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[Dr. Alan Guttmacher:] I'm Alan Guttmacher, an obstetrician/gynecologist.

I feel very strongly that a man trained in modern medicine cannot carry out

the high quality of performance because of the restrictive, restrictions imposed

by our very archaic abortion laws, and I feel they must be changed.

[Dr. Frank Ayd:] I'm Dr. Frank Ayd, a psychiatrist. I am opposed to any liberalization of abortion laws,

especially for psychiatric, social, and economic indications.

[Richard Lamm:] My name is Richard Lamm. By vocation I'm an attorney.

By avocation I'm a member of the Colorado House of Representatives.

I was chief sponsor two years ago of Colorado's

new liberalized abortion law, and I will act today as the moderator.

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[Narrator:] Welcome to the exploration of concepts and controversies in modern medicine,

one of a series of programs dedicated to examining the uncertain,

candidly recognizing that much of today's teaching is necessarily based upon opinion,

and that the opinions of eminent physicians in a given field vary widely.

The National Medical Audiovisual Center believes that openly airing

such opposing views is a basic responsibility of medical communications.

The Honorable Richard Lamm, state representative, state of Colorado,

will act as moderator of this presentation.

[Mr. Lamm:] I think one of the problems dealing with the subject of abortion,

and I think this is at least one thing that we can all agree on,

is the problem about in what category, in what terms, and what discipline

should the subject be discussed in?

Some people say this is a strictly medical problem.

Other people I've heard say it's strictly a legal problem.

Many people are beginning to think it's perhaps a sociological problem,

a public health problem.

There are many disciplines which lay claim to an interest in the subject of abortion.

I think that there is an agreement even among a lot of people

that it may be a little bit of all of these disciplines, but there again

that doesn't solve the problem because then each profession continues to say,

well, it's more of my problem than it is of those other disciplines.

Without solving that problem, let me give you just a brief summary of what happens

in a state that does liberalize its abortion law.

Colorado liberalized their abortion law by,

it was signed by the governor on April 25th, 1967.

We are a state of two and a half million people

and there is approximately 35,000 live births a year in Colorado.

Previous to the signature of the new law there was approximately

50 abortions, hospital abortions performed in Colorado in a year.

In the first nine months after the passage of our law, there was 140 abortions

performed in Colorado hospitals, and in the calendar year 1968 there was

476 abortions performed. The grounds ofthese, that total 616 abortions,

the grounds were about 55 percent under the mental health provision of our law.

There was approximately 26 percent of these abortions were performed on non-residents

of the state of Colorado which generally is about, approximates the other medical care,

being a state like Colorado drains a great deal of western Kansas, eastern Utah.

We have, uh, the abortions were performed on, generally on people

that make up a cross-section of our community. 

One of the things that was seen was is that the lower economic groups

have now had a lot more access to abortion than they had ever had under the previous law.

Fifty percent of the abortions were performed on

single women, 40 percent were performed on married women, and 10 percent on divorced women.

Now, to try to discuss what problems there are in the subject of abortion,

to try to decide whether this is the right, whether this is the end product, 

whether Colorado's experience is the end result or whether or not it has gone too far, 

or whether or not we in effect have not gone far enough, we will have other panelists,

and we will turn to Dr. Guttmacher.

[Dr. Guttmacher:] I think that the medical audience realizes that

there are seven additional states out ofour 50 that have liberalized their laws,

from my point of view not broadly enough, but nevertheless eight of our states

out of 50 now have more liberal laws. The old law of course in practically all states

was that abortion could be done purely and simply and only to preserve

the life of the mother, and from my point of view that is much too restrictive.

You must remember that when these laws were framed, medicine was a very different thing.

Most of the laws date from about the 1820s and '30s. 

At this time there was no anesthesia, there was no antisepsis, there was no transfusion,

and carrying out an abortion must have been a hideously painful, and I should think a dangerous procedure.

Now, since then medicine has made magnificent progress,

and abortion in hospital can be performed with extraordinary safety.

I know in my rich experience, which goes back in medicine in some 40 years,

I've never seen a death after therapeutic abortion, and I think that it's fair to say

that it is one of the least dangerous operations.

Actually we have excellent statistics from Czechoslovakia, from Hungary, 

on a million consecutive legal abortions, and there were 25 deaths.

That's 2.5 per hundred thousand operations.

So I think we can say that this is a very safe operation. Now, in addition to its safety,

medicine now I think can pay much more attention to the whole personality of the individual.

We can relax because most of our killers have disappeared:

pneumonia, various infections, and we can now become more than just kind of carpenters.

I think we can see the personalities' totality,

and from my point of view, abortion can contribute tremendously

to the happiness of the woman involved, and very often to the family constellation.

[Mr. Lamm:] To give his viewpoint on the subject, Dr. Ayd.

[Dr. Ayd:] Well, I think several points

have already been made which warrant thorough discussion.

My first point would be of course that abortion means that a human life is being taken.

Now to declare that any individual's life, at any time from the moment of conception,

is devoid of value in my opinion is a judgment that no man

has the right to make, and to end an individual's life is murder,

committed because it has been decided that he's no longer a human being in need 

of help and protection, but merely an object whose worth is measured according to

whether or not his continued existence or his destruction is expedient for someone or the nation.

As Honorable Lamm has pointed out, whenever an abortion law

is liberalized, there is an immediate and significant increase in the number of

therapeutic abortions performed, but I think also what must be stressed,

that regardless of how many legal abortions are performed, there's absolutely

no evidence that this in any way affects the rate of illegal abortions.

Furthermore, Dr. Guttmacher has pointed out the progress in medicine and quite properly

stressed the advances that have been made which make surgery in general

much safer than it used to be, but I honestly believe that also it must be stressed

that therapeutic abortion is, as the British Medical Journal just simply

pointed out on December 28, 1968 in an editorial, it is not a simple operation.

It does carry its hazards. Its safety depends on the surgeon performing

the operation and even the method of termination that is employed.

Admittedly, Dr. Guttmacher's absolutely right when he says that the mortality rate

associated with therapeutic abortion is relatively low, but the morbidity rate

depends on the skill of the surgeon performing the termination of pregnancy

and also on the method of termination. Accurate statistics coming out of

England for example, where very fine records are kept, would indicate

that the morbidity rate varies from one to five percent,

depending primarily on the method of termination used, but I would point out

that you do have hemorrhage, you do have perforation of the womb,

sometimes requiring secondary exploratory abdominal surgery as a result,

so that it's not an innocuous operation. 

But also as a psychiatrist I would stress one very, very important aspect of this problem.

Technically it is true, we can empty the womb of the baby, but we cannot scrape the idea

of the baby out of the mother's mind, and therefore there are going to be women

who while in the early stages of pregnancy and being emotionally upset

would be inclined to destroy the infant within their womb.

Subsequently, although the infant has been removed by whatever termination method is used,

the idea of having had a baby in her womb is still in her mind, and that's not easily

eradicated, and subsequent feelings of guilt and things of this sort are real.

We psychiatrists see them and we have to contend with them.

[Dr. Guttmacher:] Dick, I don't know whether I'm allowed to to question some of the things Frank said,

but we're old friends, so I think he won't mind. 

In the first place, to him abortion is murder.

I'm no murderer, and I've done abortions.

To me it's quite different than shooting even a man in warfare. 

To me these are undifferentiated cells which have the potential for being a human being,

but to me this baby is not a human being until born, and I am not willing to let it go that all doctors agree

that this is murder because I daresay of the group listening to me, or to us,

a certain proportion, perhaps I think the largest number, will think it's not murder.

So I think you have to define this processaccording to your own intellectual point of view,

and perhaps your own social and religious background,

and in the second place, I think that the psychiatric sequelae of abortion...

this can be challenged. This is Dr. Ayd's experience.

I daresay that he has perhaps had patients who, perhaps because of religious affiliation,

who have more feelings of guilt than perhaps most of the most of the rest of us.

Now we did a study at Mount Sinai, on our ward patients who are largely Puerto Rican,

and Marcus and Peck published a study on 50 consecutive abortions done at Mount Sinai,

therapeutically for psychiatric indications. We had one patient of the 50

who developed an acute psychosis about three months post-abortum.

This lasted about three months and apparently she made a satisfactory recovery.

As far as they could determine, and perhaps their study was not as profound 

as perhaps Dr. Ayd would like, it they could find no evidence of psychiatric sequelae.

So that I think we, there are areas ofdisagreement, this thing is not nearly

so easy to analyze as perhaps Dr. Ayd and I both make it.

I see it from one point of view and Dr. Ayd sees it from an entirely different point of view.

[Mr. Lamm:] I would like to ask you both

what you would write into the law if you were dealing,

what kind of law would you propose to deal with the problem of abortion?

[Dr. Ayd:] Well, before I answer your question, sir,

I think that in order to keep this dialogue going in a meaningful way for the audience

that I should make two comments about what Alan has said.

Number one, this study that he referred to of only 50 patients,

I'd have to have more data as a scientistbefore I would accept or reject

the validity of the findings. Number two, although it is true, I am a Roman Catholic,

I'm not opposed to abortion just on religious grounds.

In fact, the majority of the patients that I'm called on to treat 

are not Catholic, and still I see feelingsof guilt and so forth.

But, he also raised I think one of the crucial questions and that is, is the fetus a human being?

Now I admit that many abortion supporters say that the fetus

is nothing more than a blob of protoplasm, nothing more than that,

but I don't think that they honestly recognize their own contradiction.

Now, if the fetus is not a human being, what is it that's damaged in the early weeks

of its experience by a viral infection such as rubella, by drugs,

chemicals, x-rays and so forth, which isused to justify abortion?

If the fetus is not a human being, why are so many physicians and scientists

spending millions of dollars and countless hours trying to develop a vaccine for rubella,

trying to devise ways of avoiding birth defects, trying to develop an artificial placenta,

trying to fertilize the ovum outside the body in a test tube

and by artificial insemination and genetic engineering and genetic surgery,

to enable man to improve the mere and remote descendant that he may have.

Now furthermore, in this country, if the fetus is not a human being,

then I must ask the question, why does the United States Food and Drug Administration caution against,

or in some instances prohibit, the administration of certain drugs in the first three months of pregnancy? 

[Dr. Guttmacher:] Now I can answer that, because...

[Dr. Ayd:] May I finish please? 

[Dr. Guttmacher:] I thought you had.

[Dr. Ayd:] No, I have one other point that I'd like to make and that is, it, to my mind,

to say that a fetus is not human is sheer nonsense. 

Dr. Guttmacher was a fetus, I was a fetus, you were a fetus. 

You see, our existence began this way, and for someone to terminate it,

if someone had terminated the fetal existence of any one of the three of us,

we wouldn't be here on this panel today. So that the fetus is a human being.

I think it's semantics to say that human life doesn't begin

until implantation or until the third monthor the sixth month or until a baby's born.

What constitutes humaneness or humanness?

[Dr. Guttmacher:] Well, I agree with you for once, about this:

I think that a sperm is a living potential human being, I think an egg is a potential living human being.

I think nothing is changed by the process of fertilization.

These were living cells before fertilization, they become, continue to live after fertilization.

But they are potential human beings.

This is where you and I differ. I think that human life, potential human life

begins at the moment of fertilization. It actually precedes it.

Now what I think is that you're not, I was a fetus to be sure, but I was a potential human being

until I was born, and that's where you and I differ, and no matter how much

we argue we're not coming to a common area of agreement.

[Dr. Ayd:] Well, I'll agree that it would be

very difficult to come to a common area of agreement. I will agree that the sperm

is a living cell and so too is an ovum, but the genetic composition of a sperm

is different from the genetic composition of the ovum and it isn't

until you have fertilization that you now have a unique human being that never

existed before and will never exist again and after all, the ovum only contributed half

of a genetic or chromosomal makeup of that fertilized...

[Dr. Guttmacher:] But that is a unique cell, too.

[Dr. Ayd:] No, no, it's not though.

[Dr. Guttmacher:] The sperm is a unique cell. Every sperm has a different chromosomal makeup.

[Dr. Ayd:] Precisely. But it only has half of any other cell in the body

and so does the ovum, but when you have a new human being,

every cell, until they're differentiated again into ovum or sperm,

has a complete chromosomal complement, not a half. 

Now, I mean, to say that this sperm is a potential human being, I think genetically at least

you're completely erroneous, and that it is misleading to say this...

[Dr. Guttmacher:] You have half a human being then, you'll grant that?

[Dr. Ayd:] No, because it can become nothing but sperm until it actually fertilizes an ovum,

then you have a new human being.

[Dr. Guttmacher:] I think we're splitting hairs.

You and I differ in the fact that I think that a fetus is until birth is a potential,

you think a fetus is actual as a human being immediately after fertilization, 

so let's agree on that and let's go on.

[Dr. Ayd:] All right, fine.

[Dr. Guttmacher:] We're losing a lot of valuable time.

[Mr. Lamm:] I would then be interested, both doctors, to, uh, at your viewpoints on what should be the indications

of therapeutic abortion when you're dealing in the realm of law,

and that to me is the problem right now, because medical indications only

designate a certain stage of medical learning at a certain point in history

and yet when you try to write these things into law, you have at least in

Colorado, one hundred legislators, only one of whom is a doctor, trying to decide

what is good medical practice, and this is very difficult. 

I would like to ask you, what would you see to be a model abortion law, or dealing with the subject?

[Dr. Ayd:] Well, in dealing with the subject my answer immediately would be that I live in a pluralistic society.

I'm perfectly willing to accept the law that is now on the books,

which permits abortion to save the life of the mother. 

I frankly, at this moment, deny that there are any psychiatric indications that justify

liberalization of the abortion laws. After all, psychiatry has made progress,

just as surgery and medicine has made, and it would be a rare pregnant woman,

psychiatrically ill, who could not be carried to term safely

with the modern psychiatric therapies that we have. Now, once you get out of the psychiatry and

the medical indications, you're talking in terms of social and economic indications.

If we're going to have abortions done for social and economic reasons,

then I think we're in for very dangerous waters and as a matter of fact,

I confess that most of the so-called psychiatric indications which have

justified up to 70 percent of the abortions done in your state, and in fact in California,

and even in the state of Maryland from which I come, have been done for alleged

psychiatric reasons, they're called reactive depression. Until the laws were

liberalized I'll tell you we never had so many reactive depressions, all right?

Now in fact these are socio-economic indications, not strictly speaking

psychiatric indications. Now what I also must stress is that

the evidence we already have from the United States and from England is that

the minute you liberalize the abortion laws, women think that they are entitled,

that they have a legal right to abortion on demand, and this puts pressure on the

physician and I'll illustrate that. Suppose the physician prescribes

an oral contraceptive or inserts an intrauterine device and this woman becomes pregnant.

Now she comes back and accuses him and says, "You're responsible for this.

Do something about it." These emotional pressures are going to be to abort this woman.

Now also there's been something that was unforeseen when the laws

were liberalized in Colorado and in California and in Maryland, and that is

that we now have an unwritten rule which goes, "If in doubt, abort,"

because if one allows the pregnancy to go on, this may subsequently be used

as grounds for a malpractice suit against the physician. If I may go back from the

socio-economic and we'll take up the other indication, namely the question of

a suspected fetal abnormality. This puts the physician in a very difficult position

because he must now decide how many normals he's going to sacrifice

to prevent the birth of one abnormal baby. Now this is one reason why physicians

in general are not too in favor of abortion.They find it repugnant, and if you

actually check the figures in your state and in California and in Maryland,

what is coming out is that the majority of the abortions are being done in a few hospitals

by a relatively small number of physicians. The majority of obstetrician-gynecologists

are not performing abortions any more than they did before the law

was liberalized, and a great majority of them are doing them what would still be

considered valid medical indications.

[Mr. Lamm:] Turn to Dr. Guttmacher.

[Dr. Guttmacher:] I think we must liberalize laws

because the current situation is highly discriminatory,

both in regard to legal and illegal abortion. 

In New York there are five times as many therapeutic abortions done on the private services

of hospitals than on the clinic services. Theoretically then, the private patient

is five times as ill. This is ridiculous. In the second place, anybody knows that

$700 will buy a safe abortion in Puerto Rico, and if you don't have $700

and you only have five bucks, your chance of having a safe abortion is extraordinarily hideous.

We have a million illegal abortions estimated in the United States,

and what I want to see is to give poor people, people who don't have the money

and the influence a decent break, and I think we have to do this by liberalizing

our laws and spelling out for the time being what are those indications quite clearly.

Now, I agree that abortion should be done for the preservation

of life or health, mental or physical. I agree that abortion should be done

in cases of proved sex crime. I agree that abortion should be done when there is

grave likelihood of the fetus being born either malformed or retarded.

Furthermore, I think that any woman who has had four living children should have the choice

as to whether or not another pregnancy is gonna be an asset to the family constellation.

Who can make this judgment better? A doctor, a lawyer, a legislator?

No! The woman herself is in the position to make that decision.

I further feel that any woman who's 40 years old should have the choice as to whether or not to remain pregnant.

I agree with Plato in his Republic, who thought that any woman of 40 or more

should be aborted and by that time she certainly is mature enough

to make the proper decision. I think that any woman who is physically

or mentally incapable of caring for a child should be aborted if she wishes it,

and I think that any girl of 16 or less who is illegitimately pregnant should be

aborted if she desires it, because I can'tsee that that's a constructive experience

for either the girl or a healthy environment for the child to be born in.

[Mr. Lamm:] Dr. Guttmacher, let me ask you this: Do you think that the fact of

the statistics that were just presented by Dr. Ayd with regards to the large

number of abortions performed under psychiatric grounds, do you think number one,

that this needs explanation, and if you do would you care to comment?

[Dr. Guttmacher:] No, I think it simply shows a sense of humanity in the medical profession.

We're not rigid psychiatrists, we're not saying a woman's going crazy because

she's not aborted, we're simply saying that this woman

doesn't have the emotional maturity, the emotional background to be a good parent,

or we feel that this pregnancy is going to be emotionally destructive on her,

something that's not going to add to her happiness or to her growth

or to her personality and therefore it can be eliminated. We're looking at psychiatry

not from the point of view of insanity and sanity or psychoses, but looking at it

from a much more general point of view. What is the growth likelihood of the

personality due to the pregnancy? That to me is a much more important concept.

[Mr. Lamm:] You have a rebuttal to that?

[Dr. Ayd:] Yes, I would simply say that right away we're putting

some people into the classification of second class citizens and that if

someone is unwanted this is justification for terminating their

existence and that if someone is likely to be a burden either on the mother

or on society, that this is justification for terminating their existence.

Now, my feeling is that if that philosophy, which is an anti-light philosophy in my opinion,

permeates the United States, then the weak and the dependent and the aged

have a lot to be afraid of, because if your existence is going to depend on

your quality, and not on the inviolateness of your life,

not on its intrinsically determined value, but just on that judgment as to

whether or not you're going to be a burden either to a mother

or to society, and I think many, many people in the United States today

better start worrying, because they're in trouble.

[Dr. Guttmacher:] I don't think that follows logically at all,

but go on with your...

[Mr. Lamm:] Let me ask you, along the same line though,

we had evidence before the Colorado Legislature that all we were doing was bringing up

what was obviously a long-existing medical practice,

for instance in the 1960 issue of Obstetrics and Gynecology, there was a statement 

showing the indications performed, abortions were performed

in the 367 major hospitals in the United States,

and neuropsychiatric, rubella, all of these reasons were already being performed,

and so we thought all we were doing is bringing up to law what medical practice

had been doing for years.

[Dr. Ayd:] Well that doesn't necessarily make it right.

I know this is exactly what you've done and I have no question about

the sincerity of your motives at all, but I insist, you see, that we've got to decide

whether or not human life is sacred, because if human life isn't sacred

nothing else is. We've got to decide whether you, or I, or any other person

in this world has the right to decide who shall live and who shall die.

[Mr. Lamm:] I think on that, I see that

we are getting a summary. I wonder if each of you would like to

give just a very short summary of your positions again?

[Dr. Ayd:] Well, I am opposed to abortion

and I would stress that so far in England and the United States,

abortions have been done primarily for so-called psychiatric indications

on young, single girls, you see, who certainly are not socioeconomically

classifiable as disadvantaged.

[Mr. Lamm:] Dr. Guttmacher.

[Dr. Guttmacher:] I would say that the main difference

is that I have just as much reverence for human life I believe

as anyone who opposes changes in the abortion laws. I want them changed

because I revere human life. I want it to be strong and healthy and happy.

[Mr. Lamm:] Let me say in summary that in dealing with the problem,

at least from the point of the legislator, we have certain problems.

Number one is, should abortion be performed? Number two, by who, where and with whose consent?

These are some of the problems

that we deal with in the legislature as opposed to the medical. Thank you.

[Narrator:] We thank Dr. Alan Guttmacher, Dr. Frank Ayd Jr., 

and the Honorable Richard Lamm for their interesting analysis of a critical problem

in patient care. In subsequent programs we shall continue to record equally

significant concepts and controversies in modern medicine.

The opinions expressed on this program do not necessarily constitute endorsement

by the Department of Health, Education, and Welfare, the Public Health Service, or its constituents.

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