Nobody wants to talk about abortion. The conversation is more complex, polarizing and tiring than COVID or the corporate takeover of health care. But emergency medicine is the profession that trains EPs to brave the conversations no one wants but needs: domestic violence, child abuse, end-of-life issues, depression, sexually transmitted infections, homelessness, drug addiction, sex trafficking, social determinants of health, mental health, suicide… the list goes on and on.
Why should abortion be any different? It can, in many cases in the ER, even be part of the same discussion. Like COVID, the politicization of scientific information makes objective factual expression an arduous skill to detach from controversies embedded in our culture and language. This is as true for doctors and medical staff as it is for patients. Winning your position becomes personal and moral anger rather than being with someone in distress and agreeing to a solution you might disagree with.
Many years ago, I remember a reclusive elderly woman with STEMI who would not agree to go to the cath lab until someone went to feed her cats. “I would rather die than see my cats starving,” she said. She literally meant it. I was in total disbelief.
But it wasn’t until I accepted her assessment of her situation that we could begin to resolve a life and death issue for her and her cats. We ended up sending one of our security guards to her house to feed them. And that’s the first thing she talked about when she woke up from the sedation. She taught me a valuable lesson as a young doctor to train me not to shake my head in disagreement (metaphorically or literally) while someone says something to me that I don’t want to hear.
Abortion is far more nuanced than a heart catheterization lab and cats, but approaching suffering with another person you may disagree with instead of trying to win your position is a valuable emotional setting. on which to practice medicine. I will not provide any heroic or heartwarming story about a woman seen in the emergency room who wants to terminate her pregnancy or about a woman who is pregnant again and is not in a physical, social or mental situation conducive to childbirth and the education of a child. These types of anecdotal stories should not be told because a single story, like the woman and her cats, is in danger of being medically generalized under a subject as immeasurably complex and variable as any subject in all of medicine.
Binary thinking and wisdom
How we define terms in the most measurable and objective way possible is the crucial first step in discussing what exactly we are talking about, whether it is sepsis, heart attack or an abortion, and should happen long before we can start talking about treatment. Definitions and approaches to circumstances are subject to wide variation.
The circumstances surrounding the induced abortion are often multiple: is it a blastocyst or a 10-week-old fetus completing organogenesis? A previable fetus or a fetus that may be viable outside the womb? Healthy fetus or anencephalic fetus? A mother whose life is reasonably in physical danger (and how are these probabilities determined?), a pregnant woman as a result of a criminal act of violence, a pregnant woman under duress, or a mother (and father) without economic resources , mental or social resources for raising a child without neglect being likely? An egg fertilized by sperm and saved for embryo transfer, an embryo or fetus terminated out of family or community shame, or an embryo or fetus terminated at an inopportune time in life due to demands or aspirations professional? Or a combination of several of them?
It’s not just about a woman who can choose to have an abortion. Some women don’t have an abortion but don’t want to be pregnant and are deeply unhappy and scared at the thought of having a baby. Some women have an abortion even if they want to have a child because, in their immediate circumstances, having a baby seems to destroy them. The physical and emotional permutations are frankly unimaginable and not necessarily static. Anyone from any political side who wants to vote on this topic with a thumbs up or thumbs down shows a serious lack of knowledge and possibly a lack of empathy for the human beings on the other side of the argument. Binary thinking destroys any opportunity for wisdom.
I offer no expertise in approaching the obstetrical, medical, legal, ethical and social dilemmas of induced abortion, but would like to explore several aspects of scientific medical definitions and community language surrounding unwanted pregnancy that often lead us away from objectivity and towards political polemics. Using COVID again as an analogy, the medical community should be compelled to repeat over and over again these scientific definitions and facts that we know with as much clarity and fairness as possible in the hope that we can begin to have a discussion about integrity and purpose.
Can we agree on at least the same set of scientific language without people just shouting their opinion into existence with half-truths? We need clarity. We need a scientifically neutral lexicon surrounding the use of the word “abortion” in medicine. Here is my short list of suggestions regarding our current abortion medical lexicon.
An ambiguous umbrella
The reporting of G3P1Ab2 lacks the necessary clarity. Abortion is a loaded word, and our medical lexicon needs careful subdivisions of the ambiguous abortion umbrella. Terms like “spontaneous abortion” or “threatened abortion” should be dropped for the word “miscarriage” in our speech, dictation, and grading.
“Elective abortion” should be dropped for the term “induced abortion”. The word “elective” is often used in abortion centers around the fulcrum of choice. A miscarriage is not a choice, and termination of pregnancy due to maternal danger is an extremely limited choice. A termination of pregnancy following rape or with a fetus with limited life capacity is logically not the same unconstrained choice as other abortions.
An abortion necessary to save the physical life of the mother is not really elective and could be called an “imminent termination of pregnancy”. And perhaps abortions following rape or fetal abnormalities that are devastating and unlikely to sustain life deserve another term like “termination of pregnancy.” Women deserve this clarity. Ignoring these distinctions under an ill-defined word containing “abortion” blurs the conversation and can wrongly blame women for choosing a situation in which they may feel they have little choice.
“Pregnancy” should not be used as an understatement. Pregnancy is a condition of a woman who is pregnant. It’s not a condition of the father—he’s not pregnant. The fetus is not the pregnancy. We don’t look at your pregnancy; we scan your fetus. A woman does not fake pregnancy; she miscarries a fetus.
The words “mother” and “baby” in an initial interview should be stated as “the pregnant woman” and “the embryo” (less than eight weeks) or “the fetus” (eight weeks or more gestation). “Fetus” will be the most likely terminology for pregnant women in the emergency department receiving ultrasound or fetal heart tones.
The fetus is not the female body. The fetus has its own unique DNA which is not part of the female body. The fetus is not a collection of cells. Anyone who has studied embryology knows that it is a unique human tissue that is in the process of being. The word “person” is more problematic because the legal arguments are not about whether the fetus is a human being, but whether it has the rights of a “person”, the same rights as women and blacks didn’t have earlier in our history.
“Life” is also more problematic for legal reasons, as “ending a life” could be translated as “killing”. A fetus as a human being or a human emergence would be more precise and less controversial than “a part of the female body”, “a drop of tissue” or “the life of the baby”.
Abortion is not a reproductive term. The embryo-fetus is already produced. It is not a decision about reproduction. This is a decision about carrying and giving birth. Induced abortion would be more a matter of parturition rights than of reproductive rights.
Women’s rights have historically centered on full personality and citizenship through the vote and later on cultural power in leadership within the family and society. These good developments in empowering women to have their voices heard are often placed under the positive umbrella of women’s individual rights.
Complex science deserves an objective and precise lexicon. Medical terms and definitions, like scientific data, should be created with as little bias as possible. Manipulation using polemical phrases should be avoided. The polarization of the subject of abortion in the United States has destroyed even the ability of the medical community to create verbiage that does not vote for a political camp.
It is not wrong to have an informed medical opinion on a course of action in unique and particular circumstances, but these discussions cannot be entertained, let alone translated for our communities, unless we adopt and did not speak with clarity of terms. The subject of abortion deserves better. Those who are pregnant in the emergency room deserve better.
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Dr. Mosleyis an emergency physician in Wichita, KS.