Monday, April 6, 2015

Fetal Heartbeats and Abortion Politics

(This is another one of those pieces I found that I had written a while ago and just not got around to posting.  I re-read it this week and I think the points are still relevant.  There will always be a desire for politicians and policy-makers to insert themselves between the patient and the physician in pursuit of their own agendas, and I continue to feel that those efforts must be resisted at any cost.  And it was fun to do a bit of homework and find out what happened to the bills I've mentioned. Updates on the referenced bills follows the text.)

As mentioned in a previous post (“A De-Funding Fallacy”), I really don’t like to wade into the abortion debate. When I do, I try to keep it clinical, as given what I do for a living that’s the best way I can conceptualize and think through the issue at hand. It’s this clinical bent that has me concerned about a bill moving through the Ohio legislature. HB 125, which has just passed the State House of Representatives and is on it’s way to the State Senate, prohibits abortion under any circumstances besides an emergent threat to the mother’s life once a fetal heartbeat has been detected.

In principle, I don’t have any objection to giving women the option to receive as much information as they want about alternatives to abortion before making a final decision. I have no problem with reasonable waiting periods like we have with firearms purchases, to allow emotions to cool and for true thought and reflection. I have no problem with parental notification of a minor’s intent to abort, as long as “real world” circumstances such as single parent households are taken into account. I have no problem with regulatory inspection of abortion clinics, as long as other outpatient and office surgery centers are held to the same high standards. (It’s a sad state of affairs when overzealous legislation means that it’s safer to get an abortion than an office procedure.)

I start to draw lines when policy interferes with the most intimate parts of the doctor-patient relationship. For example, some state are requiring physicians to read state-approved language aloud to patients considering abortion. In most cases this information is written by politicians, not clinicians, and may not reflect the actual state of knowledge. But in a larger sense, most physicians recognize that medicine works best when information is exchanged freely between doctor and patient, and when conversations are driven by the patient’s needs rather than the needs of others not involved in care. That’s why the confidentiality of the doctor-patient relationship is held sacred by the medical profession. And no matter how I try to spin it in my head, I can’t see the physician reading a prepared statement written by folks in a distant Statehouse doing anything but build resentment among physicians for having to do it and among patients for having to hear it. It can only project the physician as the agent of the state rather than an advocate for the patient.

(I make a point of being consistent on preserving the confidential and uninhibited exchange between doctor and patient, for that’s the only way real medicine, and especially preventive care, gets done. That’s why I am unequivocally opposed to those laws proposed in Florida and other states which would make it a felony offense for physicians to ask patients about the presence of guns in the home. The NRA and their allies would argue that it’s an invasion of privacy and property rights to ask about gun ownership, which is surely a perfectly legal act. My opposition is not based on any desire to abrogate the Second Amendment. But can it really be that it’s no longer considered appropriate to ask about things in the home that pose risks of injury or illness so the right advice can be offered to mitigate these problems? And if it’s not right for pediatricians and ER physicians to ask about guns in the home so we can pass on reminders about gun safes and the need to keep them away from kids, can we also no longer ask about other home hazards considered as “property” that people have a legal right to own, such as swimming pools, cars, and motorcycles? The nonsense has got to stop somewhere.)

The Ohio bill goes even farther than mandating that physicians simply read information prepared by the state. HB 125 predicates a woman’s ability to opt for abortion on the presence or absence of fetal heartbeats. Clinically, there are a couple of ways to assess this. If the pregnancy has gone past twenty weeks, you can usually hear the heartbeat with a regular stethoscope. From 12-14 weeks up to 20, you use an external “Doppler” device which amplifies sounds at the frequency of the fetal heartbeat. Before 12 weeks, the only way to accurately assess the presence or absence fetal heart tones is do to a vaginal ultrasound. (It’s nearly impossible to identify fetal heartbeats with a reasonable certainty prior to 6-7 weeks of gestation.)  According to my understanding of the bill, there can be no elective abortion once a fetal heartbeat has been identified.

The ultrasound probe is essentially a large hard plastic cone which is wrapped in a rubber glove, lubricated, and placed into the vagina. So in this case, the state is essentially forcing a woman to have an object inserted into her vagina in an effort to deny her federally-guaranteed legal rights to an abortion, whether she wants this done or not. I’m not a lawyer, but I seem to recall that unconsented touching is battery, and forcible insertion of an object into the vagina constitutes rape. Ohio physicians are, in essence, being forced to become state-sanctioned rapists. While you may endorse the goal of stopping abortions, I don't know how anyone can endorse this imposition into the doctor-patient relationship.

I won’t claim to know if the voters of Ohio feel the same way as their legislators. But I’m pretty damn sure that Buckeye State physicians don't want to be put in this position, and that violation of their person to promote a social agenda is certainly not what their patients need. The abortion debate is difficult, and I don't have the magic answer. But when clincal realities are ignored, everyone looks silly.

Call me a conservative, but I always thought the patient was supposed to come first.

(Update:  In Ohio, House Bill 125, 2011, made it out of the House but was not taken up the State Senate.  The 2011 Florida legislation was enacted into law but was blocked by a Federal Judge, citing violations of First Amendment free speech rights of doctors.  And here in Kansas, there was a 2013 effort to place a similar prohibition on physician inquires about guns in the home within a bill that exempted "Made in Kansas" firearms from federal regulation.  The provision was stripped from the final bill prior to passage by advocates for child safety and the First Amendment.  I wish I could be hopeful for lessons learned.  But this is politics, and the right-wing base needs more red meat.  It's just a matter of time.)

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