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Dear Texas Campaign for Mothers,

Prochoice and Right to Life have become such difficult words. They have become political in their affiliation and rigid in their meaning. Caught in the middle, doctors are hamstrung, and patients are suffering at the hands of decisions no individual patient could have made. Prochoice militants have vandalized crisis pregnancy centers whose only crime has been their providing women with unexpected pregnancies with options other than termination. Right to life activists, on the other hand, have made abortion procedures difficult to obtain in situations placing maternal health at serious risk. Surely education and discussion can overcome ideology to work for the common good in an ethical, moral manner.

My intent is to provide a series of cases that illustrate the dilemma and harm that comes from e "heartbeat" law, TX SB8, enacted in Texas. However, first I must disclose my own bias. I am not a proponent of abortion. When I began my training, the first trimester fetus was a drawing in textbooks of embryology, and we understood the historical injuries and death that had been wrought by illegal, then criminal abortions. But by the time my training reached its last year, ultrasound had been widely introduced. I saw the first trimester fetus on screen, its heartbeat at 6 weeks gestation, its head and body, and budding limbs at 8 weeks, its movements at 10 weeks, and its human face in profile at 12 weeks. This was life that I was seeing, and I still regret every elective abortion in which I participated during those training years. I told myself I would never do one again. In practice, I provided women in crisis pregnancy the full range of their options rather than simply giving them the names of abortion providers. Yet, there were other cases in which various medical complications placed women in health threatening or life endangering situations. In those cases, I could provide women with immediate access to abortion providers. In sudden emergencies, I could provide that care myself. But for OB GYNs confronted with the heartbeat law, this is no longer an option.

The heartbeat law, long sought by pro life groups and in some states achieved, was followed by the overturn of Rowe v. Wade by the Supreme Court. Overturned was the 1973 court decision that decriminalized abortion throughout the United States. In the wake of this decision, it will become possible to charge physicians with felonies even if the pregnancies they terminate are performed for medical rather than elective circumstances. At this time, even without the threat of criminal prosecution, physicians have self-restricted their practices. Here are some example  

A patient presenting to the emergency room with profuse, first trimester bleeding is denied an indicated d&C, because a fetal heartbeat is detected. It doesn't matter that she's been bleeding a week and over that time her normal hemoglobin of 14 has dropped to 10. It's very likely to drop lower, but because it hasn't and because she is not in shock, no one will perform a d&c. She is instead told to wait.  

A similar patient presents with bleeding in the first trimester, a hemoglobin of 7, shock, and an intact heartbeat. The law requires that she wait two hours before her d&c and sign extensive consents. The doctor discovers that the OR personnel will not assist him until the two hours are up.He begins volume replacement and waits for a type and cross for blood products he can transfuse while he waits and she bleeds.

A patient presents at 19 weeks with sudden rupture of membranes. Ultrasound reveals a heartbeat and almost no amniotic fluid around the baby. The cervix is soft and dilated one centimeter. The physician informs the mother that the low volume of amniotic fluid will, if it remains low and the pregnancy progresses, result in pulmonary hypoplasia (lungs that do not grow with the baby), a lethal condition. He also informs her that waiting can result in infection and septicemia. But she no longer has the option of medical termination. The patient is told she must wait for infection that would justify termination.

A specialist has spent the day with patients referred from generalist OBGYNs. Today the specialist has seen a patient who's sonogram has revealed a baby with anencephaly, a condition in which the upper brain is not present. The specialist has also seen a woman whose baby has trisomy 13 and another with trisomy 18. Then there was the couple who are both carriers of the Tay Sachs gene; their baby has two copies and therefore will display Tay Sachs. All of these conditions are lethal for the fetus. Termination is denied in all cases. They must therefore carry these children with lethal anomalies to term while knowing their babies will not survive and that they as mothers will face all of the risks associated with the third trimester and delivery at term.

Another specialist has just seen a patient referred by her cardiologist. The patient has mitral stenosis, meaning that her cardiac output will remain fixed and her heart unable to manage the increased demands that will take place in labor and immediately after delivery. She is at risk for dying in childbirth, but her abortion is denied. The day is not over. In the next room, the specialist sees a poorly controlled juvenile diabetic whose vision and renal function are deteriorating. A continued pregnancy increases her chances of diabetic blindness and renal failure severe enough to indicate dialysis.

You may have noticed that in all of these circumstances, the physicians determined that there was no "immediate" indication for pregnancy termination under the law "as they understood the law". That's because these laws are written by legislators rather than physicians. As such their overly vague language has left room for interpretation and left doctors at risk for serious legal consequences for doing what should be done in medical circumstances. Notice that the law does not make an exception for rape or incest.

Once more I want make a point of my bias. I am not a proponent of abortion. But I am a proponent for the patient and the doctor patient relationship. The case illustrations I've provided are not theoretical or imagined. These types of decisions have been made. Yes, we need sensible abortion laws. The "any abortion goes, even into the late second and entire third trimester" is completely wrong. But so is the other extreme, because it hurts patients and denies them needed care in medically indicated circumstances.    

- A Texas Doctor who cares

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