I’m writing in response to Sam Armstrong’s anti-choice piece “Who Counts, Who Doesn’t: Human Value, Reproductive Freedom and the Abortion-on-Demand Debate” that was recently published online at in-Training.  While a comprehensive review of student doctor Armstrong’s arguments is warranted, I will only attack those I found particularly troublesome.  I’ll also add salient points he did not discuss, while maintaining an eye on the neo-proverbial “TL;DR” clock.

Mr. Armstrong (who I’ll now refer to as “Sam,” as he is actually a friend of mine and a thinker I admire very much) is right to define the fundamental problem as one about what type of being the “unborn” is. The typical abortion debate circles around this issue, rather unproductively in my experience, for too long. I will not use the term “unborn” however, as it is inherently misleading: we don’t refer to a pre-medical student as a medical student.  The pre-med isn’t even necessarily going to be a medical student until she is admitted somewhere and passes the boards.  “Fetus” or “embryo” is more objective and accurate. In addition, and sadly, up to 50% of even the wanted pregnancies will not make it to birth. So, again, calling them the “unborn” is even more cart-before-the-horse than one would think.  Please remind others that if an unwanted pregnancy is an “unborn child” with all the rights of a child then any infant should be able to register with AARP.

I’ve organized my response as follows below.  Should you be interested in jumping straight to the meat of my main argument, skip down to section II.

I. Common Ground: We Want Fewer Abortions
II. Love Your Product of Rape! You Must!
III. Intrinsic Value/Shmintrinsic Value
IV. An Exit Not Taken and Leaving The Arm Chair
V. Closing Remarks to the Pro-Life Students and Doctors

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I.   Common Ground: We Want Fewer Abortions

As Sam has said to me, if the fetus is something devoid of moral worth, then it surely deserves no more oxygen than its host decides it is worthy of.  If it enjoys the moral worth of an adult, as Sam believes, then killing it should land you directly in jail, along with the doctor or student who actually stopped the heartbeat.

Sam and I agree that more effective contraception and contraceptive use would mean fewer abortions, and that would be great.  The other thing we agree on is the odd, dichotomous nature of abortion of a fetus at 23 weeks being legal and one at 25 weeks residing in murder territory.  Indeed, Sam gets to the problem at the core of the traditionally liberal view on abortion: how late is too late?  The 24-week cutoff does seem to be an arbitrary one, and I’m unconvinced by “viability” arguments that seem to be the basis for the magical number 24; Sam seems to be unconvinced as well. That we could grow an embryo to full-term in a fish tank shouldn’t change our view on the worth of that fetus. No matter what artificial life support we have, the worth of the fetus shouldn’t change.

Before I jump in to where I think Sam’s arguments go seriously (though consistently) awry, I must add these caveats:

1. In thinking about this topic do not make the mistake of seeing the standard “pro-life” view as “more compassionate” because it involves protecting those who are deemed to be “more” defenseless than many of the women who are already unsupported or abused.  This reminds me of those who may protest the consumption of veal on grounds that it kills calves while chomping down a regular burger with feigned self-awareness, saying “Ol’ bessy probably had a long life.” Did that adult cow have any more autonomy than the calf? I think not.  As such, even those women who have the financial means and emotional capital to raise a child should still be the focus of the physician’s attention, not the embryo growing within (or outside) her womb. Although politicians love to capitalize on this emotional trigger point, apparent discrepancies in vulnerability should not color our perspectives.

2. Though I am vehemently “pro-choice,” [1] I, along with every abortion provider I’ve ever spoken with, would be happy never to have to provide another abortion (I’ve begun my training through Medical Students For Choice’s Reproductive Health Externship, and you can too). We provide, as Linda Harris so eloquently said in her NEJM article, out of conscience. And with the exception of a few rogue providers, all the others do so as well.  We provide abortions to help women in distress, not because we love evacuating uteruses.

II.   Love Your Product of Rape! You Must!

One of the most problematic issues in Sam’s view is that it conscripts women who have become pregnant by rape to a lifelong commitment to that rape.  Why am I going straight for the jugular with this not-so-rare conception-by-rape discussion?  It gets straight to the issue: Sam’s argument must either commit to the “sanctity of life” approach and continue the assault on the woman or allow an abortion under these circumstances thus negating any claims of inherent value of the fetus.  Here is my basic argument:

1. Conception by rape, occurring around 32,000 times per year in the United States alone, poses a special problem to the pro-life view.
2. The pro-lifer can allow an exception to “intrinsic human value” or “sanctity” of human life and agree to stop the ongoing harm to the rape victim by allowing an abortion of the fetus conceived by rape.
3. Or the pro-lifer must consign the rape victim to nine months of bodily, emotional, and financial harm.
4. Therefore either human value is not intrinsic, but subjective to the circumstances of conception, or the pro-life physician must continue the emotional and physical torture [2] by forcing gestation.

Unfortunately, Sam’s view says, effectively, “You’ve been raped? That’s awful, but that embryo has a right to life and you might be post-rape right now but you’ll also be a murderer if you decide to terminate your pregnancy.”  Is this really the compassion we show our patients?  It is not.  However, we don’t avoid saying things to our patients just because they might be hurtful.  We don’t say things like this also because they’re untrue.

III.   Intrinsic Value/Shmintrinsic Value

The anti-choice among us may have picked up on an important point and question that I skimmed over in the last paragraph: I only referenced the woman when mentioning compassion. How could one possibly be said to show “compassion” for a fetus by killing it? Aren’t I turning a blind eye to the fetus here?  How can I claim to be a holistic, compassionate physician if I’m executing humans before they’re born?  Every abortion provider must answer this for his or herself, but, personally, the answer is fairly straightforward: I reject the premise that every member of the species homo sapiens sapiens necessarily has a right to life just by showing up, and I think it’s dishonest for people to say otherwise.  Sam does a strong job attacking the support of infanticide that the typical pro-choice advocate seems to slide into if we’re consistent with our claims.  This is another (very interesting) topic, but I will ask exactly why infanticide is wrong.  The typical answer involves a “guffaw” followed by the person effectively placing a loudspeaker to their gut to broadcast their personal nausea, without explicitly stating why it’s wrong.  I know Sam has a straightforward answer (intrinsic value).  I don’t believe some authors’ admission of certain cases of infanticide do irreparable damage to their case, though, again, this is another topic.

I have at least two problems with arguments based on the so-called “intrinsic value” of human beings.  First of all, including the off-putting “humans shall conquer all” egocentricity it implies, “intrinsic human value” is an overtly speciesist concept that I believe shoots itself in the foot.  I’m not going to go down Peter Singer’s Animal Liberation rabbit hole, but the underbelly of the humans-only right to life argument reeks of this speciesism.  It doesn’t take even a haphazard vegetarian like myself to acknowledge that if you hold humans up on this pedestal you’ve got a hell of a lot of explaining to do about why a helpless infant has more rights than a dog that can save hundreds of lives with one sniff in locating a bomb. We kill millions of full grown animals a day without remorse, yet here we are debating the moral permissibility of aborting a parasitic mass of cells that was the product of a rape because it happens to be of holy human lineage.

Second, how and when does moral worth magically appear?  Sam says that “locating our value in accidental properties raises a lot of questions,” yet he’s willing to use the sperm and egg’s meiotic dance as the moment of moral relevance? Somehow acrosomal degradation commences your moral worth?  Why not start with the proper alignment of hydrogen bonding between complementary strands of DNA?  “A-two-T, G-three-C = Morali-tee” I always say.

I don’t mean to invoke the beard fallacy here (Sam has called me out on doing so in the past: simply because we can’t say exactly how many hairs make a “beard” doesn’t mean there’s no such thing as a beard).  Clearly we’ve got a zygote after fertilization and just a couple of gametes before, so we can speak of the zygote as having moral worth that is greater than the sum of its parts, right? Well, I’m not so sure.  Does uterine implantation guarantee moral worth?  Or is soon-to-kill-mom ectopic implantation enough?  When and where are we talking about here?  In a lot of writing we’re left with few answers on these topics, allowing Sam and others to do a lot of implied hand-waving about how this intrinsic value works, exactly, and why it doesn’t apply to our mammalian brethren.

Nonetheless, let’s see what Sam says about intrinsic value:

Locating our value in accidental properties raises a lot of questions. For example, what possible non-arbitrary justification could ground our value in acquired properties? Further, why are these alleged value-giving properties value-giving in the first place? On the other hand, if you affirm human beings as valuable for the kind of thing they are–in other words, their nature or substance is value giving–then we have a principled reason to respect all human life at every level of development.

Don’t get sucked in by the buttered slide into “a-ha! I understand what he means! Like gravity and mass! Human substance and worth!”  It’s a catchy meme for sure, but it’s empty.  Sam is being selective about what he means by “accidental properties.”  Included in the list should have been the happenstance evolution of apes into a human (rather than, say, a Centaur. Would we have inherent value then?  What about an awkward Minatour? [5]).  He argues that people like me arbitrarily assign moral value to human abilities like consciousness or feeling, while his argument skips over the fundamental issue of how human evolution, a phenomenon caused by the accidental winds of selective pressure, somehow obtained the garnish of “inherent value.” Meanwhile, all a pig gets is ketchup and mustard.  If consciousness is an accidental property, evolution into our current form surely is as well and should be suspect.

While I agree that it’s difficult to create hard lines on what characteristics give a being moral value, let’s not play dumb here.  We do this every day.  As the neuroscientist Sam Harris says, we don’t give rocks moral consideration because they can’t feel anything.  In hospice care our goal is to minimize discomfort because those people can feel. We don’t feel bad locking a dog in a cage for hours because we have assessed that it has a far more coarse grained view of reality than a human adult and can’t feel depressed the way humans can.  We don’t feel as bad for someone who “died instantaneously” in a crash because we know they didn’t suffer as much.  Yes: feel, feel, feel, feel. We, in reality, out of the philosopher’s arm-chair, utilize how much a being can feel (or anticipate good or bad feelings) as a de facto moral worth barometer, and I think we’re generally correct in doing so. [4] In other words, these basic properties (i.e. consciousness, feeling, anticipation, etc.) are value-giving because they enable the organism they reside within to have wishes and desires at all.  As I mentioned above, these properties are no more accidental than the evolution of our (current) species, which Sam does use as justification for our special moral worth.

I can’t speak for other providers, but this is one main reason that I am pro-choice:  Generally speaking, entities that do not have consciousness (and thus no pain, foresight of pain, etc.) and have never had consciousness are of no moral worth.  They can’t suffer and are not being robbed of anything because they do not have anything.  Indeed it’s even a misnomer to say “they,” as it implies some form of personhood [5], which the fetus unequivocally lacks (despite the unscientific, overtly pious views of the group “Personhood USA”).  That the North Dakota legislature has been convinced of such personhood says nothing about the level of consciousness of a fetus and everything about their level of scientific ignorance.

IV.   An Exit Not Taken and Leaving The Arm Chair

So, as we back out of the rape-problem, Sam could take a middle ground.  He could agree that such a horrid act has occurred that forcing the woman to carry the fetus to term would be an even greater, longitudinal physical assault on her that we’d consider such a harm (forced gestation) to be impermissible.  Does that sound reasonable to you?  It sounds reasonable to me, but not to Sam.  To his credit, he wishes to stay consistent with his views, and he admitted fully to me that he wasn’t super comfortable as they applied to cases of rape.  Nonetheless, he didn’t see any other way to approach it, lest his whole framework fall to pieces, and I think he’s right.  Either the fetus has rights or it doesn’t.  But this is where we get to leave all the arm-chair philosophy behind and really see who believes what: if it has the right to life, than you, doctor, must be the one to protect that vulnerable life and do everything in your power to prevent that rape victim from terminating the pregnancy.  As Sam said, regardless of the government’s decision on what is right and wrong, the truth may lie elsewhere.

So, I charge you, anti-choice medical students and physicians out there, to ask yourself if you’re really willing not only to not refer out for abortion services, but to actively restrain your pregnant rape victim patient lest she find a provider who is willing to help her get her life back on track.

V.   Closing Remarks to the Pro-Life Students and Doctors

This piece is entitled as it is because the title Sam used (in quoting Rep. Keith Ellison) has a typo.  It should read “who counts, what doesn’t?” because we’re not talking about killing people, we’re talking about terminating pregnancies and getting women back to work or normal daily living rather than the impregnable bovine-like existence many men (on both sides of the aisle) would prefer.  Sam rightly avoids going the “personhood” route as he knows embryos and fetuses lack such an identity, and indeed his arguments are water-tight enough that he doesn’t need this physical characteristic to justify the nine month extension of the physical assault that too many women endure each year.

In these last words, I’m not necessarily speaking to Sam, but to his many bedfellows (I don’t know much about his activist life, but I do know many of the pro-lifers’ tactics): If any pro-life physician is unwilling to make abortive exceptions in the case of conception by rape, and yet are still unwilling to stop this patient from obtaining an abortion, I must call them out and state the obvious: you’re insincere.  We can talk all day long about the ethics of abortion, but the pro-life students and physicians among us have the opportunity to prevent abortion access right in front of them and yet, from what I’ve seen,are unwilling to step in the way of this “mass murder.”  I and many others have put our money where our mouths are on this topic, acting on our beliefs, and, for consistency’s sake, at least the craziest of the crazies in the pro-life movement really seem to believe what they believe (in attempts to do harm to abortion providers or clinics).  It is because of this discrepancy that I’m unconvinced that most pro-lifers actually believe what they espouse to believe.  So if this applies to you, I encourage you to stop wasting valuable time with the verbiage and theory only to retreat behind claims that it’s illegal to stop women from entering an abortion clinic.  If you really believed what you claim to believe, you’d figure out a way; 1.2 million “little [American] people” are counting on you each year.