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91 chapter 5 Practice Constraints and the Institutionalized Buck-Passing of Abortion Care I had a lot [of residents] that were just 100 percent pro-choice who have never done an abortion in private practice . . . In a conservative state like [this one in the Midwest], if you get the reputation that your group performs abortions, all of a sudden the other groups have a marked increase in their patient load. Dr. Davis Chasey, retired founder and director of a residency abortion clinic For decades, abortion rights activists and scholars have argued that abortion should be integrated into mainstream medical care and hence treated as a legitimate part of full-spectrum reproductive health services (Lindheim 1979; Rose 2007). In theory, getting abortion services out of the clinics and into doctors’ offices would reduce stigma and make abortion care less marginalized and vulnerable to violent attack by antiabortionists. To many in the pro-choice movement, this seems a straightforward solution requiring only the politicization of physicians and their commitment to continuing to provide abortions after residency. However, this strategy fails to take into account the substantial decline in physician autonomy since the dominance of managed care. Although numerous physicians have become politically active around abortion during medical school and residency,1 the commitment appears to be too costly for most physicians to sustain. The willing physicians in this chapter explain how integrating abortion into mainstream medical services is quite difficult. Mainstream 92   willing and unable medicine passed the buck on abortion long ago, and many physicians find it both regrettable and easier that way. Abortion Stigma, Professional Civility, and Conservative­Community Pressure In many parts of the country, both urban and rural, the legacy of the pre-Roe “abortionist” is alive and well. The stigma associated with this label is pervasive yet unusual as far as stigmas go in that this one is associated with an otherwise high-status individual: a physician. Regardless , the label is “deeply discrediting,” in the words of Erving Goffman, from his seminal introduction of stigma to the field of sociology (Goffman 1963: 3). The word abortionist confers the imagery of a physician who does little else besides abortion and may be not skillful enough to do well in general or mainstream medicine. It also connotes bad intentions . In Carole Joffe’s study of doctors who provided abortion before legalization, one physician remembered that “ ‘abortionist’ was such a dirty word, it was just one step above pervert, or child abuser . . . to be called an abortionist in the 1950s, you were the scum of the earth” (Joffe 1995: 76). Also, by the mere association with abortion, especially at that time, doctors were seen as condoning a “sexually immoral” lifestyle. Remarking on how perceptions of physicians providing illegal abortions (and those parading as physicians) affected future generations of abortion providers, Joffe writes, “Abortion practices in the pre-Roe period created a complex legacy for physicians active after Roe, given the enduring images of inept ‘quacks’ and ‘butchers’ and the associations with criminality and greed” (Joffe 1995: 52). After legalization, some of Joffe’s abortion providers found that their status increased little and that the label abortionist stuck in certain medical environments, regardless of the legal legitimization. One physician objected, “I’m no more an abortionist than I am an obstetrician or a hysterectomist or any other procedure that I do” (Joffe 1995: 153). In a review of the sociological literature on stigma since Goffman (1963), Bruce Link and Jo Phelan (2001) found four principles consistent among stigmas. These can be applied neatly to abortion providers. First, Link and Phelan argue that stigmas are widely used to distinguish and constraints and institutionalized buck-passing   93 label difference—as in abortionist rather than ob-gyn or physician. Second, the label is associated with a negative attribute, in this case, a morally deficient or technically incompetent physician. Third, the stigma allows the user to separate “us” from “them,” much as the “quack” is singled out from legitimate physicians. Finally, status loss and discrimination result— exactly what was feared by several physicians in my study and widely experienced decades ago by Joffe’s abortion-providing physicians. Many physicians I spoke with, like Joffe’s physician, regard the idea of being labeled for one of the many surgical procedures they perform as absurd. For those in small-town private practices, however, the prospect of being identified with abortion in this way is profoundly threatening. For example, Dr. Bill Spellman in the Midwest said: “I didn...


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