Indications for a Therapeutic Abortion (USPHS, 1969)

[Music] [Dr. Alan Guttmacher:] I’m Alan Guttmacher,
an obstetrician/gynecologist. I feel very strongly that a man trained in
modern medicine cannot carry out the high quality of performance because of
the restrictive, restrictions imposed by our very archaic abortion laws, and I feel
they must be changed. [Dr. Frank Ayd:] I’m Dr. Frank Ayd, a psychiatrist. I am opposed to any liberalization of abortion
laws, especially for psychiatric, social, and economic
indications. [Richard Lamm:] My name is Richard Lamm. By vocation I’m an attorney. By avocation I’m a member of the Colorado
House of Representatives. I was chief sponsor two years ago of Colorado’s new liberalized abortion law, and I will act
today as the moderator. [Music] [Narrator:] Welcome to the exploration of
concepts and controversies in modern medicine, one of a series of programs dedicated to examining
the uncertain, candidly recognizing that much of today’s
teaching is necessarily based upon opinion, and that the opinions of eminent physicians
in a given field vary widely. The National Medical Audiovisual Center believes
that openly airing such opposing views is a basic responsibility
of medical communications. The Honorable Richard Lamm, state representative,
state of Colorado, will act as moderator of this presentation. [Mr. Lamm:] I think one of the problems dealing
with the subject of abortion, and I think this is at least one thing that
we can all agree on, is the problem about in what category, in
what terms, and what discipline should the subject be discussed in? Some people say this is a strictly medical
problem. Other people I’ve heard say it’s strictly
a legal problem. Many people are beginning to think it’s perhaps
a sociological problem, a public health problem. There are many disciplines which lay claim
to an interest in the subject of abortion. I think that there is an agreement even among
a lot of people that it may be a little bit of all of these
disciplines, but there again that doesn’t solve the problem because then
each profession continues to say, well, it’s more of my problem than it is of
those other disciplines. Without solving that problem, let me give
you just a brief summary of what happens in a state that does liberalize its abortion
law. Colorado liberalized their abortion law by, it was signed by the governor on April 25th,
1967. We are a state of two and a half million people and there is approximately 35,000 live births
a year in Colorado. Previous to the signature of the new law there
was approximately 50 abortions, hospital abortions performed
in Colorado in a year. In the first nine months after the passage
of our law, there was 140 abortions performed in Colorado hospitals, and in the
calendar year 1968 there was 476 abortions performed. The grounds of these, that total 616 abortions, the grounds were about 55 percent under the
mental health provision of our law. There was approximately 26 percent of these
abortions were performed on non-residents of the state of Colorado which generally is
about, approximates the other medical care, being a state like Colorado drains a great
deal of western Kansas, eastern Utah. We have, uh, the abortions were performed
on, generally on people that make up a cross-section of our community. One of the things that was seen was is that
the lower economic groups have now had a lot more access to abortion than they had ever had under the previous law. Fifty percent of the abortions were performed on single women, 40 percent were performed on married women, and 10 percent on divorced women. Now, to try to discuss what problems there
are in the subject of abortion, to try to decide whether this is the right,
whether this is the end product, whether Colorado’s experience is the end result
or whether or not it has gone too far, or whether or not we in effect have not gone
far enough, we will have other panelists, and we will turn to Dr. Guttmacher. [Dr. Guttmacher:] I think that the medical
audience realizes that there are seven additional states out of our
50 that have liberalized their laws, from my point of view not broadly enough,
but nevertheless eight of our states out of 50 now have more liberal laws. The old law of course in practically all states was that abortion could be done purely and
simply and only to preserve the life of the mother, and from my point
of view that is much too restrictive. You must remember that when these laws were
framed, medicine was a very different thing. Most of the laws date from about the 1820s
and ’30s. At this time there was no anesthesia, there
was no antisepsis, there was no transfusion, and carrying out an abortion must have been a hideously painful, and I should think a dangerous procedure. Now, since then medicine has made magnificent
progress, and abortion in hospital can be performed
with extraordinary safety. I know in my rich experience, which goes back
in medicine some 40 years, I’ve never seen a death after therapeutic
abortion, and I think that it’s fair to say that it is one of the least dangerous operations. Actually we have excellent statistics from
Czechoslovakia, from Hungary, on a million consecutive legal abortions,
and there were 25 deaths. That’s 2.5 per hundred thousand operations. So I think we can say that this is a very
safe operation. Now, in addition to its safety, medicine now, I think, can pay much more attention to the whole personality of the individual. We can relax because most of our killers have
disappeared: pneumonia, various infections, and we can
now become more than just kind of carpenters. I think we can see the personality’s totality, and from my point of view, abortion can contribute
tremendously to the happiness of the woman involved, and
very often to the family constellation. [Mr. Lamm:] To give his viewpoint on the subject,
Dr. Ayd. [Dr. Ayd:] Well, I think several points have already been made which warrant thorough
discussion. My first point would be of course that abortion
means that a human life is being taken. Now to declare that any individual’s life,
at any time from the moment of conception, is devoid of value in my opinion is a judgment
that no man has the right to make, and to end an individual’s
life is murder, committed because it has been decided that he’s no longer a human being i in need of help and protection, but merely an object whose worth is measured according to whether or not his continued existence or
his destruction is expedient for someone or the nation. As Honorable Lamm has pointed out, whenever an abortion law is liberalized, there is an immediate and
significant increase in the number of therapeutic abortions performed, but I think
also what must be stressed, that regardless of how many legal abortions
are performed, there’s absolutely no evidence that this in any way affects the
rate of illegal abortions. Furthermore, Dr. Guttmacher has pointed out
the progress in medicine and quite properly stressed the advances that have been made
which make surgery in general much safer than it used to be, but I honestly
believe that also it must be stressed that therapeutic abortion is, as the British
Medical Journal just simply pointed out on December 28, 1968 in an editorial,
it is not a simple operation. It does carry its hazards. Its safety depends on the surgeon performing the operation and even the method of termination
that is employed. Admittedly, Dr. Guttmacher’s absolutely right
when he says that the mortality rate associated with therapeutic abortion is relatively
low, but the morbidity rate depends on the skill of the surgeon performing
the termination of pregnancy and also on the method of termination. Accurate statistics coming out of England for example, where very fine records
are kept, would indicate that the morbidity rate varies from one to
five percent, depending primarily on the method of termination
used, but I would point out that you do have hemorrhage, you do have perforation
of the womb, sometimes requiring secondary exploratory
abdominal surgery as a result, so that it’s not an innocuous operation. But also as a psychiatrist I would stress
one very, very important aspect of this problem. Technically it is true, we can empty the womb
of the baby, but we cannot scrape the idea of the baby out of the mother’s mind, and
therefore there are going to be women who while in the early stages of pregnancy
and being emotionally upset would be inclined to destroy the infant within their womb, subsequently, although the infant has been
removed by whatever termination method is used, the idea of having had a baby in her womb
is still in her mind, and that’s not easily eradicated, and subsequent feelings of guilt
and things of this sort are real. We psychiatrists see them and we have to contend
with them. [Dr. Guttmacher:] Dick, I don’t know whether
I’m allowed to to question some of the things Frank said, but we’re old friends, so I think he won’t
mind. In the first place, to him abortion is murder. I’m no murderer, and I’ve done abortions. To me it’s quite different than shooting even
a man in warfare. To me these are undifferentiated cells which
have the potential for being a human being, but to me this baby is not a human being until born, and I am not willing to let it go that all doctors agree that this is murder because I daresay of the
group listening to me, or to us, a certain proportion, perhaps I think the
largest number, will think it’s not murder. So I think you have to define this process according
to your own intellectual point of view, and perhaps your own social and religious
background, and in the second place, I think that the
psychiatric sequelae of abortion… this can be challenged. This is Dr. Ayd’s experience. I daresay that he has perhaps had patients
who, perhaps because of religious affiliation, who have more feelings of guilt than perhaps most of the rest of us. Now we did a study at Mount Sinai, on our
ward patients who are largely Puerto Rican, and Marcus and Peck published a study on 50
consecutive abortions done at Mount Sinai, therapeutically for psychiatric indications. We had one patient of the 50 who developed an acute psychosis about three
months post-abortum. This lasted about three months and apparently
she made a satisfactory recovery. As far as they could determine, and perhaps
their study was not as profound as perhaps Dr. Ayd would like, it they could
find no evidence of psychiatric sequelae. So that I think we, there are areas of disagreement, this thing is not nearly so easy to analyze as perhaps Dr. Ayd and
I both make it. I see it from one point of view and Dr. Ayd
sees it from an entirely different point of view. [Mr. Lamm:] I would like to ask you both what you would write into the law if you were
dealing, what kind of law would you propose to deal
with the problem of abortion? [Dr. Ayd:] Well, before I answer your question,
sir, I think that in order to keep this dialogue
going in a meaningful way for the audience that I should make two comments about what
Alan has said. Number one, this study that he referred to
of only 50 patients, I’d have to have more data as a scientist before I would accept or reject the validity of the findings. Number two, although it is true, I am a Roman
Catholic, I’m not opposed to abortion just on religious
grounds. In fact, the majority of the patients that
I’m called on to treat are not Catholic, and still I see feelings of
guilt and so forth. But, he also raised I think one of the crucial
questions and that is, is the fetus a human being? Now I admit that many abortion supporters
say that the fetus is nothing more than a blob of protoplasm,
nothing more than that, but I don’t think that they honestly recognize
their own contradiction. Now, if the fetus is not a human being, what
is it that’s damaged in the early weeks of its experience by a viral infection such
as rubella, by drugs, chemicals, x-rays and so forth, which is used to justify abortion? If the fetus is not a human being, why are
so many physicians and scientists spending millions of dollars and countless
hours trying to develop a vaccine for rubella, trying to devise ways of avoiding birth defects,
trying to develop an artificial placenta, trying to fertilize the ovum outside the body
in a test tube and by artificial insemination and genetic
engineering and genetic surgery, to enable man to improve the mere and remote descendants that he may have. Now furthermore, in this country, if the fetus is not a human being, then I must ask the question, why does the
United States Food and Drug Administration caution against, or in some instances prohibit, the administration
of certain drugs in the first three months of pregnancy? [Dr. Guttmacher:] Now I can answer that, because… [Dr. Ayd:] May I finish please? [Dr. Guttmacher:] I thought you had. [Dr. Ayd:] No, I have one other point that
I’d like to make and that is, uh, it, to my mind, to say that a fetus is not human is sheer nonsense. Dr. Guttmacher was a fetus, I was a fetus,
you were a fetus. You see, our existence began this way, and
for someone to terminate it, if someone had terminated the fetal existence
of any one of the three of us, we wouldn’t be here on this panel today. So that the fetus is a human being. I think it’s semantics to say that human life
doesn’t begin until implantation or until the third month or the sixth month or until a baby’s born. What constitutes humaneness or humanness? [Dr. Guttmacher:] Well, I agree with you for
once, about this: I think that a sperm is a living potential human being, I think an egg is a potential living human being. I see nothing that is changed by the process of fertilization. These were living cells before fertilization,
they become, continue to live after fertilization. But they are potential human beings. This is where you and I differ. I think that human life, potential human life begins at the moment of fertilization. It actually precedes it. Now what I think is that you’re not, I was
a fetus to be sure, but I was a potential human being until I was born, and that’s where you and
I differ, and no matter how much we argue we’re not coming to a common area
of agreement. [Dr. Ayd:] Well, I’ll agree that it would
be very difficult to come to a common area of
agreement. I will agree that the sperm is a living cell and so too is an ovum, but
the genetic composition of a sperm is different from the genetic composition
of the ovum, and it isn’t until you have fertilization that you now have a unique human being that never existed before and will never exist again and after all, the ovum only contributed half of a genetic or chromosomal makeup of that
fertilized… [Dr. Guttmacher:] But that is a unique cell,
too. [Dr. Ayd:] No, no, it’s not though. [Dr. Guttmacher:] The sperm is a unique cell. Every sperm has a different chromosomal makeup. [Dr. Ayd:] Precisely. But it only has half of any other cell in
the body and so does the ovum, but when you have a
new human being, every cell, until they’re differentiated again
into ovum or sperm, has a complete chromosomal complement, not
a half. Now, I mean, to say that this sperm is a potential
human being, I think genetically at least you’re completely erroneous, and that it is
misleading to say this… [Dr. Guttmacher:] You have half a human being
then, you’ll grant that? [Dr. Ayd:] No, because it can become nothing but sperm until it actually fertilizes an ovum, then you have a new human being. [Dr. Guttmacher:] I think we’re splitting
hairs. You and I differ in the fact that I think
that a fetus is until birth is a potential, you think a fetus is actual as a human being
immediately after fertilization, so let’s agree on that and let’s go on. [Dr. Ayd:] All right, fine. [Dr. Guttmacher:] We’re losing a lot of valuable
time. [Mr. Lamm:] I would then be interested, both
doctors, to, uh, at your viewpoints on what should be the indications of therapeutic abortion when you’re dealing
in the realm of law, and that to me is the problem right now, is because medical indications only designate a certain stage of medical learning at a certain point in history and yet when you try to write these things
into law, you have at least in Colorado, one hundred legislators, only one
of whom is a doctor, trying to decide what is good medical practice, and this is
very difficult. I would like to ask you, what would you see
to be a model abortion law, or dealing with the subject? [Dr. Ayd:] Well, in dealing with the subject
my answer immediately would be that I live in a pluralistic society. I’m perfectly willing to accept the law that
is now on the books, which permits abortion to save the life of
the mother. I frankly, at this moment, deny that there
are any psychiatric indications that justify liberalization of the abortion laws. After all, psychiatry has made progress, just as surgery and medicine has made, and
it would be a rare pregnant woman, psychiatrically ill, who could not be carried
to term safely with the modern psychiatric therapies that
we have. Now, once you get out of the psychiatry and the medical indications, you’re talking in terms of social and economic indications. If we’re going to have abortions done for
social and economic reasons, then I think we’re in for very dangerous waters
and as a matter of fact, I confess that most of the so-called psychiatric indications which have justified up to 70 percent of the abortions
done in your state, and in fact in California, and even in the state of Maryland from which I come, have been done for alleged psychiatric reasons, they’re called reactive depressions. Until the laws were liberalized, I’ll tell you, we never had so many reactive depressions, all right? Now in fact these are socio-economic indications, not strictly speaking, psychiatric indications. Now what I also must stress is that the evidence we already have from the United
States and from England is that the minute you liberalize the abortion laws,
women think that they are entitled, that they have a legal right to abortion on
demand, and this puts pressure on the physician and I’ll illustrate that. Suppose the physician prescribes an oral contraceptive or inserts an intrauterine
device and this woman becomes pregnant. Now she comes back and accuses him and says,
“You’re responsible for this. Do something about it.” These emotional pressures are going to be
to abort this woman. Now also there’s been something that was unforeseen
when the laws were liberalized in Colorado and in California
and in Maryland, and that is that we now have an unwritten, workable rule which goes, “If in doubt, abort,” because if one allows the pregnancy to go
on, this may subsequently be used as grounds for a malpractice suit against
the physician. If I may go back from the socio-economic, and still take up the other
indication, namely the question of a suspected fetal abnormality. This puts the physician in a very difficult
position because he must now decide how many normals
he’s going to sacrifice to prevent the birth of one abnormal baby. Now this is one reason why physicians in general are not too in favor of abortion.They find it repugnant, and if you actually check the figures in your state and
in California and in Maryland, what is coming out is that the majority of
the abortions are being done in a few hospitals by a relatively small number of physicians. The majority of obstetrician-gynecologists are not performing abortions any more than
they did before the law was liberalized, and a great majority of them are doing them for what would still be considered valid medical indications. [Mr. Lamm:] Turn to Dr. Guttmacher. [Dr. Guttmacher:] I think we must liberalize
laws because the current situation is highly discriminatory, both in regard to legal and illegal abortion. In New York there are five times as many therapeutic
abortions done on the private services of hospitals than on the clinic services. Theoretically then, the private patient is five times as ill. This is ridiculous. In the second place, anybody knows that $700 will buy a safe abortion in Puerto Rico,
and if you don’t have $700 and you only have five bucks, your chance
of having a safe abortion is extraordinarily hideous. We have a million illegal abortions estimated
in the United States, and what I want to see is to give poor people,
people who don’t have the money and the influence a decent break, and I think we have to do this by liberalizing our laws and spelling out for the time being
what are those indications quite clearly. Now, I agree that abortion should be done
for the preservation of life or health, mental or physical. I agree that abortion should be done in cases of proved sex crime. I agree that abortion should be done when
there is grave likelihood of the fetus being born either
malformed or retarded. Furthermore, I think that any woman who has
had four living children should have the choice as to whether or not another pregnancy is
gonna be an asset to the family constellation. Who can make this judgment better? A doctor, a lawyer, a legislator? No! The woman herself is in the position to make
that decision. I further feel that any woman who’s 40 years old should have the choice as to whether or not to remain pregnant. I agree with Plato in his Republic, who thought that any woman of 40 or more should be aborted and by that time she certainly
is mature enough to make the proper decision. I think that any woman who is physically or mentally incapable of caring for a child
should be aborted if she wishes it, and I think that any girl of 16 or less who
is illegitimately pregnant should be aborted if she desires it, because I can’t see that that’s a constructive experience for either the girl or a healthy environment
for the child to be born in. [Mr. Lamm:] Dr. Guttmacher, let me ask you
this: Do you think that the fact of the statistics that were just presented by
Dr. Ayd with regards to the large number of abortions performed under psychiatric
grounds, do you think number one, that this needs explanation, and if you do
would you care to comment? [Dr. Guttmacher:] No, I think it simply shows
a sense of humanity in the medical profession. We’re not rigid psychiatrists, we’re not saying
a woman’s going crazy because she’s not aborted, we’re simply saying that
this woman doesn’t have the emotional maturity, the emotional
background to be a good parent, or we feel that this pregnancy is going to
be emotionally destructive on her, something that’s not going to add to her happiness
or to her growth or to her personality and therefore it can
be eliminated. We’re looking at psychiatry not from the point of view of insanity and
sanity or psychoses, but looking at it from a much more general point of view. What is the growth likelihood of the personality due to the pregnancy? That to me is a much more important concept. [Mr. Lamm:] You have a rebuttal to that? [Dr. Ayd:] Yes, I would simply say that right
away we’re putting some people into the classification of second-class citizens and that if someone is unwanted this is justification
for terminating their existence, and that if someone is likely to
be a burden either on the mother or on society, that this is justification
for terminating their existence. Now, my feeling is that if that philosophy,
which is an anti-life philosophy in my opinion, permeates the United States, then the weak
and the dependent and the aged have a lot to be afraid of, because if your
existence is going to depend on your quality, and not on the inviolateness of your life, not on its intrinsically determined value,
but just on that judgment as to whether or not you’re gonna be a burden either to a mother or to society, then I think many, many people in the United States today better start worrying, because they’re in
trouble. [Dr. Guttmacher:] I don’t think that follows
logically at all, but go on with your… [Mr. Lamm:] Let me ask you, along the same
line though, we had evidence before the Colorado Legislature
that all we were doing was bringing up what was obviously a long-existing medical
practice, for instance in the 1960 issue of Obstetrics
and Gynecology, there was a statement showing the indications performed, abortions
were performed in the 367 major hospitals in the United States, and neuropsychiatric, rubella, all of these
reasons were already being performed, and so we thought all we were doing is bringing
up to law what medical practice had been doing for years. [Dr. Ayd:] Well that doesn’t necessarily make
it right. I know this is exactly what you’ve done and
I have no question about the sincerity of your motives at all, but
I insist, you see, that we’ve got to decide whether or not human life is sacred, because
if human life isn’t sacred nothing else is. We’ve got to decide whether you, or I, or
any other person in this world has the right to decide who
shall live and who shall die. [Mr. Lamm:] I think on that, I see that we are getting a summary. I wonder if each of you would like to give just a very short summary of your positions
again? [Dr. Ayd:] Well, I am opposed to abortion and I would stress that so far in England
and the United States, abortions have been done primarily for so-called
psychiatric indications on young, single girls, you see, who certainly are not socioeconomically classifiable as disadvantaged. [Mr. Lamm:] Dr. Guttmacher. [Dr. Guttmacher:] I would say that the main
difference is that I have just as much reverence for
human life, I believe, as anyone who opposes changes in the abortion laws. I want them changed because I revere human life. I want it to be strong and healthy and happy. [Mr. Lamm:] Let me say in summary that in
dealing with the problem, at least from the point of the legislator,
we have certain problems. Number one is, should abortion be performed? Number two, by who, where and with whose consent? These are some of the problems that we deal with in the legislature as opposed
to the medical. Thank you. [Narrator:] We thank Dr. Alan Guttmacher,
Dr. Frank Ayd Jr., and the Honorable Richard Lamm for their interesting
analysis of a critical problem in patient care. In subsequent programs we shall continue to
record equally significant concepts and controversies in
modern medicine. The opinions expressed on this program do
not necessarily constitute endorsement by the Department of Health, Education, and Welfare, the Public Health Service, or its constitutents. [Music]