UNITED STATES GOVERNMENT POLICY ON ABORTION

UNITED STATES GOVERNMENT POLIC= Y ON ABORTION

George Contis, M.D., M.P.H., and Warren M. Hern, M.D., M.P.H.

Reprinted from American Journal of Public Hea= lth, Vol. 61, No. 5, May, 1971

The nature of federal policy on abortion is explored and the need for a uniform= and consistent position is emphasized

At this time, there is no uniform “federal government policy” on abortion. Instead, the polici= es of the various agencies exhibit a spectrum that ranges from outright endorseme= nt to outright prohibition.

     On the one hand the Departmen= t of Defense (DoD) now permits the performance of abortions for medical reasons = and reasons of mental health. In = July, 1970, Assistant Secretary of Defense (Health and Environment) Louis M. Rousselot determined that abortion may be performed in military medical facilities in the United States without regard to local state laws.^{1* This action is applicable, of cour=
se,
only to those individuals eligible to receive care in military medical
facilities.}

     On the other han= d, the Office of Economic Opportunity has a policy guideline stating that no proje= ct funds may be used for any surgical procedure intended to result in abortion= .² This is not a statutory limitation= but an internal policy that was established when the agency initiated its family planning programs in 1965.

     This policy, how= ever, is under intensive review both as the result of changing perspectives within the agency and indications from OEO constituents that a change would be desirable. For example, a rec= ent program management survey of OEO-funded family planning projects revealed that near= ly 60 per cent of the projects wanted to be able to offer abortions to their patients.

     The Department of Health, Education, and Welfare is somewhat between OEO and DoD, for HEW has= no policy for or against the performance of abortion in HEW-sponsored programs. It should be noted, however, that abortion is a reimbursable expense under Title XIX Medicaid payments in those states that are enrolled.³ In fact, abortions are being paid = for under this statute in those areas such as New York where their performance is not restricted by state laws.⁴

Separate Abortion Policies=



     It is worth taki= ng a moment to examine why three federal government agencies would have separate policy approaches to abortion services.&nb= sp; To a great extent this is due to the fact that there is no clear consensus regarding this issue among the American people. While most surveys indicate a majo= rity of the people favor legalization of abortion, there is still a sizable mino= rity that forcefully opposes it. T= hese groups all have ways of expressing their views, and the extent to which the= y do is reflected in federal policy. Thus, to a large extent, the position of a particular agency on the question of abortion is a function of its relative accessibility to pressur= es of various kinds.

     The simple facts= of survival are that Congress appropriates money for the Executive Branch, and without money, there are no programs. In certain quarters of Congress there is firm opposition to the utilization of public funds for the provision of abortion services. An amendment to the Family Planning Services and Population Research Act of 1970 goes farther than that. The amendment states that “N= one of the funds appropriated under this title shall be used in programs where abortion is a method of family planning.”⁵ The Congress clarified its intent, however, solely to be the prohibition of use of funds for the provision of abortion services.⁶

     This act will ha= ve a direct effect only on HEW programs, not including Title XIX Medicaid payments. However, the lack of Congressional enthusiasm for abortion exerts a dampening influence on policy changes in more vulnerable agencies such as OEO.

     The demand for p= ublic accountability is also felt directly from the electorate itself. Opposition to abortion programs co= mes not only from Catholics and religious fundamentalists, but from militant minority male groups making the accusation of “genocide.” Thus, the ambiguity of the federal government on abortion is basically a reflection on the complexity of this issue and the lack of unanimity of will among the American public.

No Clear Mandate

     In the absence o= f a clear mandate on this issue, there are a number of factors that federal fam= ily planning officials must heed. First, they are keenly aware of the ethical and moral considerations that confront the individual citizen making a private decision about aborti= on. The government, however, is not permitted to arbitrate the moral “rightness” or “wrongness” of the individual abortion question, or even of abortion itself, even though that ethical question may be of paramount importance to the individual.

     A second factor concerns important legal and constitutional questions. One of these is the Griswold decis= ion in 1965, stemming from the Bill of Rights, which upheld the right of marital privacy.⁷

     Another major constitutional issue, which has been raised by the Gesell decision in Washington, D.C., is that of discrimination on economic grounds. In the Gesell decision, the court indicated that the prohibitively high cost of abortions in the community co= uld be considered a violation of the constitutional rights of equal protection until such time as abortions are as available to the poor as they are to the rich.⁸ By and larg= e, legal abortions are easily available to the affluent but not to the poor. Even in New York, where there are few restrict= ions and where municipal hospitals provide free abortions for the poor, there are long waiting lists, occasional economic exploitation, and stories of women = who fail to receive a requested abortion.

     The third factor= that federal officials must consider is the relationship of abortion to public service needs and public health considerations. It is generally agreed that one-fo= urth to one-fifth of all pregnancies in the United States end in legal or illegal abortion.⁹ Under these circumstances, laws restricting the performance of abortion restrict = the physician’s exercise of his professional responsibilities and can for= ce him to break the law.¹⁰ Worse yet, these restrictions have resulted in racketeering, profiteering, and exploitation by unscrupulous individuals.

Danger of Clandestine Abortion

     Clandestine abor= tion constitutes a significant health problem affecting large numbers of people, including both the women at risk and their families. It is well known that deaths due t= o the effects of clandestine abortion account for a significant proportion of the maternal mortality in this country.¹¹ This is true even though many such deaths may go unreported or are reported under other categories.=

     Clandestine abor= tion accounts for an even larger portion of an unacceptable and disproportionate= ly high maternal mortality rate.   In 1967, for example, the rate of reported mortality due to abor= tion with sepsis was nearly seven times higher than among non-whites as it was f= or whites.¹²

     In the absence o= f a clear-cut mandate on abortion, how can federal officials reconcile these important moral, legal, and public health considerations?   In reassessing current OEO p= olicy, we are taking several factors into account. The first is the role of abortion = in the total context of health services. Our unofficial position is that abortion should be an essential part= of complete family planning and comprehensive health services. If abortions are to be made availa= ble through our programs, they will serve only as a back-up for contraceptive failure or omission and not as a substitute for contraceptives. This, it is likely that abortion w= ill be utilized primarily by women at either end of the reproductive age range.

     In reassessing OEO’s policy, we look to the experience of other countries with more liberalized abortion policies. From the Eastern European countries we have learned that large numbers of aborti= ons can be done simply and safely early in the first trimester.¹³ On the other hand, we know very li= ttle about the logistics of setting up abortion services or the costs that will = be incurred. We need to learn mo= re about the possible side effects of abortion, its psychological implications, and other outcomes of unwanted pregnancy.

Cost of High Quality Family Plann= ing

     The development = of and adherence to the highest standards of medical care are major concerns in any such government effort. Costs= are also an essential consideration, and here we must balance the comparative c= osts of high quality contraceptive care for a given number of women versus the c= osts of high quality abortion procedures for a smaller number of women. The question is, as always, who wi= ll get how much of what limited services and resources?

     We estimate curr= ently that the costs of high quality family planning services are in the range of= $60 to $80 per woman per year at the project level. By contrast, abortions may cost fr= om $50 to $600 per case depending on local fee levels, techniques, and gestational age. Abortion as an exclusive method of birth limitation could theoretically cost up to $2,000 per year or more. It is therefore not attractive as a sole or major method of birth limitation from the point of = view of cost alone.

     From these figur= es, it is easily seen that, at current cost levels, the price of one abortion could provide family planning services for the same woman for several years. If we are to provide abortion serv= ices, then, it is clear that they should also be combined with a serious effort to provide effective subsequent contraception.

     Inevitably, ther= e will be some women in these circumstances who have used and will continue to use abortion as a sole method of birth limitation. At this point, we do not know what percentage will choose to do so. As responsible health officials, we have to consider making abortion available to these women, with the hope that continuing efforts at education and understanding can direct such women tow= ard more desirable methods.

     Given our present spectrum of federal policies, and the many factors that must be considered = by the government, what steps can be taken now?   At OEO, we believe that ther= e is a pressing need to pull our various federal agency viewpoints together so that information and experiences may be shared more effectively. We have discussed this matter with= Dr. Louis Hellman, Deputy Assistant Secretary for Population and Family Plannin= g Affairs at HEW, and the office of the Assistant Secretary of Defense for Health and Environment. We have all agre= ed to pursue this further.

    We believe that in this sensitive area, governmental policy must follow a clear mandate from the people. In no circumstances c= an it be coercive. Today there is no consensus, and it may be some time before the divergent viewpoints on this matter are reconciled.

     Our second need = is to ascertain the standards of medical care, cost projections, and logistics of providing abortion services in those programs where we are able to do so. For this reason, OEO has under consideration a request from APHA to fund the recent formed APHA Task Force= on Family Planning Methods. The purpose of the Task Force is to formulate these basic guidelines and standa= rds for program development.

     At OEO, we belie= ve these steps will help us resolve some of the very complicated issues in this very complex area of abortion service delivery.

     ACKNOWLED= GMENT - The authors would like to express their apprecia= tion to Drs. Hellman and Rousselot for reviewing this paper before presentation.=

References<= /p>

1.        Memorandum for the Surgeons General of the Military Departments, from Louis M. Rousselot, M.D., Deputy Assistant Secretary for Health and &= nbsp;       Environment, Department of Defense (July 16 and July 31), 1970.

2.        Community Action for Health: = Family Planning. Program Pamphlet published by the Office of    Economic Opportunity (Oct.), 1967.

3.        Section 1905, Title XIX, 1965 Amendment to the Social Security Act.

4.        Muller, C.F.   Health Insurance for Abortion Costs: A Survey. Family Plann= ing Perspectives Vol. 2,    &nbs= p; no. 4 (Oct.), 1970.

5.        Family Planning Services and Population Research Act of 1970. Rep. No. 91-1472; House of &nb= sp;          Representa= tives, 91^st Congress, 2^nd Session.

6.        House-Senate Conference Repor= t on Family Planning Services and Population Research Act of             1970, Rep. No. 91-1667; House of   &nbs= p;        Representatives, 91^st     c= ongress, 2^nd Session.

7.        Griswold et al. vs. Connecticut, 381 U.S. 479 (1965).

8.        United States vs. Vuitch (D.C., 1969), 305 F Supp. 1032.

9.        Schwarz, R.H.= Septic Abortion. Philadelphia: Lipp= incott, 1968.

10.      U.S. vs. Vuitch, op. cit.

11.     Schwarz, op. cit.

12.       Vital Statistics of the Un= ited States, 1967. Vol. II – Mortality, Part A,= pp. 1-40, Table 1-15. U.S.       Department = of Health, Education, and Welfare,   = ;     1969. 1967 mortality rates (per 100,000 = live    births) due to septic abortio= n: whites, 1.5; nonwhites, 10.2; overall, 3.

13.     Tietze, C. Abortion Laws and Abortion Practic= es in Europe. Advances in Planned Parenthood (v. &= nbsp;     5): Proceedings of the Seventh Annual Meeting of the American Association of Planned   = ; Parenthood Physicians, San Francisco, Calif. (Apr. 9-10), 1969. New York: Excerpta Medical      Foundation, 1970.

Dr. Contis is Director, Family Pla= nning Program, and Dr. Hern is Chief, Program Development and Evaluation Branch, Family Planning Program, Office of Economic Opportunity, Washington, D.C.= 20506

This paper was presented before the Committee on Population and Family Planning of the Maternal and Child Health Section of the American Public Health Association at the Ninety-Eighth Annu= al Meeting in Houston,= Texas, October 28, 1970.

May, 1971     Vol. 61, No. 5, A.J.P.H.    1038-104= 1        =             &nb= sp;            =             &nb= sp;            =           May, 1971