliminate funding for abortion services, overturn the Roe v. Wade decision, and restrict women’s access to the procedure. In 1976, antiabortion legislators in the U.S. House and Senate passed the Hyde Amendment, which restricted federal funding for abortion. As early as 1974, Missouri and Ohio legislators tried to impose a range of restrictions on abortion, including parental consent requirements for minors, a husband’s consent to his wife’s abortion, a ban on second trimester saline abortions, a twenty-four-hour waiting period, and hospitalization requirements for second trimester abortions. While in 1976, the Supreme Court struck down the Missouri and Ohio restrictions, by the late 1980s, the U.S. Supreme Court shifted away from its refusal to allow state-imposed restrictions to abortion and embraced a new vision in which states could now express an interest in fetal life. In the 1989 Webster v. Reproductive Health Services decision, the Supreme Court allowed states to second-guess physicians by imposing specific directions and restrictions on abortion services.²³ The shift away from physician authority to a stronger role of state legislatures in the performance of abortion was further strengthened in a 1992 decision, Planned Parenthood of Southeastern Pennsylvania v. Casey.²⁴ States wishing to impose abortion restrictions now simply had to demonstrate that the burden imposed on women’s access to abortion was not undue—that is, placed no substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus.²⁵ In Casey, the justices permitted abortion barriers that the Supreme Court had found unconstitutional in previous cases: a twenty-four-hour waiting period, state-mandated counseling, parental consent for minors, and a reporting requirement. The court also began to treat women as a group who needed to be protected from their own choices. Over the following years, Supreme Court justices further expanded the restrictions on abortion. Most significantly, the 2007 Gonzales v. Carhart decision upheld the first ban on a particular abortion procedure—intact D&E or the so-called partial birth abortion procedure—without granting an exception to women’s health or