“This book isn’t a blueprint for a new conversation. It’s an explanation of why we need one, and an invitation to participate in moving that forward,” (12) says Katie Watson in the introduction to her book Scarlet A: The Ethics, Law and Politics of Ordinary Abortion. She does herself a disservice with this; in many respects her text provides us with just that – a model for what a more productive discussion of how society responds to and organizes around the issue of unwanted pregnancy might look like; a question that has remained contentious across the centuries and for which we may never have an ‘answer’. It is precisely because perceptions of abortion are so hard to prise apart from our attitudes towards women, sex, social roles and the meaning of motherhood, that we may never find permanent peace – more a truce that each generation must work out for itself anew. And Watson’s book could well be a handbook this generation needs in its arsenal as it seeks a settlement for the 21st century.
Watson, a professor of bioethics and medical humanities, wrote this book while experiencing pregnancy herself and the text reflects, as she says, the journey she has been on as a lawyer, a woman and now a mother. I work as the director of communications for a British charity providing abortion care and advocacy and for my part read this book in the Autumn of 2018; I reflected upon her thoughts as we campaigned to fully decriminalize abortion in the UK – including in Northern Ireland, where there has been no access to lawful abortion. While the book is written in reference to the febrile conversation in the US, there is much that is relevant from a European perspective – and much we can learn from successes and challenges on either side of the Atlantic.
Scarlett A is a reference to the sentence given to the character Hester Prynne in the novel The Scarlet Letter; when pregnancy reveals she has committed the sin of adultery she is to forever wear a scarlet A as a symbol of shame. Watson contends abortion stigma today brands the women who need this care and the professionals who provide it with an invisible scarlet A that most women, and indeed many care providers, will never reveal. It is this stigma which prevents women from speaking about ordinary abortion, the theme which shares the title of this book. Watson identifies ordinary abortion as the key component missing from the conversation, a conversation which is dominated by heart-wrenching tales of extraordinary abortion including rape, fatal fetal anomaly, and pregnant 12 year olds. One in five US (and UK) pregnancies end in abortion and most are for the ‘ordinary’ reason of not wanting to be a mother, or expand one’s family, at that time – and it is real stories of ordinary abortion which pepper Chapters 1 and 2, interwoven with analysis of the competing abortion narratives – “abortion is always a difficult decision” (50) (the stories illustrate it isn’t); “abortion is a women’s issue” (60) (yet this neglects the fact that many abortions are the result of a decision taken within a relationship); abortion is about sex and promiscuity (yet abortion is also a family issue, and the majority of women who have abortions are already mothers). Why don’t we hear more stories of abortion as a straightforward decision, as a couples’ issue, as a family issue, Watson asks. Ordinary abortion is a large part of abortion experience and a small part of abortion narratives.
Chapter 3 explores the language we use to speak about abortion and which in turn shapes our debate, using the case of a 17 year old girl in a small Utah town who paid a local boy to assault her so that she would miscarry her 7 month pregnancy in legal proceedings that sought to establish that that pair had undertaken the attempted murder of a ‘human being’. Against this backdrop Watson looks at the vocabulary employed by all stakeholders in the abortion discussion – life/potential life, unborn child/pregnancy, late-term/midtrimester (to describe a second trimester abortion) – “none of our words… say whether abortion is ethical or should be legal. But every one of them seems to be the first step towards different conclusions, so of course, they’re contested. These linguistic gymnastics are part of why it makes it so hard to even start a conversation about abortion” (85). It is also one reason why Ann Furedi , author of the Moral Case for Abortion which Watson’s book references, believes those who are pro-choice should not skirt around words (she herself uses the word killing in relation to abortion). “I don’t think it helps to obfuscate or be mealy-mouthed. That creates the impression that you want to draw a veil over what happens. You have to be prepared to be quite blunt.”(Meredith, 2016) In the Utah case, a distressingly vulnerable teenager – extremely poor ( she lived in a house without running water), facing abandonment by a boyfriend who was a convicted criminal if she did not end the pregnancy – became the impetus for her state legislature to pass a bill defining self induced abortion as murder after prosecutors found they could not convict her under existing legislation. Watson describes her as being a minor in need whose needs were ignored by her community until she tried to harm her fetus, and “Then her fetus got the attention she did not.”(90) The case thus provides the perfect segway in to the sentiments of Chapter 4 of the respective positioning of woman and fetus – “We can see a woman, or we can see her embryo or fetus, but we can’t see both simultaneously” (100).
In her subsequent critiques of the approaches to abortion ethics, which Watson broadly distinguishes between autonomy approaches that focus on women and biological ones, which focus on embryos or fetuses; and the public health ones which skirt around both – that women will suffer greater harm if abortion is inaccessible – she provides an excellent account of the various underpinnings used to argue whether abortion is permissible – and if so – in Chapter 5, then when. And she also reaches into whether it is acceptable to ask why, and to question whether the phrase “don’t judge me” (173) – is really apt. “Pro-choice doesn’t mean you can’t have opinions about other people’s choices, or that you can’t think a woman is wrong about moral status. To be ‘pro-choice’ is to recognize that your neighbor is a moral thinker too. In a pluralistic society, she’s allowed to disagree with your assessment, and you must have reciprocal respect for each other’s conclusion”(172). She argues the need to understand that when you disagree with someone’s reasons for abortion, that what is really happening is you are disagreeing on the moral status of embryos or fetuses; “moving from judgment of reasons to disagreement on moral status can help us productively discuss our true conflict”, Watson argues. And it is with the same clarion call for honesty in Chapter 6 that she navigates the clinic TRAP laws – or ‘Trojan Horse’ abortion regulations aiming to create obstacles to access under the false guise of patient safety as well as regulations mandating waiting periods, dressed up to look like a minor imposition, a sensible precaution to ensure a woman is certain of her choice, but with the effect of infantilizing women, besmirching doctors, and in areas where clinics are few are far between, creating significant delays to care or make associated costs prohibitive. This climate of what Watson calls “structural stigma” (184) in which doctors can also be forced to read from a script regardless of the needs of the individual patient before them, in which abortion is treated differently from all other forms of healthcare, are far more damaging than clinic blockades by protesters. And in a heartbreaking but perfectly pitched epilogue, Watson recounts her own abortion following a diagnosis of a fetal anomaly; the conversation with the hospital where she was receiving her prenatal care where an abortion cost $20,000 rather than the $700 at Planned Parenthood, but where some women still preferred to go to avoid the stigma of attending an abortion clinic. Watson tells us how she too considered not using her insurance to pay for her abortion to keep this visit separate from the rest of her life – “but a study I read finding that a large number of women with private insurance still choose to pay for their abortion themselves struck me as a sad, expensive expression of abortion stigma, and remembering that keeps me on track. Pulling out my insurance card suddenly feels like a political statement.” (225)
It’s a fine ending to this book, and one which Watson clearly struggled with whether to include. Although hers is an ‘extraordinary’ abortion, for her, her own decision sits alongside of all those belonging to other women who felt that they were not in the position to parent this child at this particular time in their lives.
From my perspective, I do think we have made huge strides in telling women’s stories – both extraordinary and ordinary – although there is much work still to be done. Stigma silences the voices of the ordinary, but it is also true that when it comes to direct campaigning we do not hang our hats on tales of ordinary abortion. We find the examples we believe most likely to help us achieve our political goals, and which will motivate constituents to lobby their elected representatives for change. This is certainly not problem-free, as Watson identifies, and her book made me reflect on the importance of weaving ordinary abortion into everything we do. But I felt her book was at its most pioneering and thought-provoking in its exploration of the issues and identities of providers, and the particular and pernicious ways in which the current abortion discussion stigmatizes them and undermines the work they do. We have yet to adequately tell the story of the doctors, nurses, and midwives who provide care to women day in, day out – some still unable to tell their own families what it is they do. A key component of the book is the identification of the ‘beneficiaries’ of abortion – the women who receive them, of course, but also their partners, who may go on to establish a much loved family with somebody they want to start a family with, the children both may go on to have, the children they may already have. But Watson also identifies another group of beneficiaries: “all the physicians, nurses, hospital administrators, and other healthcare workers who would be personally devastated to see women harmed by unsafe abortion, and who could provide this service themselves, but choose not to. Like men who benefit from their girlfriend’s choice to have an abortion, these clinicians benefit from their colleagues’ choice to provide abortion.”(192) As put by Dr Lori Freedman, physicians want both distance from abortion and someone skilled to send their patients too. But this has a sometimes considerable cost to those who provide the abortions, who carry the burden of responsibility for an entire abortion service – often leaving little space to carry out other gynaecological or obstetric practices which may bring them professional satisfaction – and become the target of various restrictions and regulations that do not apply to other areas of medical care. Watson highlights how the enthusiasm for accommodating conscientious objection to abortion within a medical practice is accepted as taking precedence over and above any doctor’s conscientious commitment to helping their patient obtain the abortion she wants. Her analysis of the framing of the doctor within the 2007 Supreme Court review of the partial birth abortion ban is superb – these doctors are not identified by medical specialty (obstetrician-gynaecologist, family physician, surgeon) but as abortion doctors, and at issue is whether they could be trusted to provide patients with details of what the partial birth abortion – itself a loaded term – would involve, that this would be a procedure they would undertake for ‘convenience’ to themselves. Watson deftly tracks the narrative of the doctor from Roe v Wade, cast as the hero rescuing the damsel in distress, to the demon of Gonzales v Carhart, where both woman and fetus needed to be rescued from the clinicians’ claws. She rightly highlights the way in which supposedly benign mandatory waiting periods enforce this view of the doctor as untrustworthy, uncaring, at the same time as belittling women. “They insult physicians – your state thinks you are so despicable that is a patient expressed uncertainty in the consent process, instead of suggesting she come back if and when she’s certain, you would herd her through for an abortion anyway.”(187-188) It was depressing to see that Ireland, in its much heralded new abortion legislation written from scratch, also opted for the mandatory waiting period and the continued criminalization of doctors in a way unmatched in any other form of Irish healthcare.
One of the abortion beneficiaries Watson identifies, an interviewee whose girlfriend ended a pregnancy while they were at college, but who has never spoken of it, or the life it has enabled him to live, comments on the need for more people to “come out”(72) about abortion. This attempt to draw parallels with the LGBT movement appears so obvious, and so tempting – particularly in the lights of the gains made on that front. But Watson is right to stress the problems of this approach – abortion is not an identity for the individual women who needs one. It is one event, usually not repeated, that may give her ownership of her own life story but which does not define her. No woman aspires to have an abortion – and on this side of the Atlantic we too are familiar with the philosophy of abortion support which runs “rape, incest, and me”(23), and not infrequently see women who say they are against abortion, but that their circumstances are different to those of the other women waiting. It explains why many of the direct beneficiaries of abortion would not necessarily be guided by that issue when it came to the polls – if it’s a service they have received, they might assume they will never need it again, and if they haven’t, they have no expectation they may need to – particularly in a climate where abortion is routinely stigmatized and exceptionalised. But for providers, not least because of the way abortion services are organized in the US – and also the UK, providing abortion care is their professional identity – and I absolutely share Watson’s view that were there to be a Will and Grace of abortion it would be providers who took center stage.
But while abortion itself as a singular event may never be an identity, there are crucial dots that must be drawn between abortion and other areas where reproductive autonomy is being eroded. I was surprised that Watson, writing from a US context where the relationship between abortion restrictions and persecution of women deemed to pose a risk to or to have harmed their fetus is more obvious than elsewhere, did not pursue this further. Paradoxically in the UK, we see support for women’s access to abortion growing at the same time as we see mounting censorship of women’s behavior in pregnancy – and indeed increasingly pre-pregnancy, including of women who have no desire or intention to get pregnant. Women of childbearing with epilepsy are now refused access to a particular drug, Sodium Valproate, unless they agree to accept a Long Acting Reversible Method of contraception and undergo regular pregnancy testing on the basis that the drug is known to be teratogenic to the fetus. It is important that women are fully informed of the risks to the fetus were they to become pregnant on this drug, but this new policy now effectively curtails women’s right to access the treatment most suited to her over the health of a fetus that does not even exist. It is particularly disheartening to see this recent development at a time when women with uncontrolled epilepsy remain among the most likely to die in pregnancy – often because they have come off medication for fear of harming their fetus. In a climate where obesity is now deemed to pose a risk not just to the fetus, but the future children of that fetus (even though the evidence for this is shaky in the extreme) women with high BMIs can struggle to persuade healthcare professionals to remove IUDs and implants to enable them to get pregnant. Although a case in 2014 seeking to establish that a woman who whose child was born with Fetal Alcohol Syndrome committed a crime by drinking in pregnancy failed, there is a relentless focus on the harms women cause their offspring by alcohol consumption. A new test is being developed in Scotland to establish whether a newborn’s first meconium can be used to accurately establish a woman’s alcohol use in pregnancy. The news of this development, which raises all manner of ethical questions about how it will be used, on whom, and what the consequences will be, was largely met with either indifference or support in a climate where fetuses are increasingly deemed to be at risk from the reckless actions of their mothers.
We may believe these initiatives are all aimed at ensuring the best possible outcomes for babies. Yet the fact that, in the UK at least, where the clear link between folate deficiency and neural tube defects in babies was first made decades ago, we have failed to fortify our flour with folic acid to improve pregnancy outcomes on the basis that we would be interfering in the diets of the entire public, not just women – shows these measures are often not driven by the desire for better outcomes but underpinned by the other social concerns such as obesity and alcohol, and the need to control women and their behavior. Which brings us back to abortion. In the final pages of her book, Watson gives us the image of the Russian Doll. “Nested inside an argument about embryonic and fetal status is a hidden argument about the proper role of women….Conflict is only productive when we’re honest about the real reasons we’re fighting. Let’s transform our political bickering into productive fighting by further unpacking the Russian Doll of abortion, and openly discussing how recent social changes are affecting people both practically and emotionally…if some abortion conflicts are largely about issues like gender, sexuality, and religion, it would be more productive to identify our true disagreements and discuss them directly.”(207)
And this is the real challenge that awaits us. Abortion discussions so often hinge on a wide range of other social tensions. A case in point is the opprobrium over sex selective abortion – where racists, feminists and anti-abortion campaigners unite in a curious alliance to crusade against a practice which largely does not exist in countries where there is not significant gender inequality – and, where it does take place, the answer is not to further restrict women’s already limited reproductive choices but challenge the misogyny that underpins and drives son preferences. Abortion is absolutely wrapped up in perceptions of good women and bad women, and nested inside that – to borrow Watson’s Russian doll analogy – good abortions and bad abortions, often also synonymous with the extraordinary and the ordinary. The role this book plays in bringing ordinary abortion to the fore, telling its story and casting the spotlight on its many beneficiaries, is invaluable to anyone involved in or looking to join the debate about abortion in the 21st Century, wherever they may be.
Director of External Affairs
British Pregnancy Advisory Service
Meredith, F. (2016, October 21). ‘The end of a life in the womb doesn’t compare with any other taking of human life’. The Irish Times. Retrieved from https://www.irishtimes.com/life-and-style/people/the-end-of-a-life-in-the-womb-doesn-t-compare-with-any-other-taking-of-human-life-1.2804888