Wednesday, April 29, 2015

Dr. Rebecca Kukla on Ultrasound Laws: a Rebuttal

Recently, Dr. Rebecca Kukla visited the university with which my college of medicine is associated. Sponsored by the departments of philosophy and humanities (and probably women's studies), she lectured on mandatory ultrasound laws regulating abortion. Her thesis: even those who favor restricted access to abortion should reject these laws, since they are bad for women and bad for clinicians.

Bad for women. Dr. Kukla argues that because the first ultrasound has become a very ritualized event (indicated by the prevalence of ultrasound pictures as the baby's first picture, the anthropomorphic language of ultrasound techs, the industry of cute-to-kitchsy merchandise to display the photos) which people use to transform themselves into fathers, mothers, families, siblings, etc. To subject a woman contemplating abortion to this ritual is traumatic and may make her choice more difficult.

Bad for clinicians. Law should not govern medicine, especially about disclosing information; the attempt to do this preoperatively (while noble) has resulted in uselessly long forms that don't demonstrably benefit patient autonomy. Realistically, physicians cannot present all possible information to their patients, nor should they, since this can be unhelpful, overwhelming, and unwanted in some cases. Physicians have the right and duty to select what kind of information is most helpful to the patient; these laws make this impossible by mandating a one-size-fits-all approach.

But it's actually Dr. Kukla's position which is bad for women and their healthcare providers.

Bad for women. I encourage us to look to the reason rituals develop. The first ultrasound has become ritualized because of the power of ultrasound to reveal what the fetus is--it allows us to sense the body and movement that we couldn't see or feel before. An ultrasound reveals a reality that already exists: an autonomous, immature organism of the human species. I agree that parents use it as an announcement tool, but they're not being transformed in any true way. Instead, they're seeing the cause of that transformation for the first time.

This part of the rebuttal relies on a premise that Dr. Kukla would probably reject--the premise that pregnancy = motherhood, that embryo/fetus = child. But even without this premise, I still have something to say, because another fundamental error in this argument is consequentialism.

To subject a woman contemplating abortion to revelation about her condition will inform her choice. I agree that this may be traumatic for her, and make her choice more difficult. But we should not base our decisions on the emotional consequences they incur; we should make decisions based on whether they are right or wrong. We don't avoid invasive procedures, chemotherapy, or psychotherapy because they are painful. We give family members of ICU patients all information about very dismal prognoses, even though that may make their decision to continue or withdraw treatment difficult. Information does not endanger freedom, although it may endanger the likelihood of someone choosing a particular option (such as to abort).

Dr. Kukla or others rightly point out that post-abortive women who are conflicted or wavering about her decision to abort have more symptoms of PTSD. They argue that we should not do anything to cause ambivalence, because this could contribute to a higher incidence of PTSD. I would repeat that we cannot make decisions (such as to perform ultrasound or not) based solely on their consequences. Instead, we should be open about risk of mental health problems and the risk factors that increase them. So, we should counsel patients about the importance of confidence in her decision, to promote her mental health. If she cannot be confident at the time of the clinical encounter, I would encourage her to take some time to consider her choice, and schedule a follow-up visit with her. This ensures that I am truly serving the patient to make the choice she can be comfortable with, not rush into the choice I want her to make.                              

Bad for clinicians. I agree that law should not govern medical practice. Medicine should govern medical practice. Protocols for ultrasound before abortion should come as "standard of care" recommendations from a professional organization, not as a regulation from lawmakers. This stems from the duty of physicians and healthcare providers to provide best practice for their patients.

But one of the duties of lawmakers is to protect citizens from injustice. When "injustice" and "failure in best practice" coincide, lawmakers must be act when physicians do not.

This argument depends on premises that Dr. Kukla would not accept, premises such as the gravity of abortion for a woman and a fetus. Without acknowledgement of the gravity of abortion, it is difficult to argue that "failure in best practice" is occurring in abortion without ultrasound. It is almost impossible to see how "injustice" applies at all.

An enormous inflamed appendix. (Want to see a gallbladder?)
So what would I say to Dr. Kukla? I did raise my hand and speak. I said nothing about being pro-life, nothing about fetuses. I also didn't start an argument about what ultrasounds are. I didn't get to finish, but here's what I wish I could've said, in full:

"I wish this policy had come from ACOG. The practice itself makes sense, because it makes terminations like other minor surgical procedures--you know, for gallbladders and appendices. They do ultrasounds for those, and good docs go over scans with their patients before elective surgeries."

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