Post-Abortion Depression and the Ethics Of Truth-Telling
By Paul D. Simmons, Clinical Professor, School of Medicine, University of Louisville
What is the moral significance of the fact that some women experience deep depression following an abortion? Does that prove that no woman should have an abortion since such a powerful and negative experience is sure to follow? Is the negative emotional response both evidence of the immorality of the practice and of the threat to the health of the woman? Or is the truth to be found in some other interpretation of the facts?
The question has generated a great deal of medical research and media attention in recent years. Those opposed to abortion and seeking a legal ban to the practice are convinced that stories of women`s depression is evidence of its threat to women`s health and/or of its immorality. The question is important and should not be summarily dismissed. After all, the issue is a concern for women`s health. Presumably all Americans support those social policies that serve best to assure optimal health and access to healthcare for women facing threats to their personal well-being. If it could be shown that women are nearly certain to be emotionally traumatized to the point of severe depression following an abortion, the case for making abortion illegal could be made on grounds of medical indicators.
The issue was addressed in vastly different ways in two different publications that recently crossed my desk. One was a weekly newspaper from a religious press; the other a news journal from the world of science and medicine. I read them both with regularity (almost religiously). Interestingly, each carried an article dealing with depression as an aftermath of abortion.
The religious journal dealt with the issue under the heading "Abortion providers may face lawsuits for withholding information."[i] The article was from Religious News Service (RNS) reporting that a Virginia anti-abortion organization was planning to sue doctors who perform abortions on behalf of women who have had a pregnancy terminated. Theresa Burke, Executive Director of the American Life League, argued that the suit would make the complaint that the provider had withheld information that a woman might experience depression, alcoholism, and infertility after the abortion. It is a scary thought that a woman who simply wanted to terminate a problem pregnancy might wind up with such severe personal problems!
The problem, argued Ms. Burke, is that women have a right to information that might affect the decision regarding terminating a pregnancy. That is true. The law requires that women provide "informed consent" before the procedure is done. The requirements of both professional ethics and the law are that all information of "material benefit" be provided a woman contemplating any medical procedure. The problem, according to Ms. Burke, is that physicians do not emphasize the dangers of abortion sufficiently to deter a woman`s choice of that option. Far from being "a safety net," she says, "[abortion] is a safety hazard." Thus, she adds "there are millions of potential clients who might seek redress through the courts."[ii]
Ethics and Medical Indicators
The question of interest to both ethics and medicine is whether abortion carries a predictable risk with regard to severe depression, alcoholism, and infertility. In other words, does having an abortion jeopardize the health and well-being of a woman in these three ways, as Ms. Burke contends? And are physicians morally, if not legally, required to make such a strong case about such negative outcomes that no woman would go through the procedure?
The arguments regarding alcoholism and infertility can be dealt with summarily and succinctly. The truth is that a woman who has an abortion will encounter alcoholism only if she is an alcoholic. The relation between abortion and alcoholism is coincidental not causative. Abortions simply do not make one an alcoholic. Alcoholism is a complex psychological, biological, and personal problem that defies simple explanation. Certainly one cannot settle for the simplistic and misleading notion that women who have an abortion will become an alcoholic. There are no studies that show any direct connection.
As to infertility, it is true that some women will become infertile as a consequence of certain types of abortion. The threat of infertility is especially true when women turn to back-alley practitioners or are forced to seek out an illegal abortion. Even worse, women may die if not given proper medical care.[iii] One of the advantages of chemical abortifacients, e.g. RU-486, is that they reduce the need for invasive procedures and thus assure greater safety for the woman. The cases of infertility traceable to an abortion procedure is statistically terribly small. Infertility is far more likely to be caused by sexually transmittable diseases (STDs) such as chlamydia and gonorrhea in those who are sexually active with infected partners, than to having an abortion.
Arguments based on the relation of abortion to alcoholism and infertility can be virtually dismissed as major threats to the woman. They belong to the category of scare tactics, not serious moral arguments built upon solid statistical findings. Where abortion providers are competent and the facilities are sterile, the woman can be relatively certain that her health will be preserved and her capacity for childbearing will remain intact.
The concern for emotional or mental consequences requires more attention. Those who oppose abortion rely on the fear of mental anguish, depression or mental illness as a way to deter women who are considering abortion. But is that a matter of fear-mongering or accurate assessment of the medical data?
The August, 2000, issue of Archives of General Psychiatry carried the results of a clinical study of nearly 1200 women randomly chosen at three abortion clinics in New York. Over one-third obtained a first-trimester abortion and completed psychological assessments 1 hour before, and 1 hour, 1 month, and 2 years afterward. They were, for the most part, unwed teenagers and young adult women. There were few Hispanics in the group and this was a first abortion for most of them; for some, this was a second or third experience.
The significance of the study is what was found regarding the psychological aftermath of having an abortion. The findings provide research data and thus a firmer foundation for ethical argument than the anecdotal stories so often used as to whether an abortion is psychologically harmful. What the study found was that abortion was not psychologically injurious for the vast majority of women. The overall mental health of these women showed no decline after an abortion.
However, about one-fifth of the women experienced "substantial depression" within the two-year follow-up. Interestingly, the report goes on to note that this rate is comparable to what would be expected in the general population among women ages 15-35, even without having an abortion. Post-traumatic stress disorder, which often appears in victims of rape and sexual abuse, was reported in 1 percent of the women, a rate which is actually lower than that for women in the general population.
Another measure dealt with how the woman felt about her decision. Most women expressed satisfaction and reported no regrets. However, the group reporting dissatisfaction increased over time. After a two year interval, between 16 and 19 percent of women indicated some sense of regret and/or mild depression. Again, that is close to the percentage of women in that age group that would be expected to go through some degree of sadness or depression even without an abortion.[iv]
Statistics, Ethics and Abortion
Several things seem reasonably obvious based on these two reports. One is that the opponents of abortion have very little, if any, statistical backing for the claim that there are dire emotional consequences to women who have abortion. No physician who provides adequate informed consent procedures to women prior to the procedure need fear a successful legal challenge from Ms. Burke and the American Life League.
The relation of abortion to depression was also confronted during the Reagan administration. U.S. Surgeon General C. Everett Koop, a devout evangelical Christian, was charged with preparing a study of the personal impact of abortion on women. His report said that data did not support the argument that abortion should be legally banned to protect the mental health of women.[v] He had gathered material from the Centers for Disease Control, the National Institutes of Health, and elsewhere. Dr. Koop knew that President Reagan wanted evidence against abortion and felt some pressure to find in his favor. Further, Dr. Koop`s personal moral position was antagonistic to abortion on demand. But his report maintained the objectivity and concern for truth basic to his medical professionalism and his oath to preserve the integrity of his office. He could not and did not recommend the President attempt to restrict abortion on grounds of its threat to the woman`s mental health. His conclusion happened also to correspond to findings by the American Psychological Association.[vi]
In spite of Koop`s definitive study, the accusations and scare tactics by those opposed to legal abortion never go away. Anti-choice groups think they have found an issue that serves their purposes of attempting to overturn Roe v. Wade or to deter women from terminating a problem pregnancy. These are apparently desperate but false arguments by groups who want to dissuade women from abortion no matter what the facts may support.
There are anecdotal stories of women who have had severe depressive reactions to an abortion they experienced, however. I am not inclined to doubt the truth of some of these stories. Even if the stories cannot be verified, however, they are consistent with what we know actually follows a certain percentage of cases as the New York study showed.
Two things should be borne in mind when assessing this information. One is that many women who go through live childbirth have also had a severe time of mental stress, called post-partum depression.[vii] The experience may be so severe as to require medical intervention or clinical treatment for psychosis. The nation was stunned by the tragic story of Andrea Yates who killed her five children whose ages ranged from 6 months to seven years. Each was drowned in the bathtub of their comfortable suburban home. Andrea was suffering from post-partum psychosis, a severe emotional and psychological reaction to physiological and emotional changes from childbirth, the stresses of care for children, and other factors. Andrea had never had an abortion. She accepted motherhood and its responsibilities. But her depression following childbirth was not an experience unknown to medical science.
The fact is that any number of women will experience some degree of depression following childbirth, or an abortion. Arguing against abortion because some women have experienced depression ignores the fact that married women also face that possibility when they are happily planning their family. It is hardly accurate to place the blame on abortion.[viii]
Second, some of those who experienced sadness, remorse, or depression (only mild cases were experienced by those in the research group) may have a chronic emotional problem. In other words, they have been through episodes of depression prior to ever becoming pregnant or having an abortion. Such stories have nothing to say about the abortion experience as such but indicate a persistent pattern in the woman`s life and the status of her mental health.
Third, it is reasonable to expect that women will often have "second thoughts" about their decision. Women facing a problem pregnancy often struggle with the alternatives: to birth or not to birth; to abort or not to abort. People are creatures who do their best to think through significant decisions they must face. But the human capacity to imagine the future and how we will think some time down the road is terribly limited if not impossible. Typically, we second guess ourselves. "What if" I had chosen to have a baby as an unmarried woman? "What if" I had insisted we get married? "What if" we were already settled and ready to start a family? The questions can go on and on. It is a normal and entirely predictable response to common human experiences, including abortion. Life being what it is, we can also be sure that many women who brought unwanted pregnancies to term also wondered at times, "what if I had had an abortion, instead."
Ethics and Pastoral Care
Finally, some assessment is required of the consequences to a woman who faces the harassment and harsh judgmentalism of that outspoken minority who are so adamantly opposed to abortion no matter the reason. A campaign of constant moral badgering can result in or exacerbate feelings of unworthiness and low self esteem on the part of women who are targeted. Insofar as such feelings contribute to the experience of depression, the woman is being victimized by those who claim the moral high ground. Gary Bauer, of the Family Research Council and a candidate for Republican presidential nominee (2000), declared that the objective of his group was to make women feel so much shame and guilt that they simply would never resort to abortion.
When those around us whose opinions we highly regard and whose approval we deeply desire give only judgmental condemnation, we are far more likely to feel shame, guilt, and remorse. People can be made to feel guilty about even the most innocent of actions, from one`s style of dress to the color of their eyes. Church-going women who have had abortions are likely to keep silent about their experience unless they sense an open attitude and supportive environment from the pastor and others at church. Even then they will likely keep the experience private since there is no way to be sure the word will not circulate among unfriendly critics.
Every sermon that condemns abortion absolutely or "in no uncertain terms" drives women further into isolation and the possibility of unwarranted feelings of guilt. Sadly, women are only too much in touch with the moral climate in many churches which strongly condemn abortion no matter the circumstances. That is hardly an environment in which a woman can feel a sense of acceptance and forgiveness. Little wonder that Christian women who have abortions rarely feel free to talk about it in church circles. They felt good about their decision, but do not feel their religious community is a supportive group.
Ministers in their role of pastoral caregivers are a vital link in conveying the grace and forgiveness of God to women having a difficult time following an abortion. A sensitive and understanding counselor can enable her to set the experience in the wider framework of her life and the context of her faith and knowledge of God`s love and mercy.[ix] The church has an opportunity to be the church, a community of love, mercy, and support to those whose experience cries out for some insight into the compassion of God. It is not God who condemns but people who do not understand, or who have never gone through the agony of decision making in which one`s entire being is on the line.
Christians should not be among those who misrepresent facts in order to pursue their own moral agenda. Rather, they should be among those who filter through the rhetoric to discover the person who has been deprived of love, denounced by the unloving, and condemned by the judgmental. That person should be the object of our love and ministry of supportive compassion. There is no moral victory in holding women who have had an abortion up to ridicule.
The ethics of journalism is also at stake when reports are made about major moral issues in medicine and society. Religious News Service (RNS) carried only the arguments of the anti-choice group that was not only condemning abortion but misrepresenting the statistical data. No group or person that is knowledgeable of the various arguments in the national debate about public policy and abortion was interviewed or asked to comment on the charges being made. Thus the article gave a jaundiced view of an extremely important topic. It might well be that there were women readers who trusted the editors of the journal and the news service to provide fair and trustworthy information as they confronted a problem pregnancy. We can grant the legitimacy of holding strong opinions against abortion on demand. But those arguments should be presented truthfully. The Christian regard for truth and the integrity of individual decision-making requires nothing less.
The central insights by which Christians live are that God calls us to be ministers of love and mercy and that the church is to be a community of support and forgiveness. The church can choose to be a minister of healing and acceptance or a major barrier to healing and the processes of grace it is called to encourage.
Endnotes
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[i]"Abortion providers may face lawsuits for withholding information," The Western Recorder(Middletown, KY), Sept. 5, 2000, 9.
[ii] Ibid.
[iii] P. G. Stubblefield and D. A. Grimes, "Septic Abortion," New England Journal of Medicine, 1994 (331) 310-314, point out that infection and other medical complications associated with abortion remain the most serious threats to the health of women throughout the world. Such complications occur primarily in places where abortion is illegal or where there is no access to trained providers. By some estimates, more than 100,000 women in developing countries die each year from abortion-related complications. Even where abortion is legal, complications and death may occur if access to trained personnel and appropriate facilities are denied.
[iv] Science News, August 10, 2000, p. 117 summarizing the report on the New York study carried in Archives of General Psychiatry (August, 2000).
[v] See "A Setback for `Pro-Life` Forces," in Time, March 27, 1989.
[vi] Ibid.
[vii] See Laura J. Miller, "Postpartum Depression: Linking Evidence and Experience," JAMA, Feb. 13, 2002, Vol. 287: No. 6, 762-765.
[viii] See Sandra Glahn and William Cutrer, "After the `Choice`: For those Facing Post Abortion Syndrome," on-line at www.creeksidebible.org.
[ix]See Karen Lebacqz, Professional Ethics: Power and Paradox. (Nashville: Abingdon, 1985), 132.
