in trying to find common ground, do we hurt abortion rights?
DESCRIPTION
Tracy A Weitz, PhD, MPA Director Advancing New Standard in Reproductive Health (ANSIRH) Bixby Center for Global Reproductive Health University of California, San Francisco January 25, 2010TRANSCRIPT
In trying to find
UCLA
In trying to find common ground,
do we hurtJanuary 25, 2010 do we hurt abortion rights?
Tracy A Weitz, PhD, MPADirectorAdvancing New Standard in Reproductive Health (ANSIRH)Bixby Center for Global Reproductive HealthUniversity of California, San Franciscoy
UCLACommon Ground and Abortion Rights
Today’s Talk
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�Define “common ground” approach to abortion
�Review its development�Discuss the implications of the p
search for common ground on abortion rights
�Offer an alternative approach
October 2009 |
UCLACommon Ground and Abortion Rights
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C G dCommon Ground
Reducing the Need for Abortion / Prevention FirstReducing the Need for Abortion / Prevention FirstMost major pro-choice social movement organizationsObama and the Democratic Leadership
UCLACommon Ground and Abortion Rights
Case Study: NARAL
Weitz 1/25/10 � NARAL, first formed in 1967 as the National Association for the Repeal of Abortion Laws
� With legalization changed its name to the National Abortion Rights Action League in 1973
� In 1993 NARAL changed its name to the National Abortion and Reproductive Rights Action League and launched the "Real Choices" campaign “to highlight thelaunched the Real Choices campaign to highlight the goals of its expanded mission: to preserve access to abortion while working to enact policies to make abortion less necessary”
� In 2003 changed its name to “NARAL Pro-Choice America” � NARAL became a word rather than an acronym,
i th d b ti f it ti lremoving the word abortion from its name entirely� In 2005 NARAL’s work prioritized a “prevention first
campaign” to reduce the need for abortion
UCLACommon Ground and Abortion Rights
Obama and Abortion
Weitz 1/25/10 � Internationally � Removal of Global Gag Rule� Appointment of Hilary Clinton as Sect of State� Appointment of Hilary Clinton as Sect. of State
� Domestically� The search for common ground� Acknowledging the importance of legality� No further expansion of abortion rights� Reducing the need for abortion� Bringing Pro-Choice and Anti-Abortion activists
together to identify places where they agree� Agree to disagree
October 2009 |
UCLACommon Ground and Abortion Rights
Obama’s Statement Commemorating Roe
Weitz 1/25/10"Today we recognize the 37th anniversary of the Supreme
Court decision in Roe v. Wade, which affirms every
fwoman’s fundamental constitutional right to choose
whether to have an abortion, as well as each American’s
right to privacy from government intrusion. I have, and
continue to, support these constitutional rights.”
“I also remain committed to working with people of good
will to prevent unintended pregnancies, support pregnant
women and families, and strengthen the adoption system.”
“T d d d t t i t th t ll“Today and every day, we must strive to ensure that all
women have limitless opportunities to fulfill their dreams.”
Obama, 2010Obama, 2010
UCLACommon Ground and Abortion Rights
Components of the new “Common Ground” agenda
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g
R d i t d d i� Reduce unintended pregnancies� 50 % of all pregnancies in the U.S. are unintended� ½ of all unintended pregnancies end in abortion
� Increase support for adoption� Data on adoptions is poor but somewhere between
1-5% of all unintended pregnancies� Increase support for families
� Low-income women and women of color have higher rates of abortion
� Goal: Reduce the need for abortion
UCLACommon Ground and Abortion Rights
The Underlying Assumptions
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� Decreasing the number of unintended pregnancies
will result in a significant decline in the number of
abortions
� Reducing the number of abortions will somehow g
reduce the social conflict over abortion
� Acknowledging that abortions should be used less� Acknowledging that abortions should be used less
frequently will demonstrate that we take abortion
seriously and thus enhance people’s support for y p p pp
abortion rights
UCLACommon Ground and Abortion Rights
Weitz 1/25/10 Women’s individual desires to avoid an unintended pregnancy is
lit ti l diff t fqualitatively different from a social goal of reducing the need for abortionfor abortion. Helping a woman achieve her reproductive desires is a laudablereproductive desires is a laudable goal, not because it reduces the need for abortion, but because it is what she wants for her life.
UCLACommon Ground and Abortion Rights
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A brief review of the how we got to th “ d” hthe “common ground” approach
UCLACommon Ground and Abortion Rights
1973: Abortion as a social positive
Weitz 1/25/10 � Roe decision articulated as a way for women to shape the course and destiny of their lives
� Seen as central to women’s equality in society� Synonymous with notions of modern feminism� Unqualified support for both the right to and use of
abortion� abortion on demand � abortion without apology
UCLACommon Ground and Abortion Rights
1980’s: Changing the Social Meaning of Abortion
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g
� 1970’s time of growing strength of the anti-abortion movementmovement
� Rise of single issue politics� Election of Ronald Reagan� Administrative restrictions on abortion� Changes in the composition of the Supreme Court
� The “Culture War”� Goal:
� To change the hearts and minds of the American� To change the hearts and minds of the American public
� To make abortion a non-normative practice unworthy of societal approval
� Tactics:� Humanizing the fetus� Vilifying women
Solidifying the relationship between religious� Solidifying the relationship between religious identification and abortion opposition
UCLACommon Ground and Abortion Rights
Understanding Abortion as Violent Social Conflict
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� Rise of direct action� Rise of direct action� Rescues
� Siege on Atlanta� Summer of Mercy� Summer of Mercy
� Clinic defense as a response� Extensive media coverage
� The violent wing� Direct targeting of abortion doctors and clinics� Murders and attempted murders
� Abortion is an angry hostile debate between two sides willing to win at all costs.
UCLACommon Ground and Abortion Rights
Longing for a way out of the war
Weitz 1/25/10 � The introduction of the mantra “abortion should be safe, legal and rare”
� Bill Clinton in 1992 presidential campaign� First day in office, reversed anti-abortion policies of
Reagan and Bush I with the affirmation that his vision was “an America where abortion is safe, legal and rare”rare
� Since introduction in 1990 almost every pro-choice politician has used the phrase� From the left and from the center/right� From the left and from the center/right
� Accepted as the middle ground � USA Today editorial, 2003
Abortion is a “right most Americans want preserved: reproductive choice that makes abortions safe, legal
d ”and rare.”
UCLACommon Ground and Abortion Rights
“Reducing the Need for Abortion” is Next Iteration
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� SLR is still used� Used in conjunction with “Reducing the Need,” which is
the implementation efforts of the sentiment� Core of the current common ground approach
UCLACommon Ground and Abortion Rights
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What’s so wrong about wanting to d th d f b ti ?reduce the need for abortion?
Discounts the role of abortion as a positive force inDiscounts the role of abortion as a positive force in women’s livesIncreases the stigma surrounding abortionProvides the fertile ground for the “abortion hurts women”Provides the fertile ground for the abortion hurts women message of the anti-abortion movementReduces access to careI di itiIncreases disparitiesDoes nothing to reduce the structural factors that produce larger social inequalities in which reproduction is imbedded
UCLACommon Ground and Abortion Rights
Produces a normative judgment about abortion
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� Suggest that abortion is happening more than it should� Separates the “good” and the “bad” abortions
� Those that could have been avoided
UCLACommon Ground and Abortion Rights
Understanding the Contradiction
Weitz 1/25/10Pastor Rick Warren challenge to Obama’s position on
abortion:
“Now, I don't understand the, the idea of it should be rare
and, and less. Well, either you believe it's life or you don't.
It--why would you believe it should be rare? Because if ifIt--why would you believe it should be rare? Because if, if
it's not--if a baby, a fetus is not a life, then why restrict it?”
Meet the Press Nov. 29, 2009,
UCLACommon Ground and Abortion Rights
Creates an understanding that women’s individual decision making
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gis the cause of social conflict
� Which women’s decisions are implicated? � African American women have 5x the abortion rate of
WhitWhite women� Latina women have women have 2x the abortion rate
of White womenW ith i l th 100% f th FPL h� Women with income less than 100% of the FPL have an abortion rate 3.2x as high as those at 200% of the FPL
� Rates for low-income and minority women are not� Rates for low income and minority women are not declining as fast as for higher-income and white women
UCLACommon Ground and Abortion Rights
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Increases stigma and creates theIncreases stigma and creates the fertile ground for acceptance of the new “Abortion Hurts Women” framenew Abortion Hurts Women frame of the Anti-Abortion Movement
UCLACommon Ground and Abortion Rights
Central Arguments
Weitz 1/25/10 � Women are victims of society, men and the abortion industry
� Promotion of restricted laws that prescribe the type and timing of information women receive related to abortion
� Focus is on telling women about the psychological risks of abortion
� Push for formal recognition of Post-Abortion Syndrome (currently not recognized by the American Psychiatric Association)
UCLACommon Ground and Abortion Rights
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Connecting g Personal experience Post-abortion recoveryy Social activism Religion
UCLACommon Ground and Abortion Rights
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UCLACommon Ground and Abortion Rights
Post-Abortion Recovery
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UCLACommon Ground and Abortion Rights
David Reardon
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� Architect of this approach� Founder of Women Exploited by
Abortion (WEBA) in 1982 toAbortion (WEBA) in 1982 to minister to the needs of aborted women and to help them heal their pain.A h f Ab d W Sil N� Author of Aborted Women Silent No More (1987)
� Founder of the Elliott Institute in Springfield IL 1988Springfield, IL, 1988
� Since 1987 –7 books and a dozen articles
UCLACommon Ground and Abortion Rights Goal is to replace Weitz 1/25/10 the fetus with the
guilt-ridden, grief-stricken images ofstricken images of women victimized by abortionby abortion
1996
1987
1996
1997
2002
1997
UCLACommon Ground and Abortion Rights
Using the Apparatus of the Gov’t
Weitz 1/25/10 Anti-abortion Surgeon General
tasked with investigating effects
fof abortion on women
1989 Koop finds insufficient data
to determine that abortion harms womento determine that abortion harms women
Koop’s Conclusion
“The pro-life movement always focused- rightly, I though-p y g y g
on the impact of abortion on the fetus. They lost their
bearings when the approached the issue on the grounds
f th h lth ff t th th ”of the health effect on the mother.”
UCLACommon Ground and Abortion Rights
Supported by the Science
Weitz 1/25/10 � 1990 American Psychological Association (APA) report published in Science:� Exhaustive review of literature� “Women tend to cope successfully and go on with
their lives”� Position of most professional medical associations
� American Psychological Association� American Psychiatric Association� American Public Health Association� American Public Health Association� American Pediatric Association
UCLACommon Ground and Abortion Rights
What do Women Experience?
Weitz 1/25/10 � Most feel relief� Some experience short-term feelings of:
� Anger regret guilt/sadness� Anger, regret, guilt/sadness� Natural emotions to big life decisions
� Rare cases of psychological problems� Best predictor of mental health after an abortion is
mental health before an abortion� No such entity as “post-abortion syndrome”� Conducting this research has many serious
methodological challenges
UCLACommon Ground and Abortion Rights
Significant methodological flaws to research finding harm
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g
� Using data not designed to answer the question� Incorrect comparison groups� Ignoring prior mental health statusg g p� Recall bias� Abortion underreporting� Conflation of association with causation� Conflation of association with causation
UCLACommon Ground and Abortion Rights
Gaining Traction
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UCLACommon Ground and Abortion Rights
Policy Change
Weitz 1/25/10 Texas Information Booklet: “A Woman’s Right to Know”
“You should know that women experience different emotions after an abortion. Some women may feel guilty,emotions after an abortion. Some women may feel guilty, sad, or empty, while others may feel relief that the procedure is over. Some women have reported serious psychological effects after their abortion, including d i i f i t l d lf t tdepression, grief, anxiety, lowered self-esteem, regret, suicidal thoughts and behavior, sexual dysfunction, avoidance of emotional attachment, flashbacks, and substance abuse. These emotions may appear substa ce abuse ese e ot o s ay appeaimmediately after an abortion, or gradually over a longer period of time. These feelings may recur or be felt stronger at the time of another abortion, or a normal birth, or on the
i f th b ti ”anniversary of the abortion”
UCLACommon Ground and Abortion Rights
Validation from the Supreme Court
Weitz 1/25/10“Respect for human life finds an ultimate expression in the
bond of love the mother has for her child....While we find
no reliable data to measure the phenomenon, it seems
unexceptionable to conclude some women come to regret
their choice to abort the infant life they once created and
sustained…Severe depression and loss of esteem can
follow.”
Gonzales v Carhart, 2007
UCLACommon Ground and Abortion Rights
But the Evidence is Still the Same
Weitz 1/25/10 � 2008 APA report� Critical review of recent literature (2006)� “Women who have abortions have no greater risk of� Women who have abortions have no greater risk of
mental-health problems than if they deliver the pregnancy.”
UCLACommon Ground and Abortion Rights But focusing on reducing the need Weitz 1/25/10 for abortion increases the
legitimacy of these arguments at a i t l l lsocietal level
UCLACommon Ground and Abortion Rights
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H #2 N N d f S iHarm #2: No Need for Services
Real implications for access to careReal implications for access to care
UCLACommon Ground and Abortion Rights
Abortion Services Today
Weitz 1/25/10 � Only 1,787 abortion providers (facilities) remained in 2005� Abortion clinics (>50% of patient visits are for abortion
services) provide 71% of all abortions� 87% of U.S. counties have no abortion provider
� 35% of women live in these counties� 97% of counties in nonmetropolitan areas have no
provider� Significant maldistribution across and within states
UCLACommon Ground and Abortion Rights
Declining Number of Abortion Providers
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41% of counties arenow without
an abortion provider
Guttmacher Institute
UCLACommon Ground and Abortion Rights Access in CaliforniaWeitz 1/25/10
Bay Guardian, 10/10/06, Front Cover
UCLACommon Ground and Abortion Rights
No Solution in Common Ground Approach
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pp
� Focus is reducing need not meeting access goals� Further negates mandates for routine training
� Currently less than 50% of Ob/Gyn residency y y yprograms offer routing training
� Only 11 of 480 Family Practice programs acknowledge abortion in the curriculum
� No NP/CNM/PA training programs incorporate
� Limits our ability to critique reductions in accessy q
UCLACommon Ground and Abortion Rights
Further legitimizes efforts to restrict use of abortion
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� 1989/1992 shift from abortion as a fundamental right to “ d b d ” th h lda new “undue burden” threshold
� States allowed to demonstrate a preference against abortion
W iti i d t l i l t d t� Waiting periods, parental involvement, mandatory information, scripted provider speech
� Allowances for misinformation� Breast cancer (6 states)� Breast cancer (6 states)� Fetal pain (8 states)� Mental health consequences (7 states)
UCLACommon Ground and Abortion Rights
South Dakota
Weitz 1/25/10Physician must tell the woman that the abortion will
“terminate the life of a whole, separate, unique, living
human being; that the pregnant woman has an existing
relationship with that unborn human being, and that the
relationship enjoys protection under the United States
Constitution and under the laws of South Dakota; and that
by having an abortion, her existing relationship and her
existing constitutional rights with regards to thatexisting constitutional rights with regards to that
relationship will be terminated.”
UCLACommon Ground and Abortion Rights
Proliferation of Policies to Reduce Use and Provision of Abortion Care
Weitz 1/25/10and Provision of Abortion Care
Targeting the Woman Targeting the ProviderTargeting the Woman
� State-mandated information
Targeting the Provider
� Public facilities and employees exclusionsinformation
� Waiting periods (usually 24-48 hours)
� Two visit minimums
employees exclusions� Broad refusal clauses� TRAP laws
� Two visit minimums� Parental involvement� Funding Restrictions
� Hospital admitting privileges
� Abortion procedure bans� Mandated ultrasound
provision and viewing� Reporting requirements
UCLACommon Ground and Abortion Rights
Impact of Reduced Access
Weitz 1/25/10 � Increases gestational age at which abortions are performed� Medical risk� Costs� Emotional consequences
UCLACommon Ground and Abortion Rights
Timing of Abortion Differences by Race/Ethnicity*
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y y
70%
50%
60%
70%
30%
40%
50%
BlackHispanic
10%
20%
30% HispanicWhite
0%
10%
<8 weeks 9-12 weeks >12 weeks
* Data does not include CA and 3 other states
UCLACommon Ground and Abortion Rights
Timing Differences by Age*
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70%
80%
50%
60%
70%
<1515-19
30%
40%
50% 15 1920-1425-29>30
10%
20%
30% 30
0%
10%
< 8 weeks 9-12 weeks 13-20 weeks >21 weeks
* Data does not include CA and 3 other states
UCLACommon Ground and Abortion Rights
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Two Other Components of the C G d A dCommon Ground Agenda
No federal fundingNo federal fundingAllowances for denials of care
UCLACommon Ground and Abortion Rights
Health Care Compromise
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“I want to clear up - under our plan, no federal dollars will
be used to fund abortions, and federal conscience laws will
remain in place”
(Obama, Joint Session of Congress
on Health Reform, 2009).
UCLACommon Ground and Abortion Rights
State Medicaid Coverage for Abortion
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17 states use state funds for all or most medically necessary abortions17 states use state funds for all or most medically necessary abortions
AK, AZ, CA, CT, HI, IL, MA, MD, MN, MT, NJ, NM, NY, OR, VT, WA, WV.• 4 of these states provide such funds voluntarily•13 of these states do so pursuant to a court order•13 of these states do so pursuant to a court order
UCLACommon Ground and Abortion Rights
North Carolina’s Natural ExperimentsWeitz 1/25/10
� Cook et al, 1999� Examined impact of episodic lack of state funds for
indigent women’s abortions between 1980-1993� Happened at different times of the yearF d d i b i d i i� Found a decrease in abortion rates and an increase in birthrates when funds were not available
� Conclude that 37% of women who obtained an abortion on Medicaid would have continued theabortion on Medicaid would have continued the pregnancy if funds were not available
� 10% more abortions among black women and 1% more among white womeng
� Morgan and Parnell, 2002 added additional administrative variables� Approx 3% of white women and 5% of black women pp
would have carried a pregnancy to term without funding
UCLACommon Ground and Abortion Rights
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Who pays the price f fi di “for finding “common ground”?g
UCLACommon Ground and Abortion Rights
Denials of Information, Referral and Services
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� Refusal clauses, often called “conscience clauses,” in which institutions and individuals are shielded from liability for failing to provide health services, counseling and/or referrals because the individual or institution has an objection to the service; j
� Institutional prohibitions in which institutions override physician-patient decision-making and prohibit the provision of certain services in their facilities, refuse to cover those services in their insurance products orcover those services in their insurance products, or otherwise restrict services that meet evidence-based standards of care; and
� Political restrictions including those laws and regulations� Political restrictions including those laws and regulations that are enacted based on political ideology or electoral politics and mandate how health care must be delivered, where and how it can be delivered, or what care is covered by health care payerscovered by health care payers.
UCLACommon Ground and Abortion Rights
An Exercise of “Conscience”
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Carla who lives in eastern Oklahoma thought she had the flu. Her family doctor referred her to an Ob/Gyn who discovered she was pregnant and that she had a largediscovered she was pregnant and that she had a large mass growing on her uterus. The Ob/Gyn refused to remove the mass because it would endanger the pregnancy. The anesthesiologist in the practice group refused to give her any drugs that would harm therefused to give her any drugs that would harm the pregnancy. At this point the mass was shutting off her colon and bladder. Eventually Carla found a doctor in another city who found that after substantial delay, he had to remo e her ter s a proced re that o ld ha e beento remove her uterus, a procedure that would have been unnecessary if the abortion had been performed earlier in her pregnancy.
Carla was uninsured. Her hospital bill forthe abortion and the hysterectomy was
$40 000over $40,000.
UCLACommon Ground and Abortion Rights
A Snapshot of Institutional Prohibitions on Care
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� 43 states allow health care institutions to refuse to provide services� Only 1 state (California) limits that refusal to religious
health care entitieshealth care entities� Federal level—The Weldon Amendment to the
FY 2005 Appropriations bill limits the ability of federal, state, and local laws to mandate abortion carestate, and local laws to mandate abortion care
UCLACommon Ground and Abortion Rights
Catholic-Owned HealthCare Facilities
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� Broadest religiously-based health care restrictions � Control > 16% of the U.S. hospital beds� Serve 1 in 6 patients in the U.S.
� Governed by the Ethical and Religious Directives for� Governed by the Ethical and Religious Directives for Catholic Health Care Services (ERDs)� Promulgated by the U.S. Conference of Catholic
Bishops� Prohibit abortion, sterilization, contraceptives and
most forms of assisted reproductive technology� Contain no exceptions
� Many patients who seek care or physicians who provide care do not adhere to the beliefs of the Catholic Hierarchy
UCLACommon Ground and Abortion Rights
Example: PROM
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� Premature Rupture of Membranes (PROM)� Amniotic membranes rupture pre-term� Risk: infection sepsis maternal mortality� Risk: infection, sepsis, maternal mortality� < 24 weeks: only 30% fetuses survive� ACOG and AAP standard of care:
balance risk to woman v potential for fetal survival� balance risk to woman v potential for fetal survival� Ob/Gy must counsel about risks and woman must
decide whether to abort or attempt to continue pregnancy
UCLACommon Ground and Abortion Rights
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“And at this point their personal decision-making runs afoul of their hospital’s policies Inducing labor afoul of their hospital s policies. Inducing labor before membranes have ruptured, or before there is a maternal indication such as infection, is technically an abortion This hospital like most hospitals in the an abortion. This hospital, like most hospitals in the metropolitan area in which they live, has a strict non-elective-abortion policy…”
“You might wonder, reading this vignette, how I happen to know so many details about this case, or even whether this is a fictional teaching care that so bedevils medical student. The unfortunate truth is that this is real life: I am the husband in this story ”
Ramesh Raghavan, MD, PhDJAMA, 4/4/07
that this is real life: I am the husband in this story.
UCLACommon Ground and Abortion Rights
Prohibits Willing Doctors from Providing Care
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“I’ll never forget this; it was awful—I had one of my hi i 19 k [P f] hpartners accept this patient at 19 weeks. [Part of] the
pregnancy was in the vagina. It was over…. And so he takes this patient and transferred her to [our] tertiary medical center, which I was just livid about, and, you know, “we’re going to save the pregnancy.” So of course, I’m on call when she gets septic and she’s septic to the point that I’m pushing pressors on labor and delivery trying to keep her blood pressure up and I have her on a cooling blanket because she’s 106 degrees. And I needed to get everything out. And so I put the ultrasound machine on and there was still a heartbeat and [the ethics committee] wouldn’t let me because there was still a heartbeat. This woman is dying before our eyes…She was so sick she was in the ICU for about ten days and very nearly died… “
Freedman, Landy, & Steinauer,, 2008
UCLACommon Ground and Abortion Rights
Low-Income and Minority Women More Vulnerable to Prohibitions
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� Less choice of care providers� Default enrollment� Less capacity to advocate for alternatives� Catholic-owned facilities more likely to be in low-income� Catholic owned facilities more likely to be in low income
communities� Historical providers of charity care
UCLACommon Ground and Abortion Rights
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Does The Frequency of Abortion E M tt ?Even Matter?
UCLACommon Ground and Abortion Rights
Examples to the Contrary
Weitz 1/25/10 � Dr. Tiller
� South Dakota� South Dakota
� California parental consent
� Perhaps the best argument for abortion is its commonness� 1.2 million abortions per year� 1 in 3 women by age 45
UCLACommon Ground and Abortion Rights
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So is there room for any “common d”?ground”?
Common ground is different from common purposeCommon ground is different from common purposeDone without the expectation that it will depolarize the abortion debate in this countryImportant goals in their own right and not because theyImportant goals in their own right and not because they offer us a solution to the abortion wars
i.e. reducing poverty, increasing self-efficacy, etc.H lth f d b t t ht i f l lHealth care reform debate taught us a painful lesson
Support for prevention did not translate unto support for abortion
Shifti th ti f b ti t UPShifting the stigma from abortion to UP
UCLACommon Ground and Abortion Rights
Alternative Approach
Weitz 1/25/10 � Acceptance that abortion is a polarizing issue in the U.S.
� Acceptance that abortion has and will always be part of the human condition� Internationally abortion is common even where it is
highly restricted� Difference is safety and social validation of the
decision� Engage in the hard conversations about abortion
� Moral status of life� Rights and autonomy of women� Right of the state to limit decisionsg� Role of religion in public life
UCLACommon Ground and Abortion Rights
What Do We Value?
Weitz 1/25/10 � Women deserve the legal right to abortion� Women deserve to have an abortion(s) without
judgment� Women deserve high quality accessible and culturally
appropriate abortion care
U f t t l th h fUnfortunately the search for common ground moves us further away from achieving each of these objectivesachieving each of these objectives.