Logic of Debate on Abortion Is Questioned

The Senate has spent the week debating how doctors may perform abortions at the midterm of a pregnancy.

Republican leaders who oppose all abortions say they want to outlaw a single procedure, which they refer to as “partial-birth abortion,” a term a former Florida congressman coined in 1995. They describe this procedure as gruesome, abhorrent and immoral.

It is “the brutal killing of a child literally inches from being born,” said Sen. Rick Santorum (R-Pa.), the bill’s sponsor.

Yet many medical experts who are familiar with how abortions are performed say they find the debate to be ill-informed, inflammatory and misleading.

They say the legislation doesn’t take into account the physician’s mandate, that patient safety is the top priority. Of the two methods commonly used for midterm abortions, many doctors say the current proposal would eliminate the safest option.

“It is not ethical for me as a doctor to subject a woman to an increased risk during surgery,” said Dr. Felicia Stewart, a professor of obstetrics at UC San Francisco. “So I don’t understand the logic of this debate. It doesn’t have a health logic to it.”

More than 90% of abortions take place during the first 12 weeks of a pregnancy. Then, the fetal tissue can be removed through a suction tube.

Abortions can be banned after the 23rd week of pregnancy, the Supreme Court has said, because fetuses that old are “viable” and may be able to live on their own.

The controversy has focused on abortions that take place in the second trimester.

At about the 18th week, a fetus is about 6 inches long, a miniature baby. But its lungs are not developed enough for it to breathe on its own.

Standard abortion procedures have changed in recent decades, and not all experts agree on what is the best procedure at this stage.

Twenty years ago, doctors typically induced labor in the woman, a slow and painful process that could last for days. And, studies showed, it carried risks.

“Because it took a long time, the physician wasn’t in control. There could be bleeding, or the uterus would rupture, and you wouldn’t be there,” said Dr. Paul Blumenthal, a professor of obstetrics at Johns Hopkins University in Baltimore.

Since the mid-1980s, surgery has been the norm. Doctors dilate the woman’s cervix so they can remove the fetus and cut the umbilical cord.

Just how this is done depends on the patient, the physician and the stage of the pregnancy, experts say. And the moment when the fetus dies is also uncertain.

“If the cervix is open, you can gently remove the fetus intact,” said Dr. Anne Davis, a professor of obstetrics at Columbia University in New York. “That’s what you hope for. There is very low risk then. But if the cervix is small, you take out the fetal parts. It will take longer, and there will be more loss of blood.”

However, under the bill that is expected to pass the Senate today and be signed into law by President Bush, the first procedure will become a federal crime, while the second “dismemberment” procedure would remain legal.

The bill says it is a crime to “deliberately and intentionally ... deliver a fetus ... outside the body of the mother” and then kill it through “an overt act.”

Senate Majority Leader Bill Frist (R-Tenn.), a heart surgeon, said the procedures should be banned because they are “repulsive, grotesque and morally offensive.” The “alternative abortion procedures are morally offensive, [but] they will still be legal.”

On Wednesday, the Senate defeated a series of challenges to the ban, including proposals by Democratic Sens. Dianne Feinstein of California and Richard Durbin of Illinois, who moved to amend the bill to make it clear that late abortions were illegal.

Republicans rejected these amendments, because they included exceptions to protect the health of the mother. Critics said these exceptions made the amendments meaningless.

Several doctors who are experts in abortions said they found the congressional debate disconcerting.

“You can see this is not their area of expertise. They think they are banning something that is dangerous. The opposite is true,” Davis said.

“And the public has been confused into thinking this is something that takes place right before birth. They are talking about infanticide. We agree we shouldn’t do abortions after the point of viability.”

If the Senate bill becomes law, Blumenthal said he and other doctors could face criminal liability in the midst of a surgery.

“In medicine, things happen quickly. You have a patient who is bleeding. We are trained to deal with the unexpected,” he said.

“When I read this bill, I wonder when I would cross the line. And who are the medical experts who say this procedure or that procedure is not ‘medically necessary?’ I suppose that’s easy to say if you are against all abortions.”

Three years ago, the Supreme Court struck down a similar state ban on “partial-birth” abortions after concluding that the prohibited procedure was often safer. Nebraska had made it a crime punishable by 20 years in prison for a doctor to “partially deliver” and then kill “a living unborn child.”

Dr. Leroy Carhart, the only doctor in Nebraska who performed midterm abortions, challenged the law. He said he sometimes performed what he called “intact removals” on patients who were 16 to 20 weeks pregnant. Because the skull is the largest part of the tiny fetus, Carhart said he crushed it with forceps before removing it.

He also said the combination of anesthesia and the cutting of the umbilical cord left the fetus numb, gray and lifeless when it emerged.

When Carhart sued state Atty. Gen. Don Stenberg to stop enforcement of the law, a federal judge who had been appointed by former President Bush convened a trial on the issue. An array of medical experts were called to testify.

In a 71-page opinion, the judge concluded that the “intact removals” were safer because there was less bleeding and a lower chance of infection from fetal tissue left in the patient.

A three-judge panel of the U.S. Court of Appeals in St. Louis, with two Reagan appointees, agreed, as did the Supreme Court.

A state “may not endanger a woman’s health when it regulates the methods of abortion,” the high court said in a 5-4 ruling in Stenberg vs. Carhart.

Leaders of the National Right to Life Committee, which has been fighting the midterm procedures since 1995, say they are more optimistic of winning a ban now that Republicans control the Senate and President Bush is in the White House.

“We think five justices of the Supreme Court took a very radical position, and Congress is warranted in trying to reverse it,” said Douglas Johnson, the group’s legislative director.

Last week, the American College of Obstetrics and Gynecology sent the senators a letter reaffirming its view that “intact dilation and extraction” fits with “established obstetric techniques.”

This procedure is not “the only option to save the life or preserve the health of the woman,” the group said. However, it “may be the best or most appropriate procedure in a particular circumstance and only the doctor, in consultation with the patient, can make this decision.”