Before Roe, abortion providers operated on the margins of medicine. They still do.
Doctors of Conscience: The Struggle to Provide Abortions Before and After Roe v. Wade
Life before Roe. For those of us who lived it, it is hard to believe there is already a generation that can only imagine it. It is the stuff of women's cinema, unveiling conversations, demonstrations, stories cast in print or still untold.
Doctors of Conscience does not offer detailed accounts of individual women seeking abortions, or the oft-quoted public health statistics on the morbidity and mortality of illegal abortion. Rather, Joffe captures the "lengths to which women would go" to control their reproduction in horrific snapshot images that come from the health professionals who treated them: emergency rooms teeming with women bleeding from corrosive agents, broken Coke bottles, catheters, and coat hangers; late-night operating rooms crowded with stretchers holding women who waited to have their instrumented uteruses evacuated or removed; a woman delivered to the emergency room with a paper bag containing eight feet of her intestines. This collective human suffering is attended by a palpable paranoia permeating the wards in which it occurred--the pervasive police presence; physicians, under the threat of the law, forced to grill patients about the identities of their abortionists in the moments before they died. No less chilling is the insidious misogyny that stigmatized these women, and devalued their lives. As one physician recounts, the special wards of public hospitals where women suffered and often died from septicemia, or overwhelming infection, were referred to as "septic tanks."
Much of the powerful storyline of Joffe's book describes the methods by which doctors of conscience opposed these atrocities, and the consequences they suffered even at the hands of their own colleagues. But its political heart lies in her observation that the bulk of the medical community failed to act responsibly. Countering the common assumption that the emergence of an organized anti-abortion movement led to the marginalization of abortion and its providers, Joffe asserts that the mainstream medical establishment itself had long before relegated abortion to the "back burners" of women's health care.
This argument makes sense in view of the historical relationship of the medical establishment to women's reproductive health. Linda Gordon, Rosalind Petchesky, and others have documented that women practiced contraception and abortion throughout history, usually within the context of female-dominated and community-based networks of midwives, kin, and lay healers. Until the mid-19th century in the United States, abortion before "quickening" (perceived fetal movement usually occurring at about 20 weeks gestation) was neither subject to governmental regulation nor considered to be morally wrong, even by religious authorities.
With the emergence of a Victorian ideology of sexual prudence and virtuous motherhood for women, along with concerns about declining birth rates among Anglo-Saxon women in the face of rising immigration, contraception and abortion increasingly came under attack. Against this backdrop, the American Medical Association (AMA) led a concerted and morally reprehensible campaign to criminalize abortion and especially to discredit the popular practitioners (so-called "irregulars") who had traditionally addressed women's reproductive health needs. By the early 1900's, the campaign had succeeded: Birth control was illegal, all states had criminal abortion statutes, and the male-dominated medical profession had laid the foundation for its monopolistic control of the health care system. While the AMA supported limited abortions when necessary to protect the life, and later the health, of women, it insisted that these procedures be performed exclusively in hospitals and only by physicians. Thus, the medical profession used abortion to establish its propriety over health care and women's reproductive choices, while simultaneously condemning abortion as morally repugnant and restricting its practice.
As Joffe observes, the criminalization of abortion encouraged a flourishing black market in illegal abortion. Police pay-offs were common, and according to one account, illegal abortion ranked only behind gambling and narcotics as a lucrative organized crime "racket." A two-tiered system arose that allowed women with money and the right connections to obtain abortions from qualified practitioners, while poor women self-induced or risked their lives in the back alleys. This class-based inequity extended to the "therapeutic abortion" committees that arose in the 1960's as arbiters of "medically necessary" abortions: Having a private doctor on the hospital staff became one of the key "tickets" to obtaining safe abortions. The doctors of conscience recall bitterly the hypocrisy of colleagues who shunned them publicly, yet relied on them to assist relatives and private patients in obtaining committee-approved abortions.
The efforts of both of these groups, combined with changing socioeconomic conditions, made legalization of abortion inevitable. In the years that followed, however, the joy and relief that activists felt with the decision in Roe turned to disillusionment. For as Joffe points out, the legalization of abortion resulted neither in the acceptance of abortion as an integral part of women's health care nor in deserved respect for its providers.
Rather, two decades after Roe, we have the Hyde Amendment, which denies Medicaid funding for abortions, and the Supreme Court's 1992 ruling in Planned Parenthood v. Casey, which allows state restrictions on abortion as long as they do not impose "undue burdens" on women. We have pervasive parental consent and notification laws, mandatory waiting periods, requirements that doctors "counsel" women by showing graphic pictures of fetuses and reminding them of social services available if they would just change their minds. We have only 16 percent of US counties with an abortion provider, and only a small minority of medical training programs that still routinely teach abortion. We have women's health clinics destroyed by firebombs; chemicals poured into ventilation systems; patients accosted by zealots at clinic entrances; health personnel stalked and their families terrorized; doctors, workers, friends, and loved ones dead and wounded. We have a well-organized and well-funded right wing movement that condemns sex education, contraception, and the "murder of unborn children" while holding White Rose banquets to honor those who carry out the "justifiable homicide" of abortion providers.
In looking at these "horrific snapshots" of life after Roe, Joffe writes as a historian who helps us understand the present by looking at the past-- particularly, at the continuity of the role of mainstream medicine in the marginalization of abortion care. But in her final pages, it is as a feminist activist that she poses challenging questions to all who care about the future of abortion access for women. Who will replace the doctors of conscience who are now nearing retirement? What will motivate a young generation of practitioners who never knew the horrors of illegal abortion? What will happen to abortion services as more and more states institute restrictions on abortion? What effects will managed care have on women's access to abortion? Does the segregation of abortion services into free-standing clinics simply increase their vulnerability and perpetuate the marginalization of abortion and its providers?
Joffe does not pretend to have all the answers to these questions, although she provides important insights. She suggests that there will be an increasing regionalization of abortion services as state restrictions escalate, not unlike the pre-Roe days when women traveled long distances to obtain abortions in states that had liberalized their laws. She projects that free-standing clinics will remain attractive as providers of low-cost abortion care under a managed-care environment. At the same time, she calls on the clinics to form training alliances with the academic medical centers and to consider changes in working conditions that would make the clinics more appealing to would-be providers. And she finds hope for the better integration of abortion into the health care system with the advent of medical abortifacients (such as RU-486) and the emergence of powerful organizations, like Medical Students for Choice, that draw on a new generation of health professionals dedicated to women's reproductive choice.
However, Joffe's analysis is of necessity incomplete because it is largely confined to a medical framework. While progressive changes within the medical community are important, these must be combined with radical feminist politics and grassroots political organizing if we are to effect real change in women's lives and access to care.
With a book submitted for publication in 1994, Joffe couldn't have predicted the force with which managed care would sweep the medical world. But now we have it--a health care system in which medical access and decision-making are increasingly controlled by insurance companies who reap huge profits at our expense. Every day in my life as an obstetrician-gynecologist and abortion provider, I care for women who are forced to pay out-of-pocket for abortions their insurance companies won't cover, with anti-choice "gatekeepers" who refuse to approve abortion referrals for their patients, with women seeking alternative sources of care because reproductive health services have been eliminated in their communities through Catholic hospital mergers. Worse yet, the ranks of the uninsured continue to grow and the Hyde Amendment remains intact, leaving poor women little recourse. To address these problems, we must continue to struggle for a national health plan that provides health care for all and that includes the full spectrum of women's reproductive health services.
Equally important is the reclamation of a paradigm of care that fosters women's empowerment and reproductive control. Joffe argues cogently that we must fight for the integration of abortion into mainstream medical services, but she also recognizes the value of the independent clinics that have long served the needs of women against great odds. Joffe asserts that the clinics could attract more mainstream physicians by offering higher wages and more diverse work, but we must also attract providers who don't regard women's gynecological care as routine and boring. Abortion is perhaps the most challenging and intimate work I do because it is not simply about a "procedure"; it is about the totality of a woman's life. I know other physicians who feel as I do; but I also know midwives and nurses and feminist women's health advocates who would be dedicated and compassionate abortion providers, if only the law would let them.
For women and providers today, the anti-abortion movement plays a more formidable role than it did during much of the era in which the doctors of conscience practiced. Its political victories have indeed undermined access to abortion, particularly for young and poor women. After passage of the Hyde Amendment, at least 20 percent of Medicaid-eligible women who would have had publicly-funded abortions carried pregnancies against their will. In the five months after the institution of a mandatory 24-hour delay law in Mississippi, the number of Mississippi women obtaining abortions in the state fell 13 percent, and the number of women having riskier second trimester abortions rose significantly. In addition, the relentless harassment and violent tactics of the anti-abortion movement have taken their toll on the number of providers willing to perform abortions. These setbacks are real and frightening, and they will continue to form much of the context for pro-choice organizing.
Our greatest challenges, however, may come in the more elusive ideological arena. Doctors of Conscience is refreshingly free of the defensive moral discourse about the fetus that has characterized some recent pro-choice commentary. Abortion before Roe was so starkly a matter of women's survival that only the immoral actors in Joffe's book dare to challenge women's right to choose it. In the aftermath of legalization, the anti-abortion movement has succeeded in changing the terms of the debate. I hear that change in a recent Boston Globe editorial asserting that no one "can say `Abortion is not wrong' with total conviction"; it resounds in Naomi Wolf's recent article chastising the pro-choice movement for its failure to engage in a moral rhetoric about the "necessary evil" of abortion; I sense it in the attitudes of those who hold that abortion should be legal, but hard to get or laden with guilt or morally wrenching.
In my work, I've come to know the enormously diverse reasons that women choose abortion, and I have never met a woman with a "bad" reason for doing so. I've cared for some women who feel guilty, many more who feel relieved, and all who know that their decision makes sense in the context of their own lives and responsibilities. The only "morality" of abortion that I recognize is the moral authority of women to determine their own destinies. It is precisely because abortion is about women's power and sexuality that it has become the target of those who cry for a return to patriarchal "family values." Rather than capitulating to the right's attempt to resurrect a distorted moral discourse about abortion, the pro-choice movement needs to reclaim a language that stands squarely and unapologetically for women's right to reproductive freedom.
Joffe finds great promise in a younger generation of doctors of conscience who are inspired to resist the unscrupulous tactics of the anti-abortion movement. But I also find hope in the emergence of a grassroots activism aimed at issues of access, training, and safety. Feminists are picketing hospitals to demand comprehensive women's health services, challenging "physician only" abortion laws, promoting abortion training among mid-level practitioners, protesting Catholic hospital mergers, and organizing community networks of support for abortion providers. Broad-based alliances are forming that recognize abortion as but one part of reproductive freedom, and that see reproductive freedom as impossible without social justice.
Joffe's book bears witness to the heroic acts of doctors of conscience, and the difference they continue to make in women's lives. But to transform women's lives fundamentally will take nothing less than changing the world. And that will take all of us.