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Beyond Choice: A New Framework for Abortion?

Every year I teach a class called “Mind, Body, and Bioethics in Japan” to a group of Princeton undergraduates made up of students drawn to ethical dilemmas—aspiring doctors, scientists, and lawyers. The class departs from typical approaches to bioethics. Instead of attempting to arrive logically at the “right” or “best” answer to the human dilemmas posed by modern medicine, we take an anthropological approach, asking how the dilemmas themselves are shaped by and understood through the context of culture.

Every year I teach a class called “Mind, Body, and Bioethics in Japan” to a group of Princeton undergraduates made up of students drawn to ethical dilemmas—aspiring doctors, scientists, and lawyers. The class departs from typical approaches to bioethics. Instead of attempting to arrive logically at the “right” or “best” answer to the human dilemmas posed by modern medicine, we take an anthropological approach, asking how the dilemmas themselves are shaped by and understood through the context of culture.

The unit focusing on pregnancy, prenatal care, and attitudes toward abortion and human life, in particular, provokes some of the most passionate discussion. The topic is fraught in any context, but given the polarized politics of “life” vs. “choice” to which U.S. students have been exposed, Japan reveals intriguing contradictions. Japanese obstetricians do not practice aggressive prenatal screening; women are encouraged to accept the baby that is born, and fetal selection for birth abnormalities or sex is regarded as unethical. A fetus is humanized—so much so that obstetricians routinely hail their clients as “Mom,” even from the early stages of the pregnancy. At the same time, terminating a pregnancy is accepted as a morally sound means of preventing a situation in which a child would go uncared for. Small statues commemorating the unborn at Buddhist temples mark an institutionalized space in which women mourn their aborted fetuses.

Teaching the class has sharpened my feelings that there is something missing from the traditional “pro-choice” stance on abortion. The position is an heir of Roe v. Wade’s legal framework of the right to privacy and, also, of 1960s and 1970s liberal feminism, with its emphasis on women’s autonomy. When I started teaching, I had no children. Now, as a parent, even though I support the right to abortion, when I see T-shirts on college campuses emblazoned with “My body, my choice,” I feel that they are glib and vaguely irresponsible, an attitude I know I share with others who also support abortion rights. Successful campaigns against legitimating abortion primarily in terms of “choice” and “rights” have led to such bipartisan initiatives as the Prevention First Act, the Pregnant Women Support Act, and the Reducing the Need for Abortion and Supporting Parents Act. Many Democrats have backed away from aggressive promotion of “rights” and “choice.” Barack Obama’s 2010 reassertion of Bill Clinton’s statement that we should make abortion “safe, legal, and rare” reflects a liberal attempt to recognize the moral dimension of the problem while holding on to a “right” that in many places in the United States is a “right” in name only.

Meanwhile, anthropologists and sociologists who study reproductive health care on the ground, in clinics, note how the discourse of “choice” offers little space to recognize the conflicted feelings often associated with terminating a pregnancy on the part of women, abortion rights advocates, and even health care practitioners themselves. Jeannie Ludlow, in a powerful essay entitled, “Sometimes, It’s a Child and a Choice,” has written about women’s attachments to what the majority refer to as their “baby,” despite their decision to terminate the pregnancy, and about committed abortion providers’ private confusion about the status of the fetus. Most women seeking abortions must balance demanding work schedules while caring for other dependents. Some 61 percent of American women getting abortions today are already mothers of one or more children; 69 percent are economically disadvantaged. Only 18 percent of women obtaining abortions are teenagers. Concern about their ability to adequately care for an additional child is central to their decision.

The Japanese example offers a window into the particularities of the American debate and the limits of each position. As here, the fetus is humanized in many contexts, and yet abortion is ethically acceptable. Even second trimester abortions are legal in Japan. The question of when life begins, central to U.S. abortion politics, is less important to the Japanese ethical framework. The focus is neither on the rights of the mother nor on the personhood of the fetus, but rather on the social life of the child, the welfare of the family, and the question of the social good more broadly. Although teenage abortion rates are rising, the majority of women seeking abortions are in their thirties and forties. The strong sense that these are decisions made by parents out of concern for family welfare undercuts the logic of opposing abortion based on the fetus’s humanity alone. In Japan, as elsewhere, a mother is trusted to make the decision about the fate of her fetus not because she has freedom of “choice” but rather because she is its trusted caregiver; a parent alone can provide her child with an appropriate environment. Japanese parents do live with deep psychic tensions between the acceptance of the humanity of the fetus and the pervasive practice of abortion. This tension is easily exploited by Buddhist sects harboring marginal views, and images of the innocent, child-like fetuses make their appearance in comics and other forms of popular culture that treat the issue of abortion and women’s inner conflict. Still, the logic is that child rearing and a mother’s health (both physical and emotional) are central to producing a good society, and that children respond to the resources and care they receive. This notion of abortion as a social necessity differs from the notion of abortion as a “right” and deemphasizes the dividing lines between “life” and “choice.”

Japanese school textbooks treat the issue of birth control and abortion in required courses on home economics. A common middle-school textbook explains the procedure under a section entitled, “Deciding when and when not to give birth.” It begins by stating that “as an individual human being, a child has the right to be raised in an appropriate environment.” The passage suggests that a parent should be concerned foremost with appropriate upbringing and socialization of a child, and should thus practice birth control rigorously. While the textbook reassures its readers that abortion as a last resort is safe and legal, it cautions that such a measure constitutes “the termination of a life that one has cultivated,” and also that “the hardship for a woman, physically and emotionally, is large.” Thus, while the passage explicitly imagines the fetus as a life, the ethical focus is not on the fetus but rather on a mother’s welfare and the future child’s environment. The entire section appears in a chapter on “Childrearing.”

As such stories suggest, family has hardly been regarded as a “private sphere” in modern Japan. The status of abortion as a family matter must be seen in the context of social policy that has historically regarded strong families as integral to a successful society. In fact, the history of abortion is closely entwined with platforms for social betterment—producing a “planned family,” a strong society, and powerful nation. Infanticide was a common practice throughout the seventeenth and eighteenth centuries in many parts of Japan for reasons of poverty and food shortage. In prosperous areas, such “weeding” (mabiki, as it was called) was carried out by midwives at the behest of the family with the objective of creating “small, healthy, and economically productive families”—while the state looked away. Abortion was banned at the turn of the century in order to encourage population growth and fuel Japan’s imperial ambitions.

Despite citizens’ activism toward legalization in the 1920s and 1930s, the government did not officially legalize abortion until 1948, in the context of postwar devastation and starvation, out of concern for population control. At the height of the eugenic policies that influenced the industrialized world, the bill emphasized the priority of population quality, permitting abortion if there was evidence of a hereditary condition that might be transmitted to a child and compelling sterilization in certain instances. The law, the National Eugenic Protection Law (Nihon Y?sei Hogo-H?), included a list of specific hereditary conditions that legitimized abortion. In the context of the postwar baby boom, many women began to take advantage of the law, and a clause was added permitting abortion for reasons of economic hardship.

After decades of opposition by human rights activists, the eugenic clause was eventually deleted in a 1996 law, which was re-titled, “The Maternal Body Protection Law” (Botai Hogo H?). The economic necessity clause remains (in addition to rape, incest, or possible harm to the mother), and is the primary legal recourse for abortion. Abortion as a means of fetal selection is undoubtedly still practiced under the cloak of economic need, but it is regarded warily by obstetricians and families alike.

Still, family continues to be the primary prism through which decisions to terminate a pregnancy are viewed. The anthropologist Margaret Lock, who has studied Japanese attitudes toward fetal selection and new reproductive technologies, suggests that the ethical question of whether to terminate a problematic pregnancy hinges foremost on its consequences for family life. One mother whom she interviewed, who was raising a child with Down Syndrome, expressed the view that terminating a first pregnancy for reasons of the discovery of a chromosomal abnormality would be “selfish.” However, terminating a second abnormal pregnancy that could jeopardize family life and the quality of parenting for the first child would more likely be regarded as acceptable. Japanese obstetricians have steadfastly declined to conduct proactive prenatal testing, even tests that are considered routine in the United States. Instead they direct their focus to the mother’s behavior and the “environment” she creates for her fetus. As eugenic practices have come to be regarded as taboo among obstetricians, what has replaced them is a strong commitment to the power of motherhood, which is thought to begin with pregnancy. A recent ethnography of prenatal care by Israeli anthropologist Tsipy Ivry demonstrates the burden but also the pride that such practices confer on Japanese women. Ivry’s book, Embodying Culture, draws a striking contrast with Israel, where concern for birth outcomes results in more aggressive prenatal testing, trivializing the mother and the pregnancy itself as an influence on the baby.

During Japan’s decades of rapid economic growth in the sixties, seventies, and eighties, the government, together with Japanese enterprise, subsidized middle-class women to stay at home, protecting the family wage system through mutual corporate shareholding and bank loans for companies that buffered employees from economic volatility. The middle-class housewives of this era, while economically dependent on their husbands, enjoyed a good deal of economic stability and social security and regarded the work of raising children as socially important, skilled labor. Suzanne Vogel, one of the first Western scholars of the Japanese family, remarked that one rarely hears a Japanese woman refer to herself as “just a housewife.”

In some ways, the family values that have defined the discourse on pregnancy and abortion have recently come to dissuade women from having children—an irony that is visible in other “family friendly” nations, such as Italy, Spain, and South Korea. Ideals concerning motherhood are so high that it is difficult to combine them with women’s advancement in the labor force, and economic instability has made the single wage-earner model less viable for many. While it is tempting to see the low fertility rate as evidence of “women’s liberation” or a rebellion from traditional roles, there is evidence, in Japan at least, that it marks a continuing conservatism in what constitutes an ideal child-rearing environment.

Japan stands out, for example, for its low incidence of children born out of wedlock—despite the conditions of urbanization and rising rates of education for women that made illegitimacy more common in other industrialized nations. In Japan, more than half of all premarital pregnancies to women aged fifteen to twenty-nine between the years 2000 and 2004 were aborted; 38 percent of pregnancies to this age group ended up as marital births. Only 4 percent led to non-marital births. (In the United States, almost 50 percent of non-maritally conceived children result in nonmarital births.) Oxford University sociologist Ekaterina Hertog interviewed sixty-eight women from the small population of women in their thirties and forties who decided to give birth outside of marriage. All emphasized the difficulty of their decision. Her recent book, Tough Choices, demonstrates the preference among women to raising children within a dual-parent household, preferably with a primary wage-earner. Single motherhood almost always compels Japanese women to work outside the home. Japanese social support for single mothers is not generous, though it is somewhat more expansive than in the United States, and the women whom Hertog interviewed told her that having a father and breadwinner in the house allows women to be more present mothers—although such a father may be remote from the daily goings-on of family life. For many women in such circumstances, abortion is deemed the “responsible” choice, despite the often powerful desire to have a child.

Japan’s entrenched division of labor and conservative ideals about family are hardly enviable, and we might argue that Japan’s liberal policy around abortion helps to reinforce those ideals. Although Japan was one of the first nations to permit legal abortion, the law was passed from on high and reflects less concern with women’s “choice” or sexual freedom than with producing appropriate mothers and children, as some feminists have pointed out.

There are other reasons not to envy Japan. Japanese women have a high abortion rate. Abortion has continued to be the predominant form of birth control in Japan well after the invention and legalization of birth control medication in many other industrialized countries. A revealing study by political scientist Tiana Norgren showed how a cluster of professional groups with a vested interest in defending access to abortion (midwives, ob-gyns, and even feminists who worried about the pill’s health effects) obstructed the legalization of the birth control pill until 1999—more than forty years after Food and Drug Administration approval of the first pill in the United States. Given the political and economic conflicts in the country, there is no cause to celebrate the normalcy of abortion.

Still, to the extent that termination of pregnancy is inevitable in some cases, can we not find something useful in the ability to cast this decision in terms of its consequences for social stability and care for others? And should we not envy this society’s recognition and value of the dignity and importance of parenting? Japanese attitudes toward pregnancy are fully entwined with an appreciation for the importance of parenthood, an ideal celebrated in popular U.S. culture but disdained in social and economic policy and at the workplace. Can we not find here a way around the discourse that currently pits a woman’s “choice” against the sanctity of a fetus’s “life”?

In reagrding abortion as an aspect of social welfare, health, and family, Japan is not unusual among social democracies. Germany, the United Kingdom, Switzerland, Canada, and many of the East European post-socialist societies harbor similar politics and trade-offs. In Germany, abortion has been legally sanctioned as a matter of “protection”—the responsibility of the welfare state to care for German families. The 1994 law that went into effect after German unification legalized women’s rights to terminate a pregnancy within the first trimester; it linked this with state-funded abortions for women on welfare and promises to increase state support for kindergartens and other aid for childcare. In essence, the German courts weighed the potential hardship of the mother against their emphasis on the sanctity of human life. While the state requires counseling which must be “pro-life oriented but outcome-open,” the law defines its responsibility as being to “help not punish” the pregnant woman.

In Canada, just across the U.S. border, law and court deliberations on abortion led to allowing abortion largely as a matter of universal provision of health care (with health defined as emotional, physical, or psychological). Although some Canadian pro-choice feminists have expressed envy of the protection of abortion as a woman’s private right in the United States, there is a reluctance to regard the matter of abortion as a “private” matter. Abortions are financed by public insurance in Canada—a provision that was excluded from Roe v. Wade and remains one of the most contentious issues in U.S. social policy. As William Saletan and others have noted, Roe v. Wade’s protection of abortion through women’s right to privacy set the stage for the retrenchment of abortion services across the country; states may not interfere with a woman’s right to an early abortion, but they are under no legal responsibility to provide them.

What makes the German and Canadian legislation stand out in contrast to Roe v. Wade, is their focus on protection. German law, like West European law more broadly, emphasizes public health and humanitarian justifications for the practice of abortion: the social costs of unwanted pregnancy, health risks to women, the psychic toll of raising unwanted children, and the state’s positive obligation to protect women. In contrast, Roe v. Wade defined the right to first-trimester abortion primarily in terms of negative liberty—the right of the individual to decide for herself whether abortion is appropriate; it deliberately and explicitly excluded the possibility of the state’s consideration for women’s broader social circumstances.

These comparisons help us frame a bigger picture: nations that see abortion in terms of social welfare are paternalistic, “nannying,” and often socially conservative, viewing motherhood as women’s primary role. Concerns for “quality” of population and family values are sometimes uncomfortably close to concerns for social homogeneity, elitism, and what could potentially become intolerance. A woman’s right to a first-trimester abortion on any grounds in the United States is envied by many women around the world. But, as many other commentators on the debate in the United States have asked, to what extent are we protecting women’s “freedom,” “choice,” or “autonomy” when we focus on abortion as a right in the absence of other social protections for women and families: subsidized day care, job security, a family wage, quality public education, and universal health care?

Roe v. Wade created the possibility for women to have control over their lives and choices. But the discourse of “choice” alone has not provided a sustaining moral framework for handling the necessity of abortion, which will always be a final recourse. What is needed is a framework that can simultaneously be compatible with liberal and feminist values.

In fact, the inadequacy of our current categories has been known for some time. In the early 1980s, in a study widely known among anthropologists, Faye D. Ginsburg (Contested Lives: The Abortion Debate in an American Community) listened to women in Fargo, North Dakota, after the opening of the controversial Fargo Women’s Health Center. The pro-life activists remembered their mothers’ suffering in raising children they could not afford; the pro-choice activists described what they called their “Midwestern feminism,” rooted in responsibility to kin, community, and a larger social order. Both saw reproductive decision-making as an opportunity to affirm the importance of family and nurturance in the context of a society that they perceived as increasingly committed to rationalism and personal fulfillment.

Yet it is surprising how little the current discourse on either side of the abortion debate is connected to family and social welfare (although in the United States, too, the promotion of birth control was linked to eugenic concerns through the mid-twentieth century). It is a pattern that differentiates American feminism from many industrial democracies, as Eastern Europeanist Kristen Ghodsee and I have noted in an unpublished essay, “Is Individual Liberation Good for Women?” arguing that feminism in the social democracies and post-socialist East Europe has emphasized a better life for women through securing social and economic security, even at the cost of individual liberties.

Perhaps the hesitation to address abortion rights in the context of family is also because the Left has had to respond to an increasingly extremist Right. The conservative judges who dissented in Roe v. Wade worried that the decision disempowered individual states from wrestling with the “relative importance of the continued existence and development of the fetus…against a spectrum of possible impacts on the mothers.” These judges recognized the need to balance competing needs within the family. However, the humanization of the fetus in today’s political environment feels threatening rather than considerate, as conservatives push to use ultrasound images to change the minds of women who seek to terminate their pregnancies. And then there are cases of women who have been prosecuted for unhealthy practices such as smoking or other drug abuse while pregnant.

How can liberals include a concern for family in their discourse, so as not to cede this issue to the Right? Some thinkers, such as the communitarian moral philosopher Michael J. Sandel, have suggested that liberals must take a position on the life of the fetus; they can no longer ignore the issue. Feminist provocateur Naomi Wolf wrote in the New Republic several years ago that liberals must recognize abortion’s inhumanity. Others, such as the moral philosopher Judith Jarvis Thompson, have made the case that even if we grant the humanity of the fetus, a woman is still not ethically obliged to keep it. All these interventions are helpful. But what I am suggesting here is slightly different; it is a greater focus on the dignity and importance of parenthood.

From a medical standpoint, some have begun to question whether obstetrical practices that are rooted in the view of the fetus as autonomous constitute “best practices.” In a recent issue of Obstetrics and Gynecology, A group of medical sociologists, philosophers, and ethicists founded by Anne D. Lyerly and Maggie Little, who focus on the issue of risk in obstetrical practice, expressed concern with obstetrical practices that are rooted in the view of the fetus as autonomous. They explore, for instance, how obstetricians should ethically balance a mother’s need for antidepressants or asthma medications against the small likelihood of risk to the fetus. Should not physicians take into account the indisputable truth that the welfare and empowerment of the mother are also related to the outcome of the pregnancy?

As pundits, politicians, physicians, and others grapple for some vocabulary to enter into this new terrain, popular culture is already moving out in front. The 2007 film Juno, for example, captured pregnancy in a way that was startlingly fresh, highlighting the inadequacy of the standard “pro-choice” rhetoric, while remaining firmly in the liberal camp. Juno plays with all the tropes of “pro-life” and “pro-choice” discourse, tossing them aside like so many clichés. Upon learning that she is pregnant from a sexual encounter with her high school boyfriend, Juno, a slacker-type who lives with her father and step-mother, dutifully phones a clinic she finds in the yellow pages (“Women Now”), telling them in dead-pan fashion that she wishes to “procure a hasty abortion.” (She reassures her boyfriend that she intends to “nip it in the bud.”) In front of the clinic, Juno finds her high-school friend Su-Chin, carrying placards and chanting perfunctorily, “All babies want to get born!” Juno shrugs off her friend and proceeds into the clinic. In the end, however, she is unable to go through with the procedure. She leaves the clinic and, after deliberating with another friend, instead decides to seek a family to adopt the baby, consulting the classifieds in the local paper. Amid the advertisements, Juno finds an elegant, loving, stable young couple who, she decides, will be the perfect parents, and, in what follows, Juno cultivates a deep attachment to the new parents.

Through her connection to them, Juno experiences many parent-like moments, sharing images of the ultra-sound, imagining names, and visiting the home during the daytime to bond over music and horror films with the husband. In one scene, Juno and the husband begin to dance, listening to oldies, and, as Juno rests her head on the husband’s shoulder, her pregnant stomach protruding between them, one senses that Juno has fallen in love with him—but less as an object of erotic desire and more as the father of her imagined child. In another scene, Juno encounters the wife at a shopping mall and beams as the prospective mother is able to feel the baby kick.

Through this romantic fantasy, the movie offers a different approach to the politics of pregnancy. Liberals can be moved by Juno’s decision to carry the baby to term, because it is rooted in something different from the inherent personhood of the fetus (“the right to life”). At the same time, Juno’s “choice” is not constructed in terms of autonomy or freedom but rather in the context of Juno’s growing relationships to others: the new mother Juno chooses to adopt the baby; Juno’s old-fashioned working-class dad, who, despite what he might consider a source of “shame,” supports her decision; and, in particular, one of the film’s heroes, Juno’s imperfect stepmother, a hard-bitten woman who becomes Juno’s champion and caregiver during her pregnancy, but who doesn’t hesitate to remind Juno of the sacrifices she has made to help raise her and her sister. The handsome husband of the young couple (the prospective father) who, through Juno, clings to his fantasy of remaining young and unburdened is the one figure regarded with disdain. What Juno’s pregnancy affirms is neither the autonomy of fetus or woman but the value of committed social relationships, the desire to make a social contribution, and the struggle to care for those one is responsible for.

Policy analysts, moral philosophers, and social scientists—all have expressed dissatisfaction with the stale terms of the debate on abortion and the fetus. As the debate unfolds, encumbered by the language of autonomy and rights that both sides marshal to make their case, it is worth remembering that the United States looks unusual in the context of other industrial democracies, and that elsewhere it is more intuitive for liberals as well as conservatives to see pregnancy—and abortion—in terms of family.