Partial Truths in the Partial-Birth-Abortion Debate
Every abortion is gross, but the technique is not the issue.
Banning an obscure technique like partial-birth abortion would seem to be a rather modest goal for anti-abortion forces faced with the most sympathetic Congress they have had since Roe vs. Wade. But the issue could change their fortunes. That's because, as a medical technique, nothing makes partial-birth abortion fundamentally different from other forms of late-term abortion. Certainly it is no more grisly. If pro-choice politicians help pass the ban, their case for allowing other late-term procedures will be fatally weakened. But good policy on abortion would not focus on techniques at all--or even on when the fetus can survive outside the womb. It would hinge on the question of when the fetus first becomes a perceiving being.
Pro-life advocates offer a seductive argument: Whatever you think about abortion in general, partial-birth abortion is just too ghastly to permit. As Republican National Committeeman Tim Lambert argues: "It is really not about abortion. It's about infanticide, it's about a procedure so gruesome the American Medical Association is opposed to it." Now even strongly pro-choice politicians see this as a no-brainer and may provide enough votes to override President Clinton's veto of the ban.
In general, obstetricians told me, their choice of abortion method depends mainly on the fetus' size. During the first eight weeks of pregnancy, when the fetus is very small, medications like methotrexate and RU-486 can safely make the uterus slough the placenta and gestational sac. In the United States, however, obstetricians usually use "vacuum aspiration," which can be performed through the 15th week, while the fetus's head is less than an inch in size. They insert a suction tube through the cervix and suck out the sac and the fetus along with it.
People are generally comfortable with this. They don't like it, they wish it had never come to this, but they don't identify with, in antiseptic doctor argot, the "products of conception." According to the Alan Guttmacher Institute, one-fourth of U.S. pregnancies are aborted--around 1.4 million a year. The institute estimates that a whopping 43 percent of women will have at least one abortion by age 45. Almost all abortions--94 percent--are done by the 15th week of pregnancy, predominantly by vacuum aspiration.
But 6 percent--more than 80,000 abortions--are done after 15 weeks, and several hundred of these are done after 24 weeks, commonly taken to be the point of viability. The fetus is now too big to fit into the suction tubing. A 20-week fetus is commonly 6 inches long or more.
Why do women wait so long before seeking an abortion? Sometimes, they have no choice. Women who abort because of a fetal abnormality don't find out about the problem until quite late: Amniocentesis to collect fetal chromosomes for analysis generally is done at 18 weeks. A few late abortions are done for the mother's health, to save her, for example, from possible disaster caused by an infected uterus or a newly diagnosed heart condition. Most of the time, however, they are elective. Often, the mother didn't know she was pregnant. "The power of human denial is unbelievable," one obstetrician told me. It's not at all uncommon, he said, to see women go through an entire pregnancy without realizing it, come to the ER with a stomachache, and turn out to be in labor.
The usual options for late-term abortion are 1) induced labor and delivery or 2) dilatation and evacuation. For induction--used in less than 15 percent of cases--labor is stimulated with drugs. Delivery usually takes from 36 to 48 hours in the hospital, but it can take even longer. Sometimes, before delivery, the obstetrician injects the fetus with a drug that stops its heart. If not, the heart sometimes beats even after the fetus has been delivered. Even without oxygen from its barely formed lungs, I'm told, the fetus's heart can continue beating for minutes and even hours.
About 80 percent of late-term abortions are done by D and E. A couple of days ahead, small, absorbent rods are put in the pregnant woman's cervical opening to expand it gradually. Then, for the actual procedure, she--and the fetus--are given heavy sedation or general anesthesia. The doctor breaks her bag of water and drains out the fluid. The opening won't let the fetus out whole. So the doctor inserts metal tongs, physically crushes the head, and dismembers the fetus. The pieces are pulled out and counted to confirm that nothing was missed.
Partial-birth abortion is, if anything, less grotesque. The fetus is delivered feet first. To get the large head out, the doctor cuts open a hole at the base of the fetus's skull and inserts tubing to suck out the brain, which collapses the skull. Often, but not always, the fetus is injected lethally beforehand. The procedure is used for a very small percentage of late abortions, and nothing makes it especially necessary over D and E. In fact, none of the obstetricians I talked to had even heard of the technique until it became a hot political topic. It seems hardly anyone uses partial-birth abortion, and if it's banned, almost no one will miss it.
That partial-birth abortion is rare and inessential makes it easier, no doubt, for the AMA and pro-choice politicians like Republican Sen. Arlen Specter and Senate Minority Leader Tom Daschle to back the ban. But they insist that they stand by the right to any other second-term abortion. If partial-birth abortion is too gruesome to allow, however, it is hard to see how other late abortions, especially D and Es, are any different. And that's the inevitable next target for pro-life advocates.
Atul Gawande, a surgical resident in Boston, is a staff writer on medicine for The New Yorker and author of the new book Complications: A Surgeon's Notes on an Imperfect Science.