Political and ethical issues in abortion today

Transcription

1 Political and ethical issues in abortion today Karen R. Meckstroth, MD, MPH Associate Clinical Professor Dept. of Obstetrics, Gynecology & Reproductive Sciences University of California, San Francisco Director, UCSF Family Planning Services at Mt. Zion Disclosures Dr. Meckstroth receives an honorarium from Danco, Inc. (the distributors of mifepristone in the U.S.) for answering calls from clinicians who call an FDAmandated hotline on medical abortion. Acknowledgements Thank you to Tracy Weitz and Carolyn Suffrin who shared slides My goal: Help you consider some ethical tipping points in abortion law Abortion laws and trends Social disparities and abortion The Hyde Amendment and funding restrictions Conscientious refusal should there be limits? Not: When is abortion an acceptable ethical choice? When does life begin? 1

2 Influences on Abortion laws and policies Legal abortion Clear public health benefit saves women s lives Critical to women s social equality Personal autonomy Women s mental health Child welfare & protection Restricted abortion Abortion ends a human life Religious doctrines Personal responsibility General agreement: Ideal to reduce unplanned pregnancies (sadly, few laws or policies address this) Providers should not be forced to do abortions Women should not be coerced to have abortions Some restriction on abortion is reasonable? (e.g. a viable term pregnancy) Abortion is a common healthcare occurrence for women Abortions are among the most common medical procedures for women of reproductive age In 2005, 1.2 million abortions (roughly equals C-Sections) 50% of all pregnancies in the U.S. are unintended 48% of unintended pregnancies end in abortion By 45, 1/3 of American women will have had an abortion 60% of women obtaining abortions are already mothers Guttmacher

3 90% of abortions occur by 12 weeks CDC 2004 Abortion is very safe in the U.S. Abortion is one of the safest medical procedures Successful in % cases Complications are rare (0.04% % have a complication requiring hospitalization) Abortion is even safer if earlier in pregnancy Early abortion is very simple to perform Where abortion is illegal, it is often unsafe Globally, 1 in 8 maternal deaths result from unsafe abortion 3

4 The legal status of abortion does not predict its incidence The lowest abortion rates in the world less than 10 per 1,000 women of reproductive age are in Europe, where abortion is legal and available. By contrast, in Africa and Latin America and the Caribbean, where abortion law is most restrictive, rates are about 30 per 1,000 women. PRCH & Guttmacher Sedgh et al., 2007 High rates of abortion occur in countries that severely restrict abortion Abortions per 1,000 women PRCH & Guttmacher Boonstra, 2006 How well do you feel you understand major federal and state abortion laws? a. Minimally b. Vaguely familiar with the basics c. Fairly well, but without confidence d. Familiar with most of the laws 4

5 Legal framework Roe v. Wade [1973] Abortion without restrictions in 1st trimester Restrictions in the 2nd trimester for health indications Health and life exception after viability Abortion falls under the right to privacy Planned Parenthood v. Casey [1992] Eliminated distinction between 1st and 2 nd trimester Established undue burden as standard for constitutionality of abortion regulation States allowed to regulate abortion to demonstrate a preference for childbearing over abortion Majority decision comments Roe v. Wade "We need not resolve the difficult question of when life begins. When those trained in the respective disciplines of medicine, philosophy, and theology are unable to arrive at any consensus, the judiciary, at this point in the development of man's knowledge, is not in a position to speculate as to the answer. PP v. Casey "At the heart of liberty is the right to define one's own concept of existence, of meaning, of the universe, and of the mystery of human life." Restrictive U.S. abortion laws # of states Targeting providers: Physician-only 38 Hospital-only after certain gestation 19 Broad conscientious refusal clauses 46 Partial-birth abortion federal Required reporting 46 Facilities restrictions (TRAP laws) 26 Targeting women: Funding restrictions 32 No private insurance coverage 4 Parental involvement 34 Waiting periods (usually hours) 24 State-mandated counseling information 23 Ultrasound viewing or listen to heart 14 Guttmacher.org May 2010, Center for Reprod Rights

6 Pew Research Center Poll (Gallop poll agrees) Examples of recent laws ( ) ND: Requires provider to inform woman abortion ends the life of a whole, separate, unique, living human being OK: Ban on abortion for gender of fetus. Women must see ultrasound; must describe the heart, limbs and organs of the fetus. No rape/incest exception. UT: Requires counseling on fetal pain and, upon request, the provision of anesthesia for the fetus 6

7 November 2010 in Nebraska No abortions after 20 weeks because of fetal pain. Mental and physical health screen required. Includes any risk factors cited in peer-reviewed journals indexed by two major medical and scientific listing services during the year before a planned abortion. The risks could be "physical, psychological, emotional, demographic, or situational," 2010 Utah Illegal abortion/miscarriage law The "unborn child in the womb at any stage of its development" is fully covered by the state's murder and manslaughter statutes Permits prosecution of woman for seeking illegal abortion, or knowingly, willfully, and/or recklessly behaving, at the expense of the fetus Includes any activity that is known or thought to cause miscarriage Drinking coffee? changing litter box? riding bike? Other abortion restrictions Facility/hospital-level abortion restrictions Hospital admitting privileges Physician-only limits Abortion procedure bans Other state initiatives Choose life license plates Abortion alternatives funding 7

8 Arizona Law: football and abortion In 1974, the legislature s allocation of $5.5 million to renovate its football stadium included an amendment specifying that no abortion shall be performed at any facility under the jurisdiction of the Arizona board of regents unless such abortion is necessary to save the life of the woman having the abortion (A.R.S ) Basic healthcare is a right and the government should make sure it is available for everyone. 1. Strongly AGREE 2. Agree 3. Neutral 4. Disagree 5. Strongly DISAGREE Do you think the federal government should guarantee health insurance for all Americans, or isn t this the responsibility of the federal government? 2007 U.S. Poll 64% 27% 8

9 Restrictive abortion laws disproportionately affect poor women Less choice of care providers Default enrollment Political restrictions affect public facilities Religious facilities more likely to be in low-income communities, often providers of charity care Less capacity to advocate for alternatives Parental involvement laws: poor girls are more likely to live with one or neither parent Mandatory waiting periods: travel issues, childcare, time off work Facility restrictions = fewer locations = more travel Rate of Abortion by Economic Status % of poverty level Guttmacher. Jan 2008 Abortions per 1000 Poor and low-income women account for 3/4 of U.S. abortions Minorities have the majority of abortions in the U.S. 9

10 To Court Blacks, Foes of Abortion Make Racial Case - Issues4Life Foundation Goals: Zero African- American lives lost to abortion or the biblically immoral implementation of biotechnology. Denounced PPFA and its "racist and eugenic goals" and blamed abortion providers for the high abortion rate in the African-American community deeming the situation the Darfur of America Are health care providers using abortion to curb the growth of the U.S. black population? - Mar 13, 2010 No conspiracy theory needed Abortion rates mirror rates of unintended pregnancy for all ethnicities The Hyde Amendment (1976) After Roe v. Wade, medically necessary abortions were covered in most states under Medicaid. Hyde Amendment: bans federal funding of abortion except (in the current version) in cases of rape, incest and life endangerment. Physical health exception was dropped in 1979 Rape and incest exceptions added in 1981 The life exception has to be physical as of 1997 (no threat of suicide) 10

11 The Hyde Amendment "I certainly would like to prevent, if I could legally, anybody having an abortion, a rich woman, a middle-class woman, or a poor woman. Unfortunately, the only vehicle available is the Medicaid bill." Henry Hyde 1977 "If we now restrict or ban Medicaid funding for abortions, the government will accomplish for poor women indirectly what the 1973 [Supreme Court] opinion expressly forbade it to do directly a right without access is no right at all," -Sen. Edward Brooke (R-MA) State exceptions 17 states use state funds to pay for all or most abortions for women with Medicaid to protect a woman s health (=elective). Four do so voluntarily. The others were ordered by state courts. Hawaii Maryland New York Washington Alaska Arizona California Connecticut Illinois Massachusetts Minnesota Montana New Jersey New Mexico Oregon Vermont West Virginia States that follow Hyde 32 states and Wash D.C. pay as required by the Hyde Amendment (3 add fetal anomaly, 3 add grave health risk) South Dakota is in violation of federal Medicaid law because it pays for abortions only in cases of life endangerment. 11

12 Other federal funding restrictions Military personnel and dependents Abortion forbidden in military hospitals, even if selfpay (including overseas) Federal employees and dependents Most make < $40K per year Indian Health Service Twice as likely to live below poverty line Women in prison Must be give an escort, but staff can refuse Peace Corps Volunteers: NO exceptions Patient Protection and Affordable Care Act Bans the use of federal subsidies to pay for abortion by: Requiring all who buy a policy that covers abortion to divide payments in two: a small part to cover abortions and a bigger payment for the rest of the premium. Requires insurers to keep two accounts Experts agree that this will discourage insurers from offering plans that cover abortion. Patient Protection and Affordable Care Act Allows states to ban insurers who take part in the exchanges from offering policies that cover abortion. In states that don t, the exchanges must offer at least one policy that excludes abortion coverage. They are not required to offer policies that cover abortions. Attaches the abortion restrictions to the Hyde Amendment 12

13 Effects of funding restrictions Studies of multiple states concluded that 18 35% of women who would have had an abortion continued their pregnancies after Medicaid funding was cut off. Study in N.Carolina where funds were cut off before the end of year suggest 1/3 of women who would have had an abortion carried to term 10% fewer abortions among black women and 1% fewer among white women Henshaw et al. Restrictions on Medicaid Funding for Abortions: A Literature Review, Guttmacher Jun 2009 Effects of funding restrictions Evidence supports: Decreased rate of abortions Delay in access to abortion Fewer abortion providers (cause or effect?) Higher overall costs to state and federal social programs Studies inconclusive: Rates of illegal abortions (not by a physician) Abortion complication rates Pregnancy complications (preterm delivery, low birthwt) Child abuse rates Changes in sexual behavior or contraception Suicide rates Henshaw et al. Restrictions on Medicaid Funding for Abortions: A Literature Review, Guttmacher Jun 2009 Lack of funding (and poverty in general) delays abortion Poor women take up to 3 weeks longer to obtain an abortion 2 primary delays: (1) confirming pregnancy and (2) obtaining Tab after decision Poor women twice as likely to report difficulty obtaining abortion (usually obtaining $) In states with funding for abortion, poor women obtain abortion an avg of 1 week earlier than women just over the poverty limit Guttmacher Policy Review 2007, 10:1 13

14 Reasons for delay in 2nd-trimester patients Difficulty in getting to our clinic 63%* Emotional factors 51% Initially referred to other clinic(s) 47%* Afraid 35% Didn t suspect pregnancy 34%* Unsure of decision 30%* In denial about being pregnant 21%* Difficulty with Medi-Cal, money, insurance 20%* Difficulty figuring out where to go 20%* Unsupportive partner 19% Drey E et al, Ob Gyn, 2006 *statistically significant vs. early abortion patients, p<0.05 Reasons for delay in 2nd-trimester patients Difficulty in getting to our clinic 63%* Emotional factors 51% Initially referred to other clinic(s) 47%* Afraid 35% Didn t suspect pregnancy 34%* Unsure of decision 30%* In denial about being pregnant 21%* Difficulty with Medi-Cal, money, insurance 20%* Difficulty figuring out where to go 20%* Unsupportive partner 19% Drey E et al, Ob Gyn, 2006 *statistically significant vs. early abortion patients, p<0.05 After remaining stable for many years, the inflation-adjusted cost of an abortion rose in 2001, and then declined slightly in 2006 Guttmacher. Trends in Abortion Jan

15 Poverty level income Family Size Federal Poverty Level Monthly Income 200% of Poverty Level 1 $10,830 $903 $21,660 2 $14,570 $1,214 $29,140 3 $18,310 $1,526 $36,620 4 $22,050 $1,838 $44,100 Few providers accept public funding Abortion reimbursement PAYER 1 st Tri 2 nd tri +sono Medi-Cal $179 $253 $78 (profees) PPO $710 $800 $280 (profees) National avg $413 $800-$18,000 (all care) Abortion providers in California 189 Publicly listed abortion providers (sites) 49 Accept Medi-Cal for first tri (20 are in the San Francisco Bay Area) 42 Accept Medi-Cal past 14 weeks 8 Accept Medi-Cal through 24 wks Access/WHRC Mar

16 There are 954,000 physicians in the U.S How many abortion providers are there? a. 35,200 b. 19,800 c. 10,209 d. 5,672 e. 1,787 Only 2 states with >100 26% of all in CA The number of U.S. abortion providers rose until 1982 and has declined since 11% decline 2% decline Guttmacher. Trends in Abortion Jan

17 Factors Contributing to the Decline in the Number of Abortion Providers Anti abortion harassment and violence Social stigma/marginalization Professional isolation/peer pressure The graying of providers Inadequate economic/other incentives Lack of medical training opportunities Guttmacher 2009, NAF and ACOG, 1991 The percentage of U.S. counties with no abortion provider has remained high Guttmacher. Trends in Abortion Jan 2008 Training in abortion Family Medicine 11/480 training programs reported routine abortion training in Another 7 programs allowed electives. 1 OB/GYN ACGME requires abortion training for Ob/Gyn residents since Jan Supported by ACOG Residents with religious or moral objections must receive training in management of abortion complications. Internal Medicine Must seek training electively. 1. Dehlendorf. Fam Med

18 Schwarz EB. Willing and able? Provision of medication for abortion by future internists Residents training in internal medicine knew less about mifepristone and preabortion screening than other primary care trainees. 42% of internists willing to prescribe mifepristone Many concerned about lacking adequate "backup" (vacuum aspiration services) Womens Health Issues Conscientious refusal Long history of federal protection for health workers with objections to abortion and sterilization 2009 federal law defines "assist in the performance" as "any activity with a reasonable connection" to a procedure or health service, including counseling and making "other arrangements" for the activity. Cleaning instruments, serving food, etc. 45 CFR Part Oklahoma Permits withholding fetal information Must have an ultrasound and hear detailed description of fetus Cannot sue doctor who withholds information about the fetus, including about a fetal abnormality To keep pregnant women from discriminating against fetuses with disabilities and prevent doctors from influencing women to get abortions 18

19 Should there be limits to conscientious refusal? A physician finds severe anomaly and won t refer for abortion if the woman asks or won t tell the woman about the anomaly out of fear she might get an abortion A woman who is raped goes to the only hospital in her small town. The hospital won t tell her about EC because they fear it causes abortion. Limits to conscious refusal In Nov 2009, a 27-year-old woman was admitted to St. Joseph's Med Center in Phoenix. She was 11 weeks pregnant with her fifth child with severe right heart failure and an estimated mortality of ~ 100%. She was too sick to be transferred. The administrative nun agreed to abortion. The woman lived. The nun was excommunicated. The Bishop said, There are some situations where the mother may in fact die along with her child. Balancing conscientious refusal and other ethical principles in medicine Provider sacrifice vs. Conscientious refusal Professionalism: timely and effective, evidencedbased care Informed consent: the right to know options Autonomy: patient has right to choose treatment Beneficence: act in the patient s best interest Non-maleficence (first do no harm) Beneficence: act in the patient s best interest 19

20 My other goal Leaving you with more questions: Should contraception be considered basic healthcare? Can your practice help improve access to and use of contraception? Will your practice help women (especially poor women) navigate access to abortion? Maybe all can agree on prevention of unplanned pregnancy Long Acting Reversible Birth Control (LARC): Most effective, safest, easiest to use (forgettable) No controversial mechanism of action LNG-IUS Cu-T Implant 20