Project Wittenberg

Abortion in Perspective

Part I

A Report of the
Commission on Theology and Church Relations
of the Lutheran Church--Missouri Synod
as prepared by its Social Concerns Committee

May 1984

More than a decade has passed since the Commission on Theology and Church Relations issued its report, "Abortion: Theological, Legal, and Medical Aspects." Much has happened since then. While the principles and warnings issued in that document are still valid today, it would at that time have been difficult to anticipate the 1973 Supreme Court decisions which, by striking down many of the legal restrictions which surrounded abortion, made possible a dramatic increase in the number of abortions performed in this country. Since then abortion has been and continues to be an issue creating deep divisions within our society.

As Groups supporting and opposing a right to abortion emerge within our nation, as the number of abortions performed yearly grows astonishingly, and as courts consider cases which may involve all citizens in the public funding of abortion, the Christian community must struggle with the moral and spiritual issues raised by such a rapid transformation of our public policy with respect to abortion. Controversy over abortion will probably continue in our country. As Lutheran citizens we seek to participate in this national debate, participation which should be informed by the discoveries of medicine and science, be familiar with the legal situation which now exists in our country, and be guided by a vision of human life which is grounded in God's Word.

This report--intended as an aid to such informed participation-results from a request by the Commission on Theology and Church Relations that its Social Concerns Committee prepare a resource document for use by members of The Lutheran Church-Missouri Synod. While drawing on the theological principles presented in the Commission's 1971 document, this new report seeks to respond in greater detail to the changed political situation we face and to the moral problem which abortion continues to present.

A. The Beginning and Development of a New Human Life

Christian vision, even in a prescientific age, has always been shaped by words like those of Psalm 139:

For thou didst form my inward parts,
thou didst knit me together in my mother's womb.
I praise thee, for thou art fearful and wonderful.
Wonderful are thy works!
Thou knowest me right well;
my frame was not hidden from thee,
when I was being made in secret,
intricately wrought in the depths of the earth.
Thy eyes beheld my unformed substance;
in thy book were written, every one of them,
the days that were formed for me,
when as yet there was none of them.

Such words have not only moved us to wonder at the marvel of new life; they have persuaded us that the dignity and value of human lives depend on no special achievement, for God has set His hand upon us and taken care for our days even "when as yet there was none of them."

We are prepared, therefore, to accept with continuing wonder and delight what medical researchers have begun to learn about the formation of a human being. The development of a new individual begins with fertilization. Sperm and ovum, in themselves in capable of growth, unite to form something new: a cell which carries the genetic characteristics of both parents and which establishes many characteristics of a new human being (e.g., sex, color of the eyes, blood type, facial features, some elements of intelligence and temperament). Given time and the proper environment this new cell will undergo constantly changing yet continuous development marked by the terms embryo, fetus, [1] infant, child, adolescent, adult. If the fertilized ovum, already lining of the mother's womb, a "bag of waters" will begin to form in which the embryo will float freely within the womb. Around 14 days after the time of fertilization this new cell--now multiplied to thousands of cells--may mysteriously "segment" or "twin" into two or more individuals with identical genetic inheritances. After this happens or fails to happen, the individuality of the new life (or lives) is clearly established.

The rate and magnitude of change and development which follow are astonishing. After a mere three and a half weeks the tiny heart begins to beat. Backbone, spinal column, and nervous systems are taking form--as are the kidneys, liver, and digestive tract. When the embryo is four weeks old, though he/she is only the size of an apple seed, his/her [2] head and body are clearly distinguishable. By the end of six to eight weeks of gestational development electrical activity from the developing brain can be detected (a fact of some significance, since it is now common to use cessation of brain activity as a criterion for determining death). By the end of two months of development the limbs (including fingers and toes) have begun to appear and the unborn child-- now technically called a fetus--can hear, respond to touch, and make his first movements (though the mother will probably not feel such movement for several more months). By the end of the first trimester of a pregnancy the baby is fully formed. He can change his position, respond to light, noise, and pain, and even experience an attack of hiccups. In possession of his own set of fingerprints, the child now need only continue to develop size and strength until he is born.

B. Abortion

Abortion may occur spontaneously or may be induced. Not every fertilized ovum develops and matures according to the schedule outlined above. Pregnancies may end at many points in this course of development. Spontaneous abortions occur most frequently at the time when implantation must take place if the new life is to survive. For any of a number of possible reasons--improper hormone levels in the mother, some abnormality in the uterus caused by infection or scar tissue, an incapacity due to genetic defect of the fertilized ovum to sustain itself, an incomplete process of fertilization-- abortion will often occur at this point. Spontaneous abortions, usually referred to as miscarriages, are less likely after the first three months of gestational development.

Today, however, the word "abortion" is used most often to refer to action aimed at bringing pregnancy to an end. During the first trimester of pregnancy an induced abortion will usually be done by means of dilatation and curettage (D & C). The cervix opening is forcibly dilated, and the embryo and placenta are cut and scraped, or vacuum suctioned and scraped, in order to empty the uterus.

After the first trimester induced abortion is more difficult and less safe for the mother. Dilatation and extractions may be used--which requires dilating the cervix, inserting a forceps to dismember and remove the fetus, followed by curettage to be certain the uterus is emptied. A different method--known as saline abortion--is also used for second trimester abortions. A needle is inserted through the woman's abdomen into the amniotic sac ("bag of waters"), and some amniotic fluid is drawn off and replaced with a concentrated salt solution. This poisoned solution asphyxiates the fetus. Normally the mother will then go into labor and deliver a (usually) dead fetus. A more recent version of a similar method involves the injection of prostaglandins, which also induce labor and delivery. This method is considerably more likely than the saline method to result in the delivery of a living (and if the pregnancy is advanced enough, possibly viable) child.

An induced abortion beyond the second trimester will often require a surgical procedure called hysterotomy. The procedure is technically similar to a Caesarian section--except that the intent here is abortion rather than delivery of a child. It is complicated by the fact that a fetus aborted by hysterotomy may possibly still be viable when he or she is removed from the womb and the placenta is severed. Hence, this procedure raises serious legal questions about the physician's responsibility not just to the mother but to the possibly viable infant.

While some abortion procedures involve less risk than others, any abortion may involve complications. Immediate complications may include infection, hemorrhage, cervical damage, perforation of the uterus--any of which could endanger the life of the mother or prevent future pregnancies. Delayed complications may include sterility, greater chance of premature delivery in subsequent pregnancies (which may, in turn, cause physical or mental defects in the prematurely born child), and an increased incidence of ectopic (tubal) pregnancies. Finally, we should note that complications are not merely medical or physiological; they may also be emotional and psychological, for even a carefully considered decision for abortion can later be cause for intense guilt and deep regret.

C. Amniocentesis

Amniocentesis is a medical procedure in which amniotic fluid is withdrawn from the amniotic sac by means of a needle inserted through the abdominal wall of the mother. Fetal cells within this fluid can then be studied, and from such study much can be learned about the condition of the developing fetus. The procedure is not without some risks, chief among them an increase in the rate of miscarriage. (The risk of fetal death from infection or puncture is one in 200. If miscarriages are induced, then the fetal death rate is at least 3 percent.) [3]

Amniocentesis was first developed in the 1950s with the intent of detecting and treating problem pregnancies (e.g., when the mother's blood was Rh negative and the fetus's Rh positive). However, from amniocentesis we can also learn the sex of the fetus and information about chromosomal abnormalities and neural tube defects (spina bifida). As a result, the most common use of amniocentesis today is in the second trimester to detect defects, especially the possibility of chromosomal abnormalities such as Down's Syndrome when the mother is in her late childbearing years. Abnormalities are very rarely found--on an average, fewer than 0.5 percent [4]-- but if an abnormality is found, such pregnancies will often, then, end in induced abortion. Since amniocentesis cannot be successfully done before about 14 weeks gestational age, any abortion which is determined upon because of information gained through amniocentesis will necessarily be a relatively late second trimester abortion (perhaps, even, of a possibly viable fetus).

D. The IUD

The intrauterine device, discovered and developed in the late 1950s, calls for brief comment here. There has been disagreement about the precise way in which it prevents pregnancy. Some have held that the IUD prevents fertilization of the ovum, others that it prevents a fertilized ovum from implanting in the uterine lining, still others that either may be the case on different occasions. It is generally agreed, however, that the IUD's effectiveness is due mainly to prevention of implantation. Of course, precise determination of what an IUD does solves no moral problems. If an IUD prevents fertilization, the moral issue raised by its use would be that of contraception. If an IUD prevents implantation, the moral problem raised by its use would be abortion, even if it could be shown that individual human life does not begin until the time of implantation or before the possibility of "twinning" has passed. [5]

E. Fetal Therapy

In California surgeons have successfully operated on a fetus (by inserting a catheter through the mother's uterus in order to drain fetal urine) to treat a congenital defect that prevents normal growth of the ureter, obstructs the passage of urine, and can lead to serious brain damage. In Colorado physicians have inserted a brain shunt in a fetus to relieve pressure from accumulating fluid, a condition which could have resulted in brain damage and abnormalities of head and face. Even more remarkable is the case of a 21-week-old fetus partially removed from the uterus while congenital defects in both ureters were repaired and then returned to the uterus to be carried to term. (In this case the child died after birth, but from cause unrelated to the surgery.)

The fetus, bearer of an uncertain legal status at best, has suddenly become visible through fetoscopy (using instruments to see the fetus (in utero) and sonography (the "picturing" of fetal size and shape by sound waves). Fetuses have become patients, some of whose illnesses can be diagnosed and treated even while they remain within the womb. Increasing recognition of such possibilities will make more glaring the difficulties raised by medical advances for our society's attitude toward abortion.

The basic moral principle of justice is that we should treat similar cases similarly. But we now face the possibility that one fetus could be given therapy while in utero and another fetus, with similar problems in similar circumstances, could be aborted--the only difference being that in one case the mother would choose to sustain fetal life and in the other she would choose to end it. Indeed, we find ourselves in circumstances in which the legal right to abortion recognized in Roe v. Wade means that a woman has no legal duty to ensure that a fetus is born alive but, if she intends to carry the fetus to term, the law might in some circumstances impose upon her a duty to assure that the fetus receives the therapy needed to be born as healthy as possible. [6] Not only a moral but an emotional juggling act is required when in one moment we consider the most advanced medical techniques for fetal therapy and in the next moment, in a similar case, regard the status of another fetus as wholly dependent upon the will and choice of his mother. These difficulties will have to be faced, however, if we consider what the medical perspective has to teach us.

F. The Doctor's Dilemma: Medical Ethics and Abortion

In almost all professions, ethical standards frequently--perhaps usually-- exceed those laid down by law. It is not unusual, for example, for physicians who are found not guilty or are exonerated in criminal or civil proceedings to be disciplined for precisely the same act because the act is deemed unethical by their professional colleagues. One may well despair of defining "medical ethics" with any precision; but in ordinary usage the term refers, albeit somewhat loosely, to the moral, as opposed to the legal, obligations of a physician in his/her professional practice. The difference is not, admittedly, always clear; some standards which are commonly regarded as being in the province of medical ethics in fact have legal effect. Physicians may, for instance, be barred from practice if found guilty of "infamous conduct," i.e., some sort of professional behavior which can, by professional associates of good repute and recognized competence, be reasonably regarded as being disgraceful or dishonorable. Indeed, when there is a code of ethics and an association of physicians who recognize it as "approved," any violation of such a code may be regarded as infamous conduct, as decided in 1955 in the Supreme Court of Massachusetts. [7] But disputes arise when medical ethics and the law do not coincide, especially when rules in the former are very widely recognized and accepted. Then the question arises: what should take precedence, the rules of ethics or of domestic legislation and judicial pronouncements?

Professional consensus is at present inclined to regard abortion as a borderline case. Or, to say the least, it is, in the context of profoundly and rapidly changing attitudes in the religious, legal, and scientific communities-- and in the "public philosophy" as well--under relentless pressure to minimize the purely ethical component in decisions relating to abortion.

Much recent domestic legislation and a sizable number of judicial determinations now permit abortions upon request of the mother; and medical practitioners in growing numbers perform the procedure simply by virtue of the permission that is now granted by law. While it remains true that significant numbers of physicians still decline, out of professional, religious, or personal scruples, to perform or assist at abortions-- except in very extraordinary circumstances--and many others participate with varying degrees of reluctance rooted in mental and moral reservations, we are nearing the day when a majority of physicians regard abortion from a neutral ethical perspective. Or many, preferring not to face it at all, relegate these agonizing ambiguities to others for resolution.

A surprising symbol of the reversal of older attitudes and usages is the steady abandonment of the Hippocratic Oath and the Declaration of Geneva (both of which explicitly prohibit abortion) as an incident in the life of the physician at the moment he takes his profession. [8] There is, moreover, the related dilemma of those physicians, surely still a majority of those now practicing in the United States, who took the oath before the current retreat from it began. May the pledge-bound physician violate the Oath? The problem is more poignant when it is recalled that the Oath has always been taken by individual physicians, not corporately or in their behalf by an agent or agency.

Indeed, in reviewing the literature bearing upon this sensitive issue, it is difficult to overcome the feeling--or to rebut the evidence--that in the everyday practice of medicine physicians spend little time in systematic, deep, and critical reflection upon their work. They evidently take for granted a few moral principles, writes the distinguished medical scholar John Walford Todd in the current Encyclopedia Britannica,

whether they believe these are derived from Hippocrates, from the natural law, from the divine law, or just from plain common sense. They do their best to benefit their patients, by curative methods, if possible, and otherwise by relieving symptoms and by kindness or reassurance; they tell the truth (except when the truth is too wounding); and they do not reveal their patients' confidences. [9]

But there persists, even among those physicians who profess no religion (except perhaps the "civil religion" of secular sanctions for "human decency"), as well as among committed Christians, a deeply troubled pathos haunted by the sense that the startling increase in abortion in our time involves special and unique considerations. A profession whose peculiar function has always been the fostering and preservation of life is increasingly applying its skills to the termination of life; so much so that abortion is fast becoming a leading cause or form of death. The bearing of medical ethics upon such considerations is, one would suppose, decisive. But many physicians, whose number it is impossible to guess, find uneasy reassurance in the consoling premise that they are, after all, only technicians, laboring in a field clouded by agonizing uncertainties and imperfect knowledge, whose shadows it is the responsibility of others-- theologians, theoretical scientists, philosophers, ethicists, mystics, and justices of the Supreme Court--to dispel.

The relatively sudden introduction of so large a number of respectable physicians into a field so lately served almost exclusively, and more or less clandestinely (to say nothing of illegally), by a small number of physicians looked upon by their colleagues as pariahs, [10] is still of too recent development to have permitted the accumulation of substantial studies of the ethical implications for the medical profession itself. Evidence on the point is not wholly wanting, however.

An example is the pioneer study of Nathanson and Becker, published in 1977. The paper, heavily statistical in form and based on telephone interviews with 473 obstetrician/gynecologists, is introduced by a summary:

Although religion is the most powerful predictor of whether a doctor will perform any abortions, satisfaction with his or her patients and emotional reaction to the abortion procedure powerfully affect the physician's practice.Doctors who are most satisfied with their patients are less likely to ask unmarried teens for parental consent and to charge lower fees. Physicians who are severely disturbed over abortion perform terminations less frequently and more often ask spousal or parental consent--but charge lower fees and are more likely to accept Medicaid patients. [11]

The paper, like others which have canvassed American physicians more generally, also notes that inquiries of this sort demonstrate "substantial support" among physicians for "a liberal abortion policy once that policy has been enacted into law." The studies emphasize, moreover, that the "liberal" physicians are found to be "younger, non-Catholic, and from specialties other than ob/gyn."

Religion aside, Nathanson and Becker found that few responses were expressed primarily, or even incidentally, in explicitly ethical/moral terms; and they concluded that "obstetrician- gynecologists . . . remain ambivalent about various related legal and moral issues." Thus it is not surprising to find that physicians' personal feelings about the patient and the procedure become major determinants of their response to women seeking abortion. And, given the high degree of control and influence physicians have over whether, how, and where abortion services are performed, it is also not surprising that the structure of abortion services in this country appears to have developed largely in accommodation to these doctors' feelings. [12]

Many doctors appear to have accepted as at least a provisional answer for themselves the view that a living (i.e., post partum) human being is in a crucially significant way more fully human than any fetus, that a fetus's right to life is in some important sense minimal at conception but becomes progressively stronger as birth approaches, and that the morality of a particular abortion is determined by weighing the various rights of the mother against the fetus's right to life. Especially since Roe v. Wade brought doctors a measure of peace of mind, questions which probe more deeply have uneasily, and perhaps understandably, been tacitly referred by physicians to others for resolution, while they themselves go about their business as technicians primarily, and, more diffidently, as friends and counselors of their patients, in a social context which lawmakers and judges have altered drastically in recent years.