Morality and the Abortion Provider
"Sad but necessary." "A woman has the right to control her body." "Safe, legal and rare." "On demand, without apology." "Reproductive rights are human rights." "Who decides - you or them?
The above represent some of the numerous ways, past and present, that advocates in the reproductive rights movement have tried to talk about abortion. This attempt to find the most persuasive language or "frame" has, of course, been going on a long time - indeed, since the period of the Roe v Wade decision in 1973 - but has taken on new urgency in light of the recent setbacks to providing legal abortion in the United States.
This editorial was written in the early spring of 2006, with the Democratic party still reeling from its losses in the United States 2004 election and with some influential party officials blaming these losses on the albatross of the party's support for abortion (and gay rights.). Since the election, John Roberts and Samuel Alito, two conservative judges with antiabortion records, have been placed on the United States Supreme Court. The newly configured court has agreed to revisit the so-called Partial Birth Abortion case; South Dakota has passed a near total ban on abortion in the hope that this legislation will be the ultimate vehicle to overturn Roe v Wade, and several other states are considering similar action.
Given this current crisis, there is no question that such discussions of language, message and frame are extremely important. But it is striking to me, as one who studies the front lines of abortion provision and who occasionally participates in advocates' attempts at finding more effective language, what a disconnect there is between these two worlds. I have noted that there is relatively little knowledge within many sectors of the advocacy community as to what actually transpires everyday in clinics and offices that provide abortion care. And providers, as a rule, do not take part in such strategy sessions.
I believe that this absence of the provider's voice is unfortunate and costly to the movement as a whole. The current turmoil within the abortion rights movement over issues of "morality" and, particularly, the status of the fetus provide a prime example of this disconnect.
This topic initially came to prominence through a recent provocative and much-discussed article, "Is there Life after Roe? How to think about the fetus" by Francess Kissling,1 the founder of Catholics for a Free Choice. Kissling's basic point in her article was that the prochoice movement is fixated on "rights" and has conceded all discussions of morality to opponents of abortion. She accused the abortion rights movement of fearing "complexity" and questioned "whether or not regular exposure to the taking of life in abortion or the defense of a right to choose abortion would, if not addressed, lead to a coarsening of attitude toward fetal life." She went on to decry "(t)he inability of prochoice leaders to give any specific examples of ways in which respect for fetal life can be demonstrated ...."
Having spent many years observing abortion care and having interviewed hundreds of providers, I can say with some assuredness that those who work in these settings are not "coarsened toward fetal life" and that there exists countless examples of the kind of "respect for fetal life" that Kissling claims is missing in the movement. For example, consider this case posted on a listserve for abortion providers by Dr. M, a family practice doctor who has integrated abortion care into her office practice:
I had such a sad patient come in today for an abortion. She'd come in a week ago but was so tearful we could hardly talk, so I asked her to come back after thinking some more ..." [After more counseling and discussion of options, including adoption, the patient decided to proceed with the abortion]. "She asked me if she could have the pregnancy. I thought it might help her to see that it was only a tiny sac, so I washed it off and brought it back to her ... I gave it to her in a jar ... she wanted to put it in the - River, at a place she knew that felt special to her. I told her I thought a goodbye ritual like that would help her move on. We had a long long hug before she left.
This story of honoring the abortion recipient's wish to acknowledge the fetus is matched by numerous others I have heard over the years. In some facilities, such as the Women's Care Clinic in Wichita, KS, where abortions of advanced gestational age are performed, many for fetal anomalies, a chaplain is available and mourning parents are often able to hold the blanketed fetus in their arms for a private farewell. Other abortion clinic staff have told me of participating in impromptu religious ceremonies with patients. Nearly all abortion-providing facilities with which I am familiar will show the patient fetal remains if she asks to see them.
In an online discussion of the perennially complex issue of what terminology to use in abortion care - "fetus," "products of conception," "the pregnancy" and, a term used by some clients but avoided by some providers, "the baby" - Pat, an administrator of a Midwest clinic, argued for using the term used by patients, even if it made providers uncomfortable.
Patients who have a wanted pregnancy and lose it, or choose abortions because of fetal anomalies, always call it "the baby." It is a baby to them, developed or not .... Some women never "connect" to the pregnancy, for them, it is nothing like a baby. It is just there, they want it removed. They would hate the word "baby" and do not use it. I have also seen women somewhere in the middle. Our job is to meet the woman where she is and provide her with accurate information. I do not feel it is my job to correct her terminology as long as she has a thorough understanding of the facts.
Such an example of "meeting the woman where she is at" is seen in the practice of Dr. M, for whom the gratifications of abortion care are matched with those of aiding women with a wanted pregnancy. For example, a short time after the incident described above of helping her patient through a difficult abortion, Dr. M also shared with her colleagues her joy at being able to provide in-office ultrasonography for a patient who experienced some bleeding and feared she was having a miscarriage. The patient's husband and 5-year-old child were able to accompany her during this office visit. (Dr M had an ultrasound in her office because of her recent incorporation of abortion care. Had this machine not been available in her office, the patient would have had to wait for some time to be scheduled for an ultrasound at an off-site facility).
"We did the sonogram .... The sono showed a small embryo, with the visible flicker of the fetal heart.... Everyone was overjoyed. Hugs all around. She wants me to do her prenatal care and it was all in all one of those happy family medicine moments. One that I could make possible because of my abortion training!"
As these examples (and equally heartfelt hugs) make clear, the worldview that prevails in the world of reproductive health facilities that include abortion is one that is steeped in sensitivity and nuance. Above all, there is a recognition of the inappropriateness of a "one size fits all" approach to pregnant patients. Some pregnancies are desperately wanted, and the clinician shares in the exhilaration of the patient. Some pregnancies are not at all wanted, and the clinician accepts that no one is better entitled than the woman herself to decide what to do about this pregnancy.
Nevertheless, this commitment to an individualized approach to patients makes it admittedly difficult to translate the lessons of frontline abortion provision to the larger political arena, and especially to convey a coherent message on "morality." How does one extract the "soundbites" that our current political culture demands from a world in which each case is treated uniquely, and the woman is "met where she is at?" For example, some advocates like to answer the antiabortionists' charges of immorality by arguing women approach having their abortions mindfully, showing some evidence of "moral reasoning" - but while seemingly true of most women, providers know this is not the case for all women. Similarly, while abortion providers fervently believe in the necessity of legal abortion, they also fervently believe that preventing unwanted pregnancies in the first place with use of effective contraception is preferable. The standard of care in abortion facilities is to initiate a discussion of birth control with the patient at the time of her abortion. While most patients appear receptive to this, not all are.
Some issues - and abortion is one of them - do not easily lend themselves to soundbites. The fact is that the world of abortion is too mired in the complicated real world lives of women to be able to match the abstract moral absolutes of opponents of abortions. But there is still a powerful lesson to be learned from providers. To end with words that I wrote some years ago about clinicians and counselors who work in the fields of abortion and contraception: "... the most important contribution that [reproductive health workers] have to offer the larger society is a moral standpoint that is nuanced enough to recognize the necessity of accepting people as they are, even while one simultaneously struggles to create a better society. Such a moral vision without moralism is the only viable foundation for the humane regulation of sexuality".2
Carole Joffe, PhD Department of Sociology University of California, Davis Davis, CA
Wayne C. Shields President and CEO Association of Reproductive Health Professionals Washington, DC
Kissling F. Is there life after Roe? How to think about the fetus. Conscience, winter 2004-2005. Available at
Joffe C. The regulation of sexuality: experiences of family planning workers in Philadelphia. Temple University Press; 1986;p. 166.