Re: The Limits of Conscientious Refusal in Reproductive Medicine
ACOG Committee on Ethics Opinion No. 385: November, 2007
Response to the ACOG Ethics Committee
Opinion # 385
American Association of Pro-Life
Obstetricians & Gynecologists (AAPLOG)
6 February, 2008
Reproduced with permission
Joseph L. DeCook, MD, FACOG
*The American Association of Pro-Life Obstetricians and Gynecologists
(AAPLOG), one of the largest Special Interest Groups of the American College
of Obstetricians and Gynecologists (ACOG), strongly objects to the November
2007 release of ACOG Committee Opinion, Number 385, titled
"The
Limits of Conscientious Refusal in Reproductive Medicine."
We find it unethical and unacceptable that a small committee of ACOG
members would pretend to provide the moral compass for 49,000 other members
on one of the most ethically controversial issues in our society and within
our medical specialty-and that without ever consulting the full membership.
ACOG Committee Opinion #385 is in opposition to 2500 years of accepted
Hippocratic ethical medical tradition. Legal elective abortion made a unique
arrival in the late 1960s in the United States as part of a legal-societal
initiative, rather than as the culmination of a scientific process in
biomedicine. The acceptance of elective abortion in American medical
practice was contrary to the historic ethical position of Western medicine
with regard to abortion.
Therefore it is of great concern that this committee opinion repeatedly
describes elective abortion, and other controversial reproductive medical
procedures and services as "standard." The term "standard," as used in the
document, is never defined. Ideally, a care "standard" would involve a
balanced and thorough consideration of the existing medical literature for
the effect on the patient's health and well being, both in the short term
and in the long term. There is scant evidence regarding the outcomes of
elective abortion, other than its decided effectiveness at ending a
pregnancy. In general, the long term safety of abortion, and its "benefit"
for women, has been either assumed, or accepted on the basis of inadequate
follow-up studies.
On the contrary, there are poor reproductive and other health outcomes
associated with elective abortion in methodologically sound scientific
studies. The data from nations with extensive computer based health
registries, where linkage with subsequent health outcomes is a practical
reality, show that elective abortion has significant adverse association
with subsequent preterm birth,
1depression,
2
suicide,
3 placenta previa.
4
and breast cancer.
5 ("Although it remains
uncertain whether elective abortion increases subsequent breast cancer, it
is clear that a decision to abort and delay pregnancy culminates in a loss
of protection with the net effect being an increased risk.")
4
While there may be conflicting data with regard to these issues, ACOG
documents have summarily denied the significance of any literature
demonstrating an association. We are aware of no current ACOG educational
materials providing balance to this extreme position.
In this regard, we also find the Opinion statement, "Health care providers
must impart accurate and unbiased information so that patients can make
informed decisions about their health care," to be at odds with the actual
practice of informed consent in elective abortion. The College has allowed
the development of a procedure (elective abortion) in its specialty area for
which record keeping is inadequate and meaningful tracking of complications
is virtually impossible. There is a relative absence of data collected on
abortion and subsequent health status in the United States. ACOG has
colluded in this state of affairs by not insisting on adequate record
keeping and reporting for this procedure. Since accurate risk and
complication rates are unavailable, it is vacuous to make reference to
"accurate and unbiased information" for making "informed" decisions.
Further, in most instances, the abortion practitioner is not responsible to
care for "complications" of his or her work, and often may not even be aware
that a complication has occurred. Rather, the emergency room physician, or
the obstetrician/gynecologist on call for the emergency department, inherits
untoward fallout of abortion. Therefore the physician performing the
procedure cannot even accurately reference his or her own experience with
regard to complications in informed consent conversations. This is the only
instance in American medicine where the operating physician is not the
primary physician responsible for the initial oversight of complications of
their surgical procedure. Perhaps the ACOG Committee on Ethics should
address the strange ethics of this "prevailing standard" of reproductive
health service.
Dr. Allan Sawyer, who is an AAPLOG member and current Chairman of the ACOG
Committee on Coding and Nomenclature, as well as chairman of a hospital
ethics committee, has stated in a prior letter to ACOG, "It is a
foundational principle of ethics that autonomy must be balanced by the other
principles of ethics. Any one principle of ethics cannot trump all of the
others, otherwise there is distortion of truth and the dominant principle
ends up skewing the analysis. The end result often is anything but ethical.
ACOG's Committee Opinion #385 is an excellent example of the collapse of
ethical decision-making when patient autonomy is allowed to dominate over
every other principle of ethics. This is not so much an ethics committee
opinion as it is a document that promotes the right-to-abortion-on-demand
stance of ACOG."
6 Dr. Sawyer's comments
accurately reflect AAPLOG's position on this issue. The idea that physicians
are obligated to provide or refer for elective abortion services simply on
the basis of "patient request" is antithetical to the practice of modern
medicine. It is to make patient autonomy rule over physician conscience. It
is to make the physician the corner vendor. A more balanced approach would
be to accept that where opinions vary, the patient is free to seek a second
opinion, but not to impose her will on the attending physician.
The Ethics Committee directive that those who oppose elective abortion on
conscience grounds should locate their practice in proximity to an
abortionist for patient convenience is patently absurd. Quite apart from our
conscience convictions, this is a completely unrealistic idea. Conformity
with this recommendation would result in large swathes of the United States
being without any obstetric or gynecologic care (the large majority of
abortion clinics are located in the inner city).
The Committee Opinion informs us that conscience based refusals should be
evaluated on the basis of their potential for discrimination. For years a
glaring example of systematic discrimination has been implicitly accepted
within the current provision of abortion services nationwide. Year after
year, African-American women have their unborn children aborted at a per
capita rate three times that of Caucasian women. There has never been a
protest from ACOG against this extreme disproportion in the actual
distribution of abortion services. What would the Ethics Committee advise to
rectify this inequity? Should the abortion rate be increased for Caucasian
women, or should the abortion rate be decreased for African-American women,
in order to meet the standards of justice and equitable distribution of
reproductive health services?
Finally, it seems that the Ethics Committee does not understand the
strength and depth of a conscience conviction against the elective,
deliberate taking of an unborn human life. This is not a negotiable issue
for those who hold this conviction. The United States Supreme Court allowed
elective abortion to be a legal right. The U.S. Supreme Court is not an
infallible moral guide for a person's conscience, as evidenced by a previous
similar egregious ruling.7
For these reasons, we, the AAPLOG board of directors, find this Committee
Opinion to be neither scientifically nor ethically sound. We strongly urge
that Committee Opinion #385 be rescinded at the earliest opportunity.
1. National Academy of Science's Institute of
Medicine report " Preterm Birth: Causes, Consequences, and Prevention." July
2006, Appendix, page 518-19; Calhoun, B, Rooney, B; "Induced Abortion and
Risk of Later Premature Birth," Journal of American Physicians and Surgeons,
Volt 8, #2, 2003.
2. David M. Fergusson, et al;
"Abortion In Young Women And Subsequent Mental Health," J. of Child
Psychology and Psychiatry, Vol 47:1 2006.
3. Gissler, M, et.al., "Pregnancy associated deaths
in Finland 1987-1994, Acta Obsetricia et Gynecologica Scandinavica
76:651-657, 1997.
4. Thorp, et al, "Long Term Physical and
Psychological Health Consequences of Induced Abortion: Review of the
Evidence," OB GYN Survey, Vol 58, No. 1, 2002.
5. MacMahon, et al, Bull. "Age at First Birth and
Breast Cancer Risk", WHO 43:209-221, 1970; Trichopolous D, Hsieh C, MacMahon
B, Lin T, et al, Age at any Birth and Breast Cancer Risk, International J
Cancer, 31:70l-704, 1983.
6. Used with Dr. Sawyer's permission
7. We reference the infamous
Dred Scott vs Sanford
case of 1857, in which the Supreme Court of the United States found, by a
7-2 majority, that no person of African descent could claim U.S.
Citizenship. (Africans, according to the Court, were "beings of an inferior
order, and altogether unfit to associate with the white race,… so far
inferior that they had no rights which the white man was bound to respect.")
Since slaves had no claim to citizenship, they could not bring suit in
court. We find the status of the unborn under
Roe to be strikingly
similar to the plight of the African slaves under Dred Scott: Both are human
beings, but neither had/has basic human rights: neither had/has the legal
right to appeal to the courts for justice or protection when they were/are
victims of inhumane treatment or purposeful killing.
American Association of Pro-Life
Obstetricians & Gynecologists
339 River Ave, Holland, MI 49423 Telephone: (616) 546-2639 E-Mail:
prolifeob@aol.com