Intact dilation and extraction

In my medical practice and experience, late abortion is frequently a life-saving procedure. The legislation just passed is a cynical political exploitation of intense private grief and anguish.

Intact dilation and extraction (also known as D&X or DNX) is a late-term abortion procedure, incorrectly identified by the non-medical, politically motivated term "partial-birth abortion". Any medical description of it is necessarily gruesome, hence the feeding frenzy of the right to talk endlessly about it, show pictures of the procedure, and scream about how inhuman it is. It is not a pleasant subject, but again, it should be reinforced that this procedure, like all later term abortions, is almost universally done on wanted pregnancies that have become medically problematic. It would not be done simply because some woman decided that she was bored of being pregnant.

Medical description
The procedure is was one of several options for aborting a child in the last 4 months of pregnancy when the cervix itself has to be dilated to allow for the passage of the head, the largest part of a fetus or baby. The cervix is dilated either with drugs or manually with laminaria. The fetus is located within the womb and the head of the fetus is reduced in diameter usually by puncturing, though sometimes by a crushing action of forceps The "partial birth" terms comes from the fact that in some pregnancies, it is easier to do a breach birth, and pierce the head after the feet are "delivered".

Other procedures are no less gory, and "inhumane" in this abstract, fear-mongering sense. Dilation and Extraction (notice well the missing 'intact') is essentially the same procedure.

Medical uses
This procedure was the preferred medical choice when the infant's head was abnormally large, generally due to a terminal birth defect called "hydroencephalitis". A second condition where this procedure is preferred is a state where the woman for whatever reason, has a risk of internal bleeding or clotting issues. Because the fetus is removed intact, there are no small bones that could tear or perforate the uterus. These are medical conditions, and a woman who is facing such situations should be legally allowed to use whatever procedure her doctor feels is right for her particular case.

Partial-birth abortion
As with most things in politics, how you name something affects how voters see it — or that is the perception of the politicians. "Death Tax" instead of "inheritance tax", Freedom Fries instead of French fries, "pro-life" instead of "anti-abortion", "pro-choice" instead of "pro-abortion", and in this case "Partial Birth Abortion" instead of D&X. It's easier to remember, and it presents a picture in the minds of the gullible that the procedure is done while the baby is being born so "if you had only waited a moment, the baby would have been born alive and safe".

However, the term partial-birth abortion is not medical and does not actually refer to any specific procedure, and arguments have been made to the USSC that it could refer to many procedures. When "partial-birth abortion" is used in general rhetoric, people get frothy and start screaming about the horrors of abortion, which in and of itself is uninformed but does not create any true problems. However, when legislators get frothy and scream about the same thing, they use the same non-medical term which does not apply to any actual procedure, and make that vague, non-medical concept into a law, leaving the medical practitioners dumbfounded, asking "OK, but what exactly did you just attempt to outlaw and how exactly does that affect my attempts to help this woman before me".

Partial-Birth Abortion Ban Act
In 2003, the United States Congress, acting with the better part of 1/4 their brains intact, decided it was time to stop those evil doctors from doing this horror show of a procedure, 'cause the doctors clearly do not know what they are doing and are just getting a kick out of crushing the heads of tiny babies. So, they wrote a law saying "partial birth abortions" were never to be done, ever, under any circumstances, regardless of what you, Mr. Doctor, think is best. We know more than you, 'cause we are lawyers, and salesmen, and BORN FETUSES, and of course we've all had pregnancies go wrong and know that's never the choice we made.

In a run-up to the ban, partial birth itself went "on trial". The experts chosen (and how witnesses were questioned) shows the Religious Right's emphasis on the gore and sensationalist aspects. The majority of "experts" at the trial and the hearing on the ban were pro-life, thanks in no small part to a Republican-held majority in both chambers. The trial and the associated Congressional hearings were a well-known kangaroo court allowing time to only one side, the Republican anti-choice lobby defining who got to speak and for how long, rather than an open hearing where anyone who had a legitimate need to speak (like real doctors who really use this procedure) being able to address them.

The ban itself says "Any physician who, in or affecting interstate or foreign commerce, knowingly performs a partial-birth abortion and thereby kills a human fetus shall be fined under this title or imprisoned not more than 2 years, or both." Of course, PBA is not a medical term, so doctors have no idea if they have or have not just broken the law.

One of the more amusing parts of the whole Kangaroo Court is that Dr. Hern, one of only two men at the time to do non-emergency late term abortions, was not allowed to speak, despite asking several times to offer an opinion. Instead, only one doctor was a witness, and while he was an OB/GYN, he did not by choice perform abortions. Yet from that one testimony from the medical community, and 10 or 20 from the religious community, Congress decided: Rather than being an abortion procedure that is embraced by the medical community, particularly among physicians who routinely perform other abortion procedures, partial-birth abortion remains a disfavored procedure that is not only unnecessary to preserve the health of the mother, but in fact poses serious risks to the long-term health of women and in some circumstances, their lives. As a result, at least 27 States banned the procedure as did the United States Congress which voted to ban the procedure during the 104th, 105th, and 106th Congresses.

Note the sensationalist "selling point" words in the reasons for outlawing this procedure: "(1) A moral, medical, and ethical consensus exists that the practice of performing a partial-birth abortion... is a gruesome and inhumane procedure that is never medically necessary and should be prohibited." Again, other than medical issues that a doctor would consider on any specific woman, what is the "humane" and "non-gruesome" distinction between a partial birth and a typical non-intact extraction? That's what I thought.

Challenge to the ban
Gonzales v. Carhart came before the Court on April 18, 2007. For the first time in the history of abortion in the Courts, the Court found that Congress had the right to 1) define medical procedures regardless of the medical establishment's actual views or procedures, and 2) legislate an action that does not put the best interest of the woman first. There was no medical exception, no exception for life, and there was no exemption for ambiguity.

The Court held 5 - 4 that the law as written was Constitutional, but in her dissent, Ginsberg disagreed, arguing that Congress' "findings" that D&X was never safe or healthy were actually written and presented by unqualified or suspect doctors with little experience in abortion medicine, and no experience in D&X. On the contrary, when full evidence was taken and read next to this unqualified testimony (as it was at the District Court level in the cases leading to Carhart), D&X did possess particular health benefits for particular cases, which she cited.

After the Court ruled, Dr. Hern wrote an editorial for Slate.com saying, in effect: This law is ambiguous. It does not reference any specific or particular procedure, yet outlaws one anyhow. Because of that, lives will be lost. I had a patient present to me at 3 am, in full distress. The procedure I chose was what I felt was the best at that moment. I did not stop to call a lawyer or judge to ask if the procedure I would use was a vague "partial birth" procedure or if it was legal. I saved her life. I would do it again.

Some thoughts
Any abortion is the killing of a potential baby. This is the reality the mother faces when choosing to end a pregnancy. Virtually all "terminations for convenience" (another right‐wing phrase) are performed in the first 2 months, before the fetus has developed into a baby, and while it's safe for the mother to have a medical or surgical abortion.