Willing and Unable: Doctors' Constraints in Abortion Care

Chapter 2: Abortion in American Medicine: A Recent History

20 Chapter 2 abortion in american medicine: a recent history in 1995, dr. Jane hodgson, abortion provider and heroine in the movement to legalize abortion, wrote an editorial in the British Medical Journal reflecting on the period of legalized abortion in the United States.1 In it she lamented the problems that plagued abortion care—problems that, unlike antiabortion activism, were fostered within American medicine itself: The public should have been taught by medical leaders for the past 22 years that abortion is a necessary surgical service that should be available to whoever needs it. Abortion clinics should have been encouraged to occupy space in the large professional medical buildings, surrounded by other specialties, or, even better yet, to seek the protection of anonymity within hospital walls. Instead they have been forced into isolation as freestanding clinics. Removed from the mainstream of medical practice, they are more vulnerable to violence and harassment and less accessible to students and residents for the purposes of medical education . (Hodgson 1995: 548) Dr. Hodgson’s words represent the very heart of a prominent pro-choice argument for the integration of abortion services into mainstream health care. Integrationists want to see the medical profession use its muscle to protect and normalize abortion care. Yet, although increases in abortion training since Hodgson wrote her editorial have successfully changed the medical culture of some academic medical settings, little has changed in abortion in ameriCan mediCine 21 the overall organization of abortion services. This chapter examines the medical context of abortion practice since Roe v. Wade—both how the marginalization of abortion services came about, and solutions advanced by pro-choice advocates and medical constituencies to bring abortion in from the periphery. Medical leaders have been present and influential in all major stages in U.S. abortion history, including the criminalization of abortion during the nineteenth century, the illegal practice of abortion during the twentieth century, the legalization of abortion in 1973, and the persistent “abortion wars” that have followed. In each of these stages, the medical profession became interested in abortion at times when it assisted the professionalization project—that is, when it could be used to help legitimize its claims to power. Thus, abortion care has not always been “untouchable” by the mainstream. However, given the larger threats to medical autonomy after abortion became legal, abortion services seemed to garner support from mainstream medical associations only at moments when medical autonomy was threatened. Through examination of significant moments of abortion turf grabbing and guarding, one can see that not only is the medical profession’s development important to the history of abortion, but abortion is important to the history of the medical profession. American medicine’s relationship to abortion has been one marked by long-standing lethargy (Hodgson 1995), deep ambivalence (Joffe 1995), and even intentional avoidance (Halfmann 2003). Such characterizations should be unsurprising, as American medicine is not a monolithic entity. It is composed of disparate professionals with different political and religious leanings. However, the net effect of the medical profession’s noncommittal orientation toward abortion care has been to thwart efforts by abortion rights advocates within medicine to legitimize abortion as a normal reproductive health need. Since abortion was legalized in 1973, the lack of mainstream institutional and organizational support for it (Joffe, Anderson, and Steinauer 1998; Joffe 1995) has ultimately resulted in the marginalization of abortion care into freestanding abortion clinics served by politically motivated physicians. Heated contention around abortion has surfaced within the medical profession periodically over the years, and as this book demonstrates, mainstream medical settings have responded by avoiding involvement with abortion whenever possible. Such 22 Willing and Unable avoidance might not be significant if abortion were not one of the most common surgical procedures performed on women of reproductive age (DeFrances and Hall 2007; Jones et al. 2008). When those in the medical profession have not avoided the discussion ofabortion,theirpositionsonithavetakendifferentforms.Themostconsistent message has been, “no one but us should do it.” The medical profession has exerted considerable effort toward ensuring that abortion stay under the domain of physicians—and not the midwives of the nineteenth century or the “back-alley butchers” of the twentieth. The twenty-firstcentury struggle under way involves midlevel providers working through sanctioned legal and medical channels for the right to provide abortions (not always under the supervision of physicians) in order to expand the base of abortion providers.2 Regardless of medicine...