Bioethics and abortion.

Of all bioethical themes, the issue of abortion has been the subject of most articles, debates, scientific congresses and public discussions. Nonetheless, this is no indication of significant advances or democratic consensus on the issue in recent years. Much to the contrary.

The problem of abortion provides very good examples of the difficulties involved in establishing a social dialogue between opposing moral stances or an independent academic perspective given the passionate and argumentative focus that characterizes writings on the issue. For someone not versed in the matter, the greatest difficulty when faced with the literature on abortion is to make out lucid philosophical and scientific lines of reasoning from the multitude of rhetorical manipulations geared at luring crowds of people into the battlefield of ideas on the subject.

In this context, providing an overview of the bioethical studies conducted on the subject is no easy task. From such a vast myriad of academic, political and religious writings, picking the most significant cases always poses the risk of unfairness. That said, I have pinpointed some ideas that characterize the current debate on the issue, presenting the arguments of their respective advocates in an attempt to draw a bioethical panorama regarding abortion.

My approach is divided into three parts. I first clarify the terminology involved and types of abortion. I then introduce comparative legislative data. The last section is dedicated to the current bioethical debate over the issue.

A semantic assessment of the concepts of abortion used by researchers would prove extremely valid for bioethical studies. The conceptual variety is proportional to the social impact of each term. Unfortunately--and this is rather obvious for any researcher interested in the subject--the choice of concepts is not unintentional. Each category carries a different weight in a linguistic war hidden behind the very word choice that can at times appear very subtle.

There is reference to therapeutic abortion being a eugenic practice, while other practices are labeled selective or racist, in an endless semantic confusion that appears irremediable to researchers. However, instead of being discouraged over this conceptual diversity, researchers must take a first step in their work on the subject and try to understand the moral premises underlying these choices. There is a certain moral regularity into such a selection.

For the most part, abortion cases can be divided in four major types:

1. Eugenic Interruption of Pregnancy (EIP): These are abortions performed for eugenic reasons, that is, where gestation is interrupted as a result of racist, sexist, ethnic and similar values. The medical procedures carried out by Nazi doctors are commonly presented as examples of EIP since women were forced into abortion because they were Jewish, gypsy of black. (1) As a general rule, an EIP abortion is carried out against the will of the pregnant woman.

2. Therapeutic Interruption of Pregnancy (TIP): This is abortion carried out for the purpose of protecting maternal health, e.g., interrupting pregnancy in order to save the pregnant woman's life. With the scientific and technological advances in medical practices these days, TIP cases are less frequent, and there are few clinical situations requiring such procedures.

3. Selective Interruption of Pregnancy (SIP): This involves abortion in the case of fetal abnormalities. As a rule, conditions justifying a SIP are those thought to be incompatible with life outside the womb, the most obvious example of which is anencephaly. (2) In Brazil, SIP eases are reviewed by the Pro-Life Division of the Ministry of Public Prosecution.

4. Voluntary Interruption of Pregnancy (VIP): In this case, the abortion is performed through the exercise of the reproductive autonomy of the woman or the couple. VIP involves a situation where the gestation is interrupted because the woman (or couple) does not wish to carry the pregnancy to term, be it the result of rape or consensual intercourse. Very often, the legal dispositions allowing VIP practices define a gestational time limit for the procedure.

With the exception of the Eugenic Interruption of Pregnancy, all other forms of abortion take into account the woman's or the couple's desire to maintain or interrupt pregnancy. For the great majority of bioethics scholars, this is a fundamental difference between the practices since patient autonomy is a major supporting pillar of bioethics theory. Thus, as regards terminology, we shall address the three last cases of abortion here for these more directly form a part of the bioethics agenda.

In many cases, Selective Interruption of Pregnancy is also referred to as Therapeutic Interruption of Pregnancy. In fact, several researchers use the Therapeutic Interruption label to encompass the differentiation made here between Selective and Therapeutic (an option by the Public Prosecution's Pro-Life Division). This semantic tradition is, for the most part, a heritage of countries whose laws permit abortion in both cases, and where there is no reason for a clear-cut differentiation between the two. However, although Therapeutic Interruption would appear to be a more proper definition in some circumstances, the label also tends to generate confusion given the gestational limits imposed by law in view of maternal health hazards or fetal abnormalities. In addition, the focus is different for Selective and Therapeutic cases: the former presents fetal health concerns as reason for abortion whereas the latter emphasizes the health of the mother. Another reason for differentiating between fetal health and maternal health as a criterion of terminology is that several authors consider Selective Interruption as the equivalent of Eugenic Interruption.

This is an interesting example of what I call "warfare terminology." The word "selective" directly conjures up the practice it qualifies here, in which malformation of the fetus makes the pregnancy undesirable for the woman or couple who then decides to interrupt it. A selection was obviously made In this case in view of the impossibility of life outside the womb or child morbidity after birth. Therefore, treating selective abortion as eugenic creates confusion about the different definitions. This is particularly true when one considers that the eugenic ideology became famous for disdaining individual will. The fundamental difference between selective abortion and eugenic abortion is that the former implies no obligation to interrupt pregnancy as a means to willfully exterminate the undesirable as was the case with the Nazi doctors. The Selective Interruption of Pregnancy results from a conscious choice by the woman or the couple.

Several authors, especially those connected with social movements, such as the women's movement, prefer to talk in terms of reproductive autonomy as opposed to Voluntary Interruption of Pregnancy. (3) In reality, the relationship between these concepts is dependent, not exclusive. Although the orienting principle of Voluntary Interruption is one of reproductive autonomy, I regard this autonomy as an "umbrella" concept, encompassing the issue of abortion along with all other aspects of reproductive health. In fact, as previously stated, the principle of respect for autonomy provides the background for most contemporary bioethical discussions.

In addition to the conceptual diversity, another interesting aspect of the style of articles written on abortion is the choice of adjectives used by anti-abortion authors to describe their moral opponents: terms like "aborter", "murderer," "assassin" and "butcher." (4) In reality, abortion clinics have been burned, and their staff assaulted by anti-abortion groups, the self-proclaimed "pro-life advocates." The aborted fetus is commonly referred to as the "innocent victim" or even "innocent child." Adjectives such as "hypocrite" or "criminal" are applied to both sides, be it the proponents or opponents of such practices. Consensus is also absent on the result of an abortion, with terms ranging from "embryo" and "fetus" to "child," "unborn," "person," or "individual." (5)

A classic, albeit isolated, example of this alluring and violent rhetoric characterizing debates on abortion is a video titled The Silent Scream produced by a group opposed to the practice of abortion. The documentary shows the reaction of a 12-week fetus (the upper gestational limit in several laws for Voluntary Interruption of Pregnancy) while an abortion is being conducted. Noteworthy is the part when spectators are invited to associate with the fetus: "This little person at twelve weeks is a fully formed, absolutely identifiable human being. He has had brain waves for at least six weeks ... And all the rest of his human functions are indistinguishable from any of ours." (6) Such productions ignore recent discoveries of neurophysio-embriology proving the impossibility of a 12-week old fetus to feel pain. (7) The idea is to encourage viewer compassion for the fetus' alleged pain and as a consequence sustain the right to life from conception, a fundamental argument of those against abortion. However, this is exactly the type of approach that creates the most difficulties in literature on abortion: the mixing of scientific argument with moral beliefs as easily as one would mix ingredients in the making of a cake. This is a common practice by both sides. The degree of delirium varies in direct proportion to passion.

If we could imagine a scale having the extreme stances on abortion on opposite ends, the graphic configuration would be as follows:

Although it grossly reduces reality to graphic language, the above chart facilitates the understanding and identification of different ideas on abortion. Among the moral extremes depicted, there is an infinity of miner variations apparently inconsistent with major principles, be it heteronomy or autonomy. Let us look at some examples.

Certain groups in favor of life heteronomy stand for life tangibility when it comes to abortion. The best example of this combination is the group known as "Catholics for a Free Choice." This movement is made up of Catholic women, followers of a Christian faith who advocate the right of women to make decisions regarding their own reproductive rights. Given their religious ties, these women work under the idealistic principles of heteronomy (life as a divine gift, not the property of individuals). On the other hand, they are also supportive of a social movement in favor of autonomy.

Another example involves political leaders known for their commitment to individual freedom and for their advocacy of individual autonomy, who take the stance of life heteronomy with regard to abortion. In Brazil, we have the case of a left-wing federal representative who has proposed a bill banning any movement towards decriminalizing abortion. Save for rare exceptions, in the moral field people do not often express the logical coherence that characterizes the works of moral philosophy. Moral choices are processed in several different ways--under the influence of family, spouse, school, mainstream media, etc.--which results in combining principles and beliefs thought to be irreconcilable. As a matter of fact, a great many people are puzzled by the moral extremes alluded to here. Few groups and social or religious movements are willing to associate themselves with either of them.

However, the effectiveness of the chart lies in its precise summary of the conflict among bioethical researchers. Many of the articles written on abortion revolve around the principles of heteronomy and autonomy. Thus, for didactical purposes, we shall refer to the proponents of life heteronomy and those of reproductive autonomy respectively as abortion opponents or proponents. This is only one way of collecting the differences across distinct groups, the purpose being to clarify the direction taken among bioethies scholars at present. In addition, the moral extremes, for their very radicalism, add heuristic properties to the analysis at hand.

The principal argument of those in favor of abortion decriminalization is respect for the woman's or the couple's reproductive autonomy, drawing from the principles of individual freedom. In bioethics, abortion is not a theme exclusively debated by activists of the women's or other social movements; the notion of individual autonomy is one of immense penetration in the context of secular bioethics. It is on their view of respect for reproductive autonomy that the proponents of abortion agree. Perhaps the best representation is Thompson's analogy in his 1971 article, "A Defense of Abortion," that likens a woman who wishes to interrupt pregnancy to someone who is involuntarily tied to a famous violinist:

"... You wake up in the morning and find yourself back to back in bed with an unconscious violinist. A famous unconscious violinist. He has been found to have a fatal kidney ailment, and the Society of Music Lovers has canvassed all the available medical records and found that you alone have the right blood type to help. They have therefore kidnapped you, and last night the violinist's circulatory system was plugged into yours, so that your kidneys can be used to extract poisons from his blood as well as your own. The director of the hospital now tells you, "Look, we're sorry the Society of Music Lovers did this to you--we would never have permitted it if we had known. But still, they did it, and the violinist is now plugged into you. To unplug you would be to kill him. But never mind, it's only for nine months. By then he will have recovered from his ailment, and can safely be unplugged from you. (8)

This metaphor triggered an avalanche of discussions and debates, with some arguing that Thompson's example would be valid only for cases where pregnancy is the result of sexual assault. For others, respect of the autonomy principle is the key element in Thompson's text.

Abortion opponents, in turn, hold heteronomy as the central issue, that is, the notion that human life is sacred by definition. (9) In bioethics, those opposed to abortion are not just people with religious beliefs. This theory is quite popular even among secular bioethicists. In fact, the life heteronomy principle runs so deep in the training of health care and legal professionals that they cannot even discuss themes like euthanasia and cloning. The search for meaning in human life beyond the mere physiological sphere is also popular in western Christian cultures.

Since proponents of abortion decriminalization find shelter in the principle of reproductive autonomy, with their opposing counterparts relying on human life heteronomy theory, the differences between the two groups are exacerbated further as the discussion of these principles deepens. While proponents gather around the autonomy value, their opponents strive to push forward the principle of heteronomy in their arguments. As the rhetoric of these opponent groups was incorporated to a bioethical approach to abortion, the discussion took an unexpected turn. Since then, opponents of abortion have been highly visible whereas the proponents constantly take a reactive stance against the arguments presented against abortion. Let us examine what this implies.

Once the human life heteronomy principle is accepted, the theorists concerned with its support are quick to look for justifying philosophical, moral, or scientific arguments, some of which are now classics on the issue of abortion. I shall analyze here two of these arguments which are so deeply intertwined that it is impossible to separate them. The first is the belief that the fetus is a human being from the moment of conception; the second is the acknowledgment of the fetus' potential to become a human person.

Sustaining the idea that the fetus is a human being from conception transfers to the fetus all social rights and achievements regarded as privileges of human beings in comparison to other animals. The first of such rights--all the more publicized by abortion opponents--is the right to life. This would mean extending to fetuses all judicial and anthropological implications of human status. For the extremists, if the fetus is a human being, any legal move towards legalizing abortion is, by definition, an impossibility (...)

The second idea--that the fetus has the potential to become a human being--has a larger following than the one granting the fetus the status of human person from conception. This "potentiality theory" suggests that the human fetus represents a possible human being and therefore cannot be eliminated. For advocates of the potentiality theory, the transformation of a fetus into a full human being is just a matter of time and, of course, evolution. Thus, in view of the fetus' future transformation into a child, with marked emphasis on the episode of birth, abortion must not be allowed. For the advocates of the potentiality theory, as well as for those who understand the fetus as a human being from conception, abortion assumes the moral and legal status of murder, and this is exactly how their advocates refer to the practice.

In view of such arguments, abortion legalization activists then take a reactive line of reasoning. With few exceptions, bioethicists supporting the right to abortion rarely make positive statements, (10) For the most part, whenever the arguments in favor of abortion drift from the principle of reproductive autonomy, the researchers' efforts are immediately geared towards deconstructing anti-abortion rhetoric, especially the two theories alluded to here. Faced with the notion that the fetus is human from conception, proponent bioethicists argue that the concept of "human person" is anthropological rather than legal and that hence it is meaningful only within a social context. The status of person is not a given, but rather the result of achievements only made possible by social interaction. Other writers argue that if the fetus is truly a person, the mother or couple willing to interrupt pregnancy is even more so than the fetus which would put the interests of the mother or couple above the interests of the fetus. (11)

Strikingly, the potentiality theory is gaining increased support among abortion proponents, as evidenced in the huge debate regarding the gestational limits within which abortion would be morally acceptable. In general, these limits are based on scientific reasoning addressed at issues such as: when does the fetus start to feel pain? When do fetal movements start? At which point would life outside the womb be feasible? However, the determining factor of whether or not a woman may have an abortion is dictated not by the evolution of fetal physiology, but by the social values assigned to each organic achievement of the fetus. Whether of not it experiences pain, has a conscience or is able to move are social values which once transferred to the fetus provide the limits within which something may or may not be done. More extreme authors argue that there is no moral difference between an embryo, a fetus, or a newborn, adding furthermore that any imposition of gestational limits (number of months) as a criterion for abortion is pure hocus-pocus. On the other hand, the argument of potentiality may admit the sexual cells of human beings to be potential human beings. Nevertheless, most pro-abortion bioethicists hold the view that some limit is needed, with birth being a marked divide: infanticide would be out of question. (12)

Despite their differences, there are a few points over which a dialogue between proponents and non-extremist opponents is possible. Both science and common sense tend to accept abortion in cases involving rape, maternal health hazards or fetal abnormality incompatible with life. (13) The conflict will resume when it is time to define the gestational limits for each of these cases. The major source of disagreement lies in the possibility of giving the woman/couple the final word on reproductive matters. The interesting thing about this problem is that countries such as Russia face a completely opposite dilemma. After introducing what they term the "culture of abortion" (given the ease with which one can procure an abortion in Russia), the authors of an article entitled "The Moral Status of Fetuses in Russia" demand the recognition of some sort of morality in support of the fetus. (14)

Thus, although quite widespread, the problem of abortion morality is historically and contextually localized. Any attempt at untying this Gordian knot has to take into account the complex moral and cultural diversity of the populations involved. Because of the legal diversity and the multiplicity of arguments in the bioethical debate at present, abortion remains a paradigmatic bioethical issue. It holds that tragic essence of moral dilemmas which represent the conflicting bottleneck of bioethics. There simply are no immediate solutions for certain moral dilemmas, and perhaps there never will be. In that case we would be left only with our search for mechanisms to ensure our coexistence in the face of differences.

Moral friends and enemies are pushed to the limit of their tolerance, a hard-to-practice virtue, for the issue of abortion brings with it a martial appeal. The fight over abortion spurs into action otherwise indifferent groups and communities who mobilize in their defense whatever physical, psychological, or rational tool available to dissuade or destroy opposing beliefs. Understanding that one can survive in a society where opposing beliefs coexist around the issue of abortion is one of the greatest challenges facing democratic societies. Extreme dilemmas, of which abortion may be the best example, defy the ability of enemies to coexist peacefully. (15)

ANIS: Institute of Bioethics, Human Rights, and Gender

Based in Brasilia, ANIS: Institute of Bioethics, Human Rights, and Gender is the only non-profit, non-governmental organization in Latin America devoted to bioethics research, advocacy and education. ANIS was formed in 1999 as a multidisciplinary team of seasoned bioethics professionals. In 2002 ANIS was included as a bioethics research institution in the directory of the Brazilian National Research Council.

The work of ANIS focuses on bioethical issues related to human reproduction, such as abortion, reproductive technologies, cloning and the Human Genome Project. Inspired by the theoretical and political contributions of feminism and human rights, ANIS conducts its activities through four major programs.

Advocacy Program

This program coordinates the political activities of ANIS. The Advocacy Program works with Brazilian legislative bodies, offering technical support and academic cooperation for the legislative debate on bioethical issues related to human reproduction. ANIS' own researchers take part in public hearings, legislative debates and draft bill appraisals to provide lawmakers with sensitive, non-partisan information.

Education Program

This program encapsulates the institutional mission of ANIS: to promote ethics. Its educational activities aim to sensitize and recruit researchers while building their knowledge. Three training workshops are offered nationwide, including workshops on bioethics and advocacy. ANIS' facilities in Brasilia include a well-equipped room for courses, lectures and seminars which are regularly offered in the form of all-inclusive scholarships.

Information Program

This is a pioneering program in Brazilian bioethics. ANIS' Information and Documentation Center is a reference resource for bioethics research in Latin America. The Information Program disseminates bioethical information throughout Brazil and is coordinated by information scientists specialized in bioethics.

Research Program

This is ANIS' main program and encompasses theoretical and ethnographic research in bioethics in conjunction with national and international academic partners. The Research Program is committed to actively engaging young bioethics researchers in Brazil while providing the basis on which the Advocacy program's activities can be developed.

* For more information, visit the ANIS website http://www.anis.org.br

This article was adapted from the chapter "Bioetica e Aborto" by Debora Diniz and Marco Almeida in Iniciando Bioetica (Sergio Costa, et al., ed., Brasilia: CFM, 1998). It was delivered as a speech in celebration of International Women's Day on March 8, 2001, at a conference entitled "Abortion and Morality" held at Brazil's Ministry of Public Prosecution. As a result, the author was fired from her position as Professor of Bioethics in the graduate program of psychology at the Universidade Catolica de Brasilia (UCB). For more information about this violation of academic freedom and freedom of opinion and expression, visit the ANIS website (http://www.anis.org.br) or contact the author care of [e-mail]/

Notes

(1.) B. Muller-Hill, Ciencia assassina: como cientistas alemaes contribuiram para a eliminacao de judeus, ciganos e outras minorias durante o nazismo (Rio de Janeiro: Xenon, 1993).

(2.) D. Diniz, "O aborto seletivo no Brasil e os alvaras judiciais." Bioetica 5(1997): 19-24.

(3.) L. Lloyd, "Abortion and health care ethics III." In Principles of health care ethics (R. Gillon, ed., Chichester, England: John Wiley and Sons, 1994) pp. 559-76.

(4.) M. Mori, "Abortion and health care ethics I: A critical analysis of the main arguments." In Principles of health care ethics (R. Gillon, ed., Chichester, England: John Wiley and Sons, 1994) pp. 531-46.

(5.) J. Finnis, "Abortion and health care ethics II." In Principles of health care ethics (R. Gillon, ed., Chichester, England: John Wiley and Sons, 1994) pp. 547-57; Video "The Silent Scream" (American Portrait Films, 1984).

(6.) "The Silent Scream," op. cit,

(7.) R.R. Linnas, The working of the brain: development, memory and perception (New York: WH Freeman, 1990).

(8.) J.J. Thomson, "A defense of abortion." Philosophy and Public Affairs 1 (1971):51.

(9.) G. Franca, "Aborto: breves reflexoes sobre o direito de viver." Bioetica 2(1994):29-35.

(10.) P. Singer, Etica pratica (Sao Paulo: Martins Fontes, 1993); H. Kuhse and P. Singer, Should the baby live ? (Oxford: Oxford Press, 1985).

(11.) J. Harris, "Not all babies should be kept alive as long as possible." In Principles of health care ethics (R. Gillon, ed., Chichester, England: John Wiley and Sons, 1994) pp. 644-55.

(12.) J.L. Bermudez, "The moral significance of birth." Ethics 106(1996):378-403.

(13.) M. Mori, op. cit, pp. 531-46.

(14.) P. Tichtchenko and B. Yudin, "The moral status of fetuses in Russia." Cambridge Quarterly of Healthcare Ethics 6(1997):31-8.

(15.) T.H. Engelhardt, Los fundamentos de la bioetica (Barcelona: Paidos, 1995).

The author is an anthropologist and the recipient of the PAHO/WHO Manuel Velasco-Suarez prize for Bioethics. She is currently co-director of ANIS, Instituto de Bioetica, Direitos Humanos e Genero (ANIS, Institute of Bioethics, Human Rights and Gender) in Brasilia.