With the leak Monday of a draft Supreme Court decision that would overturn Roe v. Wade, the future of abortion in the United States has been a very busy topic of conversation all week. Doctors are among those wondering what’s next. Louise King is assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School and one Brigham and Women’s Hospital physician whose practice includes abortion services. King, who is also director of reproductive bioethics for the medical school’s Center for Bioethics, spoke with the Gazette about the ethical dimensions of abortion and how a ruling against Roe could affect providers.
GAZETTE: In the United States, abortion is framed in broad ethical terms: life versus death, privacy versus government intrusion, and so on. From a medical ethics perspective, what are the important concerns to balance on this issue?
KING: I frame the subject in the context of the patient in front of me. In other words, I primarily look at autonomy and beneficence in the context of doing good to the patient. It could mean confirming that person’s choice not to pursue what is still a very dangerous proposition, namely carrying a pregnancy to term and giving birth. If someone says to me “I’m pregnant and don’t want to be”, for a multitude of reasons, I support this decision, because the alternative of carrying to term is risky. I want to protect this person’s bodily autonomy. From a reproductive justice perspective, I want to help people who have a womb decide when they want to start a family, what they want it to look like, if they want to start a family, express their sexuality, and all sorts of of different things.
I don’t believe that life begins at conception. Among the minority of people in this country who believe this is the case, some are vocal and aggressive in forcing this belief on others, which could happen with this upcoming ruling. But a number of students I meet who believe that life begins at conception still don’t believe they have the right to impose that belief on others. To contextualize what we’re asking of people with wombs when we make abortion illegal, it’s helpful to compare instances where we might ask people to undergo high-risk procedures to help others. For example, we don’t require people to donate blood. It’s okay and it could save lives every day, but we don’t require anyone to donate blood or bone marrow. We do not require kidney donations, which are less risky than childbirth these days.
So we don’t usually ask a human being to give themselves so completely to another, but we do when it comes to a pregnant person. This, I believe, is not in line with our ethics. But it also doesn’t entirely address the concerns of people who believe that life begins at conception. They come to these beliefs honestly, but I think they need to explore them more deeply and figure out if, even if they are true, do they hold up to the point where we require someone to have a pregnancy forced to term? I would say, in my understanding of ethics, no.
GAZETTE: Abortion is one of the most divisive issues in the country. Is the medical profession unified in any way?
KING: It’s hard to say with certainty. No studies or surveys exist to really quantify this. The American Medical Association and the America College of Obstetricians and Gynecologists say abortion is health care, and I agree. ACOG is very strong in its formulation on supporting the right to access abortion. Unfortunately, only 14% of practicing OBGYNs provide abortion care. As a profession, our words and actions do not match. I think there are a multitude of reasons for this. One is the stigma associated with providing abortion care in some parts of the country.
I guess most vendors feel the same as the majority of americans — that abortion is health care and should be available. Although I have met medical students and medical practitioners in all kinds of disciplines who strongly believe that abortion is unethical, the vast majority I have spoken to agree with me: that they are health care and that it should be provided.
GAZETTE: Much of the debate over the decades has focused on sustainability. Is this a problem that science must determine? Is it a social issue? Is this a problem for religion?
KING: I don’t think science can tell us for sure when life begins. Life is a broad term and includes a variety of living entities. I don’t think religion can define it because we have freedom of religion and religions see it differently. The rabbis will explain that in the Torah it is very clear that an embryo is simply an extension of a woman’s body, like a limb, and should not be considered another person until birth. The leaked ruling assumes that one version of Christianity’s assessment prevails, which appears to violate our understanding of religious freedom in this country.
Ultimately, “when does life begin” is the wrong question because it is unanswerable. The question then must be: how can we, as a society, find a compromise that respects the autonomous rights of the people before us who may become pregnant, who may have undue risks associated with pregnancy or who may simply not wish being pregnant also respects our society’s accepted understanding of the existence of a protected entity.
I think Massachusetts is absolutely right. If you read the egg law: Abortion is allowed for any reason in the first and second trimesters, then abortion for medical reasons or fatal fetal abnormalities may extend into the third trimester with careful consideration between the patient and the medical teams. To me, this is an exceptionally well-thought-out compromise. It is a societal decision. It shouldn’t be done by a minority of people based on their narrow definition of “when life begins”.
GAZETTE: If something like the leaked draft decision emerges, is there a risk that medical providers will be caught in the middle?
KING: Overthrowing Roe would send the question back to the States. This would mean that providers that exist in states that are clearly going to pass legislation banning abortion would be in dire straits. In Massachusetts, we could provide the care that we already provide and would expect people to travel from out of state to us. I don’t think long arm statuses would reach a provider here, that someone could pick me up from Texas if someone traveled from Texas to me and I was providing care. But if I was traveling to Texas, for a conference, it could. Legal experts aren’t sure.
GAZETTE: Have you ever been threatened for offering abortions?
KING: I didn’t, but many of my colleagues did. I did my training in Texas, so I lived in the South for a long time. I was not directly threatened, but I was harshly challenged by many people who disagreed with me. I mentioned earlier that there are a lot of people who believe that life begins at conception but don’t think they should impose their views on others – these are people I met at Texas and Louisiana. There are a lot of people like that, but they can’t talk for fear of being ostracized. The feeling I have through all the conversations I’ve had over many years is that we’re all talking behind each other. You started by saying that this is a subject that divides our country, but it is not. The vast majority of people agree with having abortion as an option, having contraception as an option, and having access to sex education. There is a group of politicians who give the impression that we are divided and build their political careers from that. It is incredibly discouraging and unethical for them to do so.
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