Is Abortion ever Medically Necessary?

Most abortions laws in the United States of America have exceptions for cases of rape, incest, and “life of the mother.” Whatever the restrictions on abortion are in the particular law, cases of rape, incest, or endangerment of the mother’s life are still legal.

Let’s examine the legal meaning of “medically necessary” abortions and whether they are the same thing as abortions for the life or health of the mother. We’ll also look at what types of health conditions fall under “medical necessity”, how often they are performed, and who pays for them. We’ll also study the pro-life response to “medically necessary” abortions. “Medically necessary” abortions are typically performed starting in the middle or late second trimester and may be performed throughout the third trimester. We’ll conclude by examining possible complications of these late-term abortions.

What is the Legal Definition of “Medically Necessary”?

Pro choice advocates claim that abortion must be legal because some abortions are not elective, and are in fact “medically necessary.” The term “medically necessary” originated in the 1940s, “to ensure that hospitals and physicians were paid for the services they performed.” [1] It was a vague catchall phrase used by insurance companies that mostly relied on physician judgment about what services were necessary for a patient’s care. Abortion rights advocates ever since Roe v Wade and Doe v Bolton in 1973 have argued that “medical necessity” is an objective standard based on medical judgment. But in reality, “medical necessity” is more nuanced because “doctors often differ in their estimation of comparative health risks and appropriate treatment.” [2]

Is “Medically Necessary” the same as “Life of the Mother”? What about “Health of the Mother”?

“Health of the Mother” and “Life of the Mother”

As we’ll see by the legal definition of maternal “health” below, “medically necessary” abortions can technically include abortions for the life of the mother or the health of the mother.

Abortions to “save the (physical) life of the mother” are recommended for a variety of maternal reasons, including the mother having preexisting heart disease or uncontrolled diabetes or cancer. Sometimes, the mother develops pregnancy complications like preeclampsia or eclampsia (toxemia of pregnancy) or chorioamnionitis. [3]

Abortions to “save the life of the mother” also may be recommended when something goes wrong with the fetus itself, as in ectopic or molar pregnancies.  Abortions for the “health of the mother” generally refer to medical conditions which cause the mother illness and varying degree of physical discomfort. One example is gestational diabetes (diabetes that develops during pregnancy and goes away when the fetus is delivered). Another example is hyperemesis gravidarum (severe nausea and vomiting during pregnancy). “Health of the mother” conditions do not endanger the mother’s life.

Doe v Bolton

“Mary Doe” in Doe v Bolton was a Georgia woman who sought an abortion at 9 weeks pregnant in 1968. “Bolton” in Doe v Bolton was Arthur Bolton, Attorney General of Georgia. Mary Doe wanted an abortion because she was financially unable to provide for another child. She also did not have custody of any of her three other children. She had been a patient of a mental hospital. Finally, she had recently been left by her husband. At that time, Georgia law allowed for an abortion only in the following cases: 1) endangerment of or serious and permanent injury to the woman’s life 2) pregnancy because of rape 3) baby “very likely” to be born with a grave mental or physical defect. [4]

The Doe v Bolton case started in a district court and went all the way to the Supreme Court. The case was decided on the same day in 1973 as Roe v Wade. Doe v Bolton set a legal precedent, or legal definition of a term that is used in other court cases on similar topics in the future. That legal precedent says that the “health” of the mother includes her physical, emotional, psychological, and familial health, and her age. This Supreme Court ruling struck down many state restrictions on abortion. [5] So, any pregnancy that could impact the mother’s physical, emotional, psychological or family health could be grounds for a “medically necessary” abortion. Likewise, presumably a woman who is older than 35 years or younger than, say, 18, could also have grounds for a “medically necessary” abortion.

How often are Abortions performed for “Medical Necessity”?

The Alan Guttmacher Institute has published several studies on reasons that women have abortions. One of these was published in 1987, and another was from 2004. In both studies, “mother has health problems” was cited in 2.8-4% of cases. “Mother has health problems” is another term for “medically necessary” cases and includes both life-threatening and non-life-threatening cases. So, the total of abortions done for the life of the mother is, at the most, less than 4% of all abortions. The most recent abortion statistics are from 2014, and there were 652,639 abortions that year. At the most, then, somewhere between 13,053 and 26,106 abortions were for “medically necessary” reasons, and a portion of these would have been for “life of the mother” cases. [6]

Are Tax Dollars used for “Medically Necessary” Abortions?

Medicare and Medicaid

Tax dollars pay for both Medicare and Medicaid. [7] Medicare is a federal health insurance program available to all American citizens over age 65. Tax payer money goes directly to Medicare at the federal level. Every American citizen who gets a paycheck pays a small percentage of their earnings directly into Medicare. Since Medicare covers Americans over age 65, there is no argument about it covering abortions since all women participants are past child-bearing age.

Medicaid is a health insurance program for poor Americans. Medicaid has both federal and state branches. Each state has its own office and its own rules for eligibility. Some funds from incomes taxes go to Medicaid at the state level. Other federal funds support Medicaid at the national level. [8]

Hyde Amendment

The Hyde Amendment states that federal Medicaid funds cannot be used for abortions except in cases of rape, incest, or the mother’s life being endangered. [9] The Hyde Amendment was originally passed in 1976. Every president since then has either repealed or reinstated the Hyde Amendment depending on his political affiliation.

In 17 states, only state Medicaid money is used to pay for medically necessary abortions. No federal funds are used in these states. In the other 33 states of the 50 states total, federal Medicaid funds are used for some “medically necessary” abortions. [10]

A research study of 25 abortion providers in 6 different states found that in many cases Medicaid did not reimburse them for abortions that qualified under the Hyde Amendment. Many providers reported that going through so much paperwork only to be turned down was a waste of their time. In the few cases where they did actually get reimbursed, the amount of money was so small that it was not worth their time to keep applying. [11]

What is the Pro-life Response to “Medically Necessary” Abortions?       

Moral Principle of Double Effect

Pro-lifers respond that the goal of medical interventions should always be to save life. In select rare cases, the fetus may die as a result of interventions to save the mother’s life. However, the goal is never to purposefully end the life of the fetus. [12] This concept is called the moral principle of double effect, a good action is done that has a foreseen bad side-effect. [13] So, in the case of a woman with uterine cancer, she might have to have her uterus removed to get rid of the cancer. The fetus would unfortunately die as a result, but the woman was helped as a result of the uterus being removed and not because of the fetus’ death.

Moral Principle of Double Effect and Flight 93

Let’s take another example of the moral principle of double effect. Recall the passengers of Flight 93 on September 11, 2001? When they learned that the plane had been hijacked, they made a decision to resist and to prevent the plane from hitting the hijackers’ target. Their goal was to save lives, even though they knew that in the process they would lose their own. So, the goal was to save lives, even though they foresaw that the bad side effect would be their own deaths. Each passenger was granted the Congressional Medal of Honor for this bravery. Pro-lifers abide by this same principle when a mother’s life is in danger.

The Dublin Declaration

The Dublin Declaration on Maternal Healthcare was written in 2012 and signed by over 1,000 Irish obstetricians and other healthcare professionals. It states that:” direct abortion – the purposeful destruction of the unborn child – is not medically necessary to save the life of a woman. We uphold that there is a fundamental difference between abortion, and necessary medical treatments that are carried out to save the life of the mother, even if such treatment results in the loss of life of her unborn child. We confirm that the prohibition of abortion does not affect, in any way, the availability of optimal care to pregnant women.” [14]

What about Abortion for Maternal Health Conditions?

Some medical problems may be exacerbated by pregnancy. These include preexisting heart disease and diabetes and a known or new diagnosis of cancer. Typically, close monitoring and treatment of heart disease or diabetes by a maternal-fetal medicine specialist, also known as a high-risk pregnancy doctor, can prevent threats to the mother’s life. In rare cases where the mother’s life is in danger the longer that the pregnancy continues, the fetus can be delivered early either through induction of labor or a cesarean section.

Generally, a fetus is viable, or can live outside the womb with medical assistance, starting around 24 weeks (less than 6 months pregnant). If a woman has cancer and needs treatment, the treatment could either be started promptly and potential birth defects be managed after delivery, or treatment could be delayed until an early delivery is achieved. Either of these options ensures effective treatment of the woman’s health conditions, and respects the life of the fetus to the fullest extent possible.

Occasionally, a mother decides to forego medical treatment altogether, to give her baby the best chance at a healthy life. While this is not necessary from an ethical standpoint, it is consistent with mothers throughout history who have given their lives to save their children. Mothers have run into burning buildings to rescue children, carried them on their backs through flooded waters, and jumped into dangerous waters to save a drowning child. [15]

What about Abortion for Preeclampsia or Eclampsia?

Preeclampsia, also known as toxemia of pregnancy, develops after 20 weeks of pregnancy and involves high blood pressure and oftentimes kidney, liver, heart, lung, or eye damage. Preeclampsia plus seizures is considered eclampsia. Uncontrolled high blood pressure can lead to seizures, stroke, and even death of the mother. Liver, kidney, heart, or lung failure can also be life-threatening.

Once symptoms start, they do not generally go away until the pregnancy ends. Typically, goals of treatment include outpatient medications to control blood pressure, and frequent doctor’s office monitoring of fetal wellbeing. If symptoms are severe enough, the mother has to be hospitalized until delivery. She is often on intravenous (IV) medication to prevent seizures.

Once a fetus reaches the age of viability, labor can be induced or a Cesarean section performed. If the mother progresses to eclampsia before 24 weeks, the fetus must be delivered regardless. This would not be considered a direct abortion because the goal would be to end the pregnancy by delivery, not to kill the fetus. The preterm fetus would not be expected to live outside the womb, but its death would not be directly caused. [16]

Preeclampsia occurs in between 5 and 8 pregnancies out of 100, but progression to life-threatening eclampsia is rare with proper treatment. [17]

What about Savita Halappanavar?

In 2012, a woman named Savita Halappanavar who was living in Ireland went into the hospital at 17 weeks pregnant with symptoms of a miscarriage. Her situation was unusual from the beginning, as only 1-2% of all miscarriages occur during the second trimester.

Unfortunately, the miscarriage was related to an uterine infection called chorioamnionitis, which was not diagnosed and treated appropriately and in a reasonable timeframe. Chorioamnionitis is typically treated by intravenous (IV) antibiotics, and spontaneous miscarriage of the fetus often occurs. If spontaneous miscarriage does not occur, the fetus may have to be delivered regardless of gestational age because infection in the fetus can progress to life-threatening systemic infection via the mother’s bloodstream. This would not be considered a direct abortion because the intent was to deliver the pregnancy, though the fetus was not expected to survive due to prematurity.

By the time that the spontaneous miscarriage completed, Savita’s untreated infection had progressed to her entire bloodstream and caused organ damage, a condition known as sepsis. Her sepsis worsened to severe sepsis and then septic shock. Her heart stopped, causing her death, seven days after she entered the hospital.

Abortion advocates called for a repeal of Ireland’s abortion laws. They argue that if Savita had received an abortion then she would not have developed sepsis. Unfortunately, the facts lead to a different conclusion in Savita’s case. The investigation into her death found that the real problems were that she was not monitored closely enough, that the fetus’ infection was not treated appropriately, and that her own possibility of infection was not anticipated correctly.  By the time her treatment team realized just how sick she was and responded, it was too late. [18]

What about Abortion for Ectopic Pregnancies?

An ectopic pregnancy occurs when the embryo implants somewhere other than the woman’s uterus, oftentimes in a Fallopian tube. Because the Fallopian tube is small, the pressure of the growing embryo on the Fallopian tube can cause it to rupture. Fallopian tube rupture can lead to life-threatening complications.  Ectopic pregnancy affects about 1 in 50 to 1 in 100 pregnancies. [19]

Ectopic pregnancies can be treated in three ways. Two of these ways arguably constitute a direct abortion. Methotrexate is considered a direct abortion because it stops production of the trophoblast. The trophoblast is produced by the embryo and normally develops into the placenta. [20] Salpinogotomy is also considered a direct abortion. The Fallopian tube is sliced open and the embryo is scooped out and dies. The woman’s Fallopian tube may still function correctly in the future.

Salpingectomy is not considered direct abortion because the whole diseased section of the Fallopian tube is removed. The death of the embryo inside is an undesired but expected side effect. Because a section of the Fallopian tube is removed, that tube will not be functional in the future. Having only one functional Fallopian tube reduces the woman’s fertility. [21]

What about Abortion for Hydatidiform Mole or Molar Pregnancies?

A hydatidiform mole, also known as a molar pregnancy, may be a partial (or incomplete) molar pregnancy or a complete molar pregnancy. Something goes wrong during fertilization of the egg by the sperm. The placenta develops abnormally and the fetus develops only partially (partial molar pregnancy) or not at all (complete molar pregnancy). In rare cases, the placental mass that develops from the molar pregnancy may become cancerous. This cancer can be life threatening, but is generally treated successfully with chemotherapy. [22]

Complete molar pregnancies occur in about 1 in 1,000 pregnancies. [23] Incomplete or partial molar pregnancies occur less frequently. If the embryo does not develop, a dilation & curettage procedure is recommended to clean out the uterus. This would not be considered a direct abortion because there is no life there. If an embryo does partially develop, the woman will typically miscarry.

What kind of Complications can occur during “Medically Necessary” Abortions in the 2nd or 3rd Trimester?

Late term abortions, or abortions performed in the second half of the second trimester or anytime during the third trimester, require several days to dilate the cervix. Risk of death from abortion increases by 38% each week starting in the second trimester. [24]  Serious, documented risks for late-term abortions include:

  • Cervical injury
  • Uterine perforation
  • Infection (may become life-threatening)
  • Life-threatening hemorrhage (bleeding)
  • Uterine rupture
  • Incomplete abortion due to body parts or placenta or other tissue left inside the uterus
  • Disseminated intravascular coagulopathy (life-threatening blood clotting and bleeding)
  • Anesthesia-complications such as respiratory depression[25]

So, is abortion ever medically necessary?

We see from the examples above that direct abortion is never medically necessary to save the life of the mother. In rare cases where the mother’s life is in danger if the pregnancy continues, the baby can be delivered via induction or cesarean section. If the baby has not yet reached the age of viability, the mother and her medical team may anticipate the baby’s death after delivery as an unintended consequence. In these unfortunate cases, perinatal hospice programs can help facilitate and guide the woman and her family through the bonding and grieving process. This approach respects the lives of both the mother and her child. [26]

 

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