Willing and Unable: Doctors' Constraints in Abortion Care

Chapter 7: Conclusion

138 Chapter 7 Conclusion at the beginning of this book i asked, What happened to dr. Chasey’s residents after he trained them in abortion care? Dr. Chasey had spent most of his career as the director of a midwestern residency’s hospital-based abortion service. He wished, aloud, that his residents had the courage (or “guts,” as he put it) to face the challenges of providing abortion and that they would continue doing so throughout their careers. But they did not, and ultimately, most of them stopped providing abortions after residency (except for the rare genetically or medically indicated exception) for fear of professional repercussions stemming from abortion stigma, contention in their communities, and/or restrictions placed on abortion by medical groups, hospitals, HMOs, or religiously affiliated institutions where they practiced. Throughout this book, I have attempted to explain why abortion practice in the United States is so vulnerable to the social and political contention surrounding it and how we have arrived at a place in time where restrictions on physician autonomy in general, and abortion practice in particular, are widely tolerated by the medical profession. During the more than thirty-five years that women have possessed the right to have an abortion, Americans have generally believed that physicians held a corresponding right to provide it. Abortion provision has thus been perceived as a personal choice. But any good sociologist would caution against explaining a growing trend in the decline of abortion providers as simply the outcome of a series of personal choices. Joining biography and history (Mills 1959), I have situated the experiences of new physicians within their ConClUsion 139 structural contexts and found that their personal choices around abortion practice are seriously constrained. By tracing the history of American medicine’s relationship to abortion over the past 150 years, I showed how major medical associations have generally been interested in abortion turf when it served the professionalization project of medicine. During the late nineteenth century, the physicians ’ crusade against abortion was crucial in criminalizing the procedure as well as in establishing physicians as both moral and medical authorities . The crusade effectively displaced other types of health practitioners competing for medical territory and established these physicians as legitimate guardians of normative sexual and reproductive behavior. This newfound legitimacy also enabled physicians to determine what exact indications made abortion justifiable; these parameters showed some flexibility during the Depression, when unwanted pregnancy was seen as especially detrimental to families, but were tightened during the 1940s and 1950s, when hostility to female independence was widespread. The tightening led to decreased access to safe abortion at the same time that major shifts in sexual culture led to a more noticeable and intolerable public health problem of abortion-related maternal mortality. Some physician activists and progressive associations (ACOG and APHA) were instrumental in abortion policy change during the 1960s and 1970s; however, many physicians worried about becoming “mere technicians” as abortion became an elective procedure decided upon by only the patient. After legalization, the AMA and many crucial medical bodies were inconsistent and silent on how abortion should be practiced. In their institutional passivity and ambivalence, they failed to incorporate abortion into mainstream medicine. Instead, freestanding abortion clinics proliferated to meet the high demand for abortions while those performed in hospitals steadily declined. Fewer and fewer abortion clinic doctors provided the lion’s share of abortions. In the decades after legalization , the marginalization of abortion from mainstream medicine became increasingly problematic as abortion clinics were plagued with harassment, violence, and legislative hurdles from a strong antiabortion movement. In response, abortion rights advocates called for physicians to mainstream abortion by integrating it into their general practices in order to decrease the stigma, visibility, and professional marginalization 140 Willing and Unable of abortion care and to counter a growing shortage in abortion providers in many parts of the country. Physicians, however, appear slow to heed the call. Given that ob-gyns are considered experts of the uterus, that abortion is the third most common procedure their patients of reproductive age will undergo, and that most of these physicians heard the “integration” message during abortion training, I asked whether physicians felt responsible to help ameliorate the growing provider shortage. I found that the lack of a clear professional or legal mandate to provide abortion, as well as the hostile conditions surrounding it, mediates their sense of duty to continue performing abortions after residency. While...