SCOTUS, Roe, Reproductive Rights, and All Our Freedoms: We must act

 

Politico, and now other outlets such as the NY Times,  have reported on a 98-page draft opinion from the Supreme Court that, in no uncertain terms, overturns both Roe v Wade and Casey and removes federal protection for abortion rights. While it is true that this is a draft and individual justices’ final decisions could change, the fact that 5 of the justices (Alito, who wrote it, Thomas, Gorsuch, Kavanaugh, and Coney Barrett) signed on to it makes it unlikely that the final decision will change. The only uncertain vote is that of Chief Justice Roberts, but he is no longer the swing vote he once was; the only difference is whether the vote to say that women have no Constitutional right to control their own bodies would be 6-3 or 5-4.

And, absolutely, let us be clear: that is what overturning the 50-year old Roe decision would mean, that the majority of the justices on the Supreme Court will have ruled that the control over a woman’s body, on whether she has to continue a pregnancy regardless of the circumstances, is in the hands of others. It may be Congress, state legislatures, governors, husbands or other relatives, churches that they may or may not belong to or believe in, petty pettifoggers, vicious misogynists, non-vicious misogynists (?), and folks with their own right-wing agendas, but not the women themselves. When Roe was decided, Justice Blackmun, who wrote the opinion, said abortion should be a decision made by a woman and her doctor. That was itself a bit paternalistic, but it was 50 years ago; I think the way that still should be read is “with adequate medical advice”, understanding the potential (or likely) risks involved in the decision that the woman makes. And ONLY the woman whose body involved should be able to make!

The majority of justices on the Supreme Court obviously do not believe this, along with a substantial minority – but definitely a minority – of the American people (most polls put support for Roe at about 70%). Their anti-abortion movement, well funded by multi-millionaires and billionaires, and supported by both the Catholic Church and many fundamentalist Protestant sects, seems to have finally won their cause after 50 years of reactionary fighting to impose their will on everyone else. It is a coup, be certain of that. It was, most immediately, made possible by the fact that Donald Trump got to name 3 Supreme Court justices, through the hypocritically evil behavior of Mitch McConnell the GOP Senate majority, which decided both to block President Obama’s appointment of Merrick Garland, not even holding hearings, 9 months before his term expired, and then approving Trump’s appointment of Amy Coney Barrett just weeks before the election he lost! This alone should be enough to make everyone who cares about reproductive rights, women’s rights, LGBTQ+ rights, voting rights, any rights, pull out all stops to make sure that the predicted Republican victory in November does NOT happen, that McConnell (and I make no analogies since anything you might compare him to would be insulted by the comparison) does NOT again become Majority Leader. The Democrats are far from perfect, but every justice who voted to repeal was appointed by a Republican, and it was the Republican majority in the Senate that facilitated the appointment of the last three. The SCOTUS opinion will say that the decision is Congress’ and there is no possibility that legislation maintaining women’s rights will get 60 votes in the Senate, or even 50 given Joe Manchin. The pundits and pollsters are all predicting a big INCREASE in GOP seats in November. Unless we do something about it.

Make no mistake: this SCOTUS decision is that the opinions of some people are worth more than the lives of others. No one who is opposed to abortion has ever been required to get one by the decision of Roe. Of course, there were many “mental disabled” people or others judged incompetent who were required to get them in the past, vicious abuse in itself. Ironically, the issue is that the same logic is now being applied to ALL women; they do not have the Constitutional right to make their own decisions about their own bodies.  As Susan Matthews in Slate writes, Justice Alito could not find a justification for the right to abortion in the Constitution because “The Constitution was not written for women”. It didn’t even give them the vote!

Although it does not change the core issue, the choice of words in the debate has been unfortunate; anti-abortion people use the term “murder” of “babies” while abortion rights advocates have used the term “choice”, as if it were a matter of convenience, or what color bedspread to get. It isn’t. It is about the decision to carry a pregnancy, something that is medically risky even in the lowest risk people (but a risk that most people who want to have a baby gladly accept), to give birth, to probably raise a child, to completely change their life, to possibly be unable to care for already-born children, to give birth to a child of a rapist (perhaps incestuous rapist), to give birth to a child already unable to survive because of genetic or other malformations occurring in utero, etc., etc., being only the right of the woman who is pregnant, and not that of anyone else. Consulting them – family, friends, doctors, is fine, but the decision needs to be that of the woman alone, not the state legislature.

This decision, if it stands, will not end abortion in the US, as it will send us back to pre-Roe times when the decision was left to the states (indeed, several states had legalized abortion before Roe). So, abortion will likely remain legal in states like NY, CA, MA, IL, etc. But other states, including of course TX and FL, which have already passed draconian restrictions on access to abortion, will almost undoubtedly make it illegal again, along with many others. It has been estimated that abortions will decrease by 14% (“only”) but if this is true, it has to be taken in the context of geographic access. Women with money from TX, FL, and other states that severely limit access to abortion may be able to travel to another state, but poor women, on whom the burden always falls the hardest, will find it much more difficult or impossible, as will teenagers, including those who are pregnant as a result of incestuous rape (see “Who gets abortions in America”, by Sanger-Katz, Miller and Bui, originally published in the NY Times Dec 21, 2021 and republished on May 3, 2022). Health and healthcare are already incredibly inequitable in the US, and this decision will make it much worse. Jill Filipovic, writing in Substack, provides a number of other concerning likely outcomes,  including that there will be a 21% increase in maternal mortality!

And if that were not enough – more than enough – to get your blood boiling,  get you out to the streets, the likelihood that this will end with abortion approaches zero. Many of the opponents of abortion rights also oppose other reproductive rights, including cheap and easy access to contraception and sex education in schools. This would be illogical if preventing abortions were truly their goal, as it is precisely access to these two factors that are universally associated with lower abortion rates – see ‘Scandinavia’. When abortions were illegal in countries such as Ireland, sex education and contraception were also severely restricted – and the abortion rate was higher than in say, Denmark. But the women receiving these abortions, illegally, were at much higher risk. These arguments, however, get little traction, since those who would restrict all reproductive rights are doing it for other reasons – maybe they hate sex, maybe they hate women, but they surely believe that they know better and freedom is not important to them. If this is hypocrisy – they will fight for the right to own and carry a gun or not wear a mask – hypocrisy is not important to them either.

And it will not end with reproductive rights and contraception. Certainly the rights of LGBT+ people will be even more infringed. And our rights to read books and have our children learn science and history. And our right to vote. Listen to the far-right carry on about restrictions on their freedoms, but think about the freedoms that are at the core of the US and on which we depend.

And most important, these are freedoms we can no longer can passively depend on. If you don’t fight for them, they won’t be there.

Reproductive Rights -- and wrongs

The “debate” on reproductive rights has taken a turn to the far right with recent laws passed in several states that create greater obstacles for women who wish to obtain abortions. Probably the most famous commentary is a series of Doonesbury strips that ran (or didn’t run, or ran on the editorial page, depending upon your hometown paper) from March 12-16. Its focus is the Texas law requiring, among other things, that women have a transvaginal ultrasound examination before obtaining an abortion. It also requires that they receive “counseling” scripted not by their physician but by the state legislature and governor (see the final strip in the series, March 16).

Unquestionably, the “Doonesbury” strips are effective but face an uphill struggle in the effort to counterbalance the extremely well-funded efforts of right wing organizations. Their “think tanks” have been writing bills that are introduced in many states with virtually identical language. For an excellent discussion, see Paul Krugman’s “Lobbyists, Guns, and Money” (itself a parody of the title of a Warren Zevon song), about the American Legislative Exchange Council, ALEC, in the NY Times, March 26, 2012. Kansas, my home state, is in the process of passing a bill that will require doctors to inform women of the increased risk of breast cancer from having an abortion. This might seem reasonable, except that it is simply not true.  How can they get away with this? Well, we can examine the syllogism, which goes something like this: there is a somewhat higher rate of breast cancer in women who have never had a term pregnancy, so if you have an abortion instead of carrying to term you might be in this higher risk group. Of course, this misses a whole lot of bases. Women who have abortions frequently have had previous term pregnancies (which sometimes contributes to why they want the abortion), and or they may have term pregnancies later. Even if they never have a term pregnancy, no one has ever studied whether having a pregnancy at all (even one ending in abortion) puts one in the higher or lower risk group, or in the middle. Most important, for this discussion, most of women who never get pregnant do not get breast cancer, and many (probably most) women who do get breast cancer have had babies. Having a term pregnancy, or multiple pregnancies, is not protective.

Of course, this is not really the issue. The issue is that anti-abortion forces wish to prevent abortions by making it more difficult for women to obtain them. Thus, the veracity of the information that the laws written by ALEC promote is not important to its supporters. There has been some discussion about the fact that these laws that affect women but are written and passed primarily by male lawmakers. The suggestion is that it indicates a profound misogyny. I agree. These guys are often flagrant hypocrites who indulge in sexual (as well, of course, of financial) shenanigans, but feel no compunction about limiting the rights of women. This view is prominent in both the Doonesbury cartoons and in this creative effort by Salt Lake City Dispatch political cartoonist Pat Bagley in which he attaches the “I thee rape” Doonesbury, not run by that paper, to his own critique of this hypocrisy. It is the same misogyny which not only leads to abortion restrictions, but to restrictions on the availability of contraceptives, one of the two things that actually reduces the abortion rate (the other being accurate and widespread sex education, another “no-no” for the right), through insurance plans.  While, of course, ensuring that that these same plans cover Viagra and other drugs that help old guys get erections. It is part of worldview that sees men and women as not only different, but hierarchically related with men firmly in control. Women are subsidiary, not supposed to make noise, do what they are told, and certainly not make any decisions about their own lives, health or reproduction.  

Those who oppose abortion, but also support contraception and sex education, have a coherent position. The imaginary story line is that once a woman is forced to have a baby, she will want to keep it and care for it and be able to do so, or, at least put it up for adoption where someone else will do so. But while sometimes one of these two things happens, it is obviously a fantasy to think that it is the norm. We all hope that all children can be brought up in a loving, supportive, and financially secure family, whether birth family or adoptive, with all options open to them. But this is simply not the case for too many children, and those opposed to abortion are not doing anything to make it more likely by cutting support for health care, childcare, and education. Which is, of course, one reason it is hard to call them pro-life (along with their support for war and capital punishment).

Another part of the Kansas law forbids state employees from doing abortions. This might seem unnecessary, since it is already state law that abortions cannot be performed (with some rigid exceptions to save the life of the mother) at the University of Kansas Hospital, the only state owned facility. It also might not prevent medical school faculty from doing abortions at other facilities for which they are paid with funds that come from the physician practice plan rather than the state. It does, however, directly affect residents, physicians in training, especially in obstetrics and gynecology (OBGYN). The accrediting body for OBYN requires that residents receive training in abortion (which they may opt out for religious or moral reasons) and in evacuating the uterus when there are stillbirths (which involves the same procedure), which they may not opt out of. Currently, OBGYN residents at KU who do not opt out of abortion training receive this in an out-of-state program, but if this bill passes intact it would forbid them from doing that, as the residents are state employees. This would put the entire OBGYN training program in jeopardy, and it would likely be placed on probation, potentially closed, a problem noted by even some usually anti-abortion legislators. But to the anti-abortion movement, this is not a problem. They see this collision course as desirable and hope that a series of such state laws would force the OBGYN accrediting body to eliminate this requirement. Then, ultimately, there would be no one being trained to do abortions, there would be no one doing abortions, and voilà! -- there would be no abortions! Without the admittedly effective, but messy, need to encourage crazy people to assassinate them, as was done with Kansas physician George Tiller.

According to the Kansas City Kansan article, “Brownback mum on KU Med Center, abortion issue”,

“Gov. Sam Brownback refused to say where he stood over legislative efforts aimed at stopping Kansas University Medical Center medical residents in obstetrics-gynecology from training in abortion-related procedures. “I’m studying the issue,” Brownback said at a news conference. Abortion rights advocates, and even some legislators who have opposed abortion, say the medical residents need the training to maintain KU’s accreditation and to be able to handle emergency pregnancies. But anti-abortion advocates disagree. Brownback has signed into law several anti-abortion measures and has welcomed the Legislature’s work in this area.” Yes, he has. Funny he hasn’t yet read the one-page bill.

Of course, the biggest flaw in this logic, beyond its complete arrogance and lack of respect for women, is the assumption that eliminating officially sanctioned training of physicians in abortion would end, or even significantly decrease, the number being done. What it would do is to decrease the safety of abortions, to increase the number of women who seek and obtain “back alley” abortions. It would, quite simply, kill many women.

But the proponents of such policies and legislation seem to have no problem with that. They are, after all, not fetuses.

Komen and Planned Parenthood: The politics of abortion meet the politics of breast cancer

As of this posting it appears that Komen has restored its funding for Planned Parenthood. I thought I would run this post anyway. I think it makes some important points.

As reported in the New York Times on February 1, 2012, “Cancer group halts financing to Planned Parenthood”, the Susan G. Komen Foundation will abruptly end a program that gave about $700,000 to 19 Planned Parenthood (PP) affiliates to fund breast mammograms and ultrasounds for women who cannot afford them. Just to be clear, the Komen Foundation, the world’s largest breast cancer foundation which is famous for its pink ribbons and “Run for the Cure” races, has not changed its position on screening for breast cancer. It just doesn’t want to fund this screeining through Planned Parenthood, which will present a problem for the three-quarters of a million women who have had their mammograms through that organization.

Why? There has been a very long standing relationship between these two organizations committed to women’s health, and this decision seems to be very sudden. According to the Times, “A spokeswoman for the Komen foundation, Leslie Aun, told The Associated Press that the main factor in the decision was a new rule adopted by Komen that prohibits grants to organizations being investigated by local, state or federal authorities. Ms. Aun told The A.P. that Planned Parenthood was therefore disqualified from financing because of an inquiry being conducted by Representative Cliff Stearns, Republican of Florida, who is looking at how Planned Parenthood spends and reports its money.”

On the face of it, this is absurd; any state legislator can do an investigation into any organization for any reason, and they do. Unlike investigations by law enforcement bodies, in which presumably there is at least a reasonable suspicion of illegal activity. It can only be inferred that this “new rule” was specifically instituted to remove funding for PP. And Komen didn’t have to wait for Rep. Stearns; my state of Kansas has been regularly investigating our Planned Parenthood, starting under former Attorney General Phill Kline, who illegally kept subpoenaed records after he left office. When it finally went to trial after several years, the case was decided by a jury in less than 30 minutes, for PP. More recently, the current administration (also, coincidentally, Republican) has tried promulgating new health department rules regulating abortion providers that were absurdly picky, such as the size of janitorial closets. This has also been discarded.

Wait, Planned Parenthood does abortions? Could that be part of the reason? Why yes. Some, but not all, PP affiliates perform abortions. PP provides comprehensive women’s health services, including contraception and education, as well as breast cancer screening. The Times article notes that many have suggested that it is pressure from right-wing anti-abortion groups that has caused this action. For example, “…in December, LifeWay Christian Resources, which is owned by the Southern Baptist Convention, said it was recalling a pink Bible it was selling at Walmart and other stores because a dollar per copy was going to the Komen foundation and the foundation supported Planned Parenthood.” Of course, this is not really a different reason; the reason that Rep. Stearns and AG Kline and others have for investigating PP is because they do abortions.

In further “explanation” (since the original one was so nonsensical), the Komen “…foundation issued a statement saying it was seeking to ‘strengthen our grants program’ and had ‘implemented more stringent eligibility and performance criteria….While it is regrettable when changes in priorities and policies affect any of our grantees, such as a longstanding partner like Planned Parenthood, we must continue to evolve to best meet the needs of the women we serve and most fully advance our mission.” I had to include this last sentence so that I can recommend that you copy it and save it for a time when you need a piece of corporate double-speak jargon that says nothing except “We’re lying here.”

Planned Parenthood affiliates who do offer abortion services see them as part of the continuum of women’s health care. They offer sex education and contraception, but sometimes this fails – or hasn’t been used -- and women seek an abortion, which may be their first contact with PP. And they may then avail themselves of PP’s other services so they do not have another unwanted pregnancy.  Of course, there are many people who are opposed to abortion who support these other missions (contraception and sex education, as well as breast cancer screening). Therefore, PP usually segregates its funds so that only donations that are unrestricted or specifically intended to support abortion services are used for that purpose. However, there are many others, particularly organized “right-to-life” groups, who are not only opposed to abortion, but to the other missions as well.

A rational, data-driven approach would note that the only things that have ever been shown to reduce the abortion rate are comprehensive sex education and easy availability of contraception. This is why the abortion rate in many countries where abortion is legal is lower than in others where it is not – because those same countries provide sex education and contraception. And, of course, they also provide safe abortions so that the women who receive them are much less likely to develop infections, become sterile, or die.

The only way to understand the opposition to contraception and sex education is to recognize that it is really about being opposed to sex. If you hold the view that sex should only occur in marriage, and then only for the purpose of procreation (thus, only heterosexual marriage), and should not be for fun (and maybe should not ever be fun) this starts to make sense. In a bizarre way. Of course, this excepts the many religious and anti-abortion leaders who are involved in active and extramarital sex. They seem to have no problem telling women what to do with their lives, while living their own lives in total hypocrisy. Of course, but these are mostly men, so what do you expect? They don’t get pregnant.

In another big news item in the same issue of the Times, we are informed that rates of second surgery after lumpectomy for breast cancer vary widely by surgeon, from 0% - 70%. (Breast Cancer Surgery Rules Are Called Unclear by Denise Grady reports on Variability in Reexcision Following Breast Conservation Surgery by Lawrence McCahill and colleagues, published in JAMA, February 1, 2012. In doing lumpectomy for breast cancer, there is a cosmetic reason for taking only the least amount of tissue necessary to remove all the cancer. After all, this is the reason that lumpectomy was developed to replace mastectomy. Sometimes, on pathological examination, the “margins” are not “clear”; that is, cancer cells are found microscopically up to or past the border of the excision, and an additional surgery is required to get the rest. The question is whether there are surgeons who regularly seem to do this more often, that is take too little tissue, rather than random variation; the answer seems to be “yes”.

However, the study shows that there seem to be many more surgeons who often do a second surgery even though the margins are clear than there are surgeons who regularly take too little and need to repeat the surgery. This also means that many surgeons who have the former practice may often take too much tissue the first time to avoid the repeat surgery. This is because they believe that there need to be larger margins of normal tissue, of 2-5mm, between the cancer the edge of the excision. Comments by McCahill and other expert breast surgeons indicate that there is no data showing the larger margins provide any lower rate of recurrence than smaller ones.

What is clear, however, is that cancers found earlier and smaller are more likely to require less invasive surgery and have a greater chance of recovery. While the age of starting and the frequency of screening may be controversial (see my perspective on October 30, 2010, Breast cancer screening: conflicting evidence? what are the important questions for health?), it is hard to argue that having making it more difficult to obtain that screening for 750,000 women who use Planned Parenthood is good policy if your goal is to identify and treat breast cancer as early as possible.

Which, of course, is supposed to be the Komen Foundation’s mission.

 The “Lede” story on the Komen Foundation’s reversal, Cancer Group Backs Down on Cutting Off Planned Parenthood quotes Komen’s Twitter post (@komenforthecure): “We want to apologize for recent decisions that cast doubt upon our commitment to our mission of saving women’s lives.”

And for thinking that they could just do this and not ignite a firestorm of protest. Good to see some life in the reproductive rights movement! The anti-abortion-people-who-talk-only-to-themselves-so-much-they-think-everyone-agrees-with-them were unsuccessful in this attempt. Hopefully the women’s health and pro-choice community can remember that these rights are not guaranteed by anything but the willingness of the people to fight for them.