Donald Trump and other reactionary Republicans are telling blatant lies about late-term abortion—repeating, in lurid detail, mythical narrative of brutal doctors and heartless women deciding to terminate a healthy fetus in the ninth month based on a flippant change of mind about becoming a mother.
Women are stepping forward in response to tell their own painful and tragic stories of abortion later in pregnancy—but even that allows the extreme right-wing to define the playing field. Professor Katie Watson is redirecting the conversation.
Watson teaches bioethics, medical humanities and constitutional law at Northwestern University’s Feinberg School of Medicine; is a Board member and Chair of the Ethics Committee of the National Abortion Federation and a member and Bioethics Advisor to the National Medical Council of the Planned Parenthood Federation of America; and previously served as Senior Counsel for the ACLU of Illinois’s Women’s and Reproductive Rights Project. She’s also the author of the award-winning book Scarlet A: The Ethics, Law and Politics of Ordinary Abortion, which the New York Times called “revolutionary.”
Watson argues for shifting the focus away from the 1.3 percent of abortions that occur at or after 21 weeks—and back toward what she calls “ordinary abortion,” which includes most of the 89 percent of abortions that occur during the first 12 weeks. She talked to Ms. about “extraordinary abortion,” the politics of respect and how we can smash stigma.
What do you mean by ordinary abortion?
The vast majority of abortion that happens in the United States is not being discussed in the public sphere. In both the abortion advocacy world and the abortion opposition world, we are talking about the most extreme examples—so advocates for the abortion right, very reasonably, will share with you stories of extreme youth or people who have been raped or terrible fetal anomalies, and people who oppose abortion will share cases of what they perceive to be abortion abuse.
But it seems like none of us are talking about the vast majority—what I refer to as “ordinary abortion”—the 74 percent of women who say that having a baby right now will be very disruptive to their family, their work, their education. The 73 percent who say they can’t afford a baby right now. The 48 percent who say they don’t want to be a single parent or to have a baby with this partner. The cases we discuss the most are the ones that happen the least.
As a bioethicist, I found that very striking and troubling. It’s rare to get good public policy when you don’t understand the facts. In medicine and bioethics, we always start with the facts and move our way up. So I hoped to capture this epidemiology with the phrase “ordinary abortion,” and then reason from there. From life as lived, rather than life as theorized.
How does our focus on “extraordinary abortion” distort public policy? How might focusing on ordinary abortion lead to new public policies?
The focus on extraordinary abortion on both sides plays to the politics of sympathy. Focusing on ordinary abortion could shift us to the politics of respect. The politics of sympathy say, “you should be able to get that abortion, because I agree with you,” putting the listener in the position of judge. “I am sympathetic, therefore you get to exercise your constitutional rights,” or “I’m sympathetic to that particular fetus, therefore you do not get to exercise your constitutional rights.”
Focusing on the ordinary moves toward the politics of respect—which is, “you are an adult with capacity and you are a moral agent and I may or may not agree with your choices, but they are your choices to make.” That has been an oddly hard argument to make and hold onto, and so even the pro-choice feminist advocates in public are being drawn to the politics of sympathy. I don’t understand why a woman who is in college, or a woman who already has three kids and can’t feed a fourth, or a woman who doesn’t want to stay with a particular partner, or a woman who does not want to have a baby this year, is not “sympathetic.” There is a failure of imagination and identification that I would like to re-engage with and recapture.
Why do you think people follow a politics of sympathy rather than a politics of respect for abortion?
There is a pro-natalist assumption—a procreative assumption—that women must have babies, should have babies and ought to want to have babies. So when a woman is pregnant and does not want to have a baby, there is still an assumption that this is an exceptional case.
People just don’t understand the incredible rate of unintended pregnancy. The average American woman today has 1.8 children. A fertile woman who wants to have only two children and no abortions, and have regular sex throughout her reproductive years, has to prevent somewhere between 16 and 29 pregnancies. That’s a real uphill battle.
Contraception has gotten a lot better, and yet we still have 2.8 million unintended pregnancies a year. Forty-five percent of our pregnancies are unintended; 42 percent of those women and couples choose to terminate that unintended pregnancy, and 58 percent choose to continue the pregnancy. So the framing of abortion as this exceptional act is inaccurate.
If everyone who has had an abortion since Roe were living, that would be 25 percent of all adult American women. That is not an abberation—that’s part of our fertility control. When you asked why we can’t get to a politics of respect, I think we do not understand how much women need abortion to control their fertility.
What are the policy implications of centering ordinary abortion over extraordinary abortion?
Treating abortion as health care. Like all other health care. That means it’s covered by Medicaid, it’s required to be covered by private insurance, it expands the pool of health care providers who provide that service. Most private OBGYN doctors are trained to do abortions; why can’t they do them in their offices? What are the institutional and structural barriers, even though they are completely willing and trained, from them just doing this as part of your ordinary health care, right?
Tell me about the title of your book, Scarlet A.
It refers to the secrecy about abortion. Why isn’t the fact that abortion is common, common knowledge? The “Scarlet A” stood for adultery in Nathaniel Hawthorne’s novel, but abortion is our era’s Scarlet A—that many people are doing it and no one wants to be associated with it. That silence has created a storytelling vacuum, that those who oppose abortion have been very happy and quick to fill.
You talk about the prevalence paradox. What is that?
The prevalence paradox explains how something that is so common can be perceived as deviant. People who have, provide or are associated with abortion face discrimination. So people engaging in abortion behaviors do not want to disclose they’ve done so because they do not want to face discrimination. Then something that is common can continue to be perceived as deviant, and marked for discrimination. The discrimination and stigma lead to the silence, which perpetuates the discrimination and stigma. If those 1 in 4 women who have had abortion just walked around with a button saying, “I had an abortion and you know I am a completely terrific colleague, neighbor and mother and whoever,” you just couldn’t bad mouth them as a group in the way that they are bad mouthed.
So speaking about ordinary abortion is a way to combat stigma?
Absolutely! To dismantle it. In the book, I compare it to coming out in the gay rights movement. It’s harder to espouse abstract bigotry when you realize you’re talking about your brother. People may still hold bigoted opinions, but they will have to be integrated with relationships.
Many people have responded to the rollback of abortion rights by encouraging women to publicly tell their stories to break the silence. What do you think about websites like Shout Your Abortion and the Abortion Diary Podcast?
I think those are absolutely terrific. Yet what I am talking about is actually something different. Public storytelling can reach a lot of people so it’s very powerful, but if you already have a mindset about an issue and a publicly told story by a stranger contradicts your mindset, you may discount that story. You may not listen to it to start with, and then even if you do you may discount it to fit your pre-existing framework. There is a lot of social science and psychology research that documents how hard it is to displace those frameworks. But when someone I actually know, like, and respect tells me their story that contradicts my frameworks, I’m gonna have to work harder to integrate that new information. It’s harder for me to dismiss them as a person.
Public storytelling is hard, but in some ways private storytelling is even more challenging because you’re disclosing to someone you’re going to stay in a relationship with. Is this going to make Thanksgiving weird for next year too? Engaging with nameless, faceless strangers is different—valuable—but there is incredible power in talking to people you actually know and like, and those are the ones we are actually sometimes more afraid to talk to.
So those are the kinds of conversations that you’re trying to get people to have?
Yes, my goal is to help equip people for private conversations—dialogues, not monologues—about both abortion opinion and abortion experience. I think they are both valuable. We make assumptions that when someone says they are pro-choice, we really know how they feel about abortion. Or when they say they are pro-life, that we really understand how they feel. But the political and public conversation becomes so toxic and polarized and the private conversation is so stigmatized that we are scared to even inquire with people who we know and like. We might ask them their opinion on 200 other things and still think, oh but you can’t talk about abortion. And I just reject that, I refuse.
How has the Trump administration affected your thinking about abortion?
It has crystalized my understanding of the abortion issue as a Trojan horse for a regressive anti-woman agenda. Regressive forces are using abortion and false concern with prenatal life as a way to bring us back to the 1950s in terms of women’s rights. But it would be wrong to paint all abortion opponents with the same brush. I think the Trump administration’s cynical deployment of religion and concepts of conscience has been depressing for people who actually care about true spectrum conscience protection—conscientious provision of services as well as conscientious refusal to provide service. And I should add that it’s odd that discussions of conscience only include health care providers, when there are always two consciences in the room—every day patients are engaged in conscientious access of services, as well as conscientious declining of services too.
The Trump administration recently issued a domestic gag rule prohibiting health clinics receiving federal Title X funds from referring pregnant patients who want abortions for abortion care, and it changes the rule that required non-directive pregnancy counseling, including on abortion, to one that permits but no longer requires non-directive counseling. Does this rule violate medical ethics?
Yes. These rules are in clear and deep violation of medical ethics. Informed decision making requires the clinician to give patients the full spectrum of risks, benefits, and alternatives of any potential provision of care. Title X clinics do not provide prenatal care, so a pregnant patient is going to be referred elsewhere no matter what. To limit those referrals to prenatal care is an attempt to steer poor women into delivering babies they did not want. That is a violation of the ethical guidelines around informed decision making, and it creates a horrible conflict of interest for clinicians who don’t want to engage in malpractice, but also don’t want their patients to lose the Title X services their clinics provide.
It is also a shocking violation of medical ethics for a clincian working in a non-religious setting to not provide a pregnant woman with non-directive counseling—in other words, to try to steer her personal medical decision toward the provider’s values. That is the worst of a bygone era of paternalism, and it’s stunning to see it codified into HHS regulations.
Allowing these rules to stand would delay poor women seeking abortion, which increases the risks of abortion and the financial costs to the woman, in clear violation of the medical ethics principle of non-maleficence.
Why is it important to talk about the ethics of abortion?
I think that feminists and people in the pro-choice movement have become gun shy about talking about the ethics of abortion. It can sound like moralizing. The idea that privacy in one’s choices means that you don’t have to explain yourself, which I agree with, means that we have lost our ability to articulate the moral defense of and moral reasoning behind the choice to use abortion. That has allowed opponents to claim moral ground while we often are on policy or law ground, and that’s a conversational mismatch. What I try to do in my book is help us remember how to make the ethical arguments in support of abortion and better understand the ethical arguments against it in order to be able to communicate with our neighbors more clearly.
I think many pro-choice people believe abortion is not merely morally acceptable, but it is a significant moral good. Our current political climate makes being called pro-abortion sound like an epithet, but pro-choice people have to transcend that and say their underlying values out loud. Legal, safe, accessible abortion supports freedom of conscience, self-determination, gender justice and economic justice, and it respects families as emotional networks of love and care rather than mere instruments of the state or products of biology. These are some of the reasons a pro-choice person might think abortion is not “a necessary evil” or an act that’s just morally acceptable. I think including the ethical arguments for abortion as a moral good in our public debates and private exchanges would be refreshing. And hopefully productive? Let’s find out.