Reviewed by Vicki Toscano (Nova Southeastern University)
Published on H-Law (March, 2016)
Commissioned by Charles L. Zelden
With this book, Johanna Schoen attempts to fill a gap in the historical narrative of legalized abortion in the United States: namely, the experience of providing abortion in the context of the politicalization of abortion after Roe. Schoen, who writes from a clear position of support for reproductive rights, tells the story of how the provision of abortion has changed through the years and the impact of this medical service on the physicians, staff, clinic owners, and patients (although she explicitly excludes Planned Parenthood from this history). In this narrative, Schoen weaves together information she has gleaned from papers held by individual abortion providers and oral history interviews with aggregate data regarding abortion and the changing political and legal context within which abortion care has operated throughout the decades since Roe. What this book delivers is a nuanced account of abortion care since Roe that is "grounded in personal stories and local histories to illustrate the lived consequences of the politics of reproductive rights" (p. 22). Schoen does not shy away from the moral complexity of abortion care, and her call for a more honest and public discussion is idealistic and admirable. However, even as her work demonstrates certain insights that shed light on the tactics of the creation of anti-abortion rhetoric, Schoen neither explicitly ties these insights together nor does she recognize the naivety in her call for open and honest communication in our current political climate. While some of her work here may be co-opted by anti-abortion forces in their drive to frame the debate around abortion, it is still, nonetheless, full of useful and unique information.
The book starts where the title promises, with the development of abortion care just after Roe vs. Wade made abortion a constitutional right and legalized abortion services throughout the country. Prior to Roe, as Schoen notes, abortion was mostly still illegal in the United States but with a widespread illegal market nonetheless. Schoen's first chapter insightfully describes the challenges and opportunities Roe's country-wide legalization presented to providers of abortion care. With legalization came more research on safer and better methods for both early and later abortions and the creation of some clinics founded explicitly on a feminist model of care. In one of her unique insights, Schoen spends time throughout the book explaining the difference between clinics established with a feminist model of care vs. those established with a medical model. She artfully demonstrates the unique issues raised for each model throughout the changing climate of the 1970s and 80s. She also discusses how throughout the 1970s, abortion providers established themselves but with extremely uneven standards of care, uneven access for patients based on geographical location, and uneven experiences for patients. Concerns around for-profit abortion providers as greedy profiteers creating unsafe "abortion mills" did not completely recede with legalization, and with good reason, Schoen points out. Nonetheless, by the 1970s, abortion had become the safest and most widely performed surgical procedure in the United States.
Next, Schoen sets out to discuss the anti-abortion response to the legalization of abortion throughout the 1970s and the effect this had on abortion providers. What this discussion highlights is that the issues, concerns, and tactics of the anti-abortion movement and their ability to impact abortion care today were founded in the initial response to legalization of the movement back in the 70s. Schoen shows that concerns over fetal research and the use of fetal "bodies" in science is not a new concern but one that dates back to the very beginning (and before) of legalized abortion care. At that time, the use of fetal remains in research was linked to the larger debates that were already occurring regarding ethical experimentation on human subjects. The result was that the accepted scientific view of pre-viable fetuses as "fetal tissue" was partially supplanted by the burgeoning vocabulary of the anti-abortion movement, the fetus as "human baby." The anti-abortion movement began to learn during this time the important emotional impact that visual images of fetal bodies could have on the debate. Further, the anti-abortion movement successfully highlighted the concern around "live births" of pre-viable fetuses as a possible result of abortion, raising the question of what counts as birth and, ultimately, what counts as life. Another important implication of this last issue that Schoen insightfully connects is how it "contributed to the establishment of live birth as a recognized complication of abortion procedures and ultimately factored into physicians' attempts to avoid procedures that carried the risk of live birth" (p. 62). This is a very real example of the way that political (and moral) considerations, rather than simply medical considerations, had direct impacts on the medical practice of abortion, which is a theme throughout this book and one that continues to be relevant today. Schoen also discusses how the challenges raised by providing abortion care, coupled with the burgeoning anti-abortion rhetoric and activities of the 1970s, had a significant impact on the abortion provider community in other ways as well. In chapter 3 she describes the creation of some of the first national organizations of abortion providers (including the National Abortion Federation, or NAF) that helped to establish communication amongst providers, encourage and enhance research on abortion methods and, ultimately, establish standards for good care in the provision of abortion by the end of the 1970s.
The next part of the book continues to contextualize abortion practice in the light of anti-abortion tactics and rhetoric throughout the 1980s. Schoen carefully recounts the choice of abortion providers, at the end of the 70s and into the 80s, to move to a new second-trimester abortion procedure known as D&E, "in which the fetus is removed, generally in parts, through the cervix and vagina" (p. 119). The procedure cut down on live births and also was a safer and better experience for the patient. On the other hand, Schoen describes how D&E took an emotional toll on doctors performing it in that it involved the extraction of recognizable fetal parts. Through mostly anecdotal recountings of physicians and others involved in abortion care, Schoen describes the willingness and necessity of the abortion provider community with NAF support in the early 80s to grapple with the moral ambiguity and emotional toll that this new procedure raised. At the same time, however, the anti-abortion movement had also begun building momentum. One particularly effective tactic was to exploit physicians' and other clinic workers own statements about their moral struggles with abortion practice. This strategy gained momentum by popularizing the accounts of some doctors who once practiced abortion and who no longer felt comfortable doing so. One such doctor became a powerful spokesperson against abortion and narrated the popular anti-abortion documentary The Silent Scream (1984), which purported to show an ultrasound image of a first-trimester abortion depicting the fetus with its mouth wide open as "the silent scream of a child threatened imminently with extinction" (p. 145). A further effect of this strategy was to silence the moral conversation for those who provided abortion care. Schoen's suggestion that this was a loss for the provider community is an important and thoughtful one. Following in the wake of the success of this rhetoric, Schoen details a similar anti-abortion strategy to recast abortion as harmful and exploitive to women. In direct contradiction to abortion supporters' belief that abortion is essential to women's liberty and health, anti-abortion forces exploited the stories of women who had abortions and regretted them or claimed they caused them serious emotional harm. As Schoen is quick to point out, the claim that abortion causes psychological harm to women has been mainly debunked and the American Psychological Association issued a report "concluding that no evidence existed that abortion caused negative mental health outcomes" (p. 282). Nonetheless, the rhetoric around abortion had been popularly recast as having negative emotional costs for women while, at the same time, abortion providers increasingly found themselves to be targets of direct action strategies and tactics that continued to place the provider community on its heels.
Schoen dedicates a chapter and a half to detail the direct action strategies employed by the anti-abortion movement during the 80s and 90s and the efforts of the abortion providers to remain resilient in the wake of these increasingly violent actions. Although this section offers nothing categorically new to the history of abortion, Schoen's focus on the practice of abortion and the experiences of providers and patients, and her use of localized anecdotal stories drive home the increasing ferociousness of parts of the anti-abortion movement during this time and the toll this took on abortion providers and patients. She also includes interesting stories of counter-action by abortion providers, including actions taken by a group of abortion providers known as the November Gang and individual stories of fighting back. Nonetheless, Schoen's history goes where it must, with the killing of abortion providers and clinic workers and the vandalizing and bombing of clinics. The debate reached a low point rhetorically too, when by the end of the 80s, Schoen says, "a positive interpretation of abortion became unspeakable, and abortion providers, who had discussed their work in the early years, fell silent" (p. 247). She describes the way televised hearings on the bill which later became the Freedom of Access to Clinic Entrances ("FACE") and its implementation worked to create a decline in "violent outbursts and blockades at clinics" (p. 217) even while its enforcement often remained uneven and problematic. Finally, she suggests that in the early 90s, as the tide of violence changed the tone of public conversations around abortion, the abortion provider community developed new strategies and tactics such as founding new organizations meant to give it a stronger voice in Washington and to re-open conversations about best-care practices, including appropriate pre-abortion counseling for patients.
In the second half of her last chapter, Schoen pivots to discuss explicitly the controversy around the medical procedure known as "intact D&E," which was recast by abortion foes as "partial-birth abortion." Developed by doctors who performed second-trimester abortions, "intact D&E" was first publicly discussed at a NAF meeting in 1992. Just as two decades before when D&E first become widely practiced, "intact D&E," which allows the physician to remove the fetal body intact rather than through dismemberment by collapsing the fetal skull prior to removal, raised a political and moral firestorm. The battle waged was partly a factual one. The factual questions in dispute were mainly about when this procedure is used, by whom, and whether it poses less risk to maternal health than traditional D&E. At this point, Schoen describes the way that both sides misrepresented the truth. Abortion providers misrepresented the facts regarding the reasons why women have abortions after the first trimester of pregnancy when this procedure might be used. Anti-abortion advocates argued that this procedure was never necessary to protect a woman's life or health and, continuing the already debunked argument regarding women's mental health problems after abortion, that it would lead to more maternal mental health problems. The culmination of this battle was the United States Supreme Court's decision in Gonzales v. Carhart, which assessed the constitutionality of a federal ban of intact D&E that did not include a women's health exception. The majority in that case, in finding the ban constitutional, embraced much of the anti-abortion rhetoric of the previous few decades, including the argument that abortion can cause mental health problems for women. In fact, the ban was discussed by the Court as in place to protect women as much as to protect unborn life. Schoen claims that the failures of this case "demonstrated the need for a new kind of pro-choice discourse--one that acknowledged the violence in second-trimester abortion and used honesty about D&E to strengthen abortion care" (p. 249). She claims this new strategy has already begun and now, "more than four decades after the legalization of abortion, the abortion provider community is articulating a vision of abortion that powerfully asserts that abortion care is a moral good" (p. 249).
Throughout this history, Schoen describes the way that the abortion provider community has attempted to respond to all of the challenges they have faced since legalization with Roe. Schoen ultimately suggests that honest and vocal engagement with the public regarding the realities of abortion care is essential to changing the political climate in which abortion is practiced. Although this idea does have merit and might even help point the way toward common ground in the continuing culture war surrounding abortion, one necessary condition for this approach to yield results is a forum for reasonable dialogue. This is not a condition that we have today. In fact, while anti-abortion direct action tactics have lessened since the 1990s, the legal attack on abortion has never been stronger or more effective. The sheer number of state abortion regulations in the last several years is unprecedented. Many of these regulations call into question the possibility of women's continued access to safe, legal abortions. Further, they are built on a framework of misrepresentation and outright lies that many reviewing courts around the country, including the Supreme Court in Gonzales, have chosen to allow. In a climate such as this, Schoen's belief that engaging in discourses of honesty that "acknowledg[e] the violence in second-trimester abortion" seems extremely naive.
In fact, Schoen's history highlights an important insight regarding effective anti-abortion rhetorical tactics that might better enable supporters of reproductive rights to find a vocabulary of protest but, interestingly, this is an insight that she fails to fully explicate herself. In decade after decade, Schoen describes how anti-abortion rhetoric is built on the same basic platform. Rhetorical success has been achieved again and again by taking anecdotal, particular, and dramatic/morally problematic outliers and representing them, often through bad science, as representative of the majority. From equating all fetal research with fetal research done on pre-viable fetuses kept alive for that purpose, to abortion doctors who "knew" they were committing murder, to patients who claim that abortion caused them serious mental problems, to a handful of doctors who, never having performed abortions, categorically claim that intact D&Es are never medically necessary, Schoen demonstrates the same pattern. Each one of these misrepresentations has supported the passage of legislation, legislation that purports to solve problems that do not really exist and to be based on scientific facts that are not really facts. This legislation comes after hearings are held where our legislators choose to believe whatever is politically expedient rather than what is scientifically supported. Then this legislation is reviewed by courts, including the Supreme Court, who pretend that it is not their job to question the factual basis upon which a regulation that impacts a fundamental right is grounded. This is the tactic that must be combated directly for abortion care to once again be about maternal health and better medical outcomes. As the next abortion case heads to the Supreme Court for review this term, making this insight explicit is crucial. The Supreme Court, in Whole Women's Health v. Hellerstedt, will soon be deciding, in part, whether a state may make hospital admitting privileges mandatory for doctors who perform abortions, even though the facts show this regulation will have no effect on health outcomes and will serve to close many abortion clinics. Hopefully, the Supreme Court will recognize that part of its job is to create conditions under which the kind of reasonable and honest dialogue Schoen calls for can flourish. In a legal system where the truth value of factual assertions upon which legislation is grounded becomes irrelevant, this is clearly an impossibility.
If there is additional discussion of this review, you may access it through the network, at: https://networks.h-net.org/h-law.
Vicki Toscano. Review of Schoen, Johanna, Abortion after Roe: Abortion after Legalization.
H-Law, H-Net Reviews.
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