Late Term Abortions in a Dysfunctional Democracy
At the end of January, the Senate rejected a measure to ban late-term abortions, with an exception to protect the life of the mother. Such abortions are quite rare. According to data from the CDC, ~1% of all abortions occur after 21 weeks. Figure 1 illustrates when abortions are typically performed.
These late term procedures are sought for a variety of reasons, but data surrounding them is hard to come by. One study concludes that the demographics between women seeking earlier and late term abortions are almost identical with the exception that late-term abortion seekers are more likely to be young and unemployed. These demographics are accompanied by similar shifts in reasons given as they are more likely to have troubles finding funds, insurance, or providers. This data did not include those seeking abortions due to life endangerment nor fetal abnormalities, which are often cited as primary reasons for late term abortions. Interestingly enough, the recent legislation did not include an exception for fetal abnormality.
That later topic, fetal abnormality, is subject to its own debate as states have introduced legislation to prohibit abortions based on medical conditions of the fetus. Such discussions often devolve into a debate about eugenics. It is an ethical quandary to say the least. In Iceland, nearly every woman who undergoes prenatal testing only to discover their child has down syndrome elects to terminate the pregnancy. As individuals, we might ask ourselves, who are we to decide who lives and who doesn’t (through selective birth, genetic modification, or otherwise)? One advocate living with cystic fibrosis, a medical condition that results in persistent lung infections and degradation of the ability to breath, encapsulates his views on the subject of gene-editing:
I have not dedicated my life to the fundamental goal of seeing a world where cystic fibrosis patients no longer have to live with a terminal illness, only to have someone fear for a future where he will be missing out on living with people who have disabilities.
Give me a f*cking break.
Do you think any of this shit is fun — waking up, disconnecting from my feeding tube and feeling like I can’t breathe, only to sit in a chair for an hour and a half to regain the gift of breath, then proceed through the day knowing that tomorrow will hold much of the same?
Ignoring genetic modification, prenatal detection of life-changing conditions also has its own moral dilemmas. For instance, it would be cruel to knowingly carry a child to term with Niemann-Pick Disease Type A. A condition that is characterized by the deterioration of the nervous system and eventual death during early childhood. At the very least, there ought to be at least some consideration given for fetal abnormality— if only to prevent the very worst of conditions from inflicting very real, conscious pain.
Conscious pain is, notably, central to the issue of late-term abortion. Advocates for late term restrictions point to fetal pain as rationale to adopt these laws. However, studies cited in advocacy for these laws acknowledge that the measured “pain” can be obtained using non-painful stimuli. The table below summarizes the neurological studies on fetal development and demonstrates that cortical function, and the respective thalamocortical connections, are not fully developed to experience pain until about 30 weeks. Such fibers do not even begin development until 23 weeks. Still, it is important that such biological development be the cornerstone from which laws are codified.
It is also useful to examine legislation in other countries. Unlike America, most countries in the European Union do have restrictions on late term abortions after completion of the first trimester (~12 weeks), with exceptions for fetal abnormality or life endangerment.
These deadlines line up well with developmental milestones. Note that the end of the first trimester also marks a milestone where natural pregnancy failure (affecting ~15% of all recognized pregnancies) has dropped off dramatically (see Figure 3). Meaning that if the fetus has made it that far, that it will almost certainly come to term. A sort of developmental viability.
Before this period, failure rates increase dramatically. From the moment of conception to implantation, ~50% of fertilized eggs are lost (~66% for all embryos). If viability is interpreted in this way, it would place greater restrictions on the rights of women, but in a way that is statistically quite small since the vast majority of these decisions are made before fetal development begins. It would also alleviate problems stemming from a position that all life beginning at conception is sacred — such a view would impose an unreasonable burden to save many lives that are lost to causes other than abortion.
Historically, the Supreme Court has balanced the rights of the mother and potential life of the unborn by enabling restrictions after viability in a different sense — the ability to live outside the womb. In Roe v. Wade, that marker was around 28 weeks, but the later ruling of Casey v. Planned Parenthood established that viability was a function of technology rather than some absolute date. Indeed, current technology has moved viability to about 20 weeks. Future technology may push viability all the way to the point of conception and possibly even antiquate traditional pregnancy. Perhaps it is a bit ironic that some of the pro-life crowd call for a Constitutional amendment to protect the unborn when in reality it could be the pro-choice crowd that needs one. Although, at that point, it would be hard to imagine there even being a desire to pursue such personal or legal actions. I digress.
Legal restrictions before 14 weeks (or outright bans) need to be assessed for their accomplishments or lack thereof. Such measures contribute to the rise of unsafe abortions (See Figure 4). Even simple restrictions can result in undesirable outcomes — Medicaid funding reductions resulted in significantly higher rates of postpartum depression. And while abortion rates have decreased nationwide, states which imposed more restrictive measures actually contributed less than states that didn’t. It seems the difficulty with declaring abortion illegal, as with so many other issues that are morally ambiguous(i.e. drug use, gun ownership), is that the legality of an issue has less of an effect on occurrence than other factors. The biggest factor to decreasing abortion rates has been a decreasing birth rate and, by extension, the increasing access and quality of birth control.
If the goal is to bring down abortion rates, which should reasonably be one of our utmost priorities (abortion is categorically the largest contributor to years of life lost), we should allow data to drive decision making. With this in mind it makes sense to pursue policies of free (or more affordable) birth control, paid maternity leave, affordable childcare, affordable education, career services, and relationship counseling. It makes intuitive sense to address these issues as they are cited by women as a specific reasons why they sought an abortion. Needless to say, spending programs need to be monitored and controlled so as to maximize results and minimize cost.
It also makes sense to foster an environment that is favorable to human life and dignity. We can do that by extending viability down to 14 or 16 weeks, in line with critical development milestones, consistent with the laws of other countries, and amenable to reproductive rights. Ambiguous cases where lack of access, resources, life endangerment, or fetal abnormality should all be taken into account when addressing such restrictive legislation.
These changes might individually be seen as unwanted compromise, but together, they achieve the greater good sought by both sides: a reduction in abortion and betterment of human life.
