|May. 8th, 2010 09:12 am My Tribute to Dr. George Tiller|
I had to write a paper on a bioethical dilemma for one of my BSN courses. I couldn't help but think of Dr. George Tiller, whose wonderful life was cut short by a "pro-life" shitstain. I don't know if my teacher is pro-choice or pro-forced birth, but I had to take that chance. To really do justice to the subject would require a 30+ page term paper, but I did not have that luxury.
Bioethical Realities of Late-Term Abortion
On May 31, 2009, Scott Roeder, an anti-abortion militant, assassinated Dr. George Tiller, one of only three (now two) providers of late-term abortion in the United States, by shooting him in the face while he was in church with his family. Dr. Tiller is only the most recent abortion provider to be murdered by anti-abortion extremists. After appearing on “wanted” posters on an anti-abortion website titled The Nuremburg Files, Drs. David Gunn and George Patterson were shot and killed in 1993, and Dr. John Britton was executed by Paul Hill in 1994 (Lithwick, 2002). Operation Rescue, an extremist anti-abortion organization, was unabashedly jubilant at Dr. Tiller’s murder, a glee shared by a number of more mainstream abortion rights opponents, including Fox News pundit Bill O’Reilly. Operation Rescue’s leaders emphatically denied any affiliation with Roeder. That claim was debunked by The Rachel Maddow Show on its June 3, 2009 broadcast (Wolff, 2009). Maddow provided incontrovertible evidence that Roeder had been in constant telephone contact with Cheryl Sullenger, senior policy advisor of Operation Rescue, and that Sullenger had been feeding Roeder minute-by-minute information on Dr. Tiller’s whereabouts (Wolff). This was not the first attempt on Dr. Tiller’s life; he was shot in 1993, yet went to work the very next day (Gettig, 2009). So dedicated was Dr. Tiller to saving women’s lives, to helping families cope with the tragedy of doomed pregnancies, that he pushed on despite these unrelenting and vicious acts of harassment and terrorism (Gettig). Anti-abortion extremists shot at Dr. Tiller, they stalked him, they vandalized his property, and they compelled him to take security measures that ultimately failed.
Many abortion rights opponents believe that abortion is never medically necessary, while some acknowledge that sometimes abortion may be necessary to preserve the life of the mother, but still believe that abortion should never be allowed under any circumstance. In a 2009 Gallup Poll, 47% of respondents consider themselves to be “pro-life” and 18% of respondents believe that abortion should be illegal in all circumstances (Abortion and birth control, 2010). Yes, 18% of all respondents, which means that nearly 40% of “pro-lifers” do not believe that pregnant women have any right to life should it require termination of a pregnancy, not even that of a doomed one that is guaranteed to result in a dead infant in the unlikely event that the pregnancy makes it to term. Sadly, this very vocal and reality-challenged contingent has managed to foster the widespread belief that flighty pregnant women are paying unscrupulous doctors to rip full-term babies out of their wombs and have their skulls crushed and limbs torn off so that they can fit into their prom dresses or bikinis. Nothing could be further from the truth. Abortions after 21 weeks’ gestation The U. S. Supreme Court, in Roe vs. Wade established that third-trimester abortions are illegal for any reason other than severe fetal deformity incompatible with life and grave threat to the health or life of the pregnant woman. According to the Guttmacher Institute (2010) abortions after 21 weeks’ gestation comprise only 1.5% of the 1.2 million abortions performed each year. Contrary to Fox News media pundit Bill O’Reilly’s repeated claims that Dr. Tiller “destroys fetuses for just about any reason right up until the birth date" (LiberalViewer, n. d.), he instead provided late-term abortions to child victims of rape, as well as to women with doomed pregnancies. In Kansas, fetal viability is legally defined to be 22 weeks’ gestational age, even though no infant born alive at 22 weeks has ever survived to discharge from NICU and so cannot truly be considered viable (Allen, Donohue, & Dusman, 1993; Seri & Evans, 2008). Kansas law also stipulates that a corroborating second opinion from another physician who has no legal or financial affiliations with the physician who will be performing the abortion must be obtained (“Dr. George Tiller abortion trial…”, 2009). Operation Rescue convened grand juries time and again to revoke Dr. Tiller’s medical license, but those efforts were unsuccessful because Dr. Tiller only ever performed medically necessary late-term abortions, in strict accordance with Kansas law. This paper shall attempt to present the anti-abortion arguments against late-term abortion, the reality of the conditions in which women find themselves needing late-term abortions, and the ethical principles that underlie those decisions. Additionally, it seeks to dispel anti-abortion fallacies regarding late term abortions that even those neutral toward or generally supportive of abortion rights have adopted.
Most of the cases Dr. Tiller handled were for very much wanted pregnancies that went horribly wrong, but sometimes he treated girls as young as 9 who were pregnant as the result of rape. Little girls’ bodies are typically too immature, their wombs too small to sustain a pregnancy. Forcing these children to attempt to give birth when doing so will result in grave bodily harm, even death, and have only an infinitesimal chance of resulting in a viable infant, is directly contrary to the ethical principles of beneficence (do only good) and non-malfeasance (do no harm). It would be nice to think that no one would dream of subjecting little girls to the risks of pregnancy and labor, but many abortion rights opponents oppose abortion even in these egregious circumstances. Last year in Brazil a Catholic bishop excommunicated the mother of and doctors who performed an abortion on a 9-year-old child raped and impregnated by her stepfather (Duffy, 2009). The stepfather was not excommunicated, though he was detained by Brazilian authorities (Duffy). The bishop’s decision was firmly supported by many abortion rights opponents in this country (Kissling, 2009). This is just one example. Sadly, there are many more.
Sometimes fetuses die in utero, but due in part to state laws, including those of Kansas, that do not distinguish between late-term abortions for fetal demise and those for other reasons, and partly due to successful anti-abortion violence against and subsequent intimidation of abortion providers, very few physicians learn how to perform and fewer still will provide late-term abortion procedures. Those procedures are dilation and evacuation (D&E), intact dilation and extraction (D&X), and induction of labor. All the procedures are relatively safe, but D&E is by far the procedure that results in the least risk of complications (4.9% D&E vs. 29% induction) (Belkin & Wilder, 2007). Complications of D&E include hemorrhage, infection, cervical laceration, and uterine perforation; those for labor induction include retained products of conception requiring follow-up dilation and curettage, infection, hemorrhage, and uterine rupture (Belkin & Wilder). In many instances, D&X, which has a lower risk of cervical laceration than D&E, is the safest option and also allows the fetus to be removed intact, thus allowing couples to hold their baby and bury him or her as they see fit. D&X is no longer an option, alas, since the Supreme Court upheld Congress’ Partial-Birth Abortion Ban Act of 2003 in the landmark Gonzalez vs. Carhart decision on April 18, 2007, which, for the first time, upheld an abortion ban that did not include an exception for the health of the woman (Gonzalez, Attorney General v. Carhart et al, n. d.).
Nevertheless, many abortion rights opponents claim that late-term abortion procedures are never medically necessary and that the only morally acceptable treatment of fetal demise is induction of labor. Many women do choose induction of labor, often because it is the only option available to them and also because they are themselves opposed to abortion. Other women choose differently. Forcing women to undergo the most risky procedure violates the principles of both beneficence and non-malfeasance. The fetus is already dead. Hence, there is no benefit whatsoever to denying a woman the option of D&E.
Many anti-abortion activists object to the grisly nature of D&E and D&X procedures. Yes, these procedures are ghastly, as are most surgeries. But just because something is gruesome, does not make it immoral and something that must be outlawed. Late-term abortions preserve the lives, health, and fertility of women and are often a mercy to their fetuses. Their life-affirming outcomes clearly meet the standard of beneficence, while their ability to reduce suffering for both women and fetuses undoubtedly meets the standard of non-malfeasance.
Conditions Threatening the Pregnant Woman’s Life
Many abortion rights opponents insist that given modern technology, there are no adverse conditions that occur during pregnancy in the United States for which treatment cannot be provided for both mother and fetus to ensure the survival of both. Others assert that women should be willing to die for their children, so abortions are never necessary.
The reality is that although developed nations have come a long way in reducing maternal mortality and morbidity, even in the most accessible and advanced healthcare delivery systems, women still die from pregnancy complications. The United States, unfortunately, with its disjointed, dysfunctional, and savage for-profit healthcare delivery system is hardly one of the safest countries in which to birth a child. The U. S. ranks a dismal 41st in maternal mortality, with an official ratio of 15.1 deaths per 100,000 births that the CDC estimates is underreported by a 2/3 margin (Gaskin, 2008). And this underreported ratio has been steadily climbing since 1982, when it was 7.5 (Gaskin).
There are several conditions that threaten women’s lives during late pregnancy. Some women are diagnosed with cancer late in their pregnancies and treatment is incompatible with pregnancy, both because pregnancy is a tremendous metabolic drain on a woman’s body and because cancer drugs are toxic to the developing fetus. Preeclampsia may often be medically managed so that the pregnancy can be brought to term or at least to a point in gestation at which inducing labor will provide the best chance at life possible. But sometimes preeclampsia cannot be controlled and the woman develops eclampsia, which left untreated results in her death. HELLP syndrome is a medical emergency The only treatment for preeclampsia-eclampsia and HELLP syndrome is termination of the pregnancy. Sometimes labor can be induced or a C-section can be performed, but at other times, the woman is too compromised to tolerate either a trial of labor or a C-section. Sometimes, even at advanced gestation, the fetus has been subjected to intrauterine growth restriction secondary to the preeclampsia-eclampsia that renders it unable to survive. These are tragedies that in an ideal world would never happen to anyone and no woman should be made to feel guilty for surviving such a catastrophe even when her fetus did not. Those who survive horrific accidents or wars, even when friends and loved ones do not, often suffer from survivor’s guilt and post-traumatic stress, yet no one would dream of adding to their suffering by blaming them for surviving. It violates the standards of beneficence and equal treatment to act differently when the survivor of the horrific accident of pregnancy complications is the woman rather than the fetus.
Some women are willing to die rather than terminate a pregnancy because they have been diagnosed with cancer and know that aggressive treatment would result in fetal demise or gross deformity at best or they are unwilling to give up the fight to give their child life when they have been diagnosed with a life-threatening pregnancy disorder or other illness. While others, including their spouses or family members might object to them taking such a risk, ultimately the decision must belong to the women who are directly affected. This is the principle of patient autonomy, which also has as its core tenet the principle of informed consent regarding the risks and benefits of treatment and of doing nothing.
However, other women are not willing to sacrifice themselves to complete a pregnancy. They may have other children who need them. They may have spouses who need and love them. They may simply want to live for their own sakes. It is only in the case of pregnancy that anyone believes that it is appropriate to require such martyrdom. However, does not the pregnant woman also have a right to life? Again, the principles of beneficence, patient autonomy, and equal treatment are violated in the case of such a mandate for maternal martyrdom.
Fetal Anomalies Incompatible with Life
Fetal anomalies incompatible with life are very rare, but are nevertheless all too real and always tragic. The website A Heartbreaking Choice (www.aheartbreakingchoice.com) offers an eye-opening compendium of those women who have had to make the agonizing choice of terminating a desperately wanted pregnancy. Contrary to the contentions of anti-abortion activists, these are not garden-variety disabilities, like blindness or mild/moderate cerebral palsy or merely developmental delay that eugenics-motivated doctors and callous, self-centered women decide are too defective to be worthy of life. These are fetuses who will not survive past birth or will face a short life filled with unrelenting pain and dismal quality of life if brought to term. Some of the disorders that are always incompatible with life include: anencephaly, exencephaly, severe hydrocephaly, trisomy 18 or Edward’s syndrome, severe osteogenesis imperfecta, Potter’s syndrome, bilateral renal agenesis, tracheal agenesis, and pulmonary agenesis.
Many anti-abortion activists proclaim that even such hopeless cases must be brought to term and the babies given the chance to live, even if it will only be for a few hours or even a few minutes. Many women do choose to complete their doomed pregnancies, based on their valuation that if the short life in the womb is all the life their baby will have, then they want nothing more than to provide it. Others choose not to prolong the inevitable based on their valuation that withdrawing the life support provided by their bodies while the fetus is incapable of feeling pain is the most humane course of action for the baby and results in a lesser amount of suffering for the women and their partners. At least two independent physicians have confirmed that the pregnancy is doomed and will not result in a viable infant. At the time that most fatal fetal abnormalities are discovered, there are still four or five months until full-term delivery. That is four or five months in which the woman will have to endure all the increasing physical risks of pregnancy, the pity or uncomfortable silence and even ostracism of well-meaning family, friends, and acquaintances, as well as the torture of clueless strangers interjecting, “when is it due?” or “is it a boy or a girl?” or “congratulations!” And then she will have to endure the dangers and agony of labor or C-section to deliver an infant who will die within minutes, hours, or days. That is, if it even survives until birth. Many fatal anomalies result in death in utero, which can lead to infection and a much riskier abortion process the later in gestation past 20 weeks’ that it survives. Since there is no real benefit to the fetus to continue the pregnancy and great risk of harm to the woman, it violates the standards of beneficence, non-malfeasance, and patient autonomy to compel her to complete the pregnancy.
There are fetal disorders than can sometimes be treated in utero with good outcomes for the resulting infant, but sometimes they cannot be treated. One such case is that of Twin-Twin Transfusion Syndrome (TTTS). TTTS is a malfunction of the pregnancy process in which an anomalous blood vessel connection results in shunting of an overabundance of blood to one twin, while the other twin is deprived of an adequate blood supply (Crombleholme, 2006). The overloaded twin develops polyhydramnios and congestive heart failure, while the deprived twin develops oligohydramnios and growth restriction. Unless treated, there is a 60-100% mortality rate in TTTS diagnosed before 28 weeks’ gestation (Crombleholme). With treatment, there is a survival rate of about 60% for both fetuses and over 90% for at least one of the fetuses (Crombleholme). Fetal laser surgery offers the best outcomes, but sometimes only amnioreduction is an option, which affords over three times the risk for moderate to severe neurologic deficits and significantly higher mortality rates than laser surgery (Crombleholme). Some women choose selective reduction in order to give the healthier of the fetuses a fighting chance at life (Darman, Campo-Flores, & Breslau, 2006). Unfortunately, in the most severe cases, both fetuses are too compromised to survive (Sherling, 2009).
Many anti-abortion activists argue that selective reduction is always immoral, that it is not for anyone to “play God” with unborn babies’ lives. Of course, it is easy to sit in judgment when it is not one’s own self or loved ones facing a horrendous situation. Humankind has been “playing God” since the advent of civilization. Human civilization would not be where it is today in terms of technological advancement, especially in its ability to prevent and treat disease if it restricted itself to the premise that only Nature/God should be the dealer of human death and life. To allow two infants to die when there is no real chance of both surviving instead of providing the healthiest twin the means to nearly conclusively assure its survival, and instead minimize the outcome to a single rather than a double tragedy, is entirely in accordance with the principle of non-malfeasance.
In a perfect world, all choices would be black and white and, hence, there would be no ethical dilemmas. In a perfect world, no desperately wanted pregnancy would ever result in life-threatening complications or fatal fetal anomalies. In the real world, pregnancy and reproduction are composed of varying shades of gray. The circumstances that lead to late-term abortion are one such tragic circumstance. Abortion rights opponents seek to condemn women and fetuses alike by interfering with physicians’ capacity to preserve lives. This is unconscionable and in direction violation of the principles of beneficence and non-malfeasance. In medicine, the principle of patient autonomy allows patients and/or their spouses and families when the patient is too compromised to speak for himself, determine whether further medical intervention is futile and allows for withholding of life support, invasive medical procedures, and even fluids and food. In the case of terminally ill children, the parents or primary caregivers are allowed to make these heart-wrenching decisions. To deny this same right to pregnant women and their spouses and families in regards to their fatally deformed fetuses and life-threatening illnesses is in direct violation of the principle of patient autonomy. It is not the realm of strangers to interfere in such private decisions. These decisions belong in the hands of those most directly affected by them.
Dr. George Tiller was a loving and courageous man who made it his mission to provide late-term abortions because he knew that women and their families needed him. He paid for that selfless dedication with constant harassment and relentless terrorism from anti-abortion extremists and ultimately he paid with his life. He always abided by Kansas law and never once were the late-term abortions he provided for “convenience,” but anti-abortion activists still malign his memory and paint late-term abortion as an unnecessary abomination. In the words of Phillip Wood, whose wife was a patient of Dr. Tiller’s:
I’ve been touched by greatness, by a real sense of commitment. It’s that and gratitude…There are many, many reasons for terminating a pregnancy that don’t fall into neat categories. And in the end, I do believe that abortion should be rare, I…but I think that is something that everyone who experiences an abortion would agree with (Sherling, 2009).
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