Abortion and the Private Practice of Medicine

Jonathan B. Imber

• Publisher: Routledge
• Year: 2017
• Print ISBN:
  9781138518582
• eBook ISBN:
  9781351534307
• Topic: Social Sciences
• Subtopic: Ethics in Medicine
• Index: Social Sciences

Originally published in 1986, Abortion and the Private Practice of Medicine was the first book to look at abortion from the perspective of physicians in private practice. Jonathan B. Imber spent two years observing and interviewing all twenty-six of the obstetrician-gynecologists in "Daleton," a city that did not have an abortion clinic. The decision as to whether, when, and how to perform abortions was therefore essentially up to the individual doctor. Imber begins the volume with a historical survey of medical views on abortion and the medical profession's response to the legalization of abortion in the United States. Quoting extensively from his interviews, he looks at various characteristics of doctors that may affect their professional opinion on abortion: their age, gender, religious background, and length of residence in the community; the nature of their training and prior experience; and the setting of the practice (whether group or solo). Imber found that the physicians' reasons for agreeing or refusing to perform abortions revealed considerable differences of opinion about how they construe their responsibilities.

1 Abortion as a Medical Responsibility

Until recently, abortion was one of the most widely proscribed practices in Western culture. The Hippocratic oath specifically prohibited it, and this injunction was supported by Judeo-Christian reverence for life. With the legalization of abortion in many parts of the world during the twentieth century, this barrier has given way to such an extent that the physician’s responsibility for deciding whether to perform the procedure is now seen to be of less consequence for its availability than the outcome of political struggles that may have little to do with medicine.

Birth control, as it was called by such leaders of contemporary Western sexual enlightenment as Margaret Sanger, offered a new sovereignty over unborn life, first to women and then to the medical profession and the state. For half a century the birth control movement publicly maintained the moral distinction between contraception and abortion, extolling the former while condemning the latter as barbaric and unnecessary. The rhetoric called for a pedagogy that would instruct patients (that is, women) and doctors in the responsible control of conception (see Kennedy, 1970; Gordon, 1976; and Reed, 1978). Until the early 1970s, the rubric family planning concealed a change in attitudes that had taken place among supporters of birth control who also endorsed a less inhibited sexuality. With the rise of the contemporary women’s movement, the right to obtain an abortion became a prerequisite to the liberation of women. The assertion that control over one’s body must include the right to choose abortion was quickly countered by the assertion that the taking of life is never permissible.

Discussion of abortion extends far back in the history of Western religions thought, and for many the matter continues to be a troubling spiritual problem (Noonan, 1970; Jakobovits, 1975; Connery, 1977). Ignorance about the biological origins and development of life also resulted in many differences of opinion about the circumstances in which abortion should be permitted. But with the rise of scientific medicine in the nineteenth century, a new consensus began to form among physicians.

In the United States, abortion was not punishable by statute before 1820, although the common law had provided penalties for the destruction of unborn life after the time of “quickening,” or that moment in pregnancy when the mother first experiences the movement of the fetus. By 1890 every state in the nation had passed a law prohibiting abortion. Historian James C. Mohr has demonstrated persuasively that in the mid-nineteenth century the “graduates of the country’s better medical schools” and the members of the newly established (1847) American Medical Association led the campaign to outlaw abortion in America (1978:33–34; 147–48). These so-called regular doctors assumed an authority over the procedure that has had a lasting effect on the moral connotations of the term abortionist, despite dramatic changes in the law in recent years.

Mohr’s study presents important revisions in our understanding of traditional resistances to the practice of abortion. The “regulars” moved against it, he argues, in order to use state power to enhance their control over the practice of medicine by those who lacked their credentials. The claim that the medical profession had the central role in this effort is supported by the apparent lack of public, and especially Protestant, opposition to abortion. Although the Catholic Church has consistently opposed abortion, for Mohr the pro-choice view that gained prominence in the 1970s can be interpreted as a continuation of the public indifference of the nineteenth century and as further evidence that abortion is neither abhorrent nor spiritually troublesome to large segments of the population. This revisionist view has found confirmation in recent changes in the law.

Mohr describes the medical profession’s allegiance to the newly emerging ideology of the scientific treatment of disease. Scientific research, technical expertise, and standardized treatment were expected to reduce the fallibility of human judgment. The opposition to abortion was thus led by a professional guild that sought legal and cultural hegemony over medical procedures, but did so in the name of science.¹

Nineteenth-century American doctors’ efforts to restrict abortion were indebted to a growing understanding of fetal development, as yet unknown to the lay population: “Scientifically regulars had realized for some time that conception inaugurated a more or less continuous process of development which would produce a new human being if uninterrupted. . . . From this scientific reasoning stemmed the regulars’ moral opposition to abortion at any stage in gestation” (Mohr, 1978:35–36). Further: “Most physicians considered abortion a crime because of the inherent difficulties of determining any point at which a steadily developing embryo became somehow more alive than it had been the moment before” (1978:165). The cultural resistance to abortion in America originated not in public opinion or in particular theological doctrine as much as in the medical profession’s commitment to scientific findings. Against the amoral image of science that Max Weber (1948) bequeathed to modernity, nineteenth-century science produced extraordinary moments of clarity in the relation between facts and values. Instead of creating new exceptions to the laws prohibiting abortion, the scientific knowledge of conception formed the basis for a powerful opposition to it and strengthened theological valuations of the sanctity of unborn life. Faced with the knowledge that a human life is developing from the moment of conception, regular doctors publicly opposed the resort to abortion. A major purpose of this chapter is to review how physicians went about determining exceptions to the rule that prohibited them from interrupting pregnancy.

The work of Dr. Frederick Joseph Taussig (1872–1943) during the first half of the twentieth century exemplifies the way in which many physicians construed their responsibilities regarding the performance of abortion. Educated at Harvard and at the Washington University Medical School, Taussig taught and practiced obstetrics and gynecology for most of his life in St. Louis. He was president of the American Gynecological Society (1936–37) and director of the American Society for the Control of Cancer (1938). His prominence in American obstetrics and gynecology was firmly established by the publication of several books, especially Diseases of the Vulva (1923) and Abortion, Spontaneous and Induced: Medical and Social Aspects (1936). (See Crossen, 1943, and Marquis, 1943, 1945).

In Criminal Abortion: A Study in Medical Sociology (1964), Jerome E. Bates and Edward S. Zawadzki wrote:

It is a relatively recent event to have physicians of national reputation speaking and writing on the social repercussions of our abortion laws. Frederick J. Taussig, M.D., pioneered in this field by publishing Abortion: Spontaneous and Induced in 1936. This work was primarily a medical book with a few chapters covering induced abortion from a sociological and historical point of view. As one might expect the book had no effect on the public although it did encourage other physicians to study the effects of criminal abortion on maternal and child welfare. (p. 115)

Bates and Zawadzki did not mention (except in their bibliography) that Taussig had written The Pretention and Treatment of Abortion many years earlier, in 1910. This work was the first full-length study in twentieth-century America of the “anatomy, pathology, etiology, and diagnosis of this condition” (p. 2).

The book addressed three important aspects of the abortion problem. First, Taussig’s analysis of the medical indications that justified therapeutic abortion guided discussions by later American physicians. Second, his remarks about the prevention of conception anticipated the role that contraception would eventually play in American medicine. And third, his thoughts on the prevention of criminal abortion offered valuable insights into the dilemma of how best to reduce the use of abortion as a means of birth control.

A distinction between therapeutic and nontherapeutic abortion has always existed in medical parlance. Both types are called induced abortions in that birth would result if pregnancy were otherwise undisturbed. According to Taussig, “Therapeutic abortion has been defined as the induction of abortion on the part of the physician in order to save the life of the mother” (1910:162). He listed three general categories of medical indications for the procedure:

1. pathologic conditions due directly to the pregnancy,
2. maternal diseases aggravated by pregnancy, and
3. extreme contractions of the birth canal.

Of the three pathologic conditions that he cited, “incarceration of the pregnant uterus,” he said, “is most often due to retroflexion or retroversion of the gravid uterus” (1910:162). In other words, the pregnant uterus is bent in such a way that it cannot assume its proper shape, thus imperiling the lives of the mother and of the unborn child. He proposed several ways to alleviate the condition, the most radical of which was hysterectomy, or removal of the entire uterus. Laparotomy, which required incision through the abdominal flank in order to reach and “break up the dense adhesions that bound down the uterus,” was also recommended before resort to a therapeutic abortion (1910:163).

Acute hydramnios, or excessive buildup of amniotic fluid in the uterus, could not only cause severe pain but result in cardiac insufficiency, making therapeutic abortion “absolutely necessary” and the likelihood of a live birth “practically nill” (1910:163). The third pathologic condition, “one of the most frequent and important indications for therapeutic abortions,” was hyperemesis, or excessive vomiting. This was occasionally misleading, Taussig noted, because “vomiting is at times brought on by the patient so as to influence the physician to hasten the emptying of the uterus.” He advised that such a patient be placed in a hospital and “kept under constant watch.” Referring to a report in the medical literature, he described a patient “who by persistent vomiting and by abstaining from food lost thirty-seven pounds in four weeks. After the doctor had finally felt compelled to do an abortion, she laughingly remarked to him that she could have refrained from vomiting if she cared to” (1910:163). Taussig warned that “one has to be on guard against such malingerers” (1910:164).

The second group of indications for therapeutic abortion consisted of those maternal diseases that were sometimes aggravated by pregnancy, “primarily heart and kidney lesions and tuberculosis of the respiratory tract” (1910:164). In these cases, therapeutic abortion did not treat the ailment but reduced the likelihood that it would become life-threatening. Taussig also believed that “certain nervous and psychic diseases at times necessitate the induction of abortion. Not, however, the neurasthenias or even the cases of so-called nervous prostration” (1910:164–65). The fatigue and mental depression often associated with pregnancy, he concluded, were not sufficient indications of the need for therapeutic abortion.

The final group of indications, “marked narrowing of the birth canal,” referred to “cases where Caesarian section is absolutely necessary for the delivery of a living child” (1910:165). Taussig recommended that the mother be permitted to decide whether she would undergo a Caesarian section, but he added: “As a rule, if she is in fair general condition she should be persuaded to await the end of pregnancy and have a Caesarian section performed, since statistics show that this operation is attended with a very small mortality” (1910:165). In a case he described as “inoperable cancer of the cervix,” Taussig saw no justification for terminating the pregnancy, “since here the mother’s life is lost anyway and every effort must be made to get a living child by Caesarian section” (ibid.). It is worth noting that Taussig viewed Caesarian section as a way of avoiding the resort to induced abortion earlier in the pregnancy. Hysterotomy or a “mini-Caesarian” section, sometimes used as a method for late second-trimester abortion, was not yet discussed, in large part because the physician’s obligation was to encourage the continuation of pregnancy until a living child could be delivered.

The medical indications that Taussig described may be said to have compelled the physician to perform an abortion, but only after other avenues of care had proved ineffective. Therapeutic abortion was most strongly indicated during medical emergency when the mother’s life was clearly in jeopardy. Although maternal diseases of the heart, lungs, and kidneys were sometimes aggravated by pregnancy, they represented weaker indications for abortion than more immediately life-threatening disorders. For Taussig, the physician’s medical judgment embodied his particular understanding of disease and its potential effect on both the mother’s health and her pregnancy. How “medical” indications were to be defined became more difficult to determine in cases of “certain nervous and psychic diseases” and “so-called nervous prostration.”

At the beginning of the twentieth century, the practice of abortion was regarded by the general public as a criminal activity regardless of the medical indications for the interruption of pregnancy. For at least the next sixty years, the social fact of abortion’s illegality—what Taussig described as “the odium attaching to the name” (1910:2)—would remain its most conspicuous feature. Indeed, as has been noted, one of the strategies of the leaders of the birth control movement was to distinguish their call for the dissemination of birth control information from any support for the legalization of abortion (Imber, 1979:825), Abortion was universally regarded as the most drastic and most dangerous form of birth control, and the advocates of birth control hoped that improved contraceptive knowledge would help to prevent it. Taussig anticipated the general acceptance by most physicians of the preventive uses of contraception, and he chided his colleagues for not taking greater responsibility for such education:

There is a natural reluctance on the part of physicians and text-books to discuss this subject, since it is apt to lead to abuses in one way or another. And yet, this very refusal on the part of the profession to speak of these subjects has led to the most serious mistakes and injurious practices on the part of their patients. There has been much prudery and prejudice in the views of Americans on this subject. (1910:167)

Of “the most frequently practiced” forms of contraception, Taussig claimed that coitus interruptus “leads in time to chronic congestion of the organs of reproduction and to certain nervous disturbances, often of a serious character” (1910:168). He criticized the “stem pessary” (a precursor of the modern intrauterine device), insisting that it was “in fact, rather an abortifacient than a means of avoiding conception” (ibid.).

Taussig’s remarks in 1910 may have struck many of his fellow doctors as unorthodox, but they were clearly derived from his clinical experience. Most of the criminal abortions he and his colleagues were compelled to complete, he believed, could have been prevented. It would always be an essential part of the training of obstetrician/ gynecologists (ob/gyns) to know how to treat an incomplete abortion, whether spontaneous or induced. But in the case of botched abortion, this knowledge was helpful only after the fact. Taussig recognized that improved medical treatment of abortion had the unintended consequence of making the procedure a safer and therefore more reasonable form of birth control:

The discovery of asepsis and antisepsis has not proved any unmixed blessing. Criminal abortion can at the present time be done with less danger of blood-poisoning than formerly. The result is inevitable. One of the main deterrent factors in the production of abortion is gone when the woman realizes that her own life is not necessarily imperiled. (1910:78–79)

A new public perception of risk slowly emerged from the once discouraging fear of being injured or dying from an illegally induced abortion. Taussig knew that physicians would be ethically compelled to treat the sequelae of badly performed abortions. He also understood that criminal abortion was bound to increase because of the improvement in the performance of abortions and the treatment of poorly performed ones.

Taussig concluded: “It seems probable that this question [criminal abortion] will become one of the most serious sociological problems of the coming years, for every community must in self-preservation enact laws and exert its utmost influence to stem this tide that will otherwise sweep it to destruction” (1910:79). He proposed that new educational strategies be developed to discourage women from seeking abortions:

The myth that life does not begin until fetal movements are felt is still so widespread that it will take many years before it is finally put aside. Almost daily the physician hears the story that the woman did not think it was wrong to stop pregnancy in the early months before the child was alive. . . . Women of all classes should know more concerning the processes of gestation. They should be shown how early the fetal heart begins to pump blood through its vessels. (1910:79)

Taussig believed that the dissemination of medical-scientific knowledge about conception and fetal development might instill a new fear in women who had believed that abortion was morally wrong only after experiencing the sensation of fetal movement. This new fear, he hoped, would counteract the effects of improvements in the management of badly performed abortions, which might otherwise lead to an increase in the resort to abortion.

Taussig’s pedagogy of prevention relied not only on scientific facts but also on effective presentation of the facts. He arranged a series of medical lectures to be given by a nurse in one of the social settlements of St. Louis. The nurse was instructed to use an enlarged picture of an embryo of six weeks in order to emphasize “the fact that at this time the eyes, ears, nose, mouth and extremities were already crudely formed.” Taussig stressed that “it is not enough merely to tell them [women] that in producing an abortion in the early months they are taking a human life; they must be shown that at this period the child is already well along in its development. I think pictures like that of the six weeks’ embryo will keep many women from having an abortion done” (1910:79). The visual image of the embryo/fetus has remained to this day a potent symbol for those persuaded against abortion. The refinement of photographic technique now allows a view of the course of fetal development and of the burns and disarticulations of the fetal body caused by certain methods of termination (compare Nilsson, 1977, and Hilgers and Horan, 1972:297–99).²

For Taussig, the image of the developing fetus symbolized a new knowledge about aspects of human life that were a mystery for many in 1910. A half-century later, the wonder of creation would be carefully separated from the reality of creation aborted. As will be seen, the split in fetal images has institutional and professional analogues. The abortion clinic in American society sets itself apart from obstetric delivery and care, and obstetrician/gynecologists have found numerous ways to keep abortion practice isolated from obstetric practice.

In addition to advocating improved scientific education in order to reduce criminal abortion, Taussig called for legislative ch...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Introduction to the Transaction Edition
• Preface
• Acknowledgments
• 1 Abortion as a Medical Responsibility
• 2 The Physician in the Abortion Controversy
• 3 Medical Practice and Family Planning in Daleton
• 4 The First-Trimester Abortion: Standard Procedures
• 5 The Second-Trimester Abortion: Limited Procedures
• 6 Innovation and the Refuge of Private Practice
• 7 Beyond the Politics of Abortion
• Epilogue to the Transaction Edition
• Appendix: Methodology and Interview Schedules
• Index