The women behind ideological debates about abortion

My patient was veiled in layers of heavy black cloth from head to toe. I could see blood staining her white socks as I waited impatiently for a female Arabic translator. Slowly, I told the patient and her sister that I was worried about her pregnancy, and would need to do a pelvic exam. As feared, I soon saw that she had a miscarriage. “Can I see the baby?” she said, gesturing to the container I discreetly covered with a clean towel. “We need to take him home for burial,” the sister added. I hesitated. A 12-week fetus wasn’t an easy image to prepare someone for. I laid it on clean gauze and explained, “It’s very early. It won’t look like a baby.” My patient nodded and held out her hand. At the sight of it, she shrieked, then clutched the fetus to her chest and began to pray.

Later that day, I saw another patient in the ER, again bleeding vaginally. She had taken a pill from the corner bodega to “make her period come down.” She got scared when the bleeding started and came to the hospital. The patient did not look me in the eye while she spoke. Sure enough, my ultrasound examination revealed a healthy-appearing 12-week fetus. Sharing this observation with her, she finally admitted, “My husband just lost his job. We already have 3 kids.” I told her if she wanted, he could come in and we could all talk together. She gratefully accepted. I counseled them extensively on their options and where they can safely follow-up, whatever their final decision.

It’s all in a day’s work for an OB/GYN to sit with couples devastated by lost pregnancies; or lay out the decision-making process for a pregnant woman with newly diagnosed cancer; or listen to a distraught patient confessing that she just can’t have a 7th baby but her husband won’t let her use contraception; or admonish a young lady requesting her 5th abortion because she thinks birth control will make her fat.

Whenever I see ideological debates about abortion in the media, I remember these real women. I find myself wrestling with paradigm shifts, engaging in the arduous task of putting myself in my patients’ shoes. In one instance, no maternal sacrifice would be too great to save a pre-viable fetus. In another, self-preservation trumps bringing new life into the world. I don’t always succeed in empathizing with my patients. Sometimes, I am dismayed by their arguments. Often, I balk at pleas that I lie to their families on their behalf.

What I have learned from my patients is that violent protesters, graphic descriptions, or philosophical discussions about when a fetus becomes a person don’t sway their decisions. Whether or not they can articulate their moral, cultural, or religious beliefs, they already follow some internal creed that brought them to my doorstep. They came seeking a doctor, a counselor to guide them through a difficult, confusing choice because they have been inundated with political sound bites, folklore, and patriarchy. What they need are facts and a confidential, nonjudgmental space to work out their apprehensions about pregnancy and motherhood.

What about the fetus though? Who protects him? I won’t pretend to have the wisdom to argue the fine points of those existential questions with you. My internal compass leads me to focus on treating my patients with as much compassion as I can muster. I think about John Rawl’s veil of ignorance: to create a just society, you need to presume that you don’t know what your status will be in it, whether you will be rich or poor, powerful or weak, someone who will one day need an abortion or not. Unbiased, you are free to devise policies that are good, just, and beneficial for society.

To date, I have yet to meet a pregnant patient, faced with the tangled web of voluntary and involuntary reasons to continue or end a pregnancy, who didn’t take a good look in the mirror and ask herself what she can live with. I can usually see in her body language, the hunger for certainty, the fleeting shame, or the hardened resolve. She alone carries the lifelong burden of her decision. Only she can appreciate the intricate calculus of the costs and benefits at stake. As a doctor, I get to decide if I will add to her pain or start her healing right away.

I believe it is my duty to meet my patients wherever they are, and alleviate their suffering. My personal comfort is not in play, but my ability to counsel without judgment is. Issues of morality, after all, should be imbued with equal parts rigor and grace. Holding on to this simple truth is what helps me sleep at night.

Eijean Wu is an obstetrician-gynecologist who blogs at The Messy and can be reached on Twitter @eijeanMD.

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  • http://twitter.com/moving4wellness Bobby Fernandez

    Very poignant piece. I think that we should consider all possibilities and scenarios as experienced by both the mother, father and OB/GYN. They should factor in to our policy decisions but only to a certain extent. Experts in any given field obviously have much to contribute to any conversation about policy however they should not be the final voice in the debate. If it were up to your local fire cheif, all classroom doors would remain closed at all times so that it is easier to contain any fires that may occur. The expert’s job is to know this sort of detail from experience but the society must consider the cost of such expert advice. If we heeded the fire cheif’s warning, our children would all be sitting in sweltering heat all day (or the school would run the air conditioning non-stop) in order to account for a very rare and unlikely scenario.

  • Anonymous

    Thanks for being a part of the discussion, Bobby. I’m a big believer in multidisciplinary partnerships. We need all sorts of experiences and perspectives and intuitions to deal with these tough issues in our society. As you said, “experts” are only a piece of the puzzle.

  • Anything Can Happen

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    A:link { so-language: zxx Dr. Eijean Wu, if you think being an OB/GYN is only about women you are mistaken. You could have a male patient get pregnant because it's already happened in Britain.

    There was a court ruling in Wisconsin that a father could no longer procreate. Can you imagine if courts ruled against women procreating?

    A mother can give up a child for adoption without telling the father and afterwards the father could be denied custody of his biological child. How would mothers feel if fathers could give up a child for adoption without her permission?

    It's common in Britain for women have abortions because they didn't want holidays spoiled by pregnancy. Reproduction isn't simple today Dr. Wu.

    “The Wisconsin Supreme Court ruled he could no longer procreate until he proves he can support kids.”
    http://www.askmen.com/top_10/dating/top-10-anti-male-court-rulings_9.html

    “Putative Father Registry law”
    http://www.askmen.com/top_10/dating/top-10-anti-male-court-rulings_7.html

    “Britain's first 'male mother': I want to live as a normal father”
    http://www.telegraph.co.uk/health/healthnews/9091472/Britains-first-male-mother-I-want-to-live-as-a-normal-father.html

    “Pregnant women have asked for terminations because they did not want their holidays spoilt”
    http://www.telegraph.co.uk/health/women_shealth/9100838/Pregnant-women-have-asked-for-terminations-because-they-did-not-want-their-holidays-spoilt.htmlDr. Eijean Wu, if you think being an OB/GYN is only about women you are mistaken. You could have a male patient get pregnant because it's already happened in Britain.

    There was a court ruling in Wisconsin that a father could no longer procreate. Can you imagine if courts ruled against women procreating?

    A mother can give up a child for adoption without telling the father and afterward the father could be denied custody of his biological child. How would mothers feel if fathers could give up children for adoption without their permission?

    It's common in Britain for women have abortions because they didn't want holidays spoiled by pregnancy. Reproduction isn't simple today Dr. Wu.

    “The Wisconsin Supreme Court ruled he could no longer procreate until he proves he can support kids.”
    http://www.askmen.com/top_10/dating/top-10-anti-male-court-rulings_9.html

    “Putative Father Registry law”
    http://www.askmen.com/top_10/dating/top-10-anti-male-court-rulings_7.html

    “Britain's first 'male mother': I want to live as a normal father”
    http://www.telegraph.co.uk/health/healthnews/9091472/Britains-first-male-mother-I-want-to-live-as-a-normal-father.html

    “Pregnant women have asked for terminations because they did not want their holidays spoilt”
    http://www.telegraph.co.uk/health/women_shealth/9100838/Pregnant-women-have-asked-for-terminations-because-they-did-not-want-their-holidays-spoilt.html

    • Anonymous

      Thanks for sharing your thoughts. When I was choosing a specialty, I ended up in OBGYN actually because I wanted to grapple with the challenging dynamics – moral, political, emotional, clinical etc. – of “women’s health” (I use _health_ to refer to the overall well-being of my patient, not just the medical aspect). While the actual patients I’m responsible for are women, I am often reminded that my patients are intimately connected to partners, families, friends, and communities. All this comes into play even in much simpler health decisions (as compared to what I discussed in this post). I can only speak from my direct experiences, but there are many others more qualified to voice the stories you have touched on. The human existence is very rich. I feel privileged to participate daily on a small level.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

       I know I’ve had the occasional woman with a half-dozen abortions, really
      using the procedure as birth control. Why, I have no idea, the
      contraception would be free. I offer the contraception, they refuse.

      Is it rare, yes, but its, not zero. I have to imagine a full-time OB/GYN
      practice would see more of this than a primary care practice.

      The Telegraph article cited above, it’s important to understand that the UK does NOT have abortion on demand. Two doctors have to sign off on a medical indication. Anyone asking for an abortion for convenience in the UK is violating their own Abortion Act.

      Now in reality, yes, the law is observed in the breach. Effectively, there is abortion on demand in the UK (they call it abortion on request), though abortion on demand/request is actually illegal by the letter of the law. They basically just ignore the law.

      Can you imagine that in the USA, with so many overlapping jurisdictions?

      Then, the Telegraph article mentions the Europeans (the Council of Europe) is considering the prohibition of sex determination of a fetus, to prevent sex selection abortions by certain cultural groups.

      Is it society’s business to regulate abortion in any way? No way? A 39 week pregnancy? A perfectly healthy girl? Abortion Number Seven ’cause she won’t use birth control (saw it myself).

      Many European countries regulate abortion in ways many would consider perfectly reasonable. Accepting the reality that some may feel differently on the matter. Here’s a compendium on European rules:
      http://news.bbc.co.uk/2/hi/6235557.stm

      Any legislator who tried to impose the rules the Germans have, the Brits, the Finns, the French, etc., would be pilloried in the USA press as misogynistic.

      Actually, IMHO, I hope Roe is overturned some day. The matter returns to the states. My state allowed abortion prior to Roe, so no change in my state. Then let the matter get settled out in the states.

      Yes, some states will heavily restrict abortion. Same way Portugal did at one time, as did the Irish. The Dutch outfitted a ship to sail off the Irish and Portuguese coast, offering the procedure at sea.
      http://news.bbc.co.uk/2/hi/europe/3592718.stm

      Finally the Portuguese liberalized their law, to me a surprising liberalization for a Catholic country, but they did it.

      Bring it to the states, the red states will find out they’re not as red as they think they are, and the blue states have a lot of Catholic ethnics who still have a problem with it. I predict in the end, it would be a good fix, custom fit to the states, and I bet no more than a tiny number of states would ban…….and those states barely offer it now. We’d end up with something fairly close to what we have now, only without the complaint that it was imposed by the courts, and harder for that rogue legislator to impose silly rules (the “shaming room” as the Doonesbury cartoon called it).

      • Anything Can Happen

        The European rules on abortion are interesting and thank you for the links. I have read about Dutch abortion ships before and the Dutch also have euthanasia ships.

  • Anonymous

    The very last person to be making rules about women’s health and reproductive rights are men. Men have no business in these matters. Male doctors “think” they know everything about everything. For once, maybe male doctors should shut up and allow female doctors some room to help their female patients make such decisions. If you ask me, there is only one reason men decide to go into the OB/GYN field. Get my drift?

    • Anything Can Happen

      The same reasoning could be applied to any medical professional that catheterizes or gives an enema to a patient of the opposite sex or a patient of the same sex. Get my drift? Lesbians go into the OB/GYN field. If boundaries are kept there shouldn’t be a problem.
      Women have equality with men in politics and they make rules that apply to other women. Women could cut funding for reproductive services or pass rules prohibiting procreation.

  • Anonymous

    Thank you. We have names and faces and stories.

  • http://twitter.com/DoctorViv Vivian von Gruenigen

    Nicely done.  You are a true advocate.

  • Anonymous

    Thank you for putting your patients first and your kindness and compassion. Until you have lived in someone’s “shoes” you have no idea what their life is like. Healthcare professionals are here to care for and  comfort their patients, not to judge. For all of those anti-choice folks who are Christians, “judge not lest ye be judged” is a quote you should take to heart.

  • Anonymous

    Thank you so much for your compassionate perspective. I believe that abortion is a private issue, not political. In theory, I think it is murder, but in reality, well, it is whatever is in your reality. I could never do it, but I would never stop you from doing it.

    Doc, you are a prolific writer. If you ever decide to leave medicine (if the ACA becomes reality) you can always be a writer!

  • Anonymous

    i’m amused that you clearly consider yourself nonjudgmental but use words like admonish and young lady (pretty condescending, both) because of a health belief.  substitute the word cancer for fat and see how that description re-reads.  do you know for sure that birth control won’t make her fat?  do you think her age group is bombarded by messages from your profession about the terror of obesity?  your empathy is pretty good overall but really hit a wall with that patient.

    • http://www.facebook.com/quartermoonranch Katie Moon

       Admonish is correct. Putting her life and future fertility on the line. Abortion as birth control isn’t sensible or cost effective.

    • Anonymous

      First, I am one of the most pro-choice people you will ever meet, however, I do agree that women should be informed about their decisions.  I’m not talking about required ultrasounds or legislation, but if a “young woman” (and I am one myself and see nothing offensive about this term) has had several abortions when she could be using a safer form of birth control, her doctor does need to make a decision about whether or not she understands the risks. This is an issue that belongs between a woman and her doctor, and if someone has successfully made their way through an undergraduate degree, a medical degree, residency and landed a job at an educational medical facility, I think I trust his or her best judgment to decide when to have a conversation about the risks.

      • Anonymous

        Yes! Much safer, more effective and inexpensive birth control and much more comprehensive birth control counseling that is also inexpensive. Both of which seem to allude the few and the loud Tea Party neanderthals in our society. It seems some red state members in the Congress would rather keep women barefoot, pregnant, in the kitchen and most of all, silent. 

  • Anonymous

    The value of one life is equal to the value of all life. When the value of one life is diminished, the value of all life is diminished.

    A person having decisions made for them is a child or a slave. When a state, by force of law, will make an abort birth decision for a female, she is diminished, the value of her life is diminished, all of life is diminished. 

    For a right to exist, choice must exist. Remove the right to abort and the right to give birth is forfeit. Birth is now a mandate, no longer a right.

    This universe has given each of us the exclusive use of the body which we operate. A zygote, embryo, fetus and I must obtain permission to use the body of a female.

  • Anonymous

    Thanks for the comments and discussion! What I hoped is to share real stories and give my current perspective, something that continues to evolve as I learn more and the scientific literature changes. I’m not sure doctors can ever pretend to be nonjudgmental. What we can strive to be is compassionate, professional, and fully committed to putting our patients first. Afterall, no human relationship, especially anything intimate and private as a doctor-patient relationship can be, is ever straightforward. Standard of care in OBGYN does not include using abortion as birth control, and the latest available data does not show that birth control pills increase weight. On other matters, I have been wrong before and I’ve found patients to be very forgiving actually, and am grateful for it. 

    • Anything Can Happen

      I don’t know how anyone can feel like they have an intimate and private relationship with a doctor after a 7 minute appointment. Physician assistants, nurse practitioners, nurses, technicians and insurance companies are already involved and soon our government will also be involved in this intimate and private relationship.
      How much time do you spend with a woman before doing an abortion?

      • Anonymous

        You bring up a very good point and something hotly debated among my colleagues. Time pressure is a serious problem in building a meaningful doctor-patient relationship. Having continuity of care is key because it means more encounters to get to know a patient. Seeing patients does sometimes feel like speed-dating, but I am also frequently amazed by the connection that can occur in a short time.

        I work at an academic medical center, so I have the luxury of spending 30-60 minutes per patient, depending on the complexity of the situation. Sometimes, people are just there for a minor problem or prescription refill, which takes less than 5 minutes. It eventually evens out through the day, though I am often apologizing to patients for being delayed. My mentor has built a solid practice of patients who are ok with sometimes needing to wait, knowing that they will always have full attention and time needed. Not all patients would be happy with this sort of practice.

        • A. Marina Fournier

          When I see someone of any profession or customer service relationship taking time to help someone in front of me, I choose to be patient so that they may give me the same thoroughness of help, should I need it.

  • Anonymous

    The cultural perception of women rely on their ability to produce healthy offspring.  Thus, marginalizing the health of women who have no control over their bodies.  By the way, the veil of ignorance as used by the philosopher, John Rawls, refers to a fictional society of healthy individuals.  The introduction of health as a social good was first introduced by the philosopher Norman Danniels. 

  • Anonymous

    In case you didn’t notice, Republicans all across America are waging war against women. State legislatures that are under GOP control have taken their November 2010 promise to focus on strictly economic issues and have turned that focus off of the economy and are now going after women’s health and a woman’s reproductive rights. Lawyers and politicians are now pushing their way into the privacy of the bedroom and the privacy of the doctor’s office. Some states have enacted laws to force women to endure unwanted and unnecessary vaginal ultrasound probes. Some states are considering laws to force women to tell their employer if they are taking birth control pills and for what reason. This is the Republican Party of 2012. This is the party of Abraham Lincoln. This is the party that claims to defend constitutional freedom and liberty. Yet, Republicans are forcing women to have unwanted medical procedures and also forcing them to pay for those unwanted medical procedures? Republicans are forcing women to share their private medical history with an employer? How outrageous is that? Neanderthals! So, where is the outrage from doctors and other providers in the medical industry? How come medical professionals are so quiet about these outrageous attacks on women? As usual, nothing but a bunch of wimps and cowards!

    • eijeanMD

      Thank you for posting this! I wrote a blog post a couple of weeks ago on this issue (http://the-messy.blogspot.com/2012/02/my-two-cents.html). I wish I could say that you are wrong, but doctors are often too silent about important issues that are directly relevant to our daily work. There is a debate happening within the medical literature about whether or not doctors should remain objective, scientific voices in the media. Some say we need to stay out of politics and focus on medicine; others say it looks ridiculous to stay on the sidelines during such times. There are also lots of discussions in my hospital among providers – doctors, nurses, physicians assistants, social workers, etc. I know a number of physicians who have spoken out on local media, joined protests, contacted elected officials, and/or are working actively with advocacy groups. The most well-known doctor’s voices on TV, i.e. Dr. Oz, Dr. Sanjay Gupta, don’t specialize in women’s health, so I don’t expect them to be key voices on contraception and reproductive rights. There have been a number of blog posts on KevinMD.com about this, which has broad reach. I don’t know many doctors that use Twitter as a discussion forum. I do believe that we doctors need to organize better and make our voices heard…and then *do* something. We have to find a way to balance our responsibilities to directly care for patients, with patient advocacy.

      Of note, Ron Paul was actually an obstetrician-gynecologist, and has made some statements against the contraception mandate. If and when doctors do speak up more, there will be viewpoints across the political spectrum, and it is hard to tell at this time where the majority will stand.

  • Anonymous

    The amazing thing about those opposed to legalized abortion is that for 40 years we have had this law without one single attempt to hold a statewide or nationwide referendum. The corrupt justices on the Supreme Court decided this issue and we got the results of their moronic decision. How can Americans allow the Supreme Court to decide such important issues? The Supreme Court decided who would be our President in 2000, and we simply let them. We simply stood by and allowed a Republican controlled court to crown George W. Bush as President. The American electorate are sheep! The American electorate are stooges! The question about whether abortion should or should not be legal should be decided at the ballot box. Yet, those opposed continue to dance around this issue and continue to try to obstruct what is currently legal. Imagine if these anti-abortion people would focus their collective energy on gathering signatures on petitions in order to put the question on the ballot. What are they afraid of? If you don’t like abortion, then get some courage, get some energy, invest some time and gather the signatures needed to change the law. What is so hard to understand about that? The people in Wisconsin have a governor that some don’t like. What are they doing about it? They are building a movement to get him recalled. Why can’t the anti-abortion people do something like that about making abortion illegal. If you ask me, they are all talk and no action! 

  • A. Marina Fournier

    You are doing exactly what I would welcome were I in need of your care. You say:
     “violent protesters, graphic descriptions, or philosophical discussions about when a fetus becomes a person don’t sway their decisions.”and later you mention “looking in the mirror” to see what she could live with. I was there twice: I was just barely making ends meet on my salary. As a single mother, I would have failed both of us. It is one thing to fall into single motherhood, and quite another to face that future from the start (unless you have a large staff and income, which most don’t).

    How many women, who having access to neither birth control nor to abortion, should the need arise, will be “a burden on the taxpayers” because of those situations? I gather some feel they can have it both ways: no means to prevent unwanted pregnancy AND no “burden on the taxpayers”. Sorry, not reality–but that doesn’t seem to enter into the equation, in this debate.

  • Anything Can Happen

    Soon everyone could be paying for abortions. It was announced that individuals enrolled in Obamacare could be paying for abortions with a $1 per person monthly surcharge. $1 monthly is the minimum people would pay and the surcharge could be more.

    “Understanding ObamaCare’s $1 Abortion Surcharge”
    http://www.aclj.org/obamacare/understanding-obamacare-abortion-surcharge-three-easy-steps

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