 All right, okay, we have quite a good crowd here. So again, I'm Bob Trug, I direct the Center for Bioethics at Harvard Medical School and welcome to the public lecture series that we do contemporary books in bioethics. And today we are so privileged to have Professor Katie Watson going to be talking about her recent book, Scarlet A. But before I introduce her, let me just go through a few ground rules here in terms of how we work. So the event is being recorded. It's being live streamed via Facebook and it will be posted on the Center for Bioethics Facebook and YouTube pages. You have two ways of participating. One is through the chat box and the other is through the Q&A box. And they're a little bit different. So in the question and answer period, I will be looking just at the Q&A box. So the chat box is to communicate with Ashley Troutman if you're having any technical difficulties, she'll be monitoring that box or to just make general comments to the other participants on the webinar. But in terms of participating in the Q&A, please use the Q&A box. And our website is there. So to look ahead for other events that we're doing, please check us out there. And there also is our Twitter handle as well. So let me go ahead and get started and introduce Professor Katie Watson. She is a lawyer. She trained at New York University School of Law. And after practicing for a while, she became a bioethicist, showing that there is life after law school. And she got training in clinical medical ethics at the University of Chicago Medical School McLean Center and also education in medical humanities at the Feinberg School of Medicine. And she currently teaches law ethics and humanities at Northwestern University, sorry, we're not in Boston, Northwestern University's master's program in bioethics and medical humanities. She's served a number of different roles. She was on the Northwestern Memorial Hospital Ethics Committee for a long time. She has served on the board of directors of the American Society of Bioethics and Humanities on the editorial board of the AMA Journal of Ethics. She is on the board of the National Abortion Federation as well as the National Medical Council of the Planned Parenthood Federation of America. Something that I did not know about her is that she also has a background in theater. She participates with Chicago's Second City Theater and she has developed a training curriculum using improvisational approaches to teach about doctor-patient communication, something I'd like to learn more about. But the reason we're here today is to discuss her recent 2018 book, excuse me, Scarlet A, The Ethics, Law and Politics of Ordinary Abortion. I read the book the first time when she came to Harvard, I think it was a couple of years ago to deliver our later lecture on reproductive ethics and it was just an amazing talk and so well received. And so I thought I would have her back for the book's course. So, Katie, I think I'm gonna turn it over to you now and we'll go ahead and get started. Thank you so much, Dr. Traug. It's a genuine honor to be here. When I first became the director of the ethics course that was then required of our second year students, when I designed the session on reproductive ethics, I thought it was important to talk about abortion care in addition to the technologies we usually associate with the topic of reproductive ethics. And I began by explaining to my students the data of the day, which was that before menopause, one in three American women were expected to have an abortion. And the numbers alone were part of what made it relevant to them, the numbers of patients, family members, colleagues who would have this procedure meant at minimum it deserved their attention no matter what specialty they were going into. And so today we were going to delve into some of those issues as well. And I went on to make my next point and as perhaps other teachers had the experience, the class just erupted into whispers and they just sort of turned into each other like a 1930s musical where they were like one in three, did she say one in three? It can't be one in three. And you just have this choice as a teacher like here's your agenda and the class has just moved elsewhere. And so I stopped and I said, I hear what you're saying. That seems amazing. I am shocked as well. And the true embarrassing confession is that I had looked up the number the night before. And that day was just an epiphany that led me on a journey that took over a decade and resulted in this book in part to realize that I was a lawyer who had a fellowship in what we called reproductive freedom back then and I taught the constitutional law of abortion. I thought I knew a lot about abortion. They were medical students so we're learning the Madison of abortion. And yet none of us knew some of the most important facts about abortion. And in medicine, is this medical issue common or uncommon is just such a basic fact. And so how is it that if we didn't know that, we experts, what else were we missing about this conversation? And so that led me on this journey to learn more and I'm gonna just share a little bit of that with you today. I just had this sense that there's something wrong with the American abortion debate. We're missing something. And in the course of what I learned, I did come to believe that we can do better. So first, why didn't we know this number? Well, there are multiple reasons but I think this is one fantastic explanation. If you go to scholars call this the prevalence paradox. How can something so common be framed or conceptualized as deviant? And they explain this circle. Women who have abortions face discrimination. Women fear stigmatization for engaging in abortion behavior. And they use that term because they're also referring to those who work in abortion care. You sit next to a plane next to a physician, they're gonna tell you, I'm an OBGYN. They're not gonna tell you, I'm director of my local Planned Parenthood, right? Cause I don't wanna talk about it for two hours. Then women under report and intentionally misclassify abortion behavior. Abortion is thought to be uncommon, not normative. A social norm is perpetuated that abortion is deviant and we're back to the discrimination, right? That prevalence paradox, the silence around the procedure for the patients and people themselves. And I wanna say in this talk, there are people across the binary, there are people who do not identify as women who are capable of pregnancy. And so sometimes you'll hear me use the inclusive word person or people but I'm also speaking of a long history of very specific gender discrimination against women. People who understood themselves and were understood to be women. So I'll use that word a lot too and I'm hoping we can hold that tension together. So what I came to realize is because of this stigma, because of this silence, excuse me, we hear more about the idea of abortion than the experience of abortion. And that's a problem in medical ethics because good ethics always start with good medical facts. It's also the case that in the medical humanities we wanna look at from other disciplinary perspectives and without that raw material, it does make it difficult. I realized that abortion was our era's scarlet A. And that just made me want to look further and learn more. So why do I care or why do I care about prevalence? Anyone over the age of 12 has heard their parents say that just because everybody's doing it doesn't make it right. I think most bioethicists would agree. But there are two reasons I'm interested in prevalence. The first is represented by this photograph. My basketball career began and ended in seventh grade. But the one thing I remember from that painful season is ignore the eyes, look away from the head. The head will fake you out, watch the body. The body doesn't lie when you're guarding someone. And in this book, I realized I'm not interested in what you tell Gallup when they call you on the phone. Also, who answers their phone anymore? I'm interested in behavior. The number I gave you at the beginning is no longer correct. That was almost 15 years ago. Today, the number is 24%. One in four American women who are between ages 15 and 44, if those current rates hold steady, will are expected to have an abortion. Looking at the numbers in other ways, every year, 18% of all US pregnancies end in induced abortions. This doesn't count miscarriages, where the products of conception do not pass and you have to do an abortion procedure. These are otherwise healthy pregnancies being interrupted. If you only look at unintended pregnancies, 42% end in abortion. And so my first idea was, is the United States as conflicted about abortion as we say we are? Our behavior suggests a general embrace in many ways of the procedure, certainly a high utilization rate. And the second reason is that the American medical ethics and patient rights revolution is premised on the idea that patients are moral agents. They're moral thinkers. And so medicine can supply facts and statistics and data and patients will filter that information and those options through their values and their life circumstances. And together, clinician and patient will come to whatever seems to be best in this more robust global, not just exclusively biological way for that patient. And so I thought, why wouldn't I give? And as a bioethicite, I'm trained to give the millions of patients who choose this procedure, almost a million a year, and their partners and families, the same dignity of moral thought that we give those who may oppose or choose to continue an unintended and actually unwanted pregnancy. So the numbers are the lowest they've ever been since Roe versus Wade decided and still one in four American women will have them. I thought that was worth our attention. These other observation and other observation I had, which was that the cases I would hear about in the news or with advocacy groups were always the extreme cases. And I'm a lawyer, rhetorically, that makes sense. You put forward your most compelling situation as the example, but for those who support abortion rights, it would be terrible anomalies, medical cases, rapes, very young patients. And for those oppose abortion rights, it would be examples of what they framed as abusive abortion, like a procedure that they thought was inappropriate or claims that Planned Parenthood was not being respectful to fetal tissue. Those kind of things. However, what that left out was what I came to term ordinary abortion, which is hard to get a perfect number, but it's approximately 95% of the abortions in the United States. And I know that word ordinary is provocative. I'll share a little behind the music tip. Originally I proposed the book be titled Ordinary Abortion, Colon, Academic, Academic and Oxford by publisher said, refused, because they said it sounded like I wasn't taking abortion seriously. And I wanna assure you that I take abortion very seriously, but I was looking for a term that would both capture the frequency, the prevalence, but also medically that abortion is a very safe procedure. You're more likely to die from running a marathon or getting your wisdom teeth extracted. It is 14 times, you're 14 times more likely to die in childbirth from delivering a baby than from having an abortion. And we don't always think about abortion or contraception as new technologies and they're not. They've been with us for centuries, but the ability to have the high efficacy and to have them be very, very safe is new, right? And we think in medical ethics of like new technologies that then become normalized or routinized, but how they challenge us in terms of medical ethics and law at the end of life. Traditionally, we really focus there or in reproductive, in assistance in reproduction, but we don't always think about how contraception and safe abortion are new technologies that opened up other worlds of possibility. They've become ordinary medically. So the second epiphany I had was that the cases we discuss are the ones that occur the least. And again, that's not all likely. It doesn't mean we shouldn't discuss those cases. It means we might not get the most robust or applicable analysis from them if we only look at them exclusively. So let's go from the abstract to the concrete because in abortion care, you have to work harder to reduce the idea of an abortion to the almost a million people who choose abortion every year. This is nationally representative, very large sample size survey of women receiving abortions. What are their reasons? And it's fascinating to me that they were allowed to pick more than one reason and that this reasoning is multifactorial. The median number of reasons women checked was four. I don't know if you would have predicted. I wouldn't have predicted. Let me say that I can't afford a baby right now, 73% would be such a high number. But then when they were asked in the same survey, what is the most important reason? If you had to pick one, these numbers shift and can't afford a baby becomes number one of the top reasons. I'm interested now in new work in childcare policy and how desperately, unfamily friendly our country is. It'd be interesting if we really had robust social safety nets and child policies that allowed people to raise the children they wanted to have if the abortion rate would go down a little bit for folks in that category, we could find out. But it's fascinating to me that when you look at the number one reason the 4% the lowest would interfere with my education or career plan. The reasons that are given are really more network reasons about the people around you, the life situation that you're in in terms of parenting. One is in. It's also when you look at the statistics, 59% of abortion patients are mothers. They already have a child. And I just will share my surprise that I realized how naive I had been teaching constitutional law this time. I just never understood or pictured mothers were the two thirds of the people practically in the waiting room. A third of them have two or more children. And so when you go back to the reasons the idea not ready for another child, other people depending on me or can't afford many people are working to raise the families that they have. I put at the bottom, this is not part of this good maca slide, 88% of abortion patients are dating or married the man they got pregnant with. And I don't mean to valorize romantic love or marriage or stigmatize the people who aren't. But just to point out, we have this idea of this women's issue and this individual making a decision and legally abortion is absolutely an individual right. But socially it rarely actually in action is an individual choice or that's in the minority. The majority of these people are consulting with their partners and their partners are in agreement. So even why don't we think of it as a couples issue or a family issue? That challenged my thinking. I also was unaware until I dug into this that half of abortion patients have incomes under the federal poverty line. So for a single person this year, I think that's around $12,500. And then another 26% are in that 100 to 200%. So it'd be $24,000-ish. And then this is difficult to talk about but I've come to believe it's important to name. Women of color are overrepresented in the demographics of abortion patients. 59% of abortion patients are women of color and that's in contrast to representation of 38% of the US population. So when you talk about abortion restrictions, the people who those hurt the most are poor women of color. And that frames this differently for me. The people that hurts the most are mothers. And we can make of that what we want. You and I may have different opinions but I think we would be remiss to not understand that when we have these conversations. Why are women of color disproportionately represented? Well, it's that economic issue is not the exclusive reason but it is the absolutely vast majority of the reason that the tragic intersection between race and poverty in our country that women of color are so disproportionately represented among when we talk about women in poverty. So that's the primary explanation for that. Abortion, why does anyone seek an abortion? Well, it's because they have a pregnancy they didn't want to continue. So let's go to the next step deeper about unintended pregnancies. There is a dramatic health disparity in unintended pregnancy. And again, I did not know any of this. For women, 200% and above the poverty line. So again, that's $24,000 a year for an individual. That's not an amazing amount of money but going on up 30% of pregnancies are unintended. Under the poverty line, 60% are unintended. So a reason that you see more abortion patients who are poor is because women living under the poverty line have more unintended pregnancies. Now we could do a whole separate lecture on what is happening there, right? Is it lack of access to effective contraception? Is it lack of interpersonal power to insist on contraception? Is it, when we talk in intended, you know, this idea of an unplanned pregnancy. Planning is a value that not everyone shares. The idea that, well, if I'm gonna time this, assumes a certain that things will change in the future and that there'll be a better or worse time to become a parent. So there's so many complicated things going on here that there's no data that perfectly unpacks it. But we don't usually use the concept of healthcare disparity in this area. And that's a mistake because actually as contraceptive technology has improved and insurance coverage for it has improved for many women of means, abortion care has become even more concentrated among poor women. So when we in medical schools do our healthcare disparity teaching, you know, it's diabetes, hypertension, like the idea of why are there differentials either among income groups or racial groups that aren't explained by biology and how can we ameliorate those differences? Abortion care and unintended pregnancy should be right on those lists. But certainly abortion care truly never is. And that's a mistake. However, I wanna leave you with one other take home point here before we switch topics on the demographics and patient profiles. More poor women, poor women are disproportionately represented. However, when you look at it in proportion by groups, higher income women terminate more pregnancies. So over that 200%, even though they have fewer unintended pregnancies, they terminate almost half of them. Women under the poverty line have more unintended pregnancies. They terminate about 38% of them. They deliver 60 unintended pregnancies per thousand women versus nine, just in that income jump. Again, why is that? Is it different in values of wanting to continue unintended pregnancies for moral reasons? Is it lack of access to getting to abortion care? Is it, there could be many factors, right? And again, there's no research that perfectly explains this. However, I think it's worthy of discussion and examination. So let's switch to the idea, let's go from epidemiology and all I did not know and I'm embarrassed to say now is the case to the concepts of law and ethics. Our country, it's interesting, there's such a slide between these categories. And when I teach on this topic, I really encourage my students to clarify, are you making an ethical argument or a legal argument or both, it's not that they're unrelated, right? But the constitutional law of, if you say I'm opposed to abortion, I think it's unethical. Okay, great. You still have to make a separate legal argument about it, right? And so I try to help at least for clarity and conversation separate those and then talk about how they do or do not overlap. And we seem to be used to this in other areas. The First Amendment, my right to practice my religion, if I tell you my religion is really so much better than your religion, first of all, that's a weird thing to say, but also no one suggests I'm saying your religion should be illegal, right? We understand there's room for this. But in abortion, we're a little confused about that. So let me do a quick review of the constitutional law behind abortion. Many of my students are surprised that as late as 1965, states had made it illegal to use any form of contraception, right? So there's no, that non-procreative sex is illegal between married people and unmarried people. And it's in the Griswold case in 1965 that the Supreme Court develops the privacy doctrine and says, you know, yeah, the contraception, that word's not in the constitution, but when you look at the Bill of Rights and multiple amendments and lots of case law, it's clear there's this realm of personal liberty in which the government cannot enter. And that the marital bedroom is one of those spaces. It's not up to the state whether your sex is procreative or not. That shouldn't be a matter of governmental concern. And think about the year here, the introduction of this radical new thing called the pill, that's woman-controlled, really brings this to the fore. In Eisenstadt, Massachusetts could have just said, like, okay, the jig is up, we're not gonna ban contraception, but they banned it just for single people. And Eisenstadt, that case said, well, it's for unmarried people too. And this is sort of the bumper sticker quote from Eisenstadt, that these cases, contraception cases are about being free from unwarranted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child. Now a year after Eisenstadt, we moved to Roe versus Wade. And the question in Roe is, does the presence of an embryo or fetus change that conclusion about the government's involvement in this individual decision to bear or beget a child? Well, the court starts out with talking about the moral personhood of embryos and fetuses and basically says that's not what we do. That's not what we're here to talk about. I wish the court had used the capital L in life because they're all well aware that biological life is certainly present in that one-celled entity that starts human development. But they're saying that there's no consensus on this in any field of thoughtful people. Why do you think we would be able to resolve it? That's really up to individual conscience. They don't use that word exactly, but that's the idea there. Now legal personhood, they say actually that's exactly what we're qualified to talk about. And what I think is so fascinating is Roe versus Wade is arguably a very original intent opinion. It's a very textualist opinion. And you see those juxtaposed as if those who say, well, the word abortion isn't in the Constitution. I mean, a lot of words are not in the Constitution. But what the Roe court did was really drill down and said, well, okay, the Constitution uses the word person 16 times. It doesn't define it, but it's impossible to use substitute embryo or fetus in any of those sentences and have them make any sense. Okay, so the framers couldn't have been talking about that. They looked at history and said, from the 17 to 1800s, abortion was not criminalized in the way it is now. So that wasn't part of the cultural milieu at the time. And they concluded the word person as used in the 14th Amendment does not include the unborn, right? They're just saying we're taking no position on the rightness or wrongness of doing this, but we're saying fetuses and embryos are not protected by the Constitution. And when you weigh that against the privacy interests of the individuals, couples, and families making these decisions, it's completely outweighed that they have this right to do it. In the case of 1992 that affirmed the core holding of Roe was phrased differently. Our obligation is to define the liberty of all not to mandate our moral code. Again, separating out this law and morality, saying some of the justices are very upset about this practice, totally opposed to it. However, that's a different decision. Casey also added what's called the undue burden standard, which I won't go into here, but really relaxed the standards for state regulation of abortion and allowed the flood of regulation that we see today. So it affirmed the core right, it affirmed the viability line that states can't ban abortion before viability, for them that it's up to doctors, not legislatures to decide when that is, but said states can do things like informed consent, scripts, waiting periods, that sort of thing. So that's the flood of regulations we see today. But this is my translation of the contraception and abortion cases. They concluded that governments can't force women to bear children against their will in the service of moral ideals of strangers, right? That these were gonna be individual decisions of conscience. And I wanna just take one step beyond contraception and abortion to just flag for you the gay rights cases and how they're constitutionally speaking tied together. So in 1986, there was a case that I and many others think is awful called Bowers versus Hardwick. It was criminalizing that states were criminalizing same sex sexual conduct, making that a crime. And in 1986, the court said, that's fine, that's not unconstitutional. In 2003, the court reversed itself and said, we got it wrong. We thought that was about sex. Really that case was about love and adult autonomy and dignity and identity. And I'm just offering to you that it did the same reasoning, like it gave a big paragraph of deference to people who to object to homosexual lifestyles that that's an issue of whether it's ethics or religion. However, they can't use the power of the state to enforce that even if they're in the majority, right? This is what the constitution is about, protecting unpopular lifestyles views, that sort of thing. And I just wanna point out for you they quote the abortion case. Our obligation is to define the liberty of all not to mandate our own moral code. So we are used to, okay, so if we pro-choice simply means you think that there's, you agree with the court's reasoning or you think they're even from a policy perspective if there were no constitutional right that abortion should be legal. Then you get into the conversation about is it an ethical act? And I think when I say no here, I'm just marking, I think many of us are familiar with the sort of the Catholic politician stance of I'm personally opposed to abortion. I think it's unethical, I wish no one would do it. However, I recognize it as a constitutional right and I support it as a constitutional right, right? And we're kind of familiar that sometimes people take that stance. What I have learned in my research and I'm just talking to people about abortion and I have to tell you it's hilarious when people say, what are you up to? What are you working on? And you say, I'm writing a book about abortion. The stories that they tell you at cookouts and cocktail parties is amazing. And then you learn to ask different questions. I have a colleague who describes himself as pro-life and I've taught with him for a long time. He's very strong in his Christian grounded beliefs about abortion. It was years of working with him before I asked him, oh, so that means you want abortion to be illegal, right? And he said, oh, no, that's ridiculous. Then we'd just be back to septic wards which is the wards we used to have the United States for people who had septicemia, blood infections from abortion that had gone wrong and unsafe abortion. And he said, no, we just be back to septic wards. I don't want abortion to be illegal. I want it to be unnecessary. And I thought, how dumb of me that I made this assumption that his box is lined up, right? I've also talked to people who were vociferously pro-choice who then surprised me by whispering, like, but I don't know if it's ethical because I had a baby and I had an abortion and now I think this and that, right? But there's room for that. Those who think abortion is unethical and want it to be illegal have to make an argument why the Constitution would protect fetuses when they are in conflict with perceived conflict with the adults who are protected by the Constitution, right? There's different legal argument to be made there. I also don't hear articulated as much as it could be or perhaps should be the ethics arguments about why abortion is either morally neutral. I think some people are comfortable articulating that. There are people who I call, I term abortion ambivalent. They're sort of like, I see good parts, bad parts, or but morally good. Those who say, I'm not troubled by the destruction of embryos. I think that's okay. And I think what abortion permits women is morally good. And so it's morally good to have it because they're afraid of being labeled pro-abortion. In my book, I review a bunch of approaches which I'm not going to torture you with now, but it was really great for me to read lots of philosophical tomes and articles to just confirm my sense that, you know, you read any one of them and you become utterly convinced. Abortion, putting them together for me just made me confirm like, oh right, the right answer is pluralism. That we're gonna come to different conclusions on this and we can try to persuade one another but that that's not an area that the legislature should enter. It's also the case that it's not just whether it's about when and just to make sure we start with a data point, I was really interested to learn that 80% of all US abortions involve embryos. Anatomically, the line between an embryo and a fetus is day one of week 11 and that's last menstrual period. It's very confusing dating for non-doctors. So that means eight weeks of conception, typically, but we date from the last menstrual period because we don't know exactly when someone got pregnant. And that line is we call it a fetus when it has all the anatomical structures are present, just the basic organization, 10 fingers, 10 toes, something that looks like a face, right? So it's often described as the great US debate about the rights of fetuses, but 80% are embryos. Is that a distinction with a difference? I don't know, that's up to you. But the ethics of when often hinge on a biological developmental point. And again, I won't use our time to go through all of these though, if in the Q&A anyone wants to talk to them, I'm happy to. I wanna point out I have pain at 24 plus weeks. I just wanna say out loud, many of the statutes that are trying to pull the viability standard back hinge to pain and claim it happens at 20 weeks. The scientific consensus does not support that, supports the earliest of that. The capacity to actually perceive pain would be around 24 weeks potentially or later. There's some irony that if you really switched out of pain standard for a viability standard, you'd actually permit abortion later. David Boonen is the philosopher associated with number eight, organized cortical activity. He argues until you have the neurological structures to form a thought, that's what makes you part of the distinctive thing about homo sapiens. We could talk about this forever, right? I simply wanna flag that these arguments about when that are separate from whether and that's what we're seeing in the state legislatures. Now, there are a couple of things. They're called single intrinsic property. That's what philosophers call, right? This one thing happens and then the switch flips from ethical to unethical. The strength of them is they speak to what philosopher Maggie Little calls gradualism. That's just an intuition that like when you're building a house and they dig the basement, that's not a house. When they put up the studs, I don't know. First of all, I don't know, are those called studs? I think so, right? The boards, is that a house? Probably most of us would agree not yet. What about when you get the walls in? But we would agree that it gets houseier at some point like it doesn't have paint and wallpaper but it's got heat, doesn't need a doorbell. That's my house and if it burns down I've lost something of value, right? So these respond to our sort of collective moral intuition that things get more serious as pregnancy progresses. They also, one of their challenges is I think they really play into what Art Kaplan calls scientism. He's a bioethicist. Using science as a moral conclusion, like that's when fetuses can feel pain and then sitting down, right? You still have to argue what is it about pain and how is that different, say, in a fetus than an animal that feels pain but can be killed and eaten? Why wouldn't Anise Jill's, excuse me, pain control be the answer for that? I used to have a lot of conversation to have, right? And also notice that all those points have made no reference to the women in whom these embryos and fetuses live. And many feminists have critiqued this. I refer to them as jar theories because when I was incredibly pregnant, past my due date, I was trying to walk myself into labor as many women do, wandering around Chicago's Museum of Science and Industry and looking at their display of embryonic and fetal development in these jars with embryos and fetuses who had been lost to miscarriage or women who had died in accidents in the 30s and 40s. And I just thought as a very pregnant woman, where am I, right? And how different that exhibit would look with 32 bodies of women? Say they had all died and consented to have their bodies displayed with their uteruses open. So you could see that development, how that would look. And so I think we have this false difference, right? The idea that those who oppose abortion talk about morality and ethics and killing and those who support abortion rights are talking about policy and women's rights. And somehow we not ethics and we're missing each other. But there's also a reason that those who support abortion rights don't like getting into conversations about embryos and fetuses. It's not because they're afraid of them. It's because they feel like that the anti-abortion argument sometimes is hiding an anti-woman agenda and you don't wanna be learned into false arguments that are a waste of time. Like if at the end of the argument, the person is gonna say, well, women were made to have babies anyway. You're like, well, that was not what we were debating. I don't wanna have that conversation. And so I simply wanna highlight that the personhood of women is at stake in this conversation too in a way that we really say out loud. Now of course, women are not a monolithic group. So it's important to name that the personhood of women of African descent who were kidnapped and enslaved was denied to the United States from the beginning until 1865 and politically it's not that it was granted and everything was fine. We all know that, but just speaking legally. Many people have forgotten that married women were legally dead in the sense that they just went from their subsidiary of their father's identity to a subsidiary of their husband's identity couldn't own property in their own names. It wasn't until 74 to assure they could get credit cards in their own names without their father or husband signing. And this is part of the two spheres model. And this is a case that I love to hate. Ms. Myra Bradwell, I should say Mrs. because it's important to the case she was traded as a lawyer but she couldn't get a bar card. She couldn't get admitted to the bar to practice in Illinois because women weren't allowed to sign contracts that were legally binding. So she challenged that what you must do with clients to represent them as their lawyer. And the Supreme US Supreme Court affirmed the decision on administrative grounds but three judges joined an opinion which basically just screamed it's because she's a girl like they just couldn't hold on to this idea. The idea that women aren't supposed to work the domestic fear, mothers and wives. That's it, you don't get to be out there. We say we've come such a long way and we have but I just wanna point out to you then in 1961 even after a whole series of cases saying you can't have racially segregated juries a Florida statute that essentially that led to gender segregated juries. The Supreme court's like, yeah, but that's different because women are needed at home. So the two spheres philosophy is very, very still still there's strains of it that are very alive and well in the United States. We just have to say out loud women were not allowed to vote until a hundred years ago and a hundred years later our Congress is 27% women. So we're not all the way there in terms of political representation, we could argue. And the first woman appointed to the Supreme court Justice Sandra Day O'Connor, when she wrote Casey that case that affirmed Roe, she didn't adopt the gender equity argument made by scholars like Sylvia Law and future Supreme Court Justice Ruth Bader Ginsburg by using an equal protection analysis. She stuck with the privacy analysis to affirm Roe but that opinion reads like a feminist manifesto in terms of how abortion has allowed women to participate in this other sphere, in this public sphere and that it's necessary to do so. And I'll throw you a curve ball here. I think many people are familiar with the Obergefell case which said that denying gay marriage was unconstitutional but here this is provocative language that it's stigmatizing to same-sex couples to demean them by saying they can't marry and this language at the end it would diminish their personhood to deny them the right to marry. This is an assertion that personhood is something that socially constructed throughout our life through the ways in which we interact with others. And I think that that's true when we think about the personhood of women in relationship to abortion care. And so I wanna close with one last point and I'm going to jump ahead in my slides if I may. I wanna speak very, very briefly to the concept of narrative in abortion care and storytelling in abortion care. And what I wanna do here is to think about these ordinary abortion stories and their power because note that when patients were polled about their reasons, no one asked them what do they think about the moral status of fetuses? Does that make sense? No one asked them that. I think the assumption was that they thought it was ethical to have an abortion because they're having an abortion and I think that's a fair assumption. So the benefits of reclaiming the ordinary is to think about why do so many women choose this and if we're assuming they're moral agents which we are, what's their reasoning process? That that just opens the ethics discussion in a different way. But it also contributes to the narratives discussion and it raises this issue of master plots and counter narratives. So I just wanna offer one. I go through several of these in the book. The idea that I think most of you have heard this idea that abortion is a difficult decision. Well, in the last 10 years there's just been this amazing body of social science research around abortion that has just explored many of these bits of conventional wisdom. This is a very large study that followed abortion patients before they got an abortion for five years and included some that were turned away from the clinic because they were too far along to see what those different trajectories were like. And I just think it's fascinating that 46% if you add up these numbers do not report that their abortion decision was difficult, right? So when you look at the data it's called a counter narrative. The idea that sometimes abortion decisions are easy. I think we put forward this to the difficulty equals like moral seriousness as opposed to people who are just very confident like a mother. Anyone would naturally say you weren't morally serious. They would say you were confident that you had thought through your values beforehand. You knew who you were and what you wanted to do even when you received surprising news, right? But we don't have that model for people ending pregnancies. It's also the case in, we hear about the concept of abortion regret which is really a subplot of the difficult decision argument. The idea it's so difficult that even if you feel really confident and clear you might feel differently later. And so I just wanna point out that what I realized in this work was that we've been told these collective stories and they purport to be factual, right? Abortion is always difficult. Some women regret it. And it's really a substitution for a philosophical position or an argument that it should always be difficult. You should regret it. And that's something we can debate, a position versus a story which you cannot contest, right? So in my program, we do think a lot about the medical humanities and how that can give us a richer and robust ethics conversation. This is one of my favorite pieces of political art. The shift between immoral, I'm moral and the way this is stamped on her back from someone who couldn't be her, right? So what do we have consensus on? I interpret our 45 years plus debate about abortion where we have not reached consensus as a different type of consensus that we're never going to agree. And therefore this is the kind of topic like the freedom of religion where it is not appropriate for governmental imposition or interference that this is an issue left for pluralistic society for individuals and their clinicians when it's relevant to come together and work out. So I'm not afraid of debating abortion but I don't see it's a problem that we have to resolve. It's a tension that we have to learn to live with in a much healthier way. And lastly, Roe versus Wade is very much under threat. It could be reversed or gutted in the very near future. And this is a map by an advocacy group of what that might look like in terms of states where state laws will be protective and they will be challenged. And so I just wanna say silence on abortion is a luxury you no longer have. I hope my book makes the prospect of talking about abortion a little more palatable and hopefully maybe even affirmatively welcome because I know every single person in this audience has so much to say. I can't wait to hear from you in the Q and A and it's been a pleasure talking with you. Take care. All right, thank you so much Katie for such a wonderful and profound talk. Let me, we have a lot of interesting questions here in the Q and A. Let me start with this one. Many societies have practiced infanticide believing that born children have no status as persons. If you were to argue on the level of ethics would you reject this view and on what grounds? So the question, the statement is many societies have practiced infanticide on the grounds that the infant is not a person. Is that what they said? Have no status as persons. Have no moral status as persons. And as you were saying that the constitution doesn't grant a fetus status as a person. So I suppose what the question is asking here is why, what is the act of birth? What difference does the act of birth make? Great, so I mean, it is a true historical fact that many societies practiced infanticide and I think that speaks to as I say in my book that I opened it with my experience at the Foundling Wheel in Italy and Rome where the pope, the first sort of adoption idea strangers would raise your baby because people in the area were throwing their infants into the river. The having unwanted pregnancies is not a new issue as this questioner is pointing out. I think abortion is an incalculably more humane response than infanticide. I wouldn't equate the two at all. And I do think that the birth and separation of an infant is of tremendous moral significance. The individuation in the world is enormous. I feel like it's hard to overstate for me. So I do think those practices are radically different and I think from a cultural and historical response I think there is something interesting about thinking about them together. I think abortion is a medical technology that has allowed us to avoid infanticide. So that would be another reason one might term it a moral good. All right, early on in the talk you had a two by two table constitutional versus ethical. So this, I believe this comment relates to that about the difference between ethics and law in medical ethics bodily autonomy is a central pillar. In the case of pregnancy, this means a woman's body is an issue of autonomy. This is not capital letters, not a couple's issue. Aside from patient safety why would the legislature or government be allowed to insert itself into discussions between women and physicians? We need a confidentiality mantle to keep the courts out of these discussions analogous to the lawyer client privilege. Interesting, great. So I appreciate this writers when they and I like the capital NOT this is not a couple's issue, right? But that's like saying an oncology patient this is a cancer as an individual issue like of course it is between you and your doctor but social scientists will tell us many people with cancer choose to involve their spouses and their children in their thought process, their support, their decision making and take them into account in their decision making. And so what I was trying to clarify and I'm, excuse me, what I was trying to make clear and I'm so glad you've said this because obviously I did so in completely is that legally and ethically it is absolutely in terms of medical ethics and patient doctor decision making absolutely an individual issue. And politically, socially, we can see data that it is a couple's issue and a family issue. And those are intention, right? And what they can be misappropriated one way or the other. So I don't want to misappropriate them I'm just naming them and to think about them in more rich and robust ways. However, when you say why would there be any governmental regulation? The Supreme Court's answer is there's a governmental interest if the government chooses to exercise it in human life from conception on. I disagree with that analysis. Interest for what? Taxpayers, soldiers. I mean, there's no explanation or defense of this if it's not a person, right? What would the governmental interest be? So I'm with you there to being confused and thinking there should be more privacy in that relationship. All right, another question. Thank you so much, Katie. Why do you think pro-choice advocacy organizations continue to use the quote unquote difficult cases narratives rather than arguing that abortion is common, safe and unremarkable? Well, whoever this writer is, email me and let's brainstorm that for an hour or so. So I said as a lawyer, when you've got three minutes and you want to present the case that everyone can agree on, right? Or the most people can see it right away. And the medical cases are so sad, but they do play into gender narratives. Those are people who wanted to become pregnant. So they were intending or accepting of procreative sex. They wanted to become mothers. So the sex piece and the mother piece right along cultural lines, but then something changed. And it was something so sad that they could no longer become mothers who used sex in a procreative way. And so they really capture a lot of people. They don't challenge the gender and sexual norms that the abortion right really does challenge. And so to say it's common, it's safe, people, Americans apparently love it when you look at the numbers, that pushes back against the gender norms and it's this Trojan horse piece. My only bit of like glass half full on the recent push for abortion restrictions is stigmatizers swing into action when what they wanted to stigmatize wasn't being done by laws and social norms already. And so the women's rights revolution has been so successful in the gay rights revolution that those who want that traditional two-spheres philosophy to be the dominant model, they're right to be panicked. They're right to go into social enforcement mode because they're losing, right? So that's where all that energy comes from. But I think in the pro-choice narratives, I mean, oh, Bersheffel, the named plaintiff, his would-be husband was dead, right? Like you didn't have to make the court even picture them kissing, right? He just wanted to be on the death certificate and have the benefits of being a widow. Like they took the most sexually neutral couple you could find, right? Cause one was not living. So we do that in litigation all the time. And it's often a winning strategy. It's the reason why. All right, here's a comment that I think plays on how we use slogans. Do you see an ethical difference in the right to die versus the right to life? The right to die and the right to life. Well, I mean, I do, so it depends if that person is targeting their thoughts when they say right to life to the existence of the embryo or fetus or to the adult woman in whom it lives, right? I do see an analogy in the bodily autonomy rights of adults with capacity in the right to terminate or carry a pregnancy and the right to access hospice care or physician assisted dying. I do think there's a conceptual link there. The difference is the growing of a potential not another person. So it's not a perfect analogy, right? But I do think there is some relevance to those conversations. Yes, okay. Here's a going back to more of the beginning of your talk where you were talking about the statistics that maybe the impact of the Hyde Amendment upon the frequency of abortions as well as the comment that white women often do not report their abortions. And so this may be massively under reported how many white women have abortions. Fantastic, okay, so two pieces. The Hyde Amendment for those who don't know is a federal writer that came in, I think around 1977, post-Rowe, the idea that the federal Medicaid program will not pay for any abortion, including those that threaten pregnancies that threaten a woman's health. Like you're gonna lose a kidney too bad if Medicaid's your insurance, you're not covered. And when you look at that percentage of women in poverty who are the patients, think about how dramatically that impacts them. In my state, the argument that won the day is this is gender discrimination. Medicaid covers all procedures for men, but doesn't cover a procedure that one in four women will need. And that number might be higher in impoverished women. That's gender discrimination. We cover childbirth, we cover contraception. States shouldn't have anything to do with it, right? So 16 states have state covered, Medicaid coverage. The effort to repeal the Hyde Amendment, which is very live, is about that sort of gender equity and dignity point. It's also the case that poor women delay their abortions to find the time to raise the money. The average first trimester abortion costs $500. And to get that cash out of pocket for someone who can barely pay rent and feed their children, it delays the procedure. So again, people who are on a comfortable or less comfortable with abortion in the second trimester versus the first, repealing the Hyde Amendment and having insurance coverage is there's great data that that would push the numbers, the dates lower for earlier abortion. There was a second piece to that question. About white women not reporting. Oh, about under-reporting. That's a really interesting hypothesis, but these numbers come from the Gutmacher Institute and they don't get them directly from patients, they get them from clinic data. And so I actually have a pretty high level of trust in these numbers because the Gutmacher numbers are higher than CDC numbers, but CDC numbers are clinic self-report and many states don't even report at all. Whereas Gutmacher has very good relationships and is perceived as neutral by abortion clinics and hospitals that provide abortion. And when they don't respond to the surveys, Gutmacher follows up like I think it's four to seven times. So they have a very low non-response rate. So your hypothesis is valid. Given what I know about Gutmacher statistics, I don't think it accounts. I think the poverty overlap is probably a stronger explanation. All right, well, let's close with a comment from one of an experienced bioethicist. This was the best presentation on this topic I've heard. Thank you. I don't think we could summarize it any better than that. So thank you, Katie. And for all of you in closing, our next one will be April 29th. Ruha Benjamin will be talking about her book, Race After Technology, Abolitionist Tools for the New Gym Code, C-O-D-E. So I hope to see you then. Thanks again, Katie. Thank you. And I'm gonna look at the chat before we close and go speak with your students. I'll just make sure. Okay, that's good. I see rich comments here.