The following was a presentation given on July 9, 2022, in Sonora, CA, during a rally protesting the recent Dobbs Decision by the U.S. Supreme Court that reversed the 1973 Roe vs Wade decision.
I found myself having to wrestle with the idea of sharing some thoughts with you today, only because of the vitriol that typically accompanies the public debate on abortion rights. I frankly find the political monikers associated with the different views – “Pro Choice” and “Pro Life” – ludicrous. From a public health perspective, one is either in FAVOR of the right to abortion, or AGAINST the right to abortion. Note that I did not say, “in favor of abortion.” In all my years as a physician I have never encountered a patient who was “in favor of abortion,” any more than I have ever encountered a patient who was “in favor of amputation,” or “in favor of gall-bladder surgery.” I HAVE however encountered MANY patients who, in the interest of their best health and in some cases to stay alive, have chosen to have an abortion and have strived to do so as early as possible in the pregnancy. They were able to do that because they were protected by the law, and unfortunately those protections have changed for many Americans following the Dobbs Decision by the U.S. Supreme Court on June 24th.
To say that this debate boils down to whether one is in favor of the right to abortion or against the right to abortion, of course, ignores the enormous complexity of the issues at hand. In the wake of the Supreme Court decision, I would argue that these complexities must be addressed before any restrictions to the right to abortion be considered. I would like to briefly share some examples of complex clinical situations that are now compounded by the recent Supreme Court decision.
Over the past thirty-five years I have participated in the Tuolumne County Sexual Assault Response Team performing forensic examinations for over 50 victims of sexual assault in Tuolumne County, nearly all of them female and many of them in their teens or younger. Post coital contraception was a regular component of the protocol when it was necessary to protect the health of the victim. However, as is true for almost every medical intervention, such preventative treatment is not 100% effective. Failure rates for post coital contraception average around 2% depending upon the method. This means that approximately two persons per 100 may become pregnant following a coital sexual assault despite appropriate post assault pregnancy prevention efforts. In the wake of the Dobbs decision, earlier this week approximately 15 states are proposing restrictive abortion legislation modeled after Alabama which does not exclude sexual assault victims from the prohibition against abortions. To me, this is absurd, and compounds the assault on sexual assault victims essentially with the state as a party in the crime.
For states that pass legislation to allow abortions only to “save the life of the mother,” health care providers will be placed in the untenable situation of deciding when the “life of the mother” is potentially compromised. Does this require imminent danger, such as eclampsia or embolism, or does a delay in treatment that is likely to adversely affect the mother’s prognosis sufficient?
Another clinical situation involves patients with infertility for whom assisted reproductive technologies provide the only option if they are to conceive a biological child. What is to be done with the many tens of thousands of frozen embryos at the earliest stages of development if abortion is prohibited without exception? According to a 2019 report,[1] in-vitro fertilization accounts for approximately 2% of all children born in the U.S. Will the potential production of unimplanted embryos constitute an illegal act on the part of fertility clinics?
A fourth important repercussion is that unsafe methods of pregnancy termination will inevitably increase as desperate women of fertility age seek illegal abortions. Having worked in a maternity hospital in a third world country where abortion was illegal, I have witnessed this result of restricted rights to abortion, and the consequences are far reaching. First, the stigma associated with the illegal act itself prevents patients from providing an accurate history to their health care provider. I recall a patient whose illness became life threatening because of her unwillingness to share the fact that her condition was a complication of an illegal abortion procedure. Second, there will be those willing to offer unsafe, substandard abortion procedures at exorbitant cost and at considerable health risk to the patient. This has happened in the past in this country and it happened in the community clinic overseas where I worked.
Incidentally, the country where that perinatal clinic was located registered the highest maternal mortality rate in the world. I was surprised at the irony and gratified to learn this week that this country is now planning to legalize abortion, partly in an effort to mitigate this tragically high maternal mortality rate.
In this country, which subpopulation is most likely to suffer the most severe consequences of lower-cost, substandard abortion procedures and deceptive communication with caregivers? It is those with low levels of health literacy, those with low confidence in the mainstream health system, those unable to travel to nearby states where abortion is accessible, and those with the least financial and health insurance resources. In this country where health insurance is largely provided by employers, this means the unemployed. Thus, the Dobbs decision is almost certain to widen an already appalling disparity in health between the affluent and the disenfranchised.
Which brings us to a central tenet of health care: Do No Harm. The core of this principle is the definition of the word, “Harm.” Harm can come from an action, like a drug reaction or an overdose, or from an inaction, like a failure to treat an infection or a failure to provide an early abortion when it is indicated. To insert the state into the private and delicately trusting relationship between patient and caregiver undermines a part of health care in this country that has already suffered under the burden of electronic medical records, corporate health care and third party insurance. This also affects other disciplines besides family planning, such as oncology where genuine germ cell treatments and advances in bioengineering have brought new life-saving treatments to the front lines and holds promises for the future.
So what course of action at this point in time following the Dobbs decision is most likely to Do No Harm?
I would suggest that the first priority is public health education, meaning universal public health education in K through 12th grades. Did you know that the U.S. National Health Education Standards for school curriculum in this country were last updated in 2007? This country’s performance during the COVID-19 pandemic revealed a dismally poor level of public health literacy in the U.S. It is time to update school curriculum with the science of public health – including curriculum covering relative and absolute risk, local health statistics, mechanisms and means of accessing various family planning methods, and something new called “lateral reading” which teaches students how to assess the reliability of web-based information – to give students the tools they need to navigate an ever-more-bewildering health care system.
Secondly, we must actively disseminate accurate information about pregnancy testing, primary contraception, post-coital contraception options, the importance of diagnosing pregnancy as soon after conception as possible, about where and how to gain access to termination services when those services are sought-after and indicated, and about the relevance of community health to individual health. Of course, we must simultaneously make pregnancy testing, primary contraception, post-coital contraception, mifepristone/misopristol treatment, sexually transmitted infection screening and other family planning services more widely available without ideological bias inserted into the counselling.
Thirdly, the public must elect representatives who are willing to look at and understand the science without ideologic or religious bias and who respect the opinions of similarly unbiased experts. Finally, please share your own experiences to let your representatives know that there are real consequences to their legislative and judicial actions.
Todd Stolp MD
[1] Lawmakers v. The Scientific Realities of Human Reproduction, Editorial Staff, New Eng J Med June 24, 2022 https://doi.org/10.1056/NEJMe2208288