The Medical Realities

   A sound approach to the ethics of abortion must be grounded in the scientific and medical facts. The facts of prenatal development are indispensable for determining when human life begins. When those facts are known, it remains for the ethicist, the physician, the legislator, and society at large to interpret their moral and legal implications. Many of the questions that arise from the abortion controversy are directly related to medical practice: under what conditions, if any, is abortion necessary to save the life of the mother: Under what conditions, if any, would abortion be indicated on the grounds of mental health? What methods of abortion are used in America today, and what medical hazards are associated with these methods? These and other related questions are central to the contemporary abortion debate.

The Facts of Prenatal Development [1]

   Any discussion of abortion that ignores the facts of prenatal development in incomplete. The unborn child, after all, is a

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central figure in the abortion controversy. His or her moral and legal status depends on a careful examination of the process of prenatal development.

   It is most unfortunate that scientific facts known for decades or longer have been quietly ignored by many proponents of abortion. Arguments that the unborn child is simply "part of the woman's body," or that human life does not begin at conception do not accord with the well-established scientific facts. Even medical authorities personally sympathetic to abortion acknowledge that. An editorial in California Medicine, the official journal of the California Medical Association, makes this clear:

The process of eroding the old ethic and substituting the new has already begun. It may be seen most clearly in changing attitudes toward human abortion. In defiance of the long held Western ethic of intrinsic and equal value for every human life regardless of its stage, condition, or status, abortion is becoming acceptable by society as moral, right, and even necessary. . . . since the old ethic has not been fully displaced it has been necessary to separate the idea of abortion from the idea of killing, which continues to be socially abhorrent. The result has been a curious avoidance of the scientific fact, which everyone really knows, that human life begins at conception and is continuous whether intra- or extra-uterine until death. The very considerable semantic gymnastics which are required to rationalize abortion as anything but taking a human life would be ludicrous if they were not often put forth under socially impeccable auspices. It is suggested that this schizophrenic sort of subterfuge is necessary because while a new ethic is being accepted the old one has not yet been rejected. [2]

The inevitable distortions caused by passion and prejudice make it all the more imperative to keep the scientific facts clearly in focus.

   It is a well-established fact that a genetically distinct human being is brought into existence at conception. During intercourse, some 300,000,000 sperm are deposited in the vagina and begin a journey upwards through the uterus and into the Fallopian tube leading from the uterus toward the ovary. If an ovum has been released from the ovary, it passes from the ovary down the Fallopian tube towards the uterus. The survival time of the unfertilized egg is

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thought to be approximately 24 hours. Both sperm and egg will die if fertilization does not occur within that time period. The newly fertilized egg, called a zygote, contains the hereditary characteristics of both mother and father, one half from each, derived from the DNA material, the genetic thread of life.

   The newly fertilized egg contains a staggering amount of genetic information, sufficient to control the individual's growth and development for an entire lifetime. A single thread of DNA from a human cell contains information equivalent to a library of one thousand volumes, or six hundred thousand printed pages with five hundred words on a page. The genetic information stored in the new individual at conception is the equivalent of fifty times the amount of information contained in the Encyclopedia Britannica. [3]

   There is an important qualitative difference between the fertilized and unfertilized human ovum. Neither sperm nor egg has any capacity for independent life, and both will die unless they participate in the fertilization process. Once fertilization has taken place, the zygote is its own entity, genetically distinct from both mother and father. The newly conceived individual possesses all the necessary information for a self-directed development and will proceed to grow in the usual human fashion, given time and nourishment. It is simply untrue that the unborn child is merely "part of the mother's body." In addition to being genetically distinct from the time of conception, the unborn possesses separate circulatory, nervous, and endocrine systems. Likewise, it is misleading to speak about the newly conceived as "potential" human life. Prior to conception the sperm and egg represent only the potentiality of a new human life, but once fertilization has taken place, an actual human life has begun. More accurately, the newly conceived individual is an actual life with great potential.

   After fertilization the zygote divides first into two cells, then four, then eight, and so on, at a rate of almost one division per day. It is now known that during this earliest stage of development the mass of cells may divide into identical parts forming identical twins. Such "twinning" may occur until the fourteenth day, though it is relatively uncommon, occurring in only one out of about 300 births. During these first several days it is also possible for twins or triplets

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to be recombined into a single individual. It thus appears that during the earliest stages of prenatal development, for at least a small fraction of zygotes, irreversible individuality may not be present. The moral implications of this eventuality will be considered later.

   After the first six or seven days of cell division, which takes place in the Fallopian tube, the new human life enters the uterus and implants itself in the uterine lining. This is often called the "blastocyst" stage. One pole of the growing sphere of cells, called the trophoblast, penetrates the uterine lining and develops into the placenta. The other pole develops as the embryonic human being. It is worth noting here that the placenta is an extension of the child's body, not the mother's. The part of the developing blastocyst that becomes the placenta produces hormones, which enter the mother's bloodstream and prevent the onset of menstruation. This hormonal signal sent to the mother's body from the newly conceived life is essential for its survival, since otherwise the new life would be sloughed away by the menstrual flow. Even at this early stage it is the newly conceived individual, rather than the mother, that takes the initiative in effecting crucial physiological changes. The newly conceived human being is far from passive in the development process. The mother provides an environment for the unborn child, but the child's hormonal system has an active influence on changes in that environment. [4]

   After two weeks of development the name of the new human life is changed from zygote to embryo. Blood cells are formed by 17 days, and a rudimentary heart as early as 18 days. The embryonic heart, beginning as a simple tube, shows irregular pulsations at 24 days and approximately one week later exhibits rhythmic contraction and expansion.

   The development of the nervous system also begins at approximately the eighteenth day. By the twenty-first day the foundations of the child's brain, spinal cord, nerves, and sense organs are completely formed. Six weeks after conception the nervous system is so well developed that it controls the movements of the child's muscles, though the woman may not yet even be aware that she is pregnant.

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   By the end of the sixth week, all the internal signs of the unborn child are present, though yet in a rudimentary form. The brain is sending out impulses, which coordinate the functions of the other bodily organs. Reflex responses are present at 42 days, and brain waves have been noted at 43 days. The blood vessels leading from the heart are fully deployed and continue to grow in size. The stomach is producing digestive juices, and the kidneys are beginning to function by extracting uric acid from the child's blood.

   By the end of the seventh week, the child will flex his neck if the mouth and nose are tickled with a hair. By this time the ears are also formed and may show the specific features of a family pattern. At about this time the name is changed from embryo to fetus (Latin, "young one or offspring").[5] By now the fingers and toes are fully recognizable. Lines in the hands and fingerprints begin to appear at eight weeks and remain a distinctive characteristic of the individual. Between the ninth and tenth weeks local reflexes such as swallowing, squinting, and tongue retraction begin to appear. If the child's forehead is touched, he may turn his head away and pucker up and frown. By now the child can bend the wrist and elbow independently and has the full use of his arms. By this time the entire body is sensitive to touch and is also capable of spontaneous movement. Thumb sucking has been observed by the eleventh week, and x-rays will disclose clear details of the skeleton.

   By the twelfth week, the child is swallowing regularly and can move his thumb in opposition to his fingers. The child, three and one half inches long by the end of the twelfth week, will have a complete brain structure, which will of course continue to grow. At this time, as Arnold Gesell has stated, the unborn child "is a sentient moving being. We need not pause to speculate as to the nature of his psychic attributes, but we may assert that the organization of his psychosomatic self is now well under way." [6]

   By this time, the child is active and the reflexes are more pronounced. Muscular response is no longer mechanical and irregular, but now graceful and fluid. This motion is present prior to "quickening," when the mother first notices the child's movements, which generally occurs between weeks 12 and 16, although some women feel very little movement as late as 20 weeks. It should be clearly

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understood that the time of "quickening," long considered important in the law, represents a mother's subjective perception, and not an objective point at which "animation" occurs or the first "signs of life" appear. As Dr. Albert W. Liley, a widely recognized authority in fetal medicine, has stated:

Historically, "quickening" was supposed to delineate the time when the fetus became an independent human being possessed of a soul. Now, however, we know that while he may have been too small to make his motions felt, the unborn baby is active and independent long before his mother feels him. Quickening is a maternal sensitivity and depends on the mother's own fat, the position of the placenta and the size and strength of the unborn child. Quickening is hardly an objective basis for making a decision about the existence or the value of the life of the unborn child. [7]

   The child grows very rapidly between the twelfth and sixteenth weeks. He has grown to eight or ten inches in height, and his weight increases sixfold. At some point between the sixteenth and twentieth week it becomes possible to hear the child's heartbeat with a simple stethoscope, as well as by the refined EKG apparatus. By the end of the fifth month, the child weighs approximately one pound and will be about 12 inches long. Fine baby hair has begun to grow on his head and a fringe of eyelashes is beginning to appear. The skeleton is hardening, and the mother can feel the child's head, arms, and legs. After the twentieth week it is customary to speak of a premature delivery rather than of a spontaneous abortion.

   By the twenty-eighth week, the child weighs slightly over two pounds, and some definitions of "viability" are fixed at this point. This, however, is only an approximation. According to Dr. Andre Hellegers of Georgetown University, 10 percent of children born between 20 and 24 weeks gestation will survive.[8] The development of an artificial placenta would push the date of viability back into the earliest stages of gestation. Modern techniques of intensive therapy are able to save premature babies that would have been considered non-viable only a few years ago.

   The progress of prenatal medicine has made it increasingly clear that the unborn child possesses a distinct individuality. As Dr.

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Arnold Gesell has noted:

Our own repeated observation of a large group of fetal infants. . . left us with no doubt that psychologically they were individuals. Just as no two looked alike, so no two behaved precisely alike. . . . These were genuine individual differences, already prophetic of the diversity which distinguishes the human family. [9]

   The unborn child is no mere "mass of tissue," but a distinctly individualized human being with a characteristic pattern of behavior. Medical advances have also eliminated the artificial distinction between prenatal and postnatal human life. Dr. H.M. Liley explains:

In assessing fetal health, the doctor now watches changes in maternal function very carefully, for he has learned that it is actually the mother who is a passive carrier, while the fetus is very largely in charge of the pregnancy. [10]

Pregnancy involves the medical care of two patients, not one. The unborn child is not a passive partner, but rather in many ways controls the dynamics of the pregnancy. This new perception of the unborn child has led to the development of a whole new medical specialty called perinatology, which cares for its patients from conception to about one year of postnatal existence. For the modern physician, human life begins at conception, and medical care and observation must start at the earliest period of life.

Techniques of Abortion

   There are four common methods of abortion:[11] dilation and curettage ("D&C"); intrauterine injection of hypertonic saline solution ("salting out"); hysterotomy; and prostaglandin infusion. None of these techniques is without risk to the mother.

   Dilation and curettage is the technique most commonly used in first trimester abortions. The cervical muscle ring is first paralyzed and then stretched open. A curette, a loop-shaped steel knife, is then inserted into the uterus. The surgeon then scrapes the uterine wall, dismembering the developing child and scraping the placenta

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from its attachment on the wall of the uterus. Bleeding is usually profuse. A common first-trimester alternative is a vacuum aspiration or suction abortion. The principle is the same as the D & C. After the cervix has been stretched, a powerful suction tube is inserted into the uterus. The body of the developing child and the placenta are sucked into a jar, where smaller parts of the child's body are often still recognizable.

  Even these early, first trimester abortions are not without significant hazards to the woman's health. In a study of 1182 legal abortions at an English teaching hospital, nearly 17 percent of the patients lost more than 500 milliliters of blood and 9.5 percent required transfusions. There were also cases of cervical laceration and perforated uteruses.[12] Another study concluded that perforation of the uterus is an almost inevitable complication of induced abortion by vacuum aspiration or during any other form of dilation and curettage.[13] Even so-called "menstrual extractions" or "lunch hour" abortions performed by vacuum aspiration within one to three weeks after failure to menstruate have been attended with complications: the woman's not being pregnant, the implanted ovum's being missed by the suction curette, and uterine perforation. [14]

   Second trimester abortions are often by salt poisoning. A long needle is inserted through the abdomen and a solution of concentrated salt is injected directly into the amniotic sac. The child breathes in the salt solution and is poisoned by it. The concentrated saline solution burns off the outer layer of the baby's skin and brain hemorrhages are frequent. It takes about one hour for the child to slowly die by this method. Approximately one day later the woman goes into labor and delivers a dead baby.

   The salt poisoning technique is common in the United States in spite of its well-documented hazards. It was used by the Japanese after World War II but later abandoned because of maternal morbidity and mortality.[15] Maternal deaths have been reported from accidental injection of the saline solution into the circulatory system, from acute kidney failure, from seepage through uterine puncture wounds into the abdominal cavity, and from infections.[16] Other documented complications of saline abortions include fevers, cervical lacerations, serious disruptions of the blood coagulation

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mechanism, and hemorrhages. [17]

   If the pregnancy is too advanced for the D & C or salting out procedures, a hysterotomy abortion may be performed. The techniques for a hysterotomy abortion are similar to those for a caesarean section, except that the incisions made in the abdomen and uterus are smaller. Having been removed from the uterus, the child is laid aside to die from neglect. This procedure is even more hazardous for the woman than the salting out procedure. The potential for accidental rupture during subsequent pregnancies is also appreciable, especially during labor. [18]

   More recently the drugs prostaglandin E₂ and prostaglandin F_2a have been widely investigated as abortifacients. These drugs artificially induce labor and may be administered orally, intravenously, by vaginal suppositories, or by direct injection into the amniotic sac. Although usually too small to survive, the child is frequently born alive. Thus far prostaglandin abortions have produced a number of significant complications. In one study 30 percent of the women undergoing prostaglandin abortions experienced vomiting.[19] Other problems encountered with prostaglandin abortions include incomplete evacuation of the uterus, hemorrhages, infections, and cervical lacerations. [20]

   The findings of the English study cited earlier accept the overall medical risks of induced abortions:

The morbidity and fatal potential of criminal abortion is accepted widely, while at the same time the public is misled into believing that legal abortion is a trivial incident even a lunch-hour procedure, which can be used as a mere extension of contraceptive practice. There has been almost a conspiracy of silence in declaring its risks. Unfortunately, because of the emotional reactions to legal abortion, well-documented evidence from countries with a vast experience of it receives little attention in either the medical or lay press. This is medically indefensible when patients suffer as a result. [21]

The well-documented medical evidence shows that induced abortion is far from a simple and hazard-free operation. There has been a dangerous silence concerning the risks of abortion not only in England but also in America. It is high time this silence be broken.

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Indications for Abortion

   Later in this volume we will discuss the problems of rape and potential birth defects as possible indications for induced abortion. Here the discussion will focus on psychiatric problems and specific physical conditions during pregnancy that might be thought to constitute a threat to the physical health of the mother.

   During the last two decades there has been a marked increase in the number of abortions performed on psychiatric grounds. Prior to the 1973 Supreme Court abortion decisions 90 percent of abortions in Oregon were performed on such grounds. It is likely, however, that many abortions aimed at preventing "grave impairments to mental health" were in fact subterfuges for other social problems and personal inconveniences. Competent psychiatric opinion is agreed that there are no known psychiatric diseases that can be cured by abortion; further, there are none that can be predictably improved by abortion.[22] Nor are there any clear-cut psychiatric indications for abortion. According to the standard psychiatric textbook of Noyes and Kolb, experience shows that pregnancy and childbirth do not adversely influence the course of schizophrenias, manic-depressive illnesses, or the majority of psychoneuroses.[23] With appropriate treatment, depressive psychoses carry a good prognosis whether or not the pregnancy is interrupted.[24]

   Threats of suicide are frequently presented as psychiatric indications for abortion. But as Sloane has pointed out,

Although the risk of suicide is perhaps the most frequently used psychiatric indication for therapeutic abortion, there is almost unanimous agreement that it is extremely rare. Hook in her follow-up study of nearly 300 women could not find a single one who had either committed or attempted suicide during the pregnancy. [25]

The suicide rate among pregnant women in fact appears to be one-sixth the rate among non-pregnant women of the same age. [26]

   The experience of one British medical social worker indicates that easy accession to abortion on psychological grounds may in fact be a grave disservice to the woman:

....the woman's feeling that she cannot tolerate bringing a

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child into the world may be a symptom of a situation such as an inability to cope with married life, and by making abortion too readily available we do little but relieve the patient's immediate suffering for a short time and thus do her no real service, producing in her a sense of guilt which she can redress only by becoming pregnant again as quickly as possible. . . . When talking to the parents of these unborn children one must at all times be aware that what may at first seem to be an uncompromising attitude may swing around to a complete reversal of the original rejection. [27]

Experience shows that maternal attitudes can change, and unwanted conceptions very often produce wanted children. Psychiatric problems, then, rarely if ever justify abortion. On the contrary, such problems call for the proper mental health care and emotional and spiritual support needed by pregnant women in difficult circumstances.

   But are there physical conditions that might constitute valid indications for abortion? According to one recent authority, there are in general "very few absolute contraindications to pregnancy and even these are gradually disappearing with modern medical advances."[28] As a result of these advances, it is now extremely rare for any pregnancy to be so hazardous to a woman as to necessitate abortion. Pregnancy, labor, and delivery, if properly managed, have no deleterious effects upon a pregnant woman suffering from tuberculosis.[29] Organic heart disease occurs in only one or two percent of pregnant women, and only about one in ten of these is serious enough even to consider an induced abortion.[30] Pregnant women suffering from diabetes or kidney disorders can, with very few exceptions, be brought safely to term.[31] A few diseases, such as rheumatoid arthritis, are actually improved during pregnancy.[32] Given this favorable outlook for pregnant women with medical complications, it is not surprising that a study reported to the World Health Organization found that, even in the permissive contemporary abortion climate, patients who had abortions on medical grounds formed only four to six percent of most reported series.[33] It is likely that, had optimal medical care been available, the latter figures would have been even lower.

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   Admittedly, there are those tragic situations, fortunately rare, where induced abortion may be necessary to save the life of the mother. Two such circumstances involve an ectopic (tubal) pregnancy and a cancerous uterus. Without intervention in such cases, both mother and child may perish. The motive for surgical intervention is not to end the child's life but to save the life that has some reasonable chance of survival, i.e., the mother's. The death of the child is a secondary result of the lifesaving intervention. Given present medical technology, the unborn in such circumstances have little or no chance of survival. But with new medical advances, which will hasten viability, such tragic dilemmas should be even less frequent, if not eliminated.

Complications of Induced Abortion

   The most serious complication of induced abortion is, of course, the death of the mother. Proponents of abortion cite data from Eastern European countries and the United States to the effect that abortion is "x-times as safe as childbirth." The limitations of such an argument have been pointed out by other writers.[34] For example, maternal deaths related to abortion may simply go unreported or, if reported, may be attributed to other causes. That would artificially deflate the actual maternal death rate. Moreover, isolating attention on maternal mortality rates overlooks two other very important considerations, namely, the death of the unborn child, and nonfatal injuries to the woman. Two individuals, not one, are at risk in an abortion, the child being subject to direct assault. And furthermore, evidence from many countries around the world indicates that women in America are not being fully informed about the long-term hazards of what has become our nation's most common surgical procedure.

   As we have already noted, a study of 1182 abortions performed in an English teaching hospital showed that nearly 17 percent of the patients lost more than 500 milliliters of blood and 9.5 percent required blood transfusions. Other women suffered cervical lacerations, perforated uteruses, peritonitis, and septicaemia. [35]

   Studies performed in Greece indicate a clear connection between

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induced abortion and subsequent stillbirths, premature births, and sterility. One study was made of 13,242 women who were admitted for delivery over a two-year period at hospitals in Athens. Of the 8,312 women whose pregnancy was not the first, 29 percent admitted to one or more induced abortions. Among that group, the average number of abortions was two. The percentage of premature births and stillbirths among the women with previous abortions, spontaneous or induced, doubled that of the control group.[36] Another study conducted in Athens carefully matched the women surveyed with a control group of similar age, socioeconomic background, and previous childbearing history. The researchers found that the relative risk of subsequent sterility among women with at least one induced abortion and no spontaneous abortions was 3.4 times that among women without any induced or spontaneous abortions. The study concluded that in Greece about 45 percent of the cases of secondary infertility may be attributed to previous induced abortions. [37]

   A study conducted in the Hebrew University-Hadassah Medical School in Jerusalem examined the effects of induced abortion on the outcome of subsequent pregnancies. Of 11,057 pregnant women interviewed in West Jerusalem, the 752 women who disclosed one or more induced abortions in the past were more likely to report bleeding in each of the first three months of their current pregnancies. They were also less likely to have a normal delivery, and more of them needed a manual removal of the placenta or other obstetrical intervention during the final stage of labor. Increases were found in major and minor birth defects. There was a significant increase in the incidence of low birthweights. [38]

   Physicians from Eastern European nations such as Yugoslavia, Czechoslovakia, and Hungary, where abortion has been legal for many years, are now calling attention to the significant complications arising from permissive abortion policies. According to J. Jurukovski and L. Sukarov, in Hungary the rate of premature births is 11 to 12 percent overall, rising to 15 percent in towns. "There seems little doubt that there is a true relationship between the high incidence of induced abortion and prematurity," according to these researchers.[39] They also conclude that the total incidence of complications

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following induced abortions is considerably higher than usually reported, probably on the order of ten percent.[40] Alfred Kotasek, a Czechoslovakian researcher studying the effects of induced abortion in his own country, found that acute inflammatory complications occurred in about five percent of the cases. Other complications, including chronic inflammation of the genital organs, sterility, and tubal pregnancies, were registered in about 20 to 30 percent of all women having induced abortions. Also observed was a high incidence of cervical incompetence, increasing the risks of miscarriage during future pregnancies.[41] These disturbing findings by Eastern European investigators are reflected in the conclusions drawn by Yugoslavian physicians after a study of over 80,000 abortions performed in that country:

In the light of our long experience . . . we must conclude that even in cases of legal abortions, despite improvements in abortion techniques, the woman suffers both physically and emotionally. This is the overriding medical and ethical consideration which for us completely resolves the choice between legal abortion and contraception." [42]

Thus far, these somber warnings have gone largely unheeded in the United States. Neither the mass media nor the American medical establishment has properly publicized the documented hazards of abortion. As a result, growing numbers of American women now having abortions, many of them unmarried teenagers, may soon awaken to the tragic discovery that they have impaired their health and their childbearing capacities in the process.

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