Transcription:
Abortion: Ethics, Access, and Viability

Welcome to the Peds Ethics podcast, where we talk to leaders in pediatric bioethics about a hot topic or a current controversy. Here’s your host, John Lantos from the Children’s Mercy Bioethics Center in Kansas City.

John Lantos, MD (Host):  Hi everybody, this is John Lantos with the Pediatrics Ethics Podcast coming to you from the Children’s Mercy Bioethics Center at Children’s Mercy Hospital in Kansas City. We’re thrilled today to have Professor Katie Watson from the Northwestern University Feinberg School of Medicine in Chicago. A core faculty member of the Northwestern Medical, Humanities and Bioethics Program and the author of a recent book with a very interesting title. It’s called “Scarlet A, The Ethics, Law and Politics of Ordinary Abortion.” Welcome Katie. Tell me, what is an ordinary abortion?

Katie Watson, JD (Guest):  Well it’s certainly a contested idea that I created for the book. But what I found was that those who oppose abortion access talk only about what I think they would consider cases of extreme abortion abuse, right? What they would call – what I would think of as extraordinary but later term in the sense of being less common procedure they object to. And what I noticed is those who support abortion access also used what are statistically extraordinary cases such as rape, severe fetal anomaly, extreme youth and very sympathetic cases.

What I realized numerically is that neither “side” was talking about what adds up to be about 95% of all abortions.

Host:  And how would you describe those if they are different from the extraordinary –

Katie:  Yeah, so 80% of all abortions in the United States happen at the embryonic stage, so under 10 weeks of pregnancy. Almost 90% are in the first trimester. They are for the most ordinary reasons and by ordinary, I mean common, right. So, I can’t afford to have the baby. I do not have a partner and I don’t think I can be a single mom. Becoming a mother now or having another child would interrupt or make it impossible for me to meet my other obligations be their education or caring for other children. It's the 59% of abortion patients who already have children and say I can’t care for another child, right 49% of all abortion patients have incomes under the poverty level. That’s a statistic that surprises some people.

So, these are the every day reasons that many of us can understand of we’re all trying to get through life and pay the mortgage or the rent and raise our kids and finish our educations or find work that’s meaningful or pays well enough to survive. So, to me, those are the ordinary reasons that we don’t see in the headlines. And it was curious to me that in bioethics generally we don’t talk abortion anywhere near as much as the American public does.

Host:  Why do you think that is?

Katie:  Well a gray haired ethicist a very senior person in our field told me when I told him I was thinking of writing a book. He said, “Oh, there’s nothing new to say. We debated abortion in the 70s and it was a tie.” And I thought well we live in the 21^st century and apparently the rest of America has not stopped talking about it. It’s one of the most common medical procedures in America yet we have cordoned it off. So, I think in our field, there are two things going on. One is we like neon light cases too. We like the extraordinary and if there’s something that hasn’t happened yet but sounds scary; we can get a grant to talk about that nonexistent technological challenge but we want to talk about why so many people can’t get hypertension care. There’s no grant for that.

The second piece is stigma. And I really believe that there’s become this fear of teaching about or talking about abortion even in medical schools, though it’s a medical procedure and a constitutional right. You know you have no constitutional right to your meniscus repair. The legislature could ban that tomorrow. And you have no recourse. This is the one of the only medical procedures you actually have a constitutional right to and if we can’t talk about it in medical schools, I’m not sure I hold out hope for the rest of the country to be able to have a thoughtful civil discourse about it. so, the stigma affects us too and the fear and the idea that being apolitical somehow means being silent as opposed to being nonpartisan, which is what academics and ethicists, I think ought to be. But our work always encounters the edges of policy and politics. But imagine to say to a bioethicist you can’t talk about fill in the blank. Vaccines for pediatric populations, because that’s too political. Or we can’t talk about transplant because that’s something Congress regulates so get out of it.

Host:  So, you decided to write about it?

Katie:  Yeah.

Host:  Well what’s the reception been? Have you gotten a lot of controversy?

Katie:  No. I’ve gotten a lot of thank you notes. Which affirmed my sense the people want to talk about it but have been taught or told that they can’t but when you open a door, and I used to think it was about how do we learn to talk about abortion. What I’ve come to understand is there’s a parallel piece that’s as or more important which is how do we signal that we’re able and willing to listen about abortion. Because people have lots to say but they’re not – they don’t raise it first. But if you open a door and mark yourself as someone whose happy to have a conversation or happy to genuinely hear them regardless of their point of view or their life experience; people get really chatty.

And so what I found is if you want to hear people’s abortion stories or abortion opinions; spend a couple of years at cookouts and cocktail parties when people say what are you up to, say I’m writing a book about abortion. And then just shut your mouth and listen. And people say you can’t talk about it, I cant tell you how many probably now verging on 1000 wonderful conversations I’ve had.

Host:  Tell me some of the stories you’ve heard.

Katie:  Well so, what I was – two that mark a pole for me, in the book I talk about the difference between abortion is a constitutional right, yes, no. And whether abortion is an ethical act. Yes, no and separating those out, not that they have no relationship but it’s very productive. And so, there is a physician I work with who identifies himself as prolife and he’s very passionate and that identity is very central to him. He’s a family physician, refuses to perform abortions. It’s a religious perspective as well as a secular perspective. We’ve worked together for many years and I’ve heard a lot about his point of view. I assumed that he wanted abortion to be illegal. I wasn’t conscious of my own assumption and it was only in writing this book that I asked him heh, so you want all abortion to be illegal. And he replied, oh no, then we’d be back to septic wards. I don’t want abortion to be illegal I want it to be unnecessary. And I thought that is so important. He’s prochoice and antiabortion. But because I conflated his ethical stance with his legal perspective, I made an unwarranted assumption.

Similarly, I was speaking to an obstetrician who fought to be trained in her residency in abortion. She trained in a part of the country where there was very conservative, very antiabortion. She had to fight tooth and nail to be the only person on her residency class to get trained in abortion procedures. That’s not her area of practice now but she’s advocated for other residents and she supports the education of it. I made an assumption about her and when we were talking one time, we were walking down the sidewalk in her city and she whispered to me, she said I mean I don’t know if it’s ethical. Now that I’ve had a kid, I sort of feel like is it ethical to end a pregnancy? I don’t know. But I will defend the right of my patients to have it and my students to do it till the end of the day.

And I thought, wow, I wouldn’t have assumed that about her ethics perspective, but she doesn’t have space to have that conversation, but I’ve been marked as safe to make the confession.

Host:  Some people’s views seem to be a little more complex and nuanced when it shows up in the culture wars where you are either prolife, prochoice and it’s sort of a monolithic cartoonish belief.

Katie:  Absolutely. And in the polling that asked the most simplistic questions, so I don’t think – in the book I talk about I’m not that interested in opinion polling. I mean it’s interesting. But my basketball career began and ended in seventh grade. And what I learned is when you’re guarding a girl, you don’t look at her eyes. Like her head can fake you out. You keep your eyes on her chest. You follow the body. The body does not lie. And so in this book, I was interested in the epidemiology and the fact that one in three women over 45 have had an abortion in the United States, one in four under 45 will if the current statistics were to stay the same and in 1800, the average white woman and that’s the only group for whom statistics were collected had seven children. In 2015, the average American woman had 1.8. It turns out we love contraception and abortion when you follow the body. I’m not sure we’re as conflicted as we say we are. And the providers I spoke with talked about how common it was for them to have appointments with people who started out by saying, listen, I’m completely prolife, I mean I’m against this. Or who, I interviewed one physician in the book who says every day and she’s in clinic at least one patient grabs her arm and says doctor, I need you to know, I’m not like these other women.

And how do you respond to that? Like yeah, you are. Like you have an idea.

Host:  So, part of your perspective is from your background as a lawyer. You’ve worked for the ACLU. What you see in the legal debates going on now, will there be changes? Will the constitutional right survive?

Katie:  Yeah. I wish I had a crystal ball and I’m very transparent in the book that I think Roe was correctly decided and that it should be maintained. Whether that will happen, I’m not sure. It will be a mistake, a legal mistake if it’s not. It would be a profound change in constitutional law and in terms as a constitutional lawyer, I’ll tell you that the principle of stare decisis, let the decision stand is central to American constitutional law in terms of the stability and the Supreme Court has reversed itself in a couple – a very small number of cases throughout history but it’s when there’s a completely new whether it’s scientific or cultural understanding of an issue. And we have no more “new science” on this issue than we did in 1973. It’s not that science hasn’t changed, but the basic foundational science that Roe was based on, we have no new cultural understanding. And what I think is fascinating, is we’ve had 47 going on 48 years of abortion and before Roe too of course, debates about abortion. We are no closer to reaching any consensus on the moral status of embryos and fetuses.

And what that proves to me is a consensus of a different type. Consensus that we can’t agree on this and so therefore, it’s an issue of conscious which is what we do. We don’t say oh it’s such a problem, we haven’t decided on the best religion. After 200 years of debate, we can’t have consensus on one religion. We leave that to pluralism. And so at the end of the day, the book is really a pitch for pluralism. To say abortion is a constitutional right is not to say that it’s right for every one or even that it is the “right thing to do.” But like other issues of conscious it is to say it’s central to some person’s identity whether they are for or against it. And it is central to their identity in life course and a woman’s life course whether she does or does not have a child, continue a pregnancy and have a child. And who else that if we have a different legal regime, what we have is a regime of government forced childbearing.

And that I think any of us concerned with theocracies or authoritarianism should oppose that regardless of whether we think abortion is a moral evil, morally neutral or morally good. There’s a separate set of sort of issues of pluralism and freedom at stake.

Host:  Were there any surprises when you did your research? Did you change your views on anything as a result of something you discovered?

Katie:  That’s a great question. Well I think what I learned that 59% of all abortion patients were women of color and 49% of them had incomes under the poverty line, I suddenly had a different picture of abortion patients. The diversity. But I began to think of it as an issue of healthcare disparities. And the idea that often, not exclusively, but often elderly white men were legislating for poor young women of color and forcing them to have children they didn’t want at the same time cutting public benefits and not supporting the children that they had. I think the hypocrisy of like living in the crosshairs and again the idea of making decisions without the people most affected because they don’t have the political power made me more invested as a white middle class straight cis woman to say this is – I’m from Indiana, I don’t like to fight. But the idea of like this is about using your privilege and your voice to stand with disempowered - people with less power and less opportunity to speak to audiences that can impact these issues.

And that’s what we do as bioethicists I think is to lift up these issues of – to stand with patients whose voices aren’t always heard as they should be. And so it helped me actually kind of destigmatize abortion to say it’s no different than what I’ve been trained to do and what I always do. And it’s also the case that as a bioethicist, I’m trained to see all patients as moral agents. And I may be not agree with them but understand that’s the whole revolution of the 70s of medical ethics that patients take the medical and scientific knowledge and filter it through their values and their life experience and their hopes and dreams for their lives and their practical world in which material world in which they live and make this decision that’s best for them. And they are the ones who will really live with that consequence. So, we support that.

I don’t know why I would treat the 42% of people and couples confronting unwanted pregnancies who choose to terminate less moral agency than the comparable number that continue their pregnancies, right? And so for me, it was about honoring both those patient sets and trying to understand them but also asking for reciprocal respect. I realize I’ve been trained to be very respectful of people who oppose abortion but those who oppose abortion are not always respectful of the patients who choose it and the physicians who provide it and that made me mad.

Host:  You and the book sort of surprisingly with a personal story. Do you want to talk about that a little bit?

Katie:  Yeah, I’ll talk about it a little bit and it’s so interesting because you are one of the very few people who have asked me when I’ve done media or podcasts about it. Which is interesting that I probably struck the right tone. During the course of writing the book, I myself was trying to get pregnant and that was just a coincidence of where I was in my life and my scholarship and I was very happy to be pregnant at one point and then my husband and I go some bad medical news and we chose to terminate. And so I found myself in a situation of doing field work I never intended, and I say that facetiously. That’s not at all how I looked at it.

But it’s impossible when you are in the midst of a project like this and you’re a scholar and you’re sitting in the waiting room of an abortion clinic not to look around. So, yes, it was profound to me and helpful to me to have already thought so deeply about stigma and how I might have reactions to think oh mine’s medical, it’s different. And I had already though through no, no, it’s not.

Host:  You talked a little bit about worrying about protestors when you went to the clinic.

Katie:  Yeah, and it’s so funny. I talked to an academic hospital first about doing it there and because that’s where we had had our testing and they told me it would cost upwards of $20,000, my insurance would cover it but there would be a 20% copay and so then we can afford to do that but I said, can you do that at the local clinics and they said yes and I said how much would it cost. And do you know, and they said $720.

Host:  $720 versus $20,000?

Katie:  Yeah and I was lucky to have been in professional and then personal relationship with someone who was a second trimester provider in another state and who trained in my city so I emailed her and said what would you do? She said, I’d go to the clinic. I actually think it’s better. They do a faster procedure. You don’t need to do all this convoluted OR stuff that this other place will do. And so I went and what was interesting is I had the impulse when I got to the clinic to not give them my insurance card to pay out of pocket even though my insurance would cover it. And I realized I was having the same stigma of like not wanting to be bureaucratically tracked and then I realized it was sort of like almost a political act to give them my insurance card, it was 100% covered and I felt good about my money going there actually so that was so striking to me.

But I was amazed at how well I was treated because I had a medical issue and so when I was speaking to the hospital scheduler, I said well why would someone go to the hospital instead of the clinic given this price differential even if you have an insurance coverage. And I expected a speech about quality. And she said well maybe they don’t want to deal with protestors. And I thought wow, talk about the tax, the stigma tax and she said also, your abortion is different. You don’t have a choice. And she tried to be very nice to me but that just hit me like a ton of bricks. Of course I had a choice. We all have choices. Some of our choices are more sympathetic or we have more limited options that other people can perceive, or they think I’d do the same thing. But we all have a choice. You have spent I’m sure hours with families in palliative pediatric care who chose to carry those lethal pregnancies or have children with severe every range of outcome who chose to do that. So, to say anybody with a medical situation doesn’t have a choice is false.

Similarly, people doing it for “social reasons” to say they have all the choices in the world is equally false. And so I realized I was having a nice lady abortion and I was going to be treated very well for being a white married woman with a medical issue and so it didn’t make me mad, but it was – it really taught me at an experiential level the caste system in care. It turns out, having a medical reason doesn’t change the procedure, right? Doesn’t make it more complicated unless I had like a cardiac condition, that’s different, but it determines where you’ll get to do it and who will pay for it. And those are the main things.

Host:  So, that is a very moving story that’s the last chapter of Katie Watson’s remarkable new book “Scarlet A, The Ethics Law and Politics or Ordinary Abortion.” The New York Times called it revolutionary. Georgetown’s Kennedy Institute of Ethics Journal praised it as pioneering. It’s published by Oxford University Press and wherever you get your books, you can order “Scarlet A” by Katie Watson a Professor of Bioethics and Medical Humanities and a lawyer. Thank you so much for joining us on this podcast.

Katie:  It’s my pleasure. Thank you.

Host:  This is the Pediatric Ethics Podcast coming to you from Children’s Mercy Hospital in Kansas City in the Children’s Mercy Bioethics Center. I’m John Lantos. Thanks for listening.