Human Nature: Science, Technology, and Life.

Safe, Legal, and Early

My buddy Steve Waldman has a new idea for building consensus on abortion. He calls it "safe, legal, and early."

I get to call him my buddy for two reasons. One is that he's a good guy. The other is that there aren't a lot of people willing to seriously talk compromise on abortion. So we'd better stick together.

I like his idea. I don't think it stands on its own. But it fits a larger common approach: abortion reduction.

Waldman thinks a timing approach is different and better because later abortions destroy a more developed and therefore more fully human fetus. "Success would be measured on the basis of moving abortions earlier in the gestational cycle—even if that conceivably means more overall abortions," he explains. For example, "abortion reducers would likely oppose making RU-486 readily available on the grounds that it could lead to a dramatic growth in what is technically an abortion. But if the goal is have fewer late abortions, then promoting RU-486 makes great moral sense."

Actually, pro-choice advocates of reduction support RU-486 precisely for Waldman's reasons. Any woman who uses RU-486 has chosen and is going to get an abortion. RU-486 just makes sure the abortion is an early one. The reduction framework doesn't capture this benefit. The timing framework does.

But the timing framework has two problems. One is that conceptually, it's too complicated. A few years ago, I tried it out on some pro-choice thinkers who are pretty good at assessing political messages. My version was almost word-for-word the same as Waldman's: moving abortions earlier in gestation. (I tried a later version of it here.) They squinted politely. The backward-in-time idea, while logical, was a bit hard to get across in a pithy way, they explained. And less of a bad thing is easy to understand. But a bad thing in smaller bites? Without the "less" part, it's not particularly compelling.

The other problem is that people won't take the more-but-earlier-abortions deal. Yes, they prefer earlier abortions to later ones, as Waldman's poll data show. But those data say nothing about a trade-off for more abortions. So earlier timing isn't a substitute for reduction. It's an add-on.

In fact, the timing approach logically fits the reduction framework. A nine-week abortion is better than a 12-week abortion. A six-week abortion is even better. But eventually, this trajectory takes you all the way back before conception. That's not an abortion anymore. It's birth control or abstinence. In other words, it's reduction.

I'll tell you where I really like Waldman's idea. It's a good answer to abortion-delaying restrictions. Waldman notes:

Parental notification also sounds reasonable if your goal is reducing the overall number of abortions. But these policies may have a secondary effect: increasing the number of abortions that happen later. The 2006 Guttmacher survey found that among women who said they wished they could have had their abortions earlier, the most common reason they cited for delay was that it took a long time to make arrangements. Therefore, efforts to reduce the number of abortion clinics, cut off government aid to women who want abortions, or otherwise delay the decision may reduce the number of overall abortions but also make it more likely that those abortions that do occur will happen later. According to the Journal of the American Medical Association, a requirement in Mississippi that a woman wait 24 hours between realizing she's pregnant and an abortion decision led to both a decline in the overall number of abortions and a rise in abortions performed after 12 weeks.

He's totally right about that. It's immoral, from an intelligent pro-life viewpoint, to impose restrictions that simply delay abortions, adding days or weeks of fetal development to what is already a tragedy.

But for the same reason, let's be careful about imposing such restrictions on a timing basis. Under Waldman's proposal, for instance, "Medicaid funding would be generous for first trimester abortions, minimal for second trimesters, and non-existent for the third." That sounds good. But suppose you're just past your first trimester. A second-trimester abortion is considerably more expensive than a first-trimester abortion, and now we've taken away your anticipated means of paying for it. Good luck raising the money from family and friends while your fetus develops and the eventual abortion becomes that much more awful.

I liked Bill Clinton's idea: safe, legal, and rare. I like Waldman's idea, too. Barack Obama has a task force working on such ideas. Safe, legal, early, and rare is a good place to start.

Plan B and Personal Responsibility

Good news in the fight against teen pregnancy: The FDA is making to it easier for young people to get morning-after pills.

Here's the FDA's announcement:

On March 23, 2009, a federal court issued an order directing the FDA, within 30 days, to permit the Plan B drug sponsor to make Plan B available to women 17 and older without a prescription. The government will not appeal this decision. In accordance with the court's order, and consistent with the scientific findings made in 2005 by the Center for Drug Evaluation and Research,  FDA notified the manufacturer of Plan B informing the company that it may, upon submission and approval of an appropriate application, market Plan B without a prescription to women 17 years of age and older.

The New York Times warns that Plan B won't solve the problem:

Contraception advocates have pushed for easy access to Plan B for girls and women of all ages because the longer a woman delays in taking the medicine after unprotected sex, the more likely she will become pregnant. Eliminating doctors from the transactions, it was hoped, would lead to far fewer pregnancies and abortions. Indeed, advocates once predicted that widespread and easy access to emergency contraceptives would cut the number of induced abortions in half and slash teenage birth rates. But young people in the United States have so much unprotected sex—one in three girls under the age of 20 will get pregnant, with 80 percent of the pregnancies unplanned—that Plan B has been little more than a sandbag on an overtopped flood wall. Even women who are given the medicine free often fail to take it after having unprotected sex. "This is not going to be a cheap cure to the unintended pregnancy epidemic in this country," said James Trussell, director of the Office of Population Research at Princeton University.

Trussell has made the same point before: Emergency contraception has

not reduced unintended pregnancies in America or anywhere else that has introduced it. There is so much unprotected sex you would have to use so much emergency contraception to make a dent. ... It is not a magic bullet. If you want to seriously reduce unintended pregnancies in the UK you can only do [that] with implants and IUDs.

Why implants and IUDs? Because you don't have to think about them. They bypass the most common cause of what we erroneously call contraceptive failure: our own failure to use contraceptives properly and consistently.

I agree that using implants to bypass human failure is the most effective way to prevent unintended pregnancies. But that's no excuse for tolerating our failure in the first place. Emergency contraception, taken promptly after sex, can be (though you shouldn't rely on it) a magic bullet. But bullets don't work unless you fire them. Technology requires human agency.

Cecile Richards, president of the Planned Parenthood Federation of America, makes precisely this point about the FDA's decision: "Providing birth control, including emergency birth control, to young women helps them make responsible decisions and avoid unintended pregnancy."

The FDA hasn't solved the problem of unintended pregnancy. It has given you one more means to solve it. Go get your emergency contraception, now. And while you're at it, ask about an implant, so you won't have to count on a last-minute pill to bail you out. The responsibility is yours.

Drugstore Choirboy

The movement to stamp out birth control appears to have taken an ominous turn. Until now, women with contraceptive prescriptions were just being turned down by individual pharmacists. Now they're being turned down by whole pharmacies. Refusals from individuals behind the counter have "resulted in pharmacists being fired, fined or reprimanded," reports Rob Stein in Monday's Washington Post. "In response, some pharmacists have stopped carrying the products or have opened pharmacies that do not stock any." Pharmacists for Life International names seven pharmacies that have signed a "pro-life" pledge and says others are doing the same.

It's not clear how many of these proprietors object to birth control per se and how many are abstaining because they think emergency contraception is abortion. Stein points out that in some states, the only legal way to refuse a prescription for emergency contraception is to abstain from offering contraceptives generally.

What's the reaction from pro-choicers and bioethicists? Here are excerpts from the Post story:

1) "I'm very, very troubled by this," said Marcia Greenberger of the National Women's Law Center, a Washington advocacy group. "Contraception is essential for women's health. A pharmacy like this is walling off an essential part of health care. That could endanger women's health."

2) "Why do you care about the sexual health of men but not women?" asked Anita L. Nelson, a professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA. "If he gets his Viagra, why can't she get her contraception?"

3) "If you are a health-care professional, you are bound by professional obligations," said Nancy Berlinger, deputy director of the Hastings Center, a bioethics think tank in Garrison, N.Y. "You can't say you won't do part of that profession."

4) Critics also worry that women might unsuspectingly seek contraceptives at such a store and be humiliated, or that women needing the morning-after pill, which is most effective when used quickly, may waste precious time. "Rape victims could end up in a pharmacy not understanding this pharmacy will not meet their needs," Greenberger said.

5) "We may find ourselves with whole regions of the country where virtually every pharmacy follows these limiting, discriminatory policies and women are unable to access legal, physician-prescribed medications," said R. Alta Charo, a University of Wisconsin lawyer and bioethicist. "We're talking about creating a separate universe of pharmacies that puts women at a disadvantage."

Let's take these objections one at a time.

First: "Walling off" women's health care? Beware dramatic metaphors from lawyers. There is no wall. You bring your scrip to the pharmacy, and the guy at the counter says, "Sorry, we don't stock contraceptives." That's annoying and, in my view, stupid. But nobody's walling you in. Your burden consists of finding another pharmacy.

Second: Why Viagra and not contraception? Because some pro-lifers view hormonal contraception as potentially lethal. I don't share their anxiety about this theoretical risk to an early embryo, particularly when the alternative, in the event of pregnancy, is a high likelihood of fetal killing. But you can't blow off the argument by assuming that contraception should be covered because it's more important than Viagra. The whole point of the argument is that you're looking at it backward: The fact that contraception is more consequential than Viagra is a reason to be more wary, not less, of distributing it.

Third: "Professional obligations" to provide all health care? Actually, doctors and hospitals draw moral lines around their practices all the time. This doctor won't pull the plug; that one won't do abortions; this other one can't in good conscience collaborate in your faith-based treatment plan.

Fourth: Humiliation? Sorry, but part of true equality is brushing off people who don't respect you. If the guy behind the counter won't sell birth control, he's the one who should be embarrassed, not you. Walk out, and don't come back.

Fifth: Whole regions where pharmacies won't stock contraceptives? Come on. Only seven have even signed the "pro-life" pledge. It's true that abortions have been driven out of rural counties. But politically, the resistance to birth control is nothing like the resistance to abortion. A pharmacy that won't stock contraceptives looks pretty silly.

Greenberger does make a good point about wasting women's time when, as in the case of morning-after pills, speed is essential. And Stein's reporting suggests the abstaining pharmacies aren't making their policies clear enough. If they won't do this voluntarily—by posting them, for instance—the law should make them do it. If I were writing the regulations, I'd draw up a big, fat, standardized "We don't stock birth control" notice, complete with a 24-hour toll-free number that will direct you to the nearest pharmacy that has what you need.

But I wouldn't force pharmacies to sell birth control if they don't want to. In particular, I dread Charo's suggestion that providers should be compelled to offer "legal" drugs. One of this country's greatest achievements is its separation of legality from morality, so that individuals can hold themselves to a higher standard, as they see it, without forcing it on everyone else. This is the principle many pro-lifers have rejected as they press for abortion bans to "teach" the immorality of killing fetuses. Happily, some have shifted their energy from attacking abortion clinics to setting up "alternative" pregnancy centers. It's a shift from violence and harassment to exhortation and, at worst, deceit.

So, please, don't tell moralists they have to do or sell whatever's legal. If you do, you won't like what happens to the law.