Analysis Law and Policy

When Lying To Women Is Mandated Care: Informed Consent, Abortion, and the Role Played by Justice Kennedy

Jessica Mason Pieklo

The Eighth Circuit Court of Appeals gave constitutional protection to misleading women seeking abortion care. Now it will almost certainly rest on Justice Kennedy to address challenges to informed consent laws, problems with which can be traced back to him in the first place.

Find all articles about this court decision here.

The federal judiciary is in the process of rendering the idea of “informed consent” in the context of abortion all but nonsensical and there may be nothing we can do about it.

On Tuesday the Eighth Circuit Court of Appeals upheld the constitutionality of a South Dakota law that requires doctors to inform women seeking abortions that they face an increased risk of suicide should they go forward with the procedure. The reason the suicide-link mandate, a provision tied up in litigation since 2005, was deemed acceptable to the seven conservative justices and Reagan appointees, was because the statement was deemed “truthful.”

Of course the “truth” of suicide-abortion link is hardly truth at all. The analysis of data on which the judges was at least partly based is considered so flawed the journal that published the findings originally is considering retracting the article together. In trial and appeal Planned Parenthood and the challengers submitted extensive data to rebut the claim that abortion is linked to suicide in their challenge of the law.

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So how was the Eight Circuit able to support such a finding? Thank Supreme Court Justice Anthony Kennedy.

Regulations that dictate what doctors must tell a woman seeking an abortion are based on two competing constitutional principles. On the one hand, an abortion restriction cannot place an undue restriction on a woman’s right to choose, and on the other doctors cannot be “compelled” to speak in a commercial context except under certain conditions. For such a regulation to be constitutional it cannot impinge on either of these constitutional protections.

In the context of the South Dakota and other “informed consent” restrictions, that means regulations that script disclosures for doctors or detail what information must be disclosed can only be constitutional if the information is truthful and not misleading and designed to help a woman understand the “full complexity” of her decision. It’s a standard first fully articulated by Justice Anthony Kennedy in Planned Parenthood v. Casey and, on it’s face, is not much more than any other informed consent requirement for any other medical procedure.

But because we’re talking about abortion there’s more.

Thanks also to Justice Kennedy, this time in Gonzales v. Carhart, the case that upheld the constitutionality of the federal partial birth abortion ban, states are free to pass informed consent laws that favor childbirth over abortion. So long as the information isn’t based on a lie, those laws will not be considered an undue burden on women’s right to choose abortion. And, in the process of passing laws that favor childbirth over abortion, states are not restricted to only regulating in areas of medical certainty. In Carhart, Kennedy held that when there’s a lack of medical consensus on an issue, legislators are free to pick the evidence they prefer. Once that choice has been made, should the law favoring childbirth over abortion face a legal challenge, judges are required to defer to those legislative choices, even in the face of a mountain of evidence that legislators’ choice is wrong.

It was an open invitation for anti-choice activists and conservative legislators to start producing their own “evidence” and creating their own facts which were then put in bills that “empowered” women by providing them more information before they could have an abortion. It’s an invitation they accepted with gusto. “Informed consent” for an abortion now requires, depending on the state, a warning that abortions can lead to suicide and a vaginal ultrasound where the doctor performing the ultrasound describes in detail the fetal image, and may include mandate crisis pregnancy center counseling.

In each of those instances doctors go from being an advocate of the patient and a representative of the best possible medical consensus to an advocate for the anti-choice cause. It’s nothing short of a perversion of the doctrine of informed consent and, to make it worse, in each case it is supported by the theory that these laws empower women.

In no other medical context do we regulate informed consent disclosures the way we do in abortion cases. The standard of care for medical professionals is to advise of any reasonable medical risk. If suicide was a reasonable medical risk associated with abortion then doctors would already have an obligation to disclose it in the context of a consultation. That this is not standard medical practice but one invented by anti-choice legislators says all that needs to be said about the truthfulness of these disclosures or the necessity of these practices.

This is an issue that will likely be settled by the Supreme Court. This decision, the 5th Circuit decision upholding mandatory vaginal ultrasounds, as well as the vaginal ultrasound case in the 4th Circuit Court of Appeals out of North Carolina all revolve on this issue of “empowering” women by subjecting them to unnecessary and medically- inaccurate, indeed outright false, information in the course of obtaining their informed consent for an abortion. Should the 4th Circuit Court of Appeals rule against North Carolina’s ultrasound law, Supreme Court intervention is all but a done deal.

Which means it all rests in Justice Kennedy’s hands. Again.

Commentary Contraception

Hillary Clinton Played a Critical Role in Making Emergency Contraception More Accessible

Susan Wood

Today, women are able to access emergency contraception, a safe, second-chance option for preventing unintended pregnancy in a timely manner without a prescription. Clinton helped make this happen, and I can tell the story from having watched it unfold.

In the midst of election-year talk and debates about political controversies, we often forget examples of candidates’ past leadership. But we must not overlook the ways in which Hillary Clinton demonstrated her commitment to women’s health before she became the Democratic presidential nominee. In early 2008, I wrote the following article for Rewirewhich has been lightly edited—from my perspective as a former official at the U.S. Food and Drug Administration (FDA) about the critical role that Clinton, then a senator, had played in making the emergency contraception method Plan B available over the counter. She demanded that reproductive health benefits and the best available science drive decisions at the FDA, not politics. She challenged the Bush administration and pushed the Democratic-controlled Senate to protect the FDA’s decision making from political interference in order to help women get access to EC.

Since that time, Plan B and other emergency contraception pills have become fully over the counter with no age or ID requirements. Despite all the controversy, women at risk of unintended pregnancy finally can get timely access to another method of contraception if they need it—such as in cases of condom failure or sexual assault. By 2010, according to National Center for Health Statistics data, 11 percent of all sexually experienced women ages 15 to 44 had ever used EC, compared with only 4 percent in 2002. Indeed, nearly one-quarter of all women ages 20 to 24 had used emergency contraception by 2010.

As I stated in 2008, “All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.”

Now, there are new emergency contraceptive pills (Ella) available by prescription, women have access to insurance coverage of contraception without cost-sharing, and there is progress in making some regular contraceptive pills available over the counter, without prescription. Yet extreme calls for defunding Planned Parenthood, the costs and lack of coverage of over-the-counter EC, and refusals by some pharmacies to stock emergency contraception clearly demonstrate that politicization of science and limits to our access to contraception remain a serious problem.

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Today, women are able to access emergency contraception, a safe, second chance option for preventing unintended pregnancy in a timely manner without a prescription. Sen. Hillary Clinton (D-NY) helped make this happen, and I can tell the story from having watched it unfold.

Although stories about reproductive health and politicization of science have made headlines recently, stories of how these problems are solved are less often told. On August 31, 2005 I resigned my position as assistant commissioner for women’s health at the Food and Drug Administration (FDA) because the agency was not allowed to make its decisions based on the science or in the best interests of the public’s health. While my resignation was widely covered by the media, it would have been a hollow gesture were there not leaders in Congress who stepped in and demanded more accountability from the FDA.

I have been working to improve health care for women and families in the United States for nearly 20 years. In 2000, I became the director of women’s health for the FDA. I was rather quietly doing my job when the debate began in 2003 over whether or not emergency contraception should be provided over the counter (OTC). As a scientist, I knew the facts showed that this medication, which can be used after a rape or other emergency situations, prevents an unwanted pregnancy. It does not cause an abortion, but can help prevent the need for one. But it only works if used within 72 hours, and sooner is even better. Since it is completely safe, and many women find it impossible to get a doctor’s appointment within two to three days, making emergency contraception available to women without a prescription was simply the right thing to do. As an FDA employee, I knew it should have been a routine approval within the agency.

Plan B emergency contraception is just like birth control pills—it is not the “abortion pill,” RU-486, and most people in the United States don’t think access to safe and effective contraception is controversial. Sadly, in Congress and in the White House, there are many people who do oppose birth control. And although this may surprise you, this false “controversy” not only has affected emergency contraception, but also caused the recent dramatic increase in the cost of birth control pills on college campuses, and limited family planning services across the country.  The reality is that having more options for contraception helps each of us make our own decisions in planning our families and preventing unwanted pregnancies. This is something we can all agree on.

Meanwhile, inside the walls of the FDA in 2003 and 2004, the Bush administration continued to throw roadblocks at efforts to approve emergency contraception over the counter. When this struggle became public, I was struck by the leadership that Hillary Clinton displayed. She used the tools of a U.S. senator and fought ardently to preserve the FDA’s independent scientific decision-making authority. Many other senators and congressmen agreed, but she was the one who took the lead, saying she simply wanted the FDA to be able to make decisions based on its public health mission and on the medical evidence.

When it became clear that FDA scientists would continue to be overruled for non-scientific reasons, I resigned in protest in late 2005. I was interviewed by news media for months and traveled around the country hoping that many would stand up and demand that FDA do its job properly. But, although it can help, all the media in the world can’t make Congress or a president do the right thing.

Sen. Clinton made the difference. The FDA suddenly announced it would approve emergency contraception for use without a prescription for women ages 18 and older—one day before FDA officials were to face a determined Sen. Clinton and her colleague Sen. Murray (D-WA) at a Senate hearing in 2006. No one was more surprised than I was. All those who benefited from this decision should know it may not have happened were it not for Hillary Clinton.

Sometimes these success stories get lost in the “horse-race stories” about political campaigns and the exposes of taxpayer-funded bridges to nowhere, and who said what to whom. This story of emergency contraception at the FDA is just one story of many. Sen. Clinton saw a problem that affected people’s lives. She then stood up to the challenge and worked to solve it.

The challenges we face in health care, our economy, global climate change, and issues of war and peace, need to be tackled with experience, skills and the commitment to using the best available science and evidence to make the best possible policy.  This will benefit us all.

News Health Systems

The Crackdown on L.A.’s Fake Clinics Is Working

Nicole Knight

"Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options," Feuer said. "And therefore every day is a day that a woman's health could be jeopardized."

Three Los Angeles area fake clinics, which were warned last month they were breaking a new state reproductive transparency law, are now in compliance, the city attorney announced Thursday.

Los Angeles City Attorney Mike Feuer said in a press briefing that two of the fake clinics, also known as crisis pregnancy centers, began complying with the law after his office issued notices of violation last month. But it wasn’t until this week, when Feuer’s office threatened court action against the third facility, that it agreed to display the reproductive health information that the law requires.

“Why did we take those steps? Because every day is a day where some number of women could potentially be misinformed about [their] reproductive options,” Feuer said. “And therefore every day is a day that a woman’s health could be jeopardized.”

The facilities, two unlicensed and one licensed fake clinic, are Harbor Pregnancy Help CenterLos Angeles Pregnancy Services, and Pregnancy Counseling Center.

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Feuer said the lawsuit could have carried fines of up to $2,500 each day the facility continued to break the law.

The Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act requires the state’s licensed pregnancy-related centers to display a brief statement with a number to call for access to free and low-cost birth control and abortion care. Unlicensed centers must disclose that they are not medical facilities.

Feuer’s office in May launched a campaign to crack down on violators of the law. His action marked a sharp contrast to some jurisdictions, which are reportedly taking a wait-and-see approach as fake clinics’ challenges to the law wind through the courts.

Federal and state courts have denied requests to temporarily block the law, although appeals are pending before the U.S. Court of Appeals for the Ninth Circuit.

Some 25 fake clinics operate in Los Angeles County, according to a representative of NARAL Pro-Choice California, though firm numbers are hard to come by. Feuer initially issued notices to six Los Angeles area fake clinics in May. Following an investigation, his office warned three clinics last month that they’re breaking the law.

Those three clinics are now complying, Feuer told reporters Thursday. Feuer said his office is still determining whether another fake clinic, Avenues Pregnancy Clinic, is complying with the law.

Fake clinic owners and staffers have slammed the FACT Act, saying they’d rather shut down than refer clients to services they find “morally and ethically objectionable.”

“If you’re a pro-life organization, you’re offering free healthcare to women so the women have a choice other than abortion,” said Matt Bowman, senior counsel with Alliance Defending Freedom, which represents several Los Angeles fake clinics fighting the law in court.

Asked why the clinics have agreed to comply, Bowman reiterated an earlier statement, saying the FACT Act violates his clients’ free speech rights. Forcing faith-based clinics to “communicate messages or promote ideas they disagree with, especially on life-and-death issues like abortion,” violates their “core beliefs,” Bowman said.

Reports of deceit by 91 percent of fake clinics surveyed by NARAL Pro-Choice California helped spur the passage of the FACT Act last October. Until recently, Googling “abortion clinic” might turn up results for a fake clinic that discourages abortion care.

“Put yourself in the position of a young woman who is going to one of these centers … and she comes into this center and she is less than fully informed … of what her choices are,” Feuer said Thursday. “In that state of mind, is she going to make the kind of choice that you’d want your loved one to make?

Rewire last month visited Lost Angeles area fake clinics that are abiding by the FACT Act. Claris Health in West Los Angeles includes the reproductive notice with patient intake forms, while Open Arms Pregnancy Center in the San Fernando Valley has posted the notice in the waiting room.

“To us, it’s a non-issue,” Debi Harvey, the center’s executive director, told Rewire. “We don’t provide abortion, we’re an abortion-alternative organization, we’re very clear on that. But we educate on all options.”

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