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  • dtoub 6:46 pm on Tuesday, July 10, 2012, 6:46 pm Permalink | Reply
    Tags: abington merger, abortion   

    stop the abington-holy redeemer merger 

    I’ve been living in the Cheltenham area for several years now, and my family has used Abington Memorial Hospital’s services as needed. I’ve known the ob/gyn chair, Dr. Joel Polin, for many years professionally, and also know that he is as supportive of abortion access as I am. Not many abortions take place annually at Abington; somewhere between 50-100/year overall. But if many are like the procedures I once performed at an inner-city hospital in Philadelphia, these are not cases that could be done at a freestanding clinic such as Planned Parenthood or Philadelphia Women’s Center. Access to abortion within teaching hospitals is important, both for the patients and for the next generation of abortion providers (ie, the residents). Hospitals are much less of a target for anti-choice protesters, and it is also easier to manage the occasional complication (abortion is a very safe procedure, but complications minor and major can happen). A few years ago, I counter-protested against some anti-choice folks at Abington, and I know that the hospital had stood up for reproductive rights and maintained their abortion services in the face of some opposition.

    That may change. In a very surprising move, the Board of Directors of Abington Memorial Hospital has moved forward with a Letter of Intent to merge with the local Holy Redeemer Hospital, a Catholic hospital located not far away in the Meadowbrook section. As a result, even though Abington is the stronger party financially, abortions, selective reductions and physician-assisted suicide cannot be performed at Abington under the merger.

    Now, physician-assisted suicide is not permitted in the Commonwealth of PA, so that is a nonissue. But abortion and selective reduction will be forbidden at Abington, as they would be at any Catholic sectarian entity. Under agreement, contraceptive and sterilization access will be maintained at Abington.

    Some might say that this is really not too bad. Unlike what happens at Catholic institutions, women will still be able to get their contraceptives, and men and women can also undergo sterilization. There will still be IVF services and other assisted reproduction at Abington (just as Holy Redeemer has reproductive endocrinology services that involve assisted reproduction). Not many women locally undergo abortion, selective reduction is probably very uncommon even with all the IVF and ovulation induction going on, and this isn’t Mississippi. There are abortion providers in the Philadelphia area, including a hospital-based service at nearby Albert Einstein Medical Center (disclaimer: I have an adjunct faculty appointment at Einstein, but have no financial or other interest in that institution).

    But this is not a minor issue; this is a problem of nuclear proportions. And it’s not just about abortion, but affects women who have very desired pregnancies. Here are some questions and issues that help demonstrate why this is a big deal:

    • Selective reduction (which is not always thought of in the same context as abortion, as the intent is to sacrifice one or more multiple fetuses to save the remaining); for those women with triplets, quadruplets and higher-order multiple pregnancies, they will either have to undergo reduction in Philadelphia or else take their chances with the outcome

    • Preterm premature rupture of membranes (PPROM); will Abington physicians be permitted to induce labor in that situation or would they have to wait for intrauterine infection to evolve into sepsis? This is not a theoretical situation; this exact scenario played out with our former Senator’s wife (Karen Santorum). In that case, she made her own personal choice to delay labor induction. While it is not what I would recommend, I respect her choice as a patient. But that was her own choice, not one imposed upon her by a Catholic hospital.

    • If there is nonreassuring fetal monitoring at < 26 weeks’ gestation, will women be given a choice of labor induction vs. stat classical Cesarean section (mandating future C/S)?

    • Management of second-trimester inevitable miscarriage (eg, 18-22 weeks); will physicians be required to take unusual and medically futile measures?

    • Provision of emergency contraception (EC); regardless of what the current plan and/or potential contract agreement is between the two hospitals, EC is (wrongly) considered to be an abortifacient by the Church and proscribed as much as surgical or medical abortion. So, if a victim of a sexual assault presents at Abington’s Emergency Ward (EW), will she be offered EC? At a significant number of sectarian and nonsectarian hospitals throughout Pennsylvania, EC is not offered to victims of sexual assault, so this is not a theoretical construct.

    • Management of anencephalic and other lethal malformations detected with sonography or with other prenatal testing prior to, or past, the 24-week viability standard; based on Catholic teachings, abortion would not be available even in the presence of lethal anomalies

    • Perinatal testing for pregnancies that are likely nonviable or severely compromised, with the potential for futile C/S if nonreassuring testing results from these actions

    • Management of pregnant women with treatable cancers that are generally managed with pregnancy termination followed by definitive treatment of the malignancy (eg, stage IB cervical carcinoma diagnosed at 14 weeks’ gestation; one potential management option would be radiotherapy or D&E to terminate the pregnancy followed by gravid radical hysterectomy)

    • What about the CREOG/RRC requirements to maintain AMH ‘s residency accreditation in light of the lack of training in abortion technique and aftercare?

    • How will women who need postabortion care (for abortions done elsewhere) be managed?

    • Will the merger affect standard management of ectopic pregnancies? I suspect not, but while treating a patient with a tubal pregnancy via laparoscopy at Graduate Hospital in the 90’s, a scrub nurse told me that if it were her, she would wait for her tube to rupture before taking action, since I was essentially terminating a life. This was a very good scrub nurse, and she knew very well the implications of untreated ectopic pregnancy, such as hemorrhage and death.

    • How iron-clad is the commitment/agreement to continue to provide standard contraception and sterilization services?

    • How will they weigh the life of a mother vs her unborn baby in circumstances where they may only save one life and the mother is not capable of expressing her desire? And would that differ from cases where the mother can express her desire?

    • Management of severe non-immune hydrops fetalis during labor and deliver (ie, given the lethal nature of the condition for the fetus, will drainage of excess fetal fluid from various cavities be considered to effect vaginal delivery, or would that be proscribed as being similar to intact D&E?)

    These are just some of the things I came up with off the top of my head in a few minutes the other week. I’m sure there are others I did not think of.

    Abington Memorial is one of the largest hospitals in the county. While it is not a major academic medical center like Mass General or the Hospital of the University of Pennsylvania, it is a very large hospital that does more deliveries per year than many hospitals in the area. Over the past several years, we have lost many obstetrical services in the Philadelphia area; the hospital where my daughter was born is now a hospice or some other outpatient facility (ironically, owned by Abington Health). Two local hospitals within a short distance of Abington Memorial, Jeanes and Elkins Park Hospitals, no longer have OB care. It is not feasible for most women in the Abington/Jenkintown/Cheltenham area where I live to travel into Philly for their OB care and delivery, nor will most people choose to go to Einstein; it’s a good hospital, but it’s in an underserved area and most folks in my area just don’t go there. Einstein is building a new facility in the Blue Bell area, but unless you’re really determined to avoid Abington at all cost, it’s quite a hike from this area. So for all practical purposes, most women do not have other good options for their OB and other care.

    I have nothing against Holy Redeemer Hospital per sé. It is a good hospital. My children see pediatricians in their medical office building. I have to remind myself that it is a Catholic institution; unlike places like Mercy-Suburban and other hospitals that are affiliated with the Sisters of Mercy, Holy Redeemer doesn’t wear its Catholicism on its sleeve. I’ve yet to see a cross there, not that there is anything wrong with it (the Pieta of Michelangelo is one of my favorite sculptures, ever). But my point is that it has a pretty low-key approach to being a Catholic hospital, to its credit. But at the same time, it remains a Catholic hospital. And while the folks who run it might be willing to look the other way when Abington, under the merger, provides sterilization and contraceptive care, they clearly will not, and cannot, support any affiliated entity having anything to do with abortion. Low-key, yes, but there are limits.

    So that’s the quandary. In order to have this merger go through (and the business rationale for the merger, other than the value of the land Holy Redeemer sits on for additional office and OR space, escapes me), Abington will have to adhere to the directives of the Catholic Church as regards abortion and selective reduction. I respect all religions, regardless of my own atheism, and while I might not agree with Holy Redeemer banning abortion within its own hospital grounds, it is well within its right to do so. The problem is when sectarian hospitals merge with nonsectarian ones and impose their own sectarian beliefs on medical care delivered at the formerly nonsectarian institution. 

    We live in a diverse country, which is a good thing. And the Cheltenham/Abington/Jenkintown PA area is known for its diversity and generally progressive population of all religions, ethnicities and backgrounds. So the idea that a proposed takeover of a Catholic hospital would lead to the loss of abortion services at our most prominent local hospital, the one that is the stronger institution at this time, is mind-boggling and offensive to many in this area. As a result, more and more people are taking a stand against the merger, and that’s a good thing.

    I’ve sent e-mails and received canned responses, so I imagine most people who write will receive similar responses from the Abington management. But the more people write, the more the board and other management at the health system know there is solid opposition to this.

    We also need more physicians on staff at Abington to speak up and, if it comes to it, even resign their positions. When I was an attending physician at one Philadelphia hospital, I ended up leaving to go to Pennsylvania Hospital in large part because my former dept. chair was anti-choice and decided to go over my head and cancel one of two second-trimester abortions I had scheduled in the OR there (he couldn’t cancel the second patient, much as he wanted to, as I had already placed laminaria into the cervix to prepare it). At some point, we physicians need to uphold our own principles and ethical standards. If we cannot make a decision based on medical evidence but have to comply with religious dogma in certain situations, all of us have a choice to make in terms of whether or not that is acceptable based on our interest in providing the best medical care for our patients.

    Abortion is not a happy procedure, unlike much of obstetrics (although OB is often anything but happy, but that’s another discussion). I’ve never had a patient who took it particularly lightly, or who loved undergoing the procedure. But it is often a necessary procedure, both medically and from a public health standpoint. Some of my colleagues have died for providing this legal procedure. LeRoy Carhart, whom I’ve spoken with and admire greatly, has had his life disrupted and threatened on multiple occasions for his dedication to providing this service to his patients. Warren Hearn, whom I also think very highly of as a physician, is often under armed guard due to threats against his life. Those of us who have provided abortion services do not have an easy time of it. Besides the protestors and the inappropriate social stigma, many of our own colleagues (even in ob/gyn) disrespect us and treat us like undesirables. So when I hear of yet another hospital that will no longer provide abortion services, it touches a raw nerve. Many people have worked for years to do whatever they could to make sure that women at least have some places where they can exercise control over their own reproductive destinies. That’s because a lot of us feel that women who cannot control their reproduction are not truly free. So this is important to those of us in women’s healthcare, and from the responses to the Abington Board’s decision, I’m glad that this is very important to a lot of people in the local area as well.

    Feel free to e-mail the management of Abington Memorial Hospital. Just to make it easier, here are their e-mail addresses (keep it civil and polite, however. This isn’t personal):

    Mr. Laurence M. Merlis (Chief Executive Officer and President): Lmerlis@amh.org

    Meg McGoldrick (COO): Mmcgoldrick@amh.org

    Ivy Silver (Chair, Foundation Board of Trustees): Isilver@amh.org

    Robert Infarinato (Chairman of the Hospital Foundation, Chairman of the Board of Trustees): RInfarinato@amh.org

    • Jenny French 10:55 pm on Tuesday, July 10, 2012, 10:55 pm Permalink

      You are a brave and caring person and doctor, and I highly respect and admire you for taking a stand and writing this.

    • dtoub 11:29 pm on Tuesday, July 10, 2012, 11:29 pm Permalink

      Thanks. Much too generous and kind, but thanks.

    • Lara Stone 8:51 pm on Wednesday, July 11, 2012, 8:51 pm Permalink

      Thank you so much for writing this very logical, medically informative and straight-forward piece. I am currently 16 weeks pregnant (happy to be!) and I find myself disturbed by the events transpiring at AMH. Luckily my OBG care is at another hospital that is unaffiliated due to my location, but other women are not so fortunate. Were I to find myself in the horrific situation of medically requiring an emergency termination of my pregnancy- I can’t imagine having that choice taken out of my hands or being delayed life-saving treatment to transfer to a distant location. I do not want my medical treatment in the hands of religious crusaders- I want it in my hands and the hands of my doctor. The impact of this merger is far-reaching and deeply concerning. It is because of voices such as yours that women have come as far with our medical care as we have. It is an ongoing pursuit and without the aid of doctors willing to stand up for what is medically, morally and humanely right- we would have been silenced often in history and drowned out by politics presently. Reading posts like these reassures me that there are doctors that are willing to do the right thing, sadly at times to their own detriment. Doctors should not live in fear of their lives, their well-being, their reputations amongst colleagues for doing what is best for their patients in their medical view. I can’t imagine being ostracized for standing up for basic human rights and liberties. I imagine many doctors at AMH, as well as locally, are facing personal and professional repercussions due to this merger or their opinions. Thank you for having the courage to speak out and for being a voice of reason within the local and medical community.

    • dtoub 8:53 pm on Wednesday, July 11, 2012, 8:53 pm Permalink

      Thanks very much, and congratulations. You make some very good points, and I appreciate your taking the time to share them with me.

    • Lucie Cutterson 8:07 pm on Saturday, July 14, 2012, 8:07 pm Permalink

      Thank you for writing this and being part of the resistance to this merger.

  • dtoub 12:20 pm on Friday, January 21, 2011, 12:20 pm Permalink | Reply
    Tags: abortion   

    my letter to the editor re: abortion in west philadelphia 

    I am not sure if this will be published or not, but it was sent to the Philadelphia Inquirer this morning:

    To the Editor: 

    I am a gynecologist, formerly in practice in Philadelphia, who provided abortion care for many years to my private patients as well as to those at three area women’s health centers. I am appalled but not surprised by the events surrounding the clinic run by Dr. Gosnell; it was an open secret among abortion providers that his practice was subpar and not reflective of the generally excellent care most abortion providers give to their patients. I had performed abortions in women who had come to his clinic for an abortion, sensed that something was not right, and fortunately left before receiving care at that facility. What surprised all of us is the fact that no local or state authority acted on longstanding concerns about the “clinic” in West Philadelphia. And while the National Abortion Federation’s guidelines and inspection process currently lack teeth as they are not a state or local health body, I think it does have an obligation to provide better oversight of member clinics and individual physicians. Unfortunately, only a portion of abortion providers are members of NAF, and like Dr. Gosnell, would not be subject to any enhanced regulation by that organization.

    I do believe that outpatient abortion clinics should be evaluated in the same light as any other outpatient facility, but also not targeted or treated more onerously than a cosmetic surgery or outpatient surgical facility.

    But lost in all of the media reports about the “house of horrors” in West Philly, is the fact that women came there because they often did not feel they had access to a safe, legal abortion. Abortion care is not generally reimbursable under medical assistance plans thanks to the Hyde Amendment. And thanks to terrorist groups like Operation Rescue and the assassinations they have inspired, many of my colleagues simply will not provide abortion, making subpar and dangerous physicians even more likely to make up for the decreased supply of qualified abortion providers. If anyone wants a preview of a future without Roe vs. Wade, look to that “clinic” in West Philly.

    Most abortion providers and clinics provide excellent care to their patients. Indeed, abortion is one of the safest surgical and medical procedures out there. However, society and, in particular, many hospitals and medical schools have marginalized abortion. That marginalization will only make it more likely that unqualified people will provide abortions to women who lack the means to obtain safe and legal abortions. It’s time to stop this marginalization, and also elevate abortion practice to the quality standards and payor reimbursement it deserves, on a par with every other routine, standard and common gynecologic surgery procedure.
    • diogenes23 4:57 am on Sunday, January 23, 2011, 4:57 am Permalink

      Well said David~!

  • dtoub 12:06 am on Tuesday, June 2, 2009, 12:06 am Permalink | Reply
    Tags: abortion,   

    we need to come out and say “enough” 

    I’m still ruminating over the murder of George Tiller yesterday.

    As one of the diminishing number of physicians who performed second trimester abortions, I can state unequivocally that it is never a procedure that is approached in a cavalier fashion. Not every gynecologist can perform it, even if trained appropriately. The sad thing is that we’ve done a really bad job at training the next generation of providers. I taught many residents, but of those, many will not provide abortion services for a variety of reasons. Part of why this is is that abortion has been marginalized. People don’t want to talk about it. My colleagues for the most part didn’t want to deal with it. Some couldn’t say the “a-word,” substituting euphemisms like VIP (voluntary interruption of pregnancy). Abortion is a very common procedure. It is a necessary procedure. But it will be an extinct, forgotten procedure if clinicians are not trained to do it safely and compassionately. We need to get it back into the hospitals so that it is again part of routine gyn practice. Abortion training must be made more widely available within residency training programs. It’s idiotic that many ob/gyn residency programs do not offer in-house abortion services, but must send “interested” residents to outside clinics, often on their own time during weekends.

    When I was in practice, I did a lot of procedures in ob/gyn. Including abortion. Some of my most grateful patients were those for whom I performed an abortion. I never performed any abortion without being absolutely certain that the patient desired it and that it was her own decision. That’s what “choice” is about, after all. My abortion patients didn’t wake up that morning and decide “What the hell, I think I’ll have an abortion.” This was a very, very difficult decision for any woman to make. People who have not walked in their shoes should not be making judgments or regulations about this most private and personal of medical decisions.

    All of us who either performed or continue to perform abortions need to finally stand up, be counted, and say “enough.” Abortion providers have this terrible stereotype of being slimy, scumbags in the margins of the medical profession. We’re not. A lot of us are academics. We’re honorable. Most of us have delivered babies. All of us provide or provided services that are challenging and that many physicians either can’t or simply won’t provide. Rather than honor abortion providers, society (including many physicians) treats them like criminals. This must change. While I recognize the potential danger in coming out as an abortion provider, there is strength in numbers. And just as the Gay community came out and took steps to remove the stigma of being gay, abortion providers should stand up, be proud, and demonstrate that we’re here to stay. Only when abortion is de-marginalized can we start addressing the onerous restrictions on the provision of abortion services and also combat the insidious demonizing of abortion providers. Such demonizing was absolutely behind the assassination of Dr. Tiller yesterday.

    • PassionateProvider 12:56 am on Tuesday, June 2, 2009, 12:56 am Permalink

      Hey David,

      Great post. Very powerful.

      I’m currently in my last year of medical school. I have organized abortion training opportunities at my school since my first year. Now that I am in my internship years, I have also had the privilege of working with and learning from practicing providers. I am looking forward to a career where I can be involved in the full spectrum of women’s reproductive health. An abortion-providing baby-delivering doctor is not an oxymoron. In fact, I think it is a pretty awesome combination.

      Your call for “coming out” of providers does not fall on deaf ears. I agree with you completely. I’m not quite there yet, unfortunately. The pseudo-anonymity of twitter et al. has made it easier for me to share my thoughts and passions. As I gain confidence, and, more importantly, a sense of interconnectedness to like-minded people, the need for anonymity is diminishing.

    • dtoub 1:06 am on Tuesday, June 2, 2009, 1:06 am Permalink

      Thanks very much. I really appreciate your comments. And no, it is not at all an oxymoron. I did it as well, although I confess I was more of a laparoscopic surgeon than an obstetrician after awhile.

      Don’t rush the “coming out” part. It’s an individual choice. I was very careful when I was in practice, especially after I had my daughter. It changes one’s perspective, since it isn’t just about you. But being careful isn’t synonymous with denial. I never lied about what I did and remain proud and humbled to have provided this service to many women. But it’s admittedly easier to be “out” in terms of abortion once one has left clinical practice. Many of my fellow abortion providers were genuinely scared in the 90’s and with good reason. Several providers were shot and killed, along with courageous volunteers and staff. That changed things quite a bit. So there’s nothing wrong at all with flying under the radar. But still, many established providers need to declare themselves or at least not deny what they do when asked. The more providers who speak out, the better. Good luck with your training. Guess I can’t talk you out of being a doctor. 😎

    • EJ Keith 11:45 am on Tuesday, June 2, 2009, 11:45 am Permalink

      I happened upon your blog in light of Dr. Tiller’s death, and I just wanted to express my utter gratitude for the work you do, and the courage and honesty with which you carry out your duties. I’m a Canadian woman, so things are a bit easier for us up here, and although I’ve never needed to consider an abortion I have friends and family members who have; and I am grateful that I live in a country that respects a woman’s life enough to allow her the courtesy of being the sole decision-maker in the choices that will most affect her.
      I was born in 1980, so I grew up as a member of the first generation of Canadian women to go trough puberty post-Morgenthaler (the SC decision that abolished the last legal restrictions on abortion in Canada). Because of this, I’ve never had to go through the agony of having nowhere to turn, nor have any of my friends of similar age. I haven’t lost friends to butchers, I haven’t known anyone – of my age – to have their dreams of future children taken away from them as a result of complications from an illegal operation (although I have met older women who have had to live with this).

      And for this freedom, this luxury of choice, I have you, and others like you – doctors, nurses, and other health care providers & supporters – to thank. To you and future doctors like the one who commented above me on this thread, THANK YOU, THANK YOU, THANK YOU. Although we are from different countries, with different laws, the stand you make strengthens us all.

      And I can’t thank you enough for having the courage to make it.

      Kindest Regards,
      EJ Keith, Ottawa, Ontario

    • dtoub 11:53 am on Tuesday, June 2, 2009, 11:53 am Permalink

      Thanks for your kind words. Your country is pretty enlightened regarding abortion, as I’ve noted before: https://dtoub.wordpress.com/2008/07/12/an-enlightened-attitude-about-abortion/.

      I’m no longer in practice, incidentally, and regret not being able to provide this service and train residents. Our health care system is very different from Canada’s, and many gynecologists end up either changing states or leaving practice entirely. Hopefully Obama’s health care reform will take hold—we need a better system.

  • dtoub 3:59 pm on Sunday, May 31, 2009, 3:59 pm Permalink | Reply
    Tags: abortion,   

    in memorium: dr. george tiller 

    I just read that someone assassinated Dr. George Tiller, an abortion provider in Kansas who was one of the few people who were skilled at and willing to perform abortions above 20 weeks’ gestation. Dr. Tiller was shot while attending church services near his home.

    For those of us who perform or performed surgical abortion, Dr. Tiller, along with Dr. Warren Hearn in Colorado, epitomized the highest ideals of medical service. Regardless of one’s stand on abortion, Dr. Tiller was a true professional who performed abortion above 20 weeks despite many obstacles, including onerous regulations, overzealous protestors, death threats, a bombing and the shooting of both of his arms. He didn’t perform abortion for monetary reward; in general, there are far less dangerous ways to earn significantly more revenue as a physician. Rather, Dr. Tiller did what he did because it was necessary, and because midtrimester abortion is best provided by someone who has the patient’s best interests at heart.

    This also demonstrates how critical it is that residents and other physicians get appropriate training in abortion services. While I provided second trimester abortion services while in practice here in Pennsylvania, I never performed one above 20 weeks to the best of my recollection, and as a resident would go to 24 weeks, but only using saline and prostaglandin amnioinfusion above 18 weeks. Dr. Tiller provided safe, legal surgical abortion up to, I believe, 28 weeks, which requires a great deal of art and skill to pull off without complications. Now that he is gone, there are far fewer people out there with that skill and experience. Only Warren Hearn comes to my mind, although I’m sure there might be a few others.

    Dr. Tiller’s murder is another indication that we need to come together and find common ground. No one is more pro-choice than I am, period. I’ve performed many abortions, introduced medical abortion to my hospital in the days before mifepristone was available, lectured about abortion technique and taught many residents how to provide a safe surgical abortion in a compassionate fashion. I’ve never dissembled about my role as an abortion provider, and am very proud of what I did. Indeed, my patients for whom I provided abortion care were often among my most grateful patients. I’ve marched on DC twice in support of abortion rights, actively supported pro-choice candidates and have always been willing to donate money to the cause of reproductive rights. That said, I’ve also worked to find areas of agreement and cooperation with reasonable people on the pro-life side of the divide. I used to be a member of a local group called Common Ground, and it brought people together from both sides to have dialogue sessions on abortion-related issues. It was moderated with strict ground rules, so no one could interrupt or become disrespectful. In this fashion, people can talk with one another without coming to blows even when there is heartfelt disagreement. None of us were trying to convert one another, and indeed, conversion wasn’t possible. The pro-life participants were just as vehement about their side as those of us on the pro-choice side were about ours. But we got along and gradually had a better understanding and respect for the other viewpoint. It taught me that one can respect and even admire those with whom there is visceral disagreement.

    We need more efforts like that. I remember the 90’s when several abortion providers were murdered along with volunteers and other staff. It seemed to be a reaction to having a pro-choice president in office, in that case, Bill Clinton. The murders can’t be justified, but I would suspect that they were born out of extreme frustration from not having a conservative administration in Washington, DC. Since January 20th, I suppose it was just a matter of time.

    So I’m very saddened by the loss of Dr. Tiller. Unlike Warren Hearn, I’ve never personally known or communicated with George Tiller. But his work always meant a lot to me, and women who need a second trimester abortion are worse off due to his loss. However, the cause of reproductive freedom is very much alive, and will continue despite this terrible act of assassination. I hope that my colleagues, regardless of their personal stands on abortion, and medical organizations such as the AMA, come out and strongly condemn this murder. And even better if we can all learn from Dr. Tiller’s example and come together to try to find some common ground on a very divisive issue.

    • Chris Becker 1:31 pm on Monday, June 1, 2009, 1:31 pm Permalink

      Great post, David. I’m pro choice, but people very close to me are not, and I can empathize with what you write here. Take care. CB

    • dtoub 2:42 pm on Monday, June 1, 2009, 2:42 pm Permalink

      Thanks Chris. I don’t care if someone is pro-life. I do care, however, if someone interferes with patient care when that patient is seeking a legal procedure and also when that person decides to kill someone for delivering abortion services. It’s a sad world.

    • Chris Becker 9:38 am on Tuesday, June 2, 2009, 9:38 am Permalink

      David, You’re right when you describe the generalities that pro-life people use when discussing the women who seek an abortion. Bring up the issue of rape – especially an underage victim of such a crime who gets pregnant – and you can shut them up pretty quickly.

      But I think pro-life people need to realize that an abortion may be done in the interest of the health of the mother. Can you describe such a scenario?

    • dtoub 5:26 pm on Tuesday, June 2, 2009, 5:26 pm Permalink

      Many. Here’s just a short list off the top of my head:

      • Significant cardiac disease/cardiomyopathy
      • Myasthenia gravis
      • Cancer (cervical cancer in particular)
      • Severe hypertension
      • Severe hyperemesis gravidarum (I’ve done at least one for this indication, on the wife of a medical resident who was on hyperalimentation)
      • Significant mental distress

      Of these, cancer, cardiac disease, myasthenia gravis and severe HTN particularly pose risks to the life, not just the health, of the mother. I also think the role of mental distress has been unfortunately misunderstood by the media as well as by many physicians. We’re not talking about having a bad day by continuing a pregnancy. We’re talking about serious mental impairment, which definitely can happen. For example, one of Dr. Tiller’s patients who had an abortion after 20 weeks for an anencephalic pregnancy did not want to sit around for 4-5 more months on a death watch and struggle every day with the doomed pregnancy she was carrying. This was a very desired pregnancy, but it was not viable, and even discounting fetal indications, her mental health was an appropriate reason for terminating the pregnancy. I should add that I had a similar experience with a second-trimester pregnancy that was doomed. My patient felt strongly that her baby was suffering and wanted to terminate. She had a normal pregnancy the year after and got on with her life.

      By the way, many pro-life people I have encountered do not consider sexual assault to be an indication for abortion. They believe that the baby shouldn’t have to suffer due to the crimes of the rapist. I disagree. No woman should be an incubator. No victim of sexual assault should ever be forced to bear her rapist’s child.

  • dtoub 12:45 am on Saturday, July 12, 2008, 12:45 am Permalink | Reply
    Tags: abortion, Canada, , political expediency   

    an enlightened attitude about abortion 

    I had dinner tonight with two Canadian colleagues, and near the end of dinner (after regaling each other with the usual gynecologic surgery “war stories”), somehow the topic of abortion came up. For starters, unlike some experiences I’ve had with gynecologists in my own country, I was not shunned nor was the conversation suddenly uncomfortable for the other physicians. Even better, I was told that in Canada, there are simply no laws regulating abortion; none whatsoever. Instead, it is considered something outside of the legal and legislative domains; it is a matter between a woman and her physician. 

    Amazing. This was literally one of the few times I didn’t feel slightly ill at ease when talking about one of the most common gynecologic procedures with my fellow gynecologists. Usually someone looks at me when the subject comes up and says something to the effect of “Oh David, do we have to talk about that?” or “Mind you, I’m ‘pro-choice.’ Really. But I don’t do voluntary interruptions of pregnancy; they’re kind of associated with a certain reputation.“ Or else they just stop talking and politely find an excuse to walk away. These folks never mention the ”a-word.“ Every medical euphemism gets used instead: ”voluntary interruption of pregnancy,“ ”VIP,“ ”elective terminations.“ But never the word ”abortion.“ I think I have a scarlet ”a“ on my forehead, even a decade after stopping clinical practice altogether.

    So it was refreshing that up here they wouldn’t interfere with the most private decisions, indeed some of the most difficult decisions, a woman makes in conjunction with her physician. They don’t determine, for example, when a fetus becomes a person. They also don’t legislate moral and religious questions such as when does life begin, questions that lack sufficient medical or scientific answers.

    In a week when the Republican candidate can’t recall his previous vote against requiring insurers to pay for birth control (when they already cover Viagra) and then claims to not have thought about the issue at all, and a week when my candidate inexplicably claims that second-trimester abortion can be restricted by states when the indication is ”mental distress,“ it’s refreshing to be in a country, albeit temporarily, that at least recognizes that women have brains and should have control over their bodies.

    Barack, just between you and me: my family and I are volunteers for your campaign in the Philadelphia suburbs. I am about as strong an Obama supporter as you’ll ever see. But with all due respect, what were you thinking? States should be able to prohibit second-trimester abortion unless there is a physical disorder that would result from the pregnancy?  I get it…you’re trying to pick up some right-wing voters. But good luck with that; they don’t trust you on abortion and probably never will. Worse: some of us progressives are now questioning your commitment to our issues in light of your FISA vote, your comments on abortion, and your sudden support for faith-based initiatives. Going to the center during the general election is one thing, but going into Rush Limbaugh-ville is scary. 

    For starters, please stop using the phrase ”late-term abortion.“ There is no such medical term. A term pregnancy is 37-42 weeks in gestation. So isn’t late-term what we would usually call ”post-term pregnancy,“ namely 42 weeks and above? We don’t do abortions at that point. I don’t think I’ve done one above 20 weeks personally, and know of very few folks who do them even at 28 weeks (and those few generally do them in cases of severe fetal defects incompatible with normal life). Also, for anyone to suggest that a woman wakes up one morning at 24 weeks of pregnancy and decides then that ”What the hell, let’s go have an abortion” is both insulting and ridiculous at the same time. When we use the term “acute situational anxiety of pregnancy” as an indication for abortion, we’re talking about women who, after a complicated and very difficult decision process, clearly indicate that their lives would be abnormally and unduly burdensome due to a pregnancy. We’re not talking about a temporary inconvenience that some women are callously avoiding, much like the way that Corporal Klinger tried to avoid being in the military on M*A*S*H by faking a gender disorder. We’re talking about much more than that. To say that “mental distress” should not justify a second-trimester abortion is not within your purview as a presidential candidate, as an attorney and legislator, and most importantly, as a non-clinician.

    I expect McCain to say something ridiculous vis a vis women’s rights, like trying to duck the fact that he voted down legislation to compel insurers to fund contraception. I expected Barack Obama to be much more sensitive to the rights of women when they are faced with an unexpected and undesired pregnancy, much like how I expected Obama to stand up for privacy rights and against the telecommunications companies that colluded with the Bush administration to spy on private communications. I’ll still vote for you and will of course continue to vigorously volunteer for your campaign as much as I can with limited free time. But please don’t disappoint me again. Do I have to visit Canada to encounter a more advanced attitude towards women? Can’t I at least expect this attitude in my own country as part of the change I can believe in? Right now I’m tired, and am not sure what to believe anymore.

    • J.C. Combs 1:32 am on Saturday, July 12, 2008, 1:32 am Permalink

      On a similar note: I’m a huge Obama supporter, but what the F was he thinking by signing the spy bill????

    • James Ross 8:47 pm on Sunday, July 13, 2008, 8:47 pm Permalink

      Strong post, David.

      Sadly, Obama is doing what he has to do. He needs the center. No matter what he may say. The “liberal/progressive” vote is in the bank. Seriously, is there anything he could do to make you to shift your vote to McCain? Or to cause you to sit out the election?

      I hate seeing him do this.

    • David 5:35 am on Monday, July 14, 2008, 5:35 am Permalink

      I agree, James. Still, had to vent a bit…

    • PassionateProvider 12:32 pm on Wednesday, June 17, 2009, 12:32 pm Permalink

      “To say that “mental distress” should not justify a second-trimester abortion is not within your purview as a presidential candidate, as an attorney and legislator, and most importantly, as a non-clinician.” Very well said. This is something that frustrates me to no end. The private lives and choices of women have been forced into the public realm where any random asshole feels justified and even entitled in imposing their judgments.

      By the way, I would advise you to stay away from Alberta (the Texas of the North). It might taint your image of our otherwise fairly progressive country.

    • dtoub 1:05 pm on Wednesday, June 17, 2009, 1:05 pm Permalink

      Thanks. So Alberta is like the US then? 😎

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