Lies, abortion, and civil disobedience: what’s the right course?

Pandagon, a shamelessly liberal/radical blog, is a great place not only to read about ideas you already agree with (if, like me, you are absurdly liberal), but also to have your assumptions questioned and your horizons broadened. The writing helps you think differently about important issues.

When they post something I disagree with I make sure I take my time to think through my objections to see if it’s me who needs to reexamine the problem.

Today, Amanda Marcotte (@AmandaMarcotte) posted a piece about doctors’ reactions to the latest abortion laws. She is responding to a piece written by an anonymous doctor a few days ago (one similar to a piece I wrote recently). These pieces called for doctors to resist abortion laws that require us to lie to patients and to perform unnecessary procedures such as transvaginal ultrasounds.

The anonymous doctor called for lying as part of a strategy of civil disobedience. I don’t happen to agree with that tactic and in my post argued that doctors should ignore the law, practice good medicine, and when punished others should step in.

Amanda found some flaws in these arguments. I think many of these are predicated on our broken society. Abortion is not a legal crisis but a societal one, one in which we allow women to be treated as chattel.  Overturning this sort of patriarchy is an important goal, but there are daily struggles that can be fought at a lower level, struggles which if won bring us closer to the liberation of half our citizens. It’s worth examining the particulars of her arguments and mine to see where we may meet.

 If you’re a doctor and you really want to fight back against the right on abortion, why not start by providing abortion?

This is complicated.  Deciding to perform abortions requires prescience at a young age.  Gynecologists are qualified to do this procedure in the US; most of us aren’t gynecologists.  Once we’ve grown up and become seasoned physicians, it’s too late to really become an abortion provider.  Training enough providers requires catching medical students early.

The anon doctor suggests that abortion providers reject the mandatory ultrasound law by refusing to do it, and doctoring patient files to make it look it was done, if necessary. This is characterized as “civil disobedience”, but it’s really not in the same way that getting arrested at protests for moral but illegal trespassing is. Civil disobedience works best if it has a public component, to draw attention to your issues in hopes of changing the law. Privately doctoring files doesn’t accomplish that.

I like this. As I stated above, I also disagree with this definition of civil disobedience.  I don’t think it’s ethical or useful to lie in this instance.  It would be more effective to protest by practicing good medicine and  not lying.  My ultimate responsibility is to the patient, not to my own ass.  If lying protects the patient it can be justified. If it only protects me, not so much.

Her next argument is the one I have some problems with.  She writes that breaking the law will be counterproductive, because it will remove our already limited supply of abortion providers from the system, giving an important victory to anti-choicers.  Providing a safe abortion is paramount, even if it means providing unnecessary and potentially harmful procedures, since the alternative would be no abortion or dangerous abortion.  Or so I read it.

We cannot wait for our entire society to change in order to fix our problems with access to abortion.  Doctors must treat patients with dignity, must not lie to them, and must provide them with appropriate care, even if this breaks the law. The consequences may at first be dire: a loss of abortion providers.  Our society though will rally and the zealots will lose.  Imprisoning doctors who provide ethical and standard-of-care services to patients will not fly (nor will stripping them of their licenses. We do have a shortage.).

I both agree and disagree with Amanda, and I hope we never stop speaking out about the outrages being done to our mothers, sisters, daughters, and friends.

 

(BTW, I’d love to hear some cogent critiques of my opinions here. –PalMD)

16 Comments

  1. D. C. Sessions

     /  March 22, 2012

    And where the law requires you to lie (e.g. misrepresent medical facts)?

    I don’t see a way around that one. Lying to your patients goes beyond unnecessary procedures — it’s an active violation of all sorts. There’s almost certainly a First Amendment issue, too, since “compelled speech” is as much a violation of “freedom of speech” as “forbidden speech” is.

    So what to do when the law requires you to tell your patients a lie? Refuse to say the words? Say them, but tell the patient that they’re lies? What?

  2. Dianne

     /  March 22, 2012

    I’m not an OB, I’m never going to be one: I have neither the interest nor the ability to be a good surgeon and you have to have good surgical skills to be a good OB. Nonetheless, I don’t see what else there is to do but refuse to comply with these laws. States are competing to write the most vicious possible law (current favorite, IMHO, is the Tennessee “open season” law which mandates publication of the names of physicians who perform abortions-and enough identifying information about women who have abortions to identify them individually even if their names are not used). There is no way to practice ethical medicine and comply with the laws requiring doctors to rape their patients or to lie to their patients.

    As a non-OB, I do what I can. I counsel patients I refer for abortion so they aren’t unprepared when they hear the crap the state is trying to pass off as facts to them. I talk to patients about their birth control options so that they are less likely to need an abortion. I contribute to planned parenthood and the ACLU.

    But I fear that we are going the way of Romania and am not sure if it’s not too late to stop the country from getting there.

  3. Dianne

     /  March 22, 2012

    Incidentally, several people commenting in various places have asked, “Where’s the AMA in all this?” The answer, as far as I can tell is, “Nowhere at all.” Do you know if the AMA or ACOG have spoken out on this issue and if there’s any way to encourage them to do so?

  4. Not a clue; if they are, it’s too quiet to matter

  5. Dianne

     /  March 22, 2012

    They need to get involved. Especially ACOG. The Tennessee bill is really, literally about making it easy to track down and kill ACOG members. You’d think they’d want to discourage that sort of thing.

  6. I live in Pennsylvania, which proposed one of these laws. The Pennsylvania Medical Society and ACOG (can’t remember if it was national or the state group) both opposed the laws, a major factor in stalling it in the House.

    The governor, mind you, thinks the bill is A-OK because you can just close your eyes. The legislature has already passed onerous regulations on clinics, using the Kermit Gosnell scandal as a pretext.

    • Dianne

       /  March 22, 2012

      Ah, yes, our dear governor who is cutting funding to hospitals and clinics, resulting in the death of real, living, thinking people, babies and otherwise. So pro-life of him.

  7. orange

     /  March 22, 2012

    The man and woman need help to make this decision. Their hearts should create their ethics and the medical profession should be careful not to accidentally impose any. I would like it if my doctor said to me ” These pictures may help you make your decision or it may just be something that makes it harder. It is not medically necessary but it might be something you may feel is spiritually necessary. Think about whether or not you would like the ultrasound before making your decision. As a medical profession we believe the material creates the immaterial and we have scientific evidence for that but some believe the opposite. If you want to explore the opposite view in a safe and non judgemental way here are the resources.”

    • Dianne

       /  March 22, 2012

      Orange, I don’t think anyone’s arguing against offering an ultrasound in the right context. But the laws and proposed laws in question force women to get ultrasounds, including invasive TVU. How is an ultrasound going to make the decision any easier for a woman who already knows that the fetus is anencephalic or carries the Tay-Sachs mutation on both chromosomes or that she is too ill to survive pregnancy long enough to produce a living baby?

  8. Aren’t most abortions medical abortions rather than surgical abortions? Does providing that medication really require an ob/gyn? (This is a real question, because I’m totally the wrong kind of doctor.)

    • A CNM or CRNP can provide a medical abortion although a few states require an MD (I know NYS does this, but my understanding is that it’s because it was passed in 1970 or so, when all abortions were surgical. I don’t know if it’s enforced. I know the law also states that any abortions over 12 weeks must be performed in a hospital, but the state admits it’s unenforceable and it is not enforced.)

      In 2008 (the MMWR is dated November 2011, so I’m guessing I won’t find more recent stats) 62.8% of abortions were performed at <= 8 weeks gestation. Of these, 22.5% were performed medically: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6015a1.htm?s_cid=ss6015a1_w

    • I’m not a physician but the last time I did some work at PP (~7 years ago) very few women who had a choice opted the medical route for abortion and surgical abortions made up at least 95% of the very early term abortions performed. I wonder if the difference between what I was hearing at PP vs the MMWR report is due to abortions performed in private practice clinics vs “women’s health” clinics that cater primarily to un/underinsured patients.

      BWT – Mississippi is looking at new legislation that, if I understand correctly, is requiring that abortions be performed only by board certified gynecologists who have admitting privileges at local hospitals. My guess is this is ALEC written legislation that will show up in a bunch more states in the not too distant future.

      FWIW, if anyone asked me which route to go, I’d suggest surgical – the medical ones are in some ways much more brutal physically and emotionally. I recall reading a report that contained interviews with French women who had medical abortions (this was shortly before ru-486 was approved in the US) and they pretty much indicated that they opted for medical vs surgical not only for the privacy of going through the process in their own home but also as a way to personalize the event in a more self-punitive way. It was additional proof to anyone who thinks women just make this rash “I just don’t want to be pregnant” decision without actually thinking it through, that women do quite the opposite – we think it through quite a bit before, during and after our decision, we do a lot of what ifs and we do punish ourselves but in the end while we’d rather have avoided the situation the majority of women have thought enough about it prior to having an abortion, are comfortable that we’ve made the right decision for us and do take full responsibility for our decisions. In dealing with anti-choice protesters who became anti-choice after having their own abortions, I’ve noticed that they overwhelmingly say they made the decision just because they didn’t want to be pregnant and didn’t think about adoption (which is why they assume everyone who aborts is “selfish”) and I’ve yet to meet one that takes full responsibility for her actions/decision – they were somehow coerced into terminating their pregnancy.

  9. A Reader

     /  March 22, 2012

    I am not a doctor, but I am a woman of reproductive age, and I just wanted to write to thank you for grappling with these issues, and seeking to find a way to stand up against them effectively. If I became pregnant, I feel that the only morally right choice for me at this time would be to have an abortion– partly because I am not at a position in life where I have the means to raise a child, but mostly because I have a medical condition which makes it impossible for me to have many of the medical procedures necessary to ensure the health of the baby, at least not without unbelievable pain. I’ve sought medical help, but I can’t afford treatment right now. The fact that there is now legislation to mandate one of the procedures I can’t tolerate before having an abortion really, really terrifies me.

    Please, keep fighting the good fight. It means a lot to me.

  10. DLC

     /  March 24, 2012

    perhaps not so much a critique as a comment: There’s nothing in the laws I’ve seen mandating that the doctor give the speech without preamble. So, you make it clear to the patient that you’re now going to read a prepared text mandated by the state, and that the content of said text is a lie put down by religious zealots. In the meantime, I advise the people who can provide for it — ACLU maybe ? to set up a test case to challenge the law(s).
    There really isn’t any “good” solution to this situation except for what amounts to a generational change. But it’s an uphill, nearly impossible battle.

  11. keileya

     /  March 29, 2012

    Depending on how willing a provider is to put his/herself on the line with civil disobedience, what about something like: “In addition to the counseling I have already provided you, I am now legally required to read you a speech that was not written by medical professionals about the procedure you are about to undergo. In my medical opinion, this speech contains a number of lies and exaggerations that are designed to cause you to change your mind about undergoing this procedure and I have already told you everything you need to know in order to provide informed consent. I am also handing you this iPod, thoughtfully pre-loaded with soothing music, and this pair of noise-cancelling headphones. It’s your choice what you would like to do with it.”

    Then, mumble.

  12. orange

     /  April 9, 2012

    You are right Dianne. I would not want my doctor to force me to do anything that she did not feel was necessary.

    I am open to the possibility that immaterial (spirit) could be the basis for material. Science doesn’t really know that this is for sure not true. Providing an abortion as a nothing procedure is an ethical position.

    With abortions or miscarriages, where the mother and father felt that the cells were a spirit/person it could bring closure and help the grieving process to have a funeral and have a picture at the funeral.

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