_ABORTION In Perspective_
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
Part One of Four
INTRODUCTION
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.
I. THE MEDICAL PERSPECTIVE
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.
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