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At an annual meeting symposium on women's health, Nada Stotland, M.D., acknowledged the prolonged controversy but asserted that APA's position statement on abortion is scientifically sound and addresses the issues of major importance to psychiatrists, particularly the doctor-patient relationship.
Stotland is chair of psychiatry at the Illinois Masonic Medical Center, Chicago; president of APA's Caucus of Women Psychiatrists; and chair of APA's Joint Commission on Public Relations.
Stotland commented that while "the wording is poor" in places, "the content is scientifically accurate."
The key portion of the statement says that APA "(1) opposes all constitutional amendments, legislation, and regulations curtailing family planning and abortion services to any segment of the population; (2) reaffirms its position that abortion is a medical procedure in which physicians should respect the patient's right to freedom of choice--psychiatrists may be called on as consultants to the patient or physicians in those cases in which the patient or physician requests such consultation to expand mutual appreciation of motivation and consequences; and (3) affirms that the freedom to act to interrupt pregnancy must be considered a mental health imperative with major social and mental health implications."
Stotland objects to the section stating that "children of unwanted pregnancies are at high risk for abuse, neglect, illness, and deprivation of a high quality of life."
While that statement is true, she said, "If a baby is born, we should help the baby." Fearing that a child is at risk for abuse and neglect "would be grounds for giving extra support to that mother, not grounds for abortion."
Moreover, Stotland said that the studies cited in the APA position statement tracked the unwanted children as they aged and now find that as they reach their mid-30's, there is no difference between them and adults whose parents had never considered aborting.
"Life has taken its toll on everybody, and they blend in," she commented.
APA's position statement was first approved by the Board of Trustees in 1977 and reaffirmed in a statement on reproductive rights in 1991. The position statement on abortion was reviewed and again reaffirmed in 1995. She noted that all position statements come up for review at regular intervals.
Whether APA should have any position on abortion remains controversial as well. A group known as American Psychiatrists for Neutrality on Abortion continues to argue that abortion is a political and moral issue, not a psychiatric one. Its members believe that APA's having any position on abortion undermines APA's credibility as a professional and scientific organization.
Another controversy emerged recently when the AMA Board of Trustees, without consultation with AMA's House of Delegates, announced that it would back the Partial-Birth Abortion Ban Act of 1997 (see story on page 1).
Stotland observed that abortion raises profound questions about the meaning and start of human life. The answers framed by each individual reflect the very core of his or her value system or religious beliefs, she said. "No brilliant mind" has ever devised a compromise that will reconcile the pro-life and pro-choice positions, she commented.
Abortion has long been widespread throughout the world, Stotland pointed out. "We haven't found any time or place when it didn't happen," she said. "Even the Roman Catholic Church hasn't had a position against abortion throughout its entire history. The church once permitted abortion through 'ensoulment,' the point when the soul enters the body. . . .Now abortion is practiced widely throughout the world, with the major difference being whether it is legal or illegal."
Stotland said that a lot of misinformation is thrown around in discussions of the psychological concomitants of abortion. First, she noted that many studies on abortion were performed when the procedure was illegal, and few studies have been conducted in the last 20 years because of the difficulty in obtaining federal funding for this purpose.
Second, most studies do not compare women who have had an abortion with women who have gone to term. "It is meaningless to talk about the outcome of abortion unless you compare it with the sequelae of delivery," she observed.
Stotland also said that the characteristics of women who obtain an abortion need to be factored in. Some of the women may have a preexisting psychiatric condition that affects their ability to formulate and carry out a decision not to get pregnant. Some women may have trouble with birth control pills or devices or do not wish to contracept for religious or other personal reasons. Other women may have been abandoned by their partners and feel they have no one to turn to for support.
Psychiatrists must weigh complex issues as they decide how they will advise or support women in a crisis pregnancy, and the conflicts they experience are not surprising, said Stotland.
"We are a healing profession; we are not supposed to hurt anyone," she said. "If a woman wants to be pregnant, we certainly don't want to hurt the pregnancy. It is not a neutral thing for us to destroy a preborn child or cells that could become a person.
"People have the sense that if we get callous about destroying life at this stage, will we snuff out the lives of people who are very ill, elderly, or whatever, because it cheapens our valuation of human life?"
Stotland also raised a number of difficult questions that psychiatrists must answer for themselves: Do psychiatrists have a duty to tell a patient whose pregnancy was not known at the time she was given huge doses of antipsychotic medication on an emergency basis that her fetus may be harmed? Do psychiatrists have a duty to tell a severely ill psychiatric patient that the illness itself may harm her fetus? Should psychiatrists warn a pregnant patient that she may not be allowed to keep her baby because she is incapable of caring for it? Should psychiatrists opposed to abortion refer a patient in a crisis pregnancy to a psychiatrist who supports abortion rights or simply dissuade the patient from having an abortion? Should psychiatrists opposed to abortion keep a suicidal patient hospitalized longer than necessary when the patient has explicitly expressed a desire to obtain an abortion?
Psychiatrists who are morally opposed to abortion may find it difficult to help patients arrive at such an important life decision without imposing his or her values. Stotland said that her approach is to ask the patient, "How will you feel in five years if you have the baby? If you don't have the baby?" She also helps the patient identify people who will be supportive regardless of the patient's decision.
"British studies show clearly that the best outcome results when the woman makes an autonomous choice and people who care about her support her choice," said Stotland. "The psychiatrist, I think, should help her into that kind of position."--C.F.B.
(Psychiatric News, July 18, 1997)