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Establishing the Problem: Texas Abortion Laws Marginalize Low-Income Women

It’s Sunday afternoon in a sleepy town in the Rio Grande Valley. By all accounts, it is a day like any other day. Quiet and somewhat removed from today’s advancing world, this place is the essence of anachronistic. Humid memories linger in the air and hopes of a better life line the weed-cracked sidewalks and narrow unpaved roads. Unused train tracks sit forgotten, overtaken by grass and brush. Dented signs, rusted by harsh years, stand on the corners forever offering direction. A dilapidated and empty corridor of houses tilts to stare at the ground as a teenage-painted water tower bows before the sky in the distance. Fresh yet dusty-faced children, invigorated by the freedom of the weekend, play a game of tag next to a field. Only a solitary fly appreciates their presence. A single engine plane flies over this nearly invisible spot of the world. As its relaxing buzz floats away, the machinery passes over a small house at the end of the street. Outwardly, there are no signs that anything is amiss here. If only reality were as simple as a game of tag.

Inside the house, a petite Hispanic woman lies supine and blood-soaked on the floor of her living room. As she glances around, perception skewed by position, she is filled with regret. A sudden realization that she might die flashes into her brain like a searing lightning strike. The sound of a clock echoes in her skull, an audible reminder that our time on earth is perilously finite. She has called an ambulance, but cannot shake the feeling of impending doom. Her heart pounds with the ritual, rhythmic dance of the second hand. As she listens to her time tick away, she recounts the events of the past 36 hours. It’s Saturday morning. The woman, driven by fear and desperation, has found herself at a flea market with a very specific goal in mind. She is not there for home furnishings, produce, or crafts. She watches families bustle about in slow motion around her. A child’s laughter in the distance becomes a mocking song. As she turns her intended purchase over and over in her trembling hands, she wonders if she can really go through with this. It has to be dangerous. What if it doesn’t work? Surely there must be an easier way. Then she remembers her fiancé, his mercurial anger, and his escalating threats. A bolt of fear shoots through her, and she knows in that moment that she has no choice. She pays the elderly vendor. Her money is heavy in her hands, and she does not know if she can lift them. A knowing look of sadness passes between the two women alongside this seemingly innocuous exchange of goods.

She has just purchased twenty-four tablets of Mifepristone. When she arrives home, she will take all of them. Mifepristone, also known as RU-486 and a component of the “abortion pill”, is an anti-progesterone agent that also possesses anti-glucocorticoid properties (Vallerand, Sanoski, & Deglin 2013). Physiologically, this drug induces endometrial bleeding and, if taken in excess, has the potential to alter levels of hormones essential for regulation of metabolism. This unfortunate woman is now suffering excessive bleeding and vital dysregulation. What will happen to her? In this situation, it is difficult to know. Perhaps she will be transported to a medical facility in a timely manner and receive necessary blood transfusions. Then, if she is lucky, she will only have the emotional scars from this traumatic event to contend with. Perhaps a more sinister possibility: that her time runs faster than the paramedics. This will be her last memory.

As morbid as this conceptualization might seem, it is nowhere close to far-fetched. It is, however distressing, one of the less horrifying accounts of what women will resort to in the absence of sufficient access to reproductive services. These kinds of desperate acts were fairly commonplace at one point in America’s history, and were a driving force behind the monumental Roe vs. Wade decision. The court’s opinion, authored by Justice Harry Blackmun, invalidated a Texas statute that made administering an abortion a felony in most cases. In his statement, Blackmun asserted that the detriment the State would impose upon the pregnant woman by denying this choice was altogether apparent (Roe, 1973). In the years prior to Roe vs. Wade, illegal and potentially unsafe abortions were a dire public health problem (Calderone 1958). Research compiled by the Guttmacher Institute, a non-profit organization concerned with advancing reproductive and public health, supports this. In 1930, abortion was listed as the cause of death in nearly 2,700 cases. This accounted for a staggering 17% of all maternal deaths that year. This mortality rate declined slowly over time, likely as a result of advancement in antibiotic therapy, but the percentage of deaths remained largely unchanged. In 1965, 18% of maternal deaths were attributed to consequences resulting from illegal abortions (Valenti 2013). These are only reported numbers; it is likely that the actual number is much higher.

While this is a part of America’s past, recent legislation passed in Texas threatens to again make this flawed and dangerous status quo a frightening reality. The culmination of a progressive assault on reproductive health, HB 2 bans all abortions after 20 weeks, even in the case of rape or incest. Abortion clinics must now meet the same standards as ambulatory surgery centers. The physicians performing these procedures must have admitting privileges at a hospital within 30 miles of the clinic (Sweany 2014). All over the state, clinics unable to meet these stringent and arguably punitive requirements have begun to close. Despite vehement protest, the status quo in Texas closely resembles the sociopolitical culture before Roe. This will only intensify as time passes (Feldt 2013). Women in this state, particularly the young and the poor, are now faced with the very real consequences of society’s failure to learn from its mistakes.

The woman’s story referenced herein may have been fictionalized in the name of anonymity, but its roots lie in poignant truth. The fact that a box of flea-market abortifacients has been someone’s reality is altogether unacceptable. If the past is any indication, this is only one example of the horrific consequences that will come to pass as a result of this legislation. It is debatable whether this is a result of malignant ignorance or willful marginalization, but that question deserves its own thesis and will not be examined here. For the sake of succinct and fair argumentation, a candid dissection of the rhetorical and ethical implications of the status quo will focus solely on the legislation as it is presented. At this time, such an examination is of critical importance, and will expose this bill for what it is: a poorly constructed policy that infringes on women’s autonomy, causes undue harm, and sets the stage for far-reaching societal stagnation.

Stay tuned. My next post will dissect the rhetoric of the bill, and why it is flawed. You cannot argue with academics and data.

References:

Calderone, M. (1958). Abortion in the United States. New York, NY: P. B. Hoeber.

Feldt, G. (2013). Crow after Roe: How Separate but Equal has Become the New Standard in Women’s Health and how we Can Change That. Brooklyn, NY: IG Publishing, Inc.

Roe v. Wade 410 U.S. 959. (1973). Retrieved from LexisNexis Academic. Web.

Sweany, B. D. (2014). A Long and Bitter Fight. Texas Monthly, 42(3), 24-28.

Vallerand, A., Sanoski, C., & Deglin, J. (2013). Davis’s Drug Guide for Nurses. 13th ed. Philadelphia, PA: F. A. Davis Company.

Valenti, J. (2013). Abortion and Magical Thinking. Nation, 296(26/27), 10.

Abuse of Autonomy: Paternalism in Politics

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         We all begin our journey on this earth as a blank canvas: a clean slate void of corruption, fear, or opinion. With a palette comprised of circumstance and choice, our lives and thoughts are painted as we age. Vibrant colors and crisp lines replace white space and blurred edges. Ideally, knowledge supersedes uncertainty; with the passage of time, the genre of our worldview is revealed to us. The term worldview will be used herein to refer to a system of beliefs that are interconnected, much like the pieces of a jigsaw puzzle (DeWitt 2010). When something in our external environment happens that does not coalesce with our value system—especially if the specific belief in question is central to our worldview—we have a few options, namely: remain in a state of uncomfortable cognitive dissonance, or take action to change the offending external event. In the United States, and certainly in the socially conservative state of Texas, it is unlikely that few issues cause as much dissonance or call to action as the matter of abortion.

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          For over thirty years, catalyzed by the controversial Roe v. Wade decision, the abortion debate has grown exponentially (Annas 2010). Pro-life collaborations rise up against clinics, physicians, and organizations that support abortion. These groups, empowered by their worldviews, act with certainty of residing on the absolute moral high ground. And yet, even in the historically conservative south, there remains a strong vein of support for the pro-choice movement. One of the core beliefs of these groups may be summarized in this way: “the right to an abortion may be a matter of standing law, but its legal underpinnings are being hacked away at an alarming rate, so that many women in this country, particularly the young and the poor, are having to resort to desperate measures we never thought we would see again… In many ways, we are back to where we were then, with a two-tiered system: women who have the means to travel to get a safe abortion could do so, and the others suffered illegal, unsafe abortions or unplanned pregnancies (Feldt 2013).” The recent passage of controversial abortion legislation in the state of Texas has made this speculation on unintended consequences a tangible possibility. Texas HB 2 (previously SB 5) stipulates, among other things, that abortion should be banned after twenty weeks gestation and that centers performing them meet the same requirements as ambulatory surgical centers. Proponents of this legislation have cited protection of fetal life and protection of maternal health as the motivation for the change that will inevitably result from this law. On the surface, these seem to be respectable claims. However, a thorough deconstruction of the stock issues and rhetoric here will expose this bill for what it is: infeasible, ripe with a plethora of negative consequences, and a very thinly veiled endorsement of paternalism.    

            The literature is very clear on the bioethical connotations of paternalism. This insidious concept can best be described as the limitation of the autonomy of another exclusively on the grounds of benefit to the person in question (Tong 2007). Respect for patient autonomy is broadly understood as recognition that patients have the authority to make decisions about their own health care, and is pervasive in bioethics literature (Sherwin 1998). On a more intimate level, it can even be said to underlie the basis of human dignity (Gaylin 1994). While a pragmatic approach to bioethics suggests removing autonomy from the forefront of the gold standard of care (Childress & Fletcher 1994), abortion is one arena where the implications of overriding autonomy are far-reaching and dangerous. The reasoning was succinctly explained by beloved Justice Harry A. Blackmun regarding his stance on Roe v. Wade: “Few decisions are more personal and intimate, more properly private, or more basic to individual dignity and autonomy, than a woman’s decision… whether to end her pregnancy (Flavin 2009).” Legislative interjection in this arena not only carries negative connotations for the state of women’s health; it carries negative connotations for the state of women’s rights (Orentlicher 2011). In a dynamic and ever-evolving society, we must be aware of the dangers of enlightened paternalism: dogmatic habits that do not adequately account for the changing environment and culture and misunderstand the place of intelligence and community in medical encounters (McGee 1999). To this end, even the most pragmatic interpretation of bioethical literature does not excuse the actions of the Texas legislature. Whatever the justification, talk of protecting women from harm caused by their own decisions is a marked recapitulation of paternalistic stereotypes, and in direct conflict with modern egalitarian ideals (Suk 2010).

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Rally at the Texas Capital, July 2013

          A thorough investigation of case construction, stock issues, and bioethical principles is likely to support this unpleasant truth: the actions of the Texas Legislature are wholly unethical. To some degree, politics has no place in the exam room. The doctor-patient relationship is a sacred one, and lawmakers affecting the inner workings of clinics makes about as much sense as doctors sitting on the bench to issue judgments and penalties. All educated individuals have a scope of practice: a skeleton system of acquired knowledge and vales. This is fleshed out over the years with experience and blossoms into expertise, much as a canvas transforms into a painting. The sprawling masterpieces that adorn the Sistine Chapel were certainly not painted in a day, or even a week. How can it possibly make sense that merely days of debate and a limited understanding of fundamental principles of bioethics are deemed sufficient to make such important decisions regarding women’s rights? Passionate ideology and moral empowerment do not a good decision make. The same principle that governs distributive justice can be slightly altered and employed here: from each according to expertise, to each according to need. In such a strange and volatile time in our world, it seems prudent that lawmakers stay within their jurisdiction: they belong in our courtrooms, not our clinics.

References:     

Annas, G. (2010). Worst Case Bioethics: Death, Disaster, and Public Health. New York, NY: Oxford University Press.

Childress, J. & Fletcher, J. Respect for Autonomy. The Hastings Center Report, 55-56.

Dewitt, R. (2010). Worldviews: an Introduction to the History and Philosophy of Science. 2nd ed. Malden, MA: Blackwell Publishing, LTD.

Feldt, G. (2013). Crow after Roe: How Separate but Equal has Become the New Standard in Women’s Health and how We Can Change That. Brooklyn, NY: IG Publishing, Inc.

Flavin, J. (2009). Our Bodies, Our Crimes: The Policing of Women’s Reproduction in America. New York, NY: New York University Press.

Gaylin, W. (1994). Knowing Good and Doing Good. The Hastings Center Report, 193-198.

McGee, G. (1999). Pragmatic Bioethics. Nashville, TN: Vanderbilt University Press.

Orentlicher, D. (2011). Policy and Politics: The Legislative Process is Not Fit for the Abortion Debate. The Hastings Center Report, 41(4), 13-14.

Sherwin, S. (1998), The Politics of Women’s Health: Exploring Agency and Autonomy. Philidelphia, PA: Temple University Press.

Suk, J. (2010). The Trajectory of Trauma: Bodies and Minds of Abortion Discourse. Colombia Law Review, Vol. 110, No. 5, 1193-1252.

Tong, R. (2007). New Perspectives in Healthcare Ethics: An Interdisciplinary and Crosscultural Approach. Upper Saddle River, NJ: Pearson Education, Inc.