I'm thickening my skin, because I know without a doubt that this column will generate significant hate comments from impassioned individuals on both sides of the abortion debate. Still, I hope you’ll at least do me the privilege of reading all of my words (trust me, if I offend you, keep reading; you’ll soon smile as I offend those holding the opposing view), and in the privacy of your own thoughts, consider some of the points.

“Pro Choice?” A 2013 Gallup poll tells us that roughly three quarters of Americans oppose pregnancy termination during the 2nd trimester, and only 14% favor abortion of 3rd term fetuses (and these are often supported only “to save the life of the mother").  In fact, 79% of Pro Choicers object to 3rd trimester abortions. As a result, only 1.3% of all abortions performed in the U.S. occur at or later than 21 weeks (a normal pregnancy is 40 weeks). These views fly in the face of the argument that abortion is primarily about “A Woman’s Right to Choose.”

Come on…  At its heart, the issue of aborting a healthy, developing fetus is not  about the mother's “choice.” The real ethically challenging question at the core of this often highly volatile and tremendously emotional debate is, When Does Life Begin?

“Pro Life,” Except in Cases of Rape and Incest? Whether or not you agree, any reasonable person can understand the argument made by those Pro Lifers who argue that “life begins at conception." But, a 2011 Gallup poll showed that a whopping 59% of Pro Lifers support fetal termination when the pregnancy is the result of rape or incest.

Wait… what?

So life begins at conception. And, therefore, abortion at any time is reprehensible (at best) or a mortal sin (at worst), a clear act of the intended murder of an innocent baby. Provided that the conception is by mutual sexual consentAnd not the result of sex with a parent, sibling, or first cousin.

(I recently asked for an explanation from a deeply religious colleague who harbored this view. He confidently explained that “such pregnancies are an abomination in God’s eyes, making termination acceptable, even preferable.” His assured tone wavered significantly when I respectfully asked how he (or any human) could be so certain of what God considers an abomination, let alone whether God might also consider the killing of any innocent unborn child an abomination.)

Come on… 

Again, The real ethically challenging question at the core of this often highly volatile and tremendously emotional debate is, When Does Life Begin? Not our interpretation of When God Says It's OK to Destroy a Life.

What Does This Have To Do With Patient Empowerment?

In a word: Everything.

We physicians must be patient advocates, including advocates for pregnant women under our care. And the silent babies developing in their wombs? They're also our patients. Now, I won’t argue here for either side in this particular debate. (Note:  I haven't shied away from arguing a controversial issue concerning my patients, such as demanding rights for patients with advanced dementia to die with dignity).  On this hot topic, what I offer to patients (both women and fetuses) are the medical facts that may be of considerable importance in an honest discussion of the partially-scientific-partially-philosophical-partially-religious question of When Does Life Begin?

This question is particularly relevant now, given the recent passage in the Ohio legislature of the “Heartbeat Law,” which bans abortions once the fetal heartbeat can be detected (usually at six weeks of pregnancy). (The law now awaits the governor decision.) If enacted, the new legislation will advance Ohio’s abortion restriction by an additional fourteen weeks (Ohio currently bans abortion at or after twenty weeks, with a few exceptions).

Let me ask this: If you stand outside of a closed garage door listening to the purr of a smoothly running engine on the other side of that closed door, does that mean there's a functional car inside of the garage, ready to drive down the road? What if upon rolling up that garage door, you find the car up on blocks, the wheels and tires not attached to the axles. For that matter, what if there are no axles? In fact, you might simply find a running, bodiless engine hanging from the rafters. Is that a car?

So, is a beating heart life?

Scientifically speaking, The American Congress of Obstetricians and Gynecologists officially states that “Most obstetrician-gynecologists understand fetal viability [the ability of the baby to survive outside of the mother’s womb] as occurring near 24 weeks gestation…”

Again, polls show that 79% of Pro Choicers oppose abortion in the 3rd trimester. If they understood that by medical experts objectively define a fetus as “viable” in the 2nd trimester (at 24 weeks), perhaps even more Pro Choice advocates would oppose abortions performed even prior to “late term.” The majority of states do recognize the current medical definition, such that they ban abortions starting at 22 to 24 weeks (some with limited exceptions).

But what about, say, the 20 week old fetus? 

This represents the halfway point of normal pregnancies. For many pregnant women, this is the first time that she can feel her baby moving inside her. While still only around six inches long, the fetus reacts to loud sounds, even light (although its eyelids remain closed). The 20 week fetal face now clearly looks like that of a baby, and the tiny hands (which now can grip) have fingerprints and growing fingernails.  While unable to survive outside of its mother’s womb, is it acceptable to terminate this tiny, moving human, a baby that in only four weeks will meet the medical definition of "viable?" This is a question at the foundation of any honest discussion with both Pro Choicers and Pro Lifers Except In Cases of Rape & Incest alike to consider and address.

Let’s jump back to the Ohio “Heartbeat Law.” The very primitive heartbeat can first be detected between five and six weeks. Around this time, the umbilical cord (upon which the developing baby will depend until delivery) forms. Tiny arm and leg “buds” (the initial bumps that become digited limbs) appear. And the brain and other organs are early along in their developmental journey (but advancing rapidly).

Compared with a baby only 14 weeks later, the destruction of this fetus is far easier to feel comfortable with for many people.

But here’s the conundrum for anyone who supports early stage abortions: As medical technology continues to advance rapidly, the developmental age at which a fetus can survive outside of the womb will continue to be earlier and earlier.

Thus, as the objective medical definition of "viability" (our clinical ability for a premature baby to survive, to grow up, maybe to go to college, get married, have children) moves nearer and nearer to the time of conception, what do individuals (and legislators) do in response? At some point, even the most radical Pro Choicers and Pro Lifers Except in the Case of Rape & Incest will be faced with terminating a medically, objectively defined "life." What then, when a poor teenager wishes to abort her child? What then when parents feel unable to care for a baby with known significant disabilities? What then when a woman is impregnated during a rape?

For many things, our advancing understanding of anatomy, physiology, and medicine often brings clarity. But for some ethical questions, knowledge and medical progress may simply further muddy the waters.

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