TL;DR: Stay curious. The abortion issue is actually very complicated. Be humble. Listen. Be willing to be uncomfortable in the conversation. 

As a matter of background, I grew up in the church and had always identified as Republican and pro-life. I questioned little and took it at face value that “abortion is murder, murder is wrong, we have to end abortion”. I remember attending a Rally for Life for the local Right to Life chapter. And pinning a small paper rose to my smocked dress at Sunday school as a child. But then, as I grew, I had new experiences both in the church and as a physician, and my understanding of this issue has started to mold and change. At this moment, I wouldn’t say I am “pro-life” or “pro-choice” as the extremists would define them. I actually reside in the middle.  

Recently, a leaked document from the Supreme Court of the United States indicated that the court is poised to overturn Roe v. Wade. Pro-life supporters immediately cheered what appears to be the victory they have been hoping for, for nearly 50 years, while pro-choice advocates took to protesting the pending decision and mourning the loss of choice women will no longer have over their bodies. The human tendency to polarize like this, to make things left or right, black or white, right or wrong, is precisely what has thwarted our ability to have rational conversations about abortion and many other issues. We are too focused on extremes and defending our position. The gray, the middle can be an uncomfortable, sticky, confusing place to be.  

Words matter. At the core of the issue, pro-life advocates are “fighting” for the life of the baby; pro-choice advocates are “fighting” for the rights of the mother. The political issue of abortion pits mother against baby from day 1! But if we stop and think about it for a minute, I imagine both “sides” actually have a lot they agree on. Pro-life supporters generally appreciate healthcare, education, and autonomy and many utilize contraception; and pro-choice supporters are generally in favor of education, healthcare, bodily autonomy and safe contraception. Interesting. Starting from some common ground can be a helpful perspective.  

Next, we should be sure we have some definitions correct. When we use the word “abortion”, what that means is the termination of pregnancy. It’s essential that we understand that in medical terminology, a miscarriage is called a “spontaneous abortion”. Upwards of 20% of all pregnancies end in spontaneous abortion. This will be important to remember later when we discuss legislation surrounding abortion. In the case of ectopic pregnancy, in which the pregnancy is non-viable and a threat to the life of the mother (risk of massive hemorrhage), “medical abortion” is indicated to save the life of the mother. All of this is to point out that not all “abortions” are elective, indiscriminate “baby-killing”. The data surrounding abortions must be interpreted clearly as lumping all “abortions” into one bucket truly muddies the story and places shame and blame where none is warranted. We have to read the fine print.  

Next, let’s consider some data. Criminalizing abortion is unlikely to reduce the number of abortions that occur in the United States. We see this by noting that even in nations where abortion is the most restricted there are relatively high abortion rates. Conversely, in nations where abortion is safe, accessible, and legal, rates are actually much lower, likely because those same nations have broad access to contraception and all forms of healthcare (eg, Scandinavian and European countries). So, if the goal of pro-life advocates is to reduce abortions, the strategy of making them illegal is very likely to have little or no impact on abortion rates. And what is more, when abortion is illegal, more women will seek unsafe, illegal abortions, with all the attendant life-threatening complications. So as far as preserving life overall, we will lose more women than the babies we will save with this approach. I agree with the argument “but it was the mother’s choice to have an illegal, unsafe abortion”. That is true, but if we learned anything from COVID, we should pause, step back, and think about large-scale public health, not only individuals.  

If the goal is to save babies, a far better strategy would be to invest heavily in free and accessible contraception, and comprehensive reproductive healthcare education.  The safety profile for oral contraceptive pills (OCP) is much better than for basic medications like Tylenol (just 12 tabs of 500mg Extra Strength Tylenol have the potential to cause a life-threatening situation; some say if the FDA were to review Tylenol now, it would be considered too dangerous for over-the-counter (OTC) use). Making OCP low cost and OTC would provide easy access to millions of women. The Plan B pill is FDA approved and already available OTC. Plan B is not an abortion pill; it is emergency contraception.  Plan B remains a safe and important option for women who are the victims of rape and seek immediate medical attention. Broad access to this resource would be another way to reduce abortions…with prevention.  

Pro-life proponents argue that abortion, the killing of a baby, should never be allowed; that the most defenseless, and vulnerable in our society should be protected. This is a noble position. And I don’t disagree. However, when all-or-nothing laws get passed that ban all abortions, we erase the delicate space in which “abortion” may actually be the ethical, and religiously accepted, approach. In cases where a non-viable pregnancy is a threat to the mother or the fetus has lethal abnormalities and pregnancy complications set in or the newly pregnant mother is the victim of a trauma with a traumatic brain injury from which she will never recover. We can’t imagine every possible scenario to carve out space for these in our laws, so we default to “none”. And this is where harm to the mother comes in.  

By criminalizing abortion, women who need these medical services may be hesitant to seek them. And physicians skittish to care for these women. Even when we allow “legal abortion in the setting of medical necessity for the life of the mother”, who gets to make the decision about what is necessary? The physician? The courts? Lawmakers? Will I, as a physician, have a duty to report a woman who seeks emergent care after a failed, illegal abortion? If I am caring for a pregnant trauma patient and the baby is lost, will there be an inquiry into my care? Did I “induce abortion”? Do I have to keep a pregnant woman on life support to incubate her baby, even if she would not want to be connected to machines for survival; is the withdrawal of the machines the same as aborting her baby? There is already some buzz about “monitoring” the digital data of women who track their menstrual periods on phone apps, Google information about abortion or contraception, and whose location tracking identifies their proximity to abortion clinics. If a woman presents to the hospital after a spontaneous abortion, will our default position become to question if she did anything to induce the miscarriage? Did she intentionally fall? Did she take a substance in an effort to harm the baby? Will I have to report this? Will this data be admissible in court? Will I have to testify about the care I provided or that the woman was seeking?  

The sanctity of life, to maintain integrity, needs to be honored at both the beginning and the end. If the precedent is set that the courts can adjudicate life in the womb, will they also be empowered to direct it at the end, particularly in cases where the patient can’t speak for themselves (dementia, stroke, trauma, etc)? Some of the most difficult situations I encounter in medicine are the intensely personal, unique, emotional conversations about end-of-life care. The decision to make comfort the priority over the priority of the duration of days. When we remove the capacity for women to have these difficult, personal, unique conversations with their providers about reproductive health, will we extend the premise to end-of-life and hospice care? Could I be prosecuted if I agree to transition a patient to comfort measures in accordance with their wishes if that decision is now prohibited by law? Several years ago, so many were worried about the “death panels” (which never existed in legislation, but I’ll let you in on a secret…they DO exist in real life and we call them “insurance denials”.) If the sanctity of life is to be preserved, especially innocent life, then we need to take a hard look at the death penalty. We know that wrongly convicted (innocent) people are placed on death row. Some have been executed. If the paramount principle is preservation of innocent life, then the death penalty as presently used in the US does not uphold that value without risk. These are the questions we need to wrestle with as possible fall out from the overturning of Roe v. Wade. It’s complicated.  

So, what will happen if Roe v. Wade is overturned? At least 13 states have so-called “trigger laws” in place that will nearly completely ban abortion upon SCOTUS decision, and an additional 10 will likely take steps to severely limit abortion. Pro-life proponents may cheer this rapid reversal of access to abortion, but as stated before, this will likely NOT have the intended effect of reducing abortions. Without a deliberate plan to bolster social supports, contraception, prenatal and children’s healthcare access, paid maternal/paternal leave, and subsidized childcare, we find ourselves in the position of shifting the burden of the law to a disproportionately Black, Brown, immigrant, and impoverished portion of society. The most developed nations have precisely the opposite approach. If the current national, cultural, and political discussion were about saving babies, this would have been a years long effort to bolster social support, put mechanisms in place to hold men accountable for child support and prosecute rape to the same extent they plan to prosecute abortion. These actions would be tangible efforts to support life across its stages. But this is not the case. And thus, the grounds on which the argument “pro-life, save the babies” rests, is shaky at best, and smells much more of the stench of politics in which the overturn of Roe v. Wade is the “win” in and of itself, not the innocent lives it claims to save. Though, deep in my heart, I know the US doesn’t have the resources to investigate and prosecute thousands of women and their doctors who may or may not have provided an elective abortion. Let’s be realistic. But the potential to do so, and the pathway for nefarious, bitter extremists to use those laws to harm, prosecute, and incarcerate fellow citizens is what should concern us.  

Here’s a wild idea…what if being “pro-choice” was really “pro-life” all along?  A society that values and supports life, ALL life, across all stages, races, class, and gender, invests heavily in an infrastructure that nurtures that life to its fullest. Where healthcare and parental leave policies are generous, parents have time and resources to care for infants. Where childcare and schools are robust and safe learning environments. Where unfettered access to firearms would be curtailed and thousands of lives saved from homicide and suicide. Where immigrants are celebrated as equal contributors to our national, collective, diverse and vibrant melting pot culture, not presumed to be criminals. Being “pro-life” sounds a lot like being “pro-human”, actually, but the way we use the term today seems to mean more like “pro-birth”.  

The Christian ethos to “love your neighbor as yourself” and to practice the extension of grace, as Jesus did, would seem to align best with policies that provide guardrails from the indiscriminate termination of life, but allow more latitude than the complete elimination and criminalization of abortion. Jesus decried the Pharisees for making complex laws and harshly enforcing them. He pointed out their hypocrisy and offered, instead, a love and grace-filled conversation. Every time the religious leaders tried to trap him with the law, he showed them that mercy is always the better high road.  

Disclaimer: My viewpoints are not necessarily reflective of my employer, or any local, regional or national organization that I belong to. As a matter of fact, I pretty much just speak for myself. Please keep that in mind.