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The 475-member House of Delegates approved the AMA board's endorsement of Congressional legislation that, as presently crafted, could impose criminal penalties on physicians who perform the procedure known as "intact dilation and extraction."
APA was one of several groups that did not go along with the House of Delegates, but opposed the board's endorsement of that legislation. The vote took place last month at the annual meeting of the AMA House of Delegates in Chicago.
(The Congressional legislation, sponsored by U.S. Senator Rick Santorum [R-Pa.], has been approved by both houses of Congress. At press time, however, it was not clear that there were enough votes to override a threatened Presidential veto.)
In ratifying the board's endorsement of the federal legislation, the "house of medicine" also called on the AMA to continue to work with the bill's sponsors in Congress to improve aspects of the legislation that were most objectionable to many delegates, including many who favor a ban on "intact D and X."
Foremost among these objections is the issue of criminalization.
Just days after the House of Delegates meeting, however, Santorum indicated in a report in the New York Times that he would not remove the language in his bill that criminalizes the use of "intact D and X."
The AMA, in a fact sheet for reporters and the public, stated that "intact D and X" is "ethically different from other destructive abortion techniques because the fetus, normally 20 weeks or longer in gestation, is killed outside the womb."
Moreover, in a letter to the New York Times, AMA Executive Vice President John Seward, M.D., stated that "the issue is whether the partial delivery of a living fetus for the purpose of killing it outside of the womb ought to be severely restricted. We believe, as a matter of ethical principle, it should rarely, if ever, be done. And although we also believe physicians should have broad discretion in medical matters, both this procedure and assisted suicide. . .can and should be regulated if the profession won't do it."
®MDBU¯A report from the AMA's Council on Scientific Affairs titled "Late-Term Pregnancy Termination Techniques"--adopted almost unanimously by house delegates, including those representing APA--states that "there does not appear to be any identified situation in which intact D and X is the only appropriate procedure to induce abortion, and ethical concerns have been raised about intact D and X."
On the issue of endorsing the Santorum legislation, APA did not go along with the house, but instead voted with those who opposed the board's endorsement of the bill.
Speaking for APA during reference committee debate prior to the House of Delegates meeting, APA President Herbert Sacks, M.D., cited APA policy--formulated in 1977 and 1978, and reaffirmed in 1991--supporting a woman's right to abortion.
Sacks told fellow physicians during the debate that psychiatry, more than any other specialty, relies on the "physician-patient covenant" and suggested that it is this covenant that is most threatened by the Santorum legislation and by the AMA board's endorsement of that bill.
Noting that psychiatry is the oldest medical specialty and the fifth largest within the AMA, Sacks told physician colleagues that "the work of psychiatry is not with sophisticated medical technology" but with the relationship between therapist and patient.
This relationship "opens the door to the most intimate human exchanges. . .giving the psychiatrist remarkable insight into the human condition," Sacks said.
It is "from the wisdom accrued from medical psychotherapy," that APA derived its policy stances regarding abortion, he said.
"APA opposes all constitutional amendments, legislation, and regulations curtailing family planning and abortion services to any segment of the population," Sacks said. "APA reaffirms its position that abortion is a medical procedure in which physicians should respect the patient's right to freedom of choice."
Sacks argued, moreover, that the AMA board, in endorsing the Santorum bill, contradicted several of its own policies, including those that state that opposition to abortion is a matter for individual members to decide based on personal values and beliefs.
Further, Sacks said, the AMA has stated that it will take no action to alter or influence the personal views of individuals regarding abortion.
"We believe the AMA board action on [the Santorum legislation]. . .is inconsistent with unambiguous AMA policy statements," Sacks told physicians at the meeting.
In the voice vote on the floor of the House of Delegates, APA delegates Joseph T. English, M.D., and Jerry Wiener, M.D.--in accordance with APA policy and at the direction of Sacks--cast votes in opposition to the AMA board's endorsement.
Yet it was Sacks who spoke for APA during reference committee debate in deference to Wiener and English, who had both expressed reservations about opposition to the ban on "intact D and X" (see story on page 2).
APA was joined by the American Academy of Child and Adolescent Psychiatry (AACAP), the American Medical Women's Association (AMWA), the American College of Obstetricians and Gynecologists (ACOG), and a sizable number of individual physicians who also objected to the AMA's endorsement of the Santorum legislation.
David Fassler, M.D., representing the AACAP, echoed Sacks during the debate. "We cannot accept and should not support any legislation which intends to ban specific medical procedures, no matter how controversial or infrequently [they may be used]," he said. "These are decisions which must be based on discussions between physicians and their patients, and the AMA has always upheld the sanctity of this relationship.
"I believe [the AMA] board made the wrong decision on this issue," Fassler continued. "I believe the action was precipitous and in violation of the spirit of existing AMA policy."
Diana Dell, M.D., AMWA's delegate and APA's member-in-training trustee-elect, emphasized the deleterious consequences of unwanted pregnancies.
"Women who carry unwanted pregnancies are at greater risk for depression and at greater risk of physical abuse," said Dell, who is a board-certified obstetrician-gynecologist and a senior resident in psychiatry at the University of North Carolina, Chapel Hill. "The relationship with her partner is at greater risk of dissolution. . . . Numerous studies show that women who carry unintended or mistimed pregnancies begin prenatal care later in pregnancy and receive less adequate prenatal care than women with wanted pregnancies. The fetuses are more likely to be exposed to harmful substances. The child produced by an unwanted pregnancy, as distinguished from a mistimed one, is at greater risk of being born with low birth weight, of dying within the first year, of being abused, and of not receiving sufficient resources for healthy development."
Dell emphasized as well that the Santorum bill focuses attention on a single controversial procedure, one that even opponents of the legislation acknowledge should be used only rarely, if ever.
In her closing remarks during the reference committee debate, she urged the house to rescind the board's endorsement of Santorum and to move the debate away from "the emotional tags of a difficult abortion procedure to the more central issue related to the well-being of women, children, and families in this country."
Discussion at the Chicago meeting about the ban on "intact D and X"--mirroring, perhaps, the abortion debate in society at large--was the occasion for a spectacular collision of politics, emotion, concerns about public perception, and professional and medical ethics.
Even many delegates who were most strongly supportive of the AMA board's action acknowledged that the Santorum legislation is a "bad bill."
In addition to concerns about criminalization, physicians at the meeting noted that the legislation does not reference a specific gestational age, so that the "late-term abortion" language in the Santorum bill could potentially be used to ban abortion at any stage of pregnancy. Moreover, language in the bill is sufficiently imprecise that it might be construed to apply to other abortion procedures as well, physicians claimed.
AMA board officials themselves acknowledged their distaste for the Santorum bill, stating that the AMA's negotiations with Congressional sponsors had helped to produce amendments that significantly improved the original legislative language.
"The [AMA] board of Trustees had to look at an array of issues, and criminalization was very high on the list," said AMA President-elect Nancy Dickey, M.D., at a press conference following the House of Delegates vote. "However, it also looked like this legislation had a reasonable chance of passing. . .and was indeed passing in virtually exactly the same language at the state level. The original language was extraordinarily fuzzy, criminalizing something that wasn't even defined. So while we did not achieve the ideal, . .we thought we had made measurable and adequate progress. . .so that supporting the amended legislation protected our patients and to a significantly greater degree protected physicians.
"We had to weigh that against the possibility of the original language going through, and finding patients and physicians in a gray zone with no definitions whatsoever to base their decision making upon," Dickey said.
Inevitably, debate at the Chicago meeting was also colored by the extraordinary nature of the procedure that has come to be known colloquially as "partial birth abortion"--a procedure in which the fetus is delivered intact, except for the head, followed by piercing of the skull and evacuation of its contents.
"Repugnant" and "infanticide" were commonly used to describe the procedure by delegates, several of whom said that the vast majority of the American people considered the procedure unethical.
A decisive moment in the debate came when family physician and Oklahoma Congressional representative Thomas Coburn, M.D. (R-Okla.), addressed the reference committee and urged physicians to back the AMA board.
Coburn promised that the Santorum legislation would become law--if not this year, then next year--and he stated that if the AMA were to rescind its endorsement of the law, it would sacrifice political influence on many other issues.
"Most people in this country believe this procedure is infanticide," Coburn said of "intact D and X." "If you undermine the board in what they have done and you backtrack, you will set the AMA tremendously far back in your ability to influence not only this legislation but other legislation."
Dickey, in a press conference following the House of Delegates' vote, flatly refuted suspicion that the board endorsement of the Santorum bill was part of a political "deal" with lawmakers or that it represented a concession to public opinion.
Whatever the board's motivations, it was clear from comments by delegates in the reference committee that at least some of the support in the House of Delegates was founded on a belief that repudiating the board would undermine the AMA politically.
"As in a good marriage, there are times when I support my spouse even when I know he's wrong," said one obstetrician-gynecologist.
Dell, following the meeting, said she believes that many delegates were "angry" about the AMA board's endorsement, but feared that rescinding the endorsement would undercut the medical association's "political viability."
APA delegate Wiener countered that he believes the vote was primarily about the appropriateness of one procedure.
"Neither the AMA board nor the House of Delegates raised any question about the right of a woman to choose to have an abortion," Wiener said. "Rather, the question was whether one procedure is acceptable."
(Psychiatric News, July 18, 1997)