«x; I z D T I .1" k ‘2 r " . 1 3' ‘ '6 HHHHHHHH - _ I THE ABORTION MARKET . {TRANSACTIONS IN A RISK COMMODITY I Thesis ToT The Degree 0T Ph. D i I, MICHIGAN STATE UNIVERSITY NANETTEI DAVIS 1973 ”HEW LIBRARY Michigan State University 3a“ 7.9 a, as» . an" JLI" L a, If ‘ .101": V mm III: dissertation ‘ III: In Iichigan (before ITIhIaIe 1972. The ethl hm presented differei War stnxmresufm Ihhtivity. This my W «cm of diffEl "IIIhizationaI consequl IIIITI clergy pMIQpI ABSTRACT THE ABORTION MARKET: TRANSACTIONS IN A RISK COMMODITY By Nanette J. Davis This dissertation traced the formation and change of the abortion market in Michigan (before abortion was legalized) from approximately I967 tolate 1972. The ethnographic study has two foci. On the one hand, we presented different phases of the market-~Iegal, illegal, and broker structures--from the point of view of various actors involved in the activity. This required a multi-perspective analysis, or one that took account-of differently positioned actors, their motives, acts, and organizational consequences. 0n the other hand, we emphasized the role of a clergy problem-pregnancy counseling and abortion-referral movement in transforming the traditional market, characterized here as a risk structure. Risk, or excessive costs, for providers and consumers. was an essential feature of the abortion market in both legal and illegal phases. By providing alternative resources (i.e., counseling and abortion referral) to those blocked by legitimate health groups, clergy brokers eliminated moral, economic, and social barriers to the receipt of services by consumers. n. basic asst!!!“ 13‘st (nudity 93" Indians. This asswI LIIIII, E. n. Schur. melted costs as consec satin. Tie asswtim S It": I.‘ abortion services iihtuere the social an manners of abortion There aItematIve so WIT he cIergy me: Before the rise of Ir“Innocents took en IIerer IIIited the Edica In “E III. videsprea “I“ ProfessionaISp mt” ”Med to a situation “3MP! INVIM- 4m WW II mom In! MIT“ and Dmfes $51 “In ISIIVOIvedne Nays new“ “VI psychiatric IIIn InTOI abomon II "s "i" as Iedio Nanette J. Davis The basic assumption ofthe study was that social control of a high-demand comnodi ty generates systematic rule evasion and alternative social forms. This assumption was derived primarily from the work of E. M. Lemert, E. M. Schur, and H. L. Packer, who consider economic crimes and related costs as consequences of normative or legally-induced scarcity. The assunption guided three empirical questions: (I) What kinds of abortion services were available under conditions of control? (2) What were the social and economic costs for legitimate and illegiti- mate providers of abortion and for consumers of these services? (3) How were alternative sources of supply generated, sustained, and changed by the clergy movement? Before the rise of the clergy counseling movement, traditional market arrangements took the following form: A proscriptive law severelynlimited the medical profession from giving hospital abortions. At the same time, widespread rule violation by women seeking abortions and by some professionals providing referral or direct services contributed to a situation of sporadic, ineffective legal enforcement. Services were provided--but at a price--which lacked quality control and regulation by public and professional bodies. Costs for providers included legal and. professional sanctions; for consumers, hospital abortions involved delays (often beyond the "safe" period for terminating the pregnancy), psychiatric labels, and for some, sterilization as a conditionnfor abortion. Illegal abortion, while more available, was expensive, as well as medically and psychologically hazardous. hdnnging the ri mtupIoited resourc markers. and volmt rhehbortionists) to mice the state. for In tscn'bing the . “TIM to role phases: ”MW We” (the le Thrown absorized cos New by issuing l MUN Stm'ces and re Shit risk by incorporatii Tisha] ”d “I Persons, (”Nils of mm 5thin of the brokerage “Women. in Nanette J. Davis In changing the risk structure of this market, the clergy movement exploited resources from both legitimate (vi 2., physicians, agency workers, and volunteer women) and illegitimate sectors (viz., criminal abortionists) to provide new service channels, both within and outside the state, for consumers. In describing the evolution of the clergy movement, we analyzed two role phases: clergy entrepreneurs (the risk-taking role) and clergy brokers (the legitimating role). In phase one, clergy entrepreneurs absorbed costs for producers and consumers participating in the market by assuming primary legal and professional risk for organizing services and referring clients. In phase two, clergy brokers spread risk by incorporating a variety of agencies, as well as pro- fessional and lay persons, into the new health delivery network. Outcomes of movement activities were traced by examining (l) the extension of the brokerage (or referral system) into agency practice, (2) consumer experience in movement routing, and (3) a series of meetings constituting attempts by health planners (including clergy, public health groups, physicians and other health occupations) to legitimate abortion by setting up future rules for abortion practice. In treating the latter as a crucial case in abortion reform, we emphasized the issues and politics in terms of which clergy and supporters negotiated to champion abortion as a "normal" medical event. For example, we considered the changing structure of the physician's role in abortion practice, and suggested how this service was intricately related to crisis and change in the health field. mmimlizm . Imminent ““1 ”i" fermion a different seI It} M9! "'3 ”I“ St" was mrariiy ”a“ :‘Ian'ntim, once 95““ alias of practice. W :ntessimai traditions and :‘d'yedIy refon was I" this little likelihood iTTIISIVIaI services fl'TI It. access lilited to a Tisiumnl opposition. iliters of the tradi ti Ona‘ WI legalized Darket. III “Id Ittblentic healt {in Nanette J. Davis Institutionalizing and legitimizing processes, we concluded, are both divergent and discontinuous. For, with recent legalization of abortion a different set of actors and conditions will arise that will change the market structure once again. Thus, while social movements temporarily redistribute social corrmodities under conditions of deprivation, once established groups move into this area as regulators of practice, the market will be shaped to conform to their professional traditions and expectations. Despite the strategic role played by reform groups in setting up a new health delivery system, there is little likelihood that the system will persist. Withdrawal of professional services from certain groups (e.g. poor, black), high prices, access limited to ability-to-pay, hospital restrictions, religious-moral opposition, and legislative regulations--all of them holdovers of the traditional order-ware likely to be chronic features of the newly legalized market. Abortion promises to continue to be a costbrand problematic health commodity for producers and consumers alike. IIIEBOII . Inch ‘" Partial n, r I1) Dena THE ABORTION MARKET: TRANSACTIONS IN A RISK COMMODITY BY Nanette waDavis A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY Department of Sociology 1973 Copyrighted by: NANETTE J . DAVIS 1973 ‘i‘I The mletion of t ItIttdtnbutors. I an in midi faulty and staff 0 Meta career rho pmyi de sTIaIIzatIm. Fiducial assistanc titted! the freak. to p mm- WittonaI fin 5th hm Mounted 3 Ohm This dissertat Thigh, IIIII SWPOI‘I yea [WWI Irish e Ashton] Efforts quid I‘nhu Wither. and f the and ”emotive gr IIth to “Hate, has TIMI II gramm Mica ACKNOWLEDGEMENTS The completion of this dissertation reflects the handiwork of many contributors. I am indebted to the continuing support and encourage- ment of faculty and staff of the Sociology department over a five—year graduate career who provided ideal working conditions for my professional socialization. Financial assistance from Michigan State University funding granted me the freedom to pursue research interests, culminating in this study. Additional financial aid from the National Institutes of Mental Health promoted a full-time commitment to fieldwork, enabling me to launch this dissertation project, even if I could not finish it during the NIMI support year. I especially wish to express my deep appreciation to those whose personal efforts guided me through the often hazardous process of problem conception and fieldwork. Bo Anderson, whose extensive knowledge and perceptive grasp of the sociological enterprise stands as a model to emulate, has been a vital intellectual source for all phases of my graduate education, as well as for this research. His Impatience with glib sociological doctrines and his insistence on probing issues, whether empirical or theoretical, stimulated me to wrestle with data that often seemed resistant to analysis. Peter Manning's intellectual energy and zeal to conmunicate new, often unpopular, ideas in the field helped initiate and sustain my iii nitsinlilm maria In I Mm than?! made: to old PM)" ndsncioIIIT‘t guide thh is 51mm] 995mm." anion as a ”I“ attend evaluation of an “flier d nettle one. I “9 it to merMcmiaI Sui "ITTIIIT draft. hnhlter, Pat Hot nits on nri0us stages ‘ hgntitude also 6 norsnted to intern/Tats 1' large part, this dissert 3th Conselling Service III of abortion services than and staff of thi Titussocial action and "homer. Wm?“ dates, I for the res If the years of g It duty. Into ”Ah professionalizing experience. His critical thinking of current assump— tions in Deviance theory first generated my own efforts to develop new approaches to old problems. William Form has been a provocative teacher and sociologist guide through earlier phases of my graduate training. His structural perspective, hopefully, is reflected in this study of abortion as a market phenomenon. Barrie Thorne offered an intensive evaluation of an earlier draft of the dissertation. If the study is a readable one, I owe it to her fine editing. James McKee and Arnold Werner provided crucial suggestions, which I attempted to incorporate in a final draft. Mary Walker, Pat Woirol and Dawn Thelen were devoted and skilled typists on various stages of the research. My gratitude also extends to the many persons and organizations who consented to interviews or shared documents, letters and memoranda. In large part, this dissertation documents the efforts of the Michigan Clergy Counselling Service for Problem Pregnancy to change the distri- bution of abortion services from a producer's to a user's market. To the clergy and staff of this organization, my deep appreciation for courageous social action and willingness to share ideas and information with an outsider. My husband, James, has been both intellectual confidant, and inspiring model for the research enterprise. His loving patience and support over the years of graduate work goes beyond any normal limits of husbandly duty. To my children, Katherine, Susan, Elizabeth, Timothy, Michael and Patricia, a special thanks for helping to hold the domestic ship together during their mother's frequent absences from home. iv I hnhdmts ...... cfiaIIes ...... ischiigures ...... .‘stdbnsu .. . ' .. I'ITI 3' THE IDRTIOI MARKET: “SI! EntrfiltrerIeui-ia Stmcture . . . . cIICIusinn ..... insorw Ti“ H W1 CONTEXT c Introdumm . ‘ . . Tomi Rules-An Ore "It Decisions ch, TIe'SIeve EffeCtu . 5‘” and Conclusi TABLE OF CONTENTS Page Acknowledgements ....................... iii List of Tables . ........... . .......... ix List of Figures . . . . . . . . . . . . ........... xi List of Maps ......................... xiii CHAPTER I. THE ABORTION MARKET: AN OVERVIEW .......... 1 Risk, Entrepreneurial Activity and the Broker Structure ..................... 5 Conclusion ...................... 12 II. THE SOCIAL CONTEXT OF THE ABORTION MARKET: THE TWO FACES OF LAW .......... . . ........ l8 Introduction .................... 18 Formal Rules--An Overview of the Abortion Law . . . . 20 Court Decisions Clarifying Legal Questions ...... 2l Rules-In—Use—-The Organization of the Criminal Court . 25 The "Sieve Effect" Model in Enforcement Procedures . . 27 Summary and Conclusions . .............. 37 III. HOSPITAL-MEDICAL MANAGEMENT OF ABORTIONS . ...... 43 Management of Abortions ............... 43 Tenmination of Pregnancy: Methods and Complications . 44 An Historical Overview of Legal Abortions in Michigan. 46 Processing Abortion Patients: Hospital Management in Two Settings . . ....... . . . . . 52 The Settings--Metro and Community Hospitals ..... 52 Metro Hospital . . . . ...... . ..... . . 53 Community Hospital . ............... 55 Professional Conceptions--Values, Ideology and RationaTeflTBF’Abortion Service ........ . . . 59 Metro Hospital ......... . ........ 59 Comnunity Hospital . . . ......... . . 6l The Patients--Characteristics. of Clientele in the Two Settings . . . . . . . 66 Abortion Programs--Control Features in the Two SEttTflgS.....-....c. o. ........ 69 V H11: nnmm Itont.) IIIII iii. tmtinued Ibtm Hospital [unity Tbsp‘ Indications of k1 tests . . . . . . Cmchsion . . "1'. HS ILLEGAL mm; Manama rm Innnction . . . TIE EXOIdI'm Mr- HoSPI'tal tinge HENRI "emf- Phase I: Mm” PM: 0Ut-of-St. Phase 3: Clergy Cod WESTON Fr " MWTIOI or R; Mm IBORIIOI 3R0. PHI I, m Ent: Imam-o? Indiana] ACCT! TABLE OF CONTENTS (Cont.) CHAPTER III. IV. Cmfinmd Metro Hospital--Strategies of Control ....... Community Hospital--Strategies of Control ..... Implications of Medical Control: Access and Social Costs . ....................... Conclusion ..................... THE ILLEGAL MARKET: ROLE OF THE MIDDLEMAN IN MEDIATING AND REGULATING TRADE Introduction .............. . . . The Exchange 0rder--Sustaining the Illegal System . Hospital Emergency Room .............. Referral Networks ................ Phase I: Underworld Linkages .............. Phase 2: Out-of—State Legal and Illegal Resources Phase 3: Clergy Connectors .............. Professional Friendship-Colleagial Linkages . . Market Operations of Physician-Abortionists . . Legitimate Control Over Illegal Practice ..... The Role of the Abortionist in Change . . . . Conclusions . . ...... . TRANSFORMATION OF RISK: RISE AND DEVELOPMENT OF A CLERGY ABORTION BROKER MOVEMENT ............ PART I. Clergy Entrepreneurs: Building the Organization ................... Individual Actions--Pre- Movement Activities . Entrepreneurial Role--Launching a Movement Constructing a Moral Mandate . ......... I . Defining the Role ................. Building the Referral Network ........ . The Referral Network . . ........... PART II. Clergy-Brokers--Sustaining the Organization . Broker Arrangements . . . ............ The Counseling-Referral Format ........ . The Brokers--Nho Are They? ............ Conception of the Role—-Motives, Gains and Costs Counseling and the Client . . . . ........ . Role Commitment ................. Processes of Change in Movement Structure ..... Conclusions . . . . . ............... Page 70 77 82 84 12de (tent-I {TIT II. EIPIIDIIB TIE KENDRA: he 4ng Linkage: rNancy-Cler‘gy-I’Tiys Derry-Agency Lint hiversity Camsei Service-Camus I Business Referral been Liberation-I Lay Volunteer-Elm Agency Variation in Al Patient-Advocate I and Referral . Crisis Client Com Referral . . , Therapy Orientatir Profit Ibdeinkefr Inclusion ..... 'T' TWIN"ER: hunt Batksrotnd Infomtjo Defining the Prob Constructing me IOItacting HEM) EeITIMtI-ng me p In thi INICIUSIOn ‘Il? Th? Ex ' PTED'ISTIIJCTING mg . INTEGRATED cm I” A Sm In, de °f PItient I ”I n Inna-{m "N Leann TABLE OF CONTENTS (Cont.) CHAPTER VI. VII. VIII. EXPANDING THE NETWORK: AGENCY LIAISONS AND PRACTICE . Clergy-Agency Linkages . . . . ............ Agency-Clergy-Physician Linkage . . . . . . . . . Clergy-Agency Linkage .......... . University Counselling Service- -University Health Service-Campus Movement Clergy Linkage Business Referral Groups-Clergy Linkages ..... Women Liberation-Campus Clergy Linkage ...... Lay Volunteer-Clergy Linkage . . . . . ..... Agency Variation in Abortion Practice . . . . . Patient-Advdcate Approach--Medical, Counselling and Referral. . . ............... Crisis Client Conception--Counselling and Referral . . . . . . . . . . . . . . . . . . Therapy Orientation- -Counselling Focus ...... Profit Model--Referral Only . . . . . ...... Conclusion . . . . . ................. THE CONSUMER: MAKING IT THROUGH THE NETWORK . . . . . Background Information--The Sample . . . . . ..... DefiningtheProblem............... Constructing Alternatives . . . . ........ Contacting Help . . . . . . . . . . . . . . . . . Terminating the Pregnancy . . ....... . . Evaluating the Experience . . . ....... . . conc1u510n O O O O O O O O O O O O O O O O 0 O O O O O RECONSTRUCTING THE DOMAIN: INSTITUTIONALIZATION AS A NEGOTIATED ORDER . . . . . . . . . . . . . . . . . . PART I. What Has Changed? ............... A Summary Statement . . . . . ........ . . Sample and Methods . . . . . . . . . Defining the Object--What Does Abortion Mean?. . . . . Social Organization of Services . . . . . . . . . . . Social Control of Abortion Service . . . . . . . . . . Blood Supply . . . . . . . . . . . . . . . . . ModeofPatientReferral....... .. How to Control the Controllers? . ......... . Abortion Terms and Context for Use . ....... . . PART II. Who Legitimates the Changes? . . . . . . . . Fermation, Conflict and Resolution of Rules for Abortion Practice . . . . . . . . . . . . . . . ’ Fermation of Two Political Cultures: Ideological Themes . . . . . . . . . . . . . . . . . . . . . Symbols of Solidarity . . . . . . ..... . . . vii Page 2l7 218 222 223 224 225 225 226 228 233 238 248 251 256 262 264 265 270 270 281 287 297 305 305 305 311 314 317 321 325 327 330 336 342 342 344 348 prom tent.) STIR Til. Tmfinwd Bomdaries of the the Resolution--I hie Resolution--‘ Ionicions . . . . Ifinal how-Ins NUTS det- Methods of lnq Tomlex Social WM- Status of Abor tndix I - Ratios of Repo Births , . . WI 0' 5“”?! Questio Wit- Inter-net Sdse 330nm TABLE OF CONTENTS (Cont.) CHAPTER Page VIII. Continued Boundaries of the Professional Role ........ 351 Rule Resolution--Phase I .......... . . . 366 Rule Resolution--Phase II ........... . . 368 Conclusions....... ...... 369 A Final Note--Inst1tut10ns and Legitimacy ..... 372 APPENDICES Appendix A - Methods of Inquiry: Social Enthnography in Complex Social Situations . . . . . . . . . . . 377 Appendix B - Status of Abortion Laws to April 1, 1971 . . . . 429 Appendix C - Ratios of Reported Legal Abortions to Live Births . .................. . 435 Appendix D - Survey Questionnaire . . ............ 438 Appendix E - Interview Schedule ...... . ....... 446 BIBLIOGRAPHY . . . . . ................... 454 viii .55 f. 5me of Abortion Rat FaciIitIes Classifiec Status, Elpioyment. F Pregnancy History, ar (due 30, IMO-June I 2. Type of Abortion Procec Hospital (II=I00) (Jur I. Inidenoe of SterilizaI toSeIected Patient I Status, Emloyuent. I Parity. and Medical I Ime1,197l)... . I Implications foilouinq Gestation, Ntntbers as It City. any I, l! I [Wiication Rates per I37Iemination, New ‘ I htimaIe for Particip Ines and Cains . I Moselor Evaluation 0 I " 15015 for Abortion C tio PAT-Abortp n of C s Ehouses for "a“ LIST OF TABLES TABLE 1. Summary of Abortion Patient Characteristics in Two Facilities Classified by Residence, Age, Marital Status, Employment, Race, Religion, Gestation Age, Pregnancy History, and Method of Patient Payment (June 30’ 1970-June 1, 197]). o o o ooooo o o o o o 2. Type of Abortion Procedure by Gestation Age--Metro Hospital (N=lOO) (June 30, 1970-June 1, 1971) ..... 3. Incidence of Sterilization at Metro Hospital, as Related to Selected Patient Characteristics of Age, Marital Status, Employment, Race, Religion, Gestation Age, Parity, and Medical Indications. (June 30,1970- Junel ,l97l). ..... . . . . . . . . . . . . . 4. Complications following Abortion, by Type and Period of Gestation, Numbers and Rates per 1,000 Abortions, New York City, July 1, 1970 - March 31, 1971 ..... . . 5. Complication Rates per 1,000 Abortions by Type and Method of Iermination, New York City, July 1, 1970 - March 31, 197 O O O O O O O 0 O O O O O O O 0000000000 6. Rationale for Participation in Abortion Counseling: Motives and Gains . . . . . . . . . . . . . . . . . . . 7. Counselor Evaluation of Abortion Counseling . ...... Reasons for Abortion Counseling . . . . . . . . . . . . . 9. Clergy Perception of Client by Expressed Importance of POST-Abortion COUNSETTHQ o o o o o o o o o o o o o o 0 IO. Commitment Patterns and Mean Number of Agency/Professional Contacts for Three Time Periods: Before Participation, First Few Months of Participation, and Present Participation . . . . . . . . . . . . . . . . . . . . ll. Number of Persons Contacted Before Abortion Source was Located 0 O O O O O O O O O O O O O O 0 O O O O O O O 12. Type of Contact Secured in Search for an Abortion . . . . 13. Period from First Contact to Time of Abortion . . . . . . 14. Type of Abortion Received by Year and Location . . . . . I5.-Average Costs fer New York Clinical Abortion and Travel Expenses . . . . . . . . . . . . . . . . . . . . . . . ix Page 67 72 74 90 91 T70 T78 179 181 T96 274 277 282 283 283 110111815 (Cont) 163 1, mt Status of Abort fl. 11101 Categories of In States-April 1. 191 25. Chmological Record 01 Changes, Abortion Re; in the lhited States. LIST OF TABLES (Cont.) TABLE Page 16. Current Status of Abortion Laws--January 1971 ...... 430 17. Major Categories of American Abortion Laws, Uni ted StateS'Apr111919710900000000000... 433 18. Chronological Record of the Status of Abortion Law Changes, Abortion Reporting, and Abortion Ratios in the United States, 1969-1971 . . . . . ....... 434 51116 1bortion lbrket Panel 1. The Sieve Effect. . - 1 $111 of Omanizatic 151.111 of Values Idi Service 1n Tip H0591 5.31.111 of Abortion PI 5 111111111 Fomtion 31101 11111111 Person and 1 llebork Formation $1101 Person to Abortioni: 1. list of Abortion R2501 Service-- -Sept- -l969 Umlative Amber of 1 Related Activities llhelsolated Cell Typ The Isolated Cell Typ "1811 al System' of tn 51191911. Deoentral 1111 of Interlinkages 3111 Nice and Other S 11111111 NetvrorirofRe Pressures as ese 1 111111101 Service ISIA1Ab°rti°n Rm 1. :i‘nff‘émtlal Cycleso ‘9' :Nations of Tenn “Attributes o 11 “301% mansion ns 11 ll 1 LI ST OF FIGURES FIGURE Page 1 Abortion Market Formation and Transformation ....... 10 2 The Sieve Effect . . . . . . . . ..... . ....... 28 3. Sunmary of Organizational Features in Two Hospitals . . . 58 4 Sumary of Values, Ideology, and Rationale for Abortion Service in Two Hospitals . . . . . . . . ........ 65 5. Sumnary of Abortion Programs in Two Hospitals (1970-1971). 81 Network Formation Showing Direct Linkages between Referral Person and Abortionist . ........... 102 7. Network Formation Showing Indirect Linkages of Referral PersontoAbortionist 105 8. List of Abortion Resources Used by Clergy Counselling SGWTCE--Sept.-]969-DEC. 1970 o o o o o o o o o o o o o 15] 9. Cumulative Number of Hours per Month on All Abortion- RelatedActivities................... 186 10. The Isolated Cell Type: Variant One ........... 202 11. The Isolated Cell Type: Variant Two . . . . . . . . . . . 203 12. "Social'System" of the Clergy Counseling Service . . . . . 205 13. Segmentary, Decentralized Network . . . . . . . . . . 209 14. Type of Interlinkages Between the Clergy Counselling Service and Other State and National Reform Groups . . . 211 15. Partial Network of Referral System Showing Countervailing Pressures as These Affect Agency Decision to Provide Abortl'on SerVice 0 O O 0 O O O O O O I O O O O O O O O 24] 16. A ”Modal Abortion Referral Network and Its Alternatives . . 279 17. Differential Cycles of Expressed Stress . . . . . . . . . 290 l8. Connotations of Term "Abortion Mill". . . . . . . . . . 315 19. Defining Attributes of the Contrast Set of Abortion on TwoDimensions................. . ..318 20. Contrast Sets of Two Abortion Facilities and Implications for0rganization.................... 320 21. Three Variant Medical Interpretations of Abortion and Implications for Organization . . . . . . . . . . . . . 322 xi uhliflfifis 11.! h. lefereice lens for Ab 11 Ideological Thus of health Care: Profes 11. locabularies of Solida l'ealth fare: mee5 15. hfinitimal and Optir hie in Legitimate A h. Pathem of Role Conpor and Disputed Characv 11. Seven Variants of Nod Abortion Service by Practice. and Role : 21. 11111111 Sunrizing R1 10112 of the Profess 291 Find]; of the Mon ll- Ratios of Reported Le late of Residence, Hath l911 . . . . LIST OF FIGURES FIGURE 22. 23. 24. 25. 26. 27. 28. 29. 30. Reference Tenns for Abortion . . . . . . ..... . . Ideological Themes of Two Opposing Conceptions of Health Care: Professional Model and Community Model . Vocabularies of Solidarity for Two Conceptions of Health Care: Professional Model and Community Model . Definitional and Optional Attributes of Physician's Role in Legitimate Abortion Practice . . . . . . . Pattern of Role Components: Minimal, Maximal, Optional, and Disputed Characteristics . . . . . . . . . . . . . Seven Variants of Modes of Political Interaction in Abortion Service by Setting, Time Period, Type of Practice, and Role Incumbents . . . . . . . . . . . . Formula Summarizing Rules of Combination for Political Mode of the Professional Role . . . . . . . . . . . . Paradigm of the Abortion Market . . . . . . . . . . . . Ratios of Reported Legal Abortions to Live Births, by State of Residence, in Geographic Order, January - March 1971 . . . . . . . . . . . . . . . . . . . . . . Page 337 349 352 355 361 363 365 385 436 11 E. 1111 Depicting Abortion LIST OF MAPS MAP Page 1. Map Depicting Abortion Referral Units in Michigan . . . . . 227 xiii THE ABORT 1111 should a medical notice. still look like a gentiora of providers-430 motions of clients, shou massive. risks to any pra espiteattents by legal, n 1111111 tteservice, there a ionization and profession this health service. How “11111118 been transforo 1181mm routinized, i hints us 11th a puzzle. milliliter-1's the subjeci WMMan‘ 111111111. ea. in action 10 1972 has y1 r ”111 court ru be. "“1196" law now. me”! the life of the m CHAPTER I THE ABORTION MARKET: AN OVERVIEW Why should a medical service, after more than decades of practice, still look like a problematic endeavor? Nhy, after several generations of providers-«both legitimate and illegitimate-~and many generations of clients, should it continue to involve high, if not excessive, risks to many practitioners and consumers? Add the fact that despite attempts by legal, medical, and administrative authorities to control the service, there are countless unauthorized persons in organizations and professions involved in various phases of delivery of this health service. How the structure of such a problematic corrmodity has been transformed from an inmoral and extraordinary procedure to a routinized, if only partially legitimated, practice confronts us with a puzzle. That puzzle--1'ts nature, causes, and consequences--is the subject of this study. The health service in question is abortion in Michigan, which in election-year 1972 has yet to be legalized by ballot, by legisla- tive action, or by court ruling and thereafter by Public Health Service decree.1 Michigan law now allows abortion only when "necessary to preserve the life of the mother." Yet a brisk interstate abortion T T motorists. “mi" N 1111 mm of a We“ opiate this service- 111111111 “'19" ° 1111111119 this traffic. til 1111151 c1113)1 9mm ashes of linkages betree 11.1, and between different :iergyvereinstrlmntal in 111111 service. 1heorganization of 1111111111111 flux. Profes 11111111 do not take account 1hints of the population 11111111111 conslners 1111 11111115 of problems cre '11 forfeited the exclusive 3111 1018111111 cormliance. 1111111111 traditionalr 1111111 "1 creating cormto "10f abortion pra ct “ifinitions of 150m 111 5911. MW of more 11 D"111111 1 1111st113 11111: 11 b1 traffic exists, wherein women are routed from one care point to another without benefit of a protective state law or public health mandate to regulate this service. Although a variety of health and reform groups are involved in 1mfintaining this traffic, the prime mover in initiating and sustaining amnerce is a clergy problem pregnancy counseling group. By organizing navnmdes of linkages between consumers and health services on the one hand, and between different health organizations on the other, the clergy were instrumental in instituting new values and practices in abortion service. The organization of abortion service in Michigan reveals an instihflfion in flux. Professional and legal attempts to control abortion do not take account of changes in medical technology and values mwlwants of the population that make this service a reasonable altern- ative for many consumers with unwanted pregnancy. In failing to adapt nonew kinds of problems created by these changes, established groups have forfeited the exclusive right to define the situation and to insure consumer compliance. Countervailing definitions have arisen thatcmallenge traditional norms. Strategies by reform groups have mmmeeded in creating counter rationales and ideoloqies that support new Runs of abortion practice. This generates disparities between new definitions of abortion as a consumer right and professional claims for monopoly of moral contrOl in this domain. How the market 15'finnmd and transformed by these influences is described in these chapters. He Wt these eve mitiesJanuary 1971 to .gm'evo. We“ moms, avert abortion Cmfemw 11am (11111101091 ‘5 fl" Given the my cum“ :‘ahortion service, 008 W 1111 coherently described ‘ 11111 related to these Chm huntmny relevant event shorts, the four-year stmg 11,111, recently, the heav 1111: against a positive vo ants in the transformation 111111 narrator. Our task is a select 5111 Whitney comseling 1111111 narket by creating 15111111. To do this, be 111111 ofthe legal stn lll ' ' lib rat1onal" use and 1119111111111, Demittev 11 1111 owner of illega' men"ionization of the 1‘11 ell15995015 into 1111 l c Ne document these events by 18 months of fieldwork in six conmunities, January 1971 to June 1972. Methods include observation, interviews, patient records, questionnaires, and documents. Atten- dance at abortion conferences and reform events were also part of the fieldwork (methodology is further elaborated in Appendix A). Given the many complex issues in the still evolving structure of abortion service, one may wonder how any institutionalizing processes can be coherently described without neglecting still other crucial issues related to these changes.2 For instance, this study does not document many relevant events. Six years of legislative reform efforts, the four-year struggle by pro—abortion groups to change the law, and, recently, the heavy push by anti -abortion groups to sway the public against a positive vote on the ballot, are all significant events in the transformation of the abortion market. But these require another narrator. Our task is a selective one. We wish to investigate how a clergy pregnancy counseling and abortion referral movement changed the abortion market by creating a broker system linking consumers to points of service. To do this, we raise several questions. First, what was the nature of the legal structure, that on the one hand, interfered with the "rational" use and distribution of this health resource, and on the other hand, permitted a limited supply of legal services, and an unknown number of illegal services to be provided? Second, what was the organization of the market, divided as it was into illegal and legal sectors into which the clergy moved to exploit resources? 1111,1111 did clergy entre 1111111115 to tie together 1111111511 various care p 11111 abortion brokerage s motion a p1blic panda faefforts to legitimate a ranges in abortion practic: ln answering these ‘ 1111mm abortion mi 1.111191 that either “all“ Market, in this anal ‘:ndvcers' or suppliers of answers. As a market can ar'produced,“ sold. suppll :anies no seek to exchan91 111911 corotraints and $61 recessive costs, to part :11 are built into this 0 m“1111 demand and errat Mil" mih‘het. 1" delineating the 151m t“Ase constraints 1 Third, how did clergy entrepreneurs work through the legal and medical constraints to tie together an abortion network linking consumers to providers at various care points? Fourth, to what extent did the clergy abortion brokerage system become a standardized agency practice, even without a public mandate to support such services? Fifth, how did efforts to legitimate abortion by public health planners reflect changes in abortion practice initiated and sustained by clergy brokers? In answering these questions we probe into the social context within which abortion market activity proceeds, and the networks of exchange that either‘maintain or alter market arrangements.3 Market, in this analysis, refers to transactions between "producers" or suppliers of services and between producers and consumers. As a market comnodity, abortion or abortion-related services are "produced," sold, supplied, bought, traded, or negotiated between parties who seek to exchange something of value for a "price." Because of legal constraints and sanctions, abortion transactions involve risk, or excessive costs, to participants. This means that constraints on trade are built into this commodity exchange. Facilitating conditions, as in high demand and erratic enforcement, further characterize the abortion market. In delineating the market situation, we seek to understand the nature of these constraints and facilitating conditions that made a clergy social movement possible.4 In turn. the movement altered market organization and transformed costs for providers and consumers. Movement activity was divided into two periods--the entrepreneurial, or high risk, phase and the broker, or referral, phase.5 In the first phase, :lergy mtrepreneurs M 11111 by assvning primary services and routing patiev initiating agents, m 111’ professionals into a no :f'larietorganization--risk elheated in the next sect 111.511.5113 Lhtil 1967, traditii 1111111111111 1191mm atinabortion. Infomatl niplaceon the margins 01 ‘iny‘husiness and "bad" 11 111511 of agencies and Hedi 311, social barriers gave minty-initially in the 1 111111 ofa referral netr 311911 and medical barr' .1 ,. 1111111111 services also abortive Market forms clergy entrepreneurs absorbed costs associated with market partici- pation by assuming primary legal and professional risk for organizing services and routing patients. In the second phase clergy-brokers, as legitimating agents, M risk by incorporating a variety of agencies and professionals into a new health delivery network. This sequence ofmarketorganization--risk, entrepreneurship and brokerage--is further delineated in the next section. Risk, Entrepreneurial Activity and the “Br0keriStructure Until 1967, traditional barriers of law and medical control tended to inhibit legitimate occupations and organizations from involve- ment in abortion. Information, counselling, and referral. if provided, took place on the margins of agencies or health groups. Abortion was a “dirty" business and “bad" medicine. In the social vacuum created by refusal of agencies and medical organizations to cope with consumer demand, social barriers gave strategic scope to entrepreneurial activity--initially in the viable illegal trade and later, in the emergence of a referral network, or broker system. This means that the same legal and medical barriers that prevented an available supply of legitimate services also acted to facilitate the development of alternative market forms. This study focuses on the changing structure of social control of a health resource. We posit that social control of a hm demand gommodity generates systematic rule evasion and violation, and in . . . . 6 sextam c1rcumstances, alternatwe social forms. Schur. specificall. 1111115' as those particul1 remain of private or “I coed as unenforceable cri :11 take place between Ill evening of value for a "n 1111111, prostitution, dnr tent to 1111111 specific 1e not prohibit certain forms alternative ions of market edet consequences of such :1. of course, consuners pa ‘1 Providers, legal sanctic hints. For conslmers, e1 “diiitlnlngical risks thai 1:11 Schur and Packer are p1 ‘1 is that are generated frv 11 '- 11111111 agencies will The organizational 1 11 1111011 one: that kind Mt I \ 111s of induced or no Schur, specifically, points to the area of "crimes without victims" as those particular forms of criminal activity that lie in the domain of private or moral activity.7 In this respect, they are viewed as unenforceable crimes. These include illegal transactions that take place between willing buyers and willing sellers who exchange something of value for a "price." Studies of the impact of criminalizing gambling, prostitution, drugs, and abortion, for example, suggest the extent to which specific legal definitions and law enforcement policies that prohibit certain forms of private behavior tend to generate alternative forms of market activity. Packer considers that the essential market consequences of such control are the added SEER that providers and, of course, consumers pay to engage in these criminalized activities.8 For providers, legal sanctions are "tariffs" or simply added costs of business. For consumers, excessive costs are economic, medical, social, and psychological risks that must be borne if transacting in this market. Both Schur and Packer are primarily concerned with criminal market forms that are generated from,and sustained by, legal enforcement of moral behavior. What these writers call "crimes without victims" could also be termed "economic crimes.“ This means that allocations blocked by legitimate agencies will be legally scarce and typically expensive.9 The organizational question regarding these economic processes is a threefold one: Whatflngs of goods and services are available under conditions of induced or normative scarcity? What are the social and economic g_0_s_t_s_ of supply and use? How are alternati ve sources of supply generated, sustained or changed? The Schur-Packer formulation does take account of scarcity, costs, and illegal sources of supply. 1111 111 mm.“ in They have little to say, however, about how new allocation systems may arise in the context of scarce legal goods or services and available criminal resources. If risk (or excessive costs) is the essential component of a controlled market, we need to know how risk is managed and trans- formed before we can understand the emergence of a new allocation system. Barth refers to the "entrepreneur" as a social- role specifically organized to change the way goods and services are evaluated and thereby categorized. 10 value of goods and services, the entrepreneur seeks to change the nature By generating new information regarding the relative of the constraints that formerly added costs to a given resource. The entrepreneur, then, is a risk taker.n Through innovative activity he influences the market by changing how the resource is used, who uses the resource, and the providers distributing the resource. These and other market components, as in price, technology, quantity and quality of the product, and social costs, only become changed if some of the crucial constraints blocking resource allocations are altered. In giving expression to the values and wants of a particular population, the entrepreneur creates a "specialized institution“ in Hughes term. Survival of the specialized institution, though, requires that it find a place in the standard of living of a people, as well as in their sentiments. By relating itself to people's sentiments an institution gains legitimacy and support.12 These theoretical considerations provide a background to understand the way in which the clergy movement coped with constraints, innovated new programs, and developed a clientele. In doing this, the Iii .l'r 3111 still I 1 a it Ill I NIH Q4I NI.‘ 5 \ A1 I! . M.‘ 1 1 n. . all nil . at 1 .11 Ha h b I I \. 1|! movement transformed abortion from a devalued or even illicit act to a reputable, if still not fully legitimated, health commodity for many professionals and consumers. Legalization of abortion in New York in July 1970 broke down the barriers impeding legitimate medical groups in that state from distributing abortion service. In Michigan, clergy-entrepreneurs beginning in 1967 worked within the legal constraints to open up formerly closed channels of supply to distribute counseling, referral, and medical services to abortion clients. They did this by three innovative strategies: (1) they used local corrmunity resources to tie the pre-abortion patient to immediate care sources, (2) they connected the patient to out-of-state abortion resources (legal and illegal), wherein jurisdictional boundaries would effectively prevent legal jeopardy to referring clergymen and to their clients, and (3) they altered the way in which abortion was defined and the context for its use and distribution. Significantly, these managerial innovations W because services could be adminis- tered by a variety of providers with little or no legal risk to the organization or occupation participating in this market. The brokerage system, which was an outgrowth of the clergy movement, brought together professionals, health care workers, and later, volunteer persons to provide services in an interlocking, albeit loose, network. Once the brokerage system was launched, the entrepreneur or risk-taking role gave way to a broker or legitimati ng, role. The counseling and referral model, over time, was developed into a routine format. This helped to standardize the enterprise, and 1218' Iv h u '1'- o'- 1 «‘0‘; l null ll -’ ..u 15 ..J 11.: vi 9 altered definitions from earlier conceptions of the activity as chancy orchngerous to that of a legitimate delivery (or pastoral) service. Women were distributed by the same system with equal or unequal ease, as the case may be, to Chicago (illegal), London (legal), Mexico and Puerto Rico (illegal), and later New York (legal). An ideology of patient need transcended the legal and medical barriers. Once the counseling/referral model was diffused to the larger conmunity of cnofessionals, health workers, and consumers, this served to encourage widespread agency adoption of the program. This process of market formation and change is shown in Figure 1. We sumarize this process. All findings refer to the Michigan abortion situation. 1. Until 1967 constraints by way of a proscriptive law and medical reluctance to provide service resulted in a legal market of limited abortion services with high economic and social costs to providers and consumers. 2. In the earliest documented period (1963-1967), consumers with their helping professionals coped with the scarcity of services by seeking alternative resources. At one time, only the criminal market offered any alternative. Prices were high or set on the basis of ability-to-pay. 2% After 1967 clergy-entrepreneurs, whose organizational nucleus was formed from individual clergy responding to their parishioners' and counselees' requests for help, mobilized a collective effort to exploit available resources--from the community and from the underworld. Through bridging trans- actions, clergy-entrepreneurs put together a health care network that incorporated legitimate and contraband services. 4. By 1970, availability of legal abortions in New York resulted in routinization of the counselling-referral activities, and transformed entrepreneurs to brokers. Innovations were standardized. Consumers were connected to points of care both before and after the abortion with the network linking in- state counselling services to out-state abortions. Legal Marke Figure 1.--Abortion Market Formation and Transformation 10 Legal Constraints Exploratory Behavior by Consumers / sh Clergy-Entrepreneurs 1 Broker Structure 1 Diffusion of Abortion\ Broker Service Model 1 Legitimation of the Model Criminal Market Bridging Transactions by ClergyaEntrepreneur between Legal and Illegal Markets 11 By early 1971, many social agencies reportedly inundated by requests for abortion referral adopted the counseling/referral model created by the clergy, if responding at all to this demand. Eventually, this model or a variation thereof, was considered by many influential professionals and reform groups, as the only viable model for abortion care. Legitimating the model through a Michigan Public Health Planning Committee, demonstrates old and new conceptions of this. health service. In reconstructing the meanings of abortion, planners negotiated the institutional order of abortion service, eventually settling on the clergy model as the only alternative if abortion was to be made publicly acceptable. Social control-~as organization, reorganization and change--may epicted as transforming the risk structure of the market, In the earliest rented phase of the legal and illegal markets, abortion control egal and medical authorities did not stop abortion traffic. er, in tightly regulating legitimate services, costs of participating he market were absorbed in the providers' business operation, thence passed on to consumers. Additional risks for consumers uded medical sanctions (e.g. sterilization) if a legal abortion procured, and low quality control and illness is an illegal tion was purchased. ' In confronting this situation, the clergy movement bargained criminal abortionists, and located local community resources for ecting clients to care points, staking their reputation and essional careers in the process. Risk was not eliminated, but the equences of risk for consumers, as in medical sanctions or low ity care, were greatly reduced. Only after the network was essfu1 y mounted, and recognized by many professionals and agency rs as a going concern, did risk or the threat of excessive costs, e reduced to a manageable proportion, and even eliminated. For 12 e providers in this new network, abortion service or a phase thereof, even profitable. Legal control reflected this change. From ive surveillance and prosecution of abortionists, enforcement became 'hnegular event, surrounded with ambiguity by enforcement agents. ical-agency control, too, adapted to the altered situation. sicians and family planning agencies provided pre-abortion testing, ic examinations and post-abortion contraceptives or other cological care. Conclusion This study proposes to trace the changing risk structure of rdfion by considering what_market conditions prevailed before the rgy movement, how clergy-entrepreneurs transformed these conditions, what consequences resulted from this movement for official legiti- ation of a new health organization. "Deviancy" and “institutional" cesses convergein this analysis. In the clergy risk-taking opera- 1, the movement served as a facilitating mechanism enabling persons rmke "deviant" choices (i.e. have an abortion), while controlling costs of these choices by transforming values and ninating social barriers. Increased frequency of "deviant" choices, urn, served to erode the traditional order and to promote institu- al change. The study has two foci. On the one hand, we present the erent organizational phases of the market--legal, illegal and er structures--from the point of view of those actors involved he activity. This requires a multi-perspective analysis, or one h takes account of differently positioned actors, their motives, l3 mum, and organizational consequences. 0n the other hand, we emphasize the role of the clergy movement in transforming traditional market nuangements. This necessitates that we consider alternative market Runs in terms of how these served as constraining and/or facilitating iactors affecting movement growth and organization. A more extended Ii scussion of the methodology of this approach is included in Appendix A. Subsequent chapters detail the organization and transformation a the abortion market along the following lines. Chapter II considers he legal context which acted to restrict legitimate services, but acilitated a variety of rule violations. Changes in values in the arger social environment and gaps between formal law and enforcement rocedures are interpreted as conditions that make for sporadic rosecution and conviction of offenders. Chapter III looks at the rganization of medical-hospital abortions. Trends and patterns of ractice are illustrated by a comparative study of two Michigan hos- itals. Regulating services generate a set of rules for practice that everely limit accessibility, or number and type of clientele served. mpter IV describes the illegal market. Direct and indirect linkages nween professionals and other referring persons and abortionists me for a "middleman" structure in which legitimate agents shore up meillegal order by various modes of exchange. Chapter V traces the igin and development of the clergy movement. We show how the inepreneurial role was developed, and the effect of this role in ccessfully mobilizing resources and processing clientele. Chapter VI nsiders the expansion of the abortion broker system into the larger cial environment. Abortion related services by agencies and pro- ssionals, while often supporting the new delivery system, are l4 constrained by lack of a public mandate. Chapter VII explores the :onsumers' experience in moving through the network. Despite reduc- tion of medical risk, many consumers continue to bear social and psy- :hological costs. Chapter VIII summarizes the findings from this study. in indicating M has changed in the abortion market, we show the :ontext within which a Michigan Public Health Planning Committee 1ttempted to grapple with the ambiguous, conflicting and even contra- Iictory meanings of abortion service. .The investigation of legitimation irocesses suggests the extent to which abortion reflects crises and .hange in the health field. The methodology of this study is summari zed in an appendix. opefully, this allows the reader to have a "continuous story" instead f the narrative .being interrupted by the investigator's self-conscious ttempt to explicate the fieldwork process. CHAPTER I--FO0TNOTES hfichigan voters defeated legalization of abortion by a 60 to 40 nmrgin on November 7, 1972. Michigan State Public Health Service has a full set of medical regulations ready for implementation if and when the 1846 law is changed. Legislative action has thus far been unsuccessful, and court rulings have been indecisive. (Since this was written the U.S. Supreme Court has struck down all abortion laws as unconstitutional. All events reported in this study refer to the pre-legal abortion situation.) The literature on various aspects of abortion is too comprehensive to be indicated here. We mention, however, a few recent studies that may sensitize readers to the broad issues involved. Association for the Study of Abortion. Abortion in the Changing World. New York: Columbia University Press, 1970 Callahan, Daniel, Abortion: Lag,,Choice, and Morality. New York: Macmillan, 1970. Dickens, Bernard M., Abortion and the Law. London: MacGibbon & Kee, 1966. Ebon, Martin (ed.), Everywoman's Guide to Abortion. New York: Pocket Books, 1971. Group for the Advancement of Psychiatry, Committee on Psychiatry and Law. The Ri ht to Abortion: A Psyghiatric View. New York: Scribner, Lader, Lawrence. Abortion. Indianapolis: Bobbs-Merrill, 1966. Lee, Nancy Howell. The Search for an Abortionist. Chicago: ‘Jniversity of Chicago Press, T969. Aanning, Peter K. "Fixing What You Feared: Notes on the Campus Abortion Search," in J. M. Henslin (ed.) Studies in the Sociology_ )f Sex. New York: Appleton-Century-Crofts, 1971. The conception of exchange and transactional behavior used in this study is taken from Barth, especially in the following works: iredrick Barth, "The Role of the Entrepreneur in Social Change in Iorthern Norway," Acta Universitas Bergensis. Series Humaniorum itterarum No. 3. ergen; ; e s of Soc1al Orgafiizationi" 15 16 Royal Anthropological Institute, Occasional Papers, 1966; "Economic Spheres in Darfur," Association of Social Anthropologists Monograph, R. Firth (ed.) forthcoming. Barth's fonnulation of exchange includes both structural conditions-- incentives and constraints--that influence actors' cost-gain calculus in making choices. A useful definition of social movement used in this study is taken from Ash: "A social movement is a set of attitudes and self—conscious actions on the part of a group of people directed toward change in the social structure and/or ideology of a society and carried on outside of ideologically legitimated channels, or which uses these channels in innovative ways." :Rooerta Ash, Social Movements in America. Chicago: Markham ’ublishing Company, 97 , p. . b distinguish these two role phases, entrepreneur and broker, w the following attributes: ntrepreneur: Relatively high-risk movement-related activities as in: (1) negative attitudes toward "official" norms and regulations, (2) development of counter ideologies, (3) development of innovative channels, (4) use of illigitimate or quasi-legitimate resources, and (5) activities largely confined to a small urban or university elite. roker: Relatively low-risk organization-related activities as in: (l) a visible formal organization, (2) routine counseling and referral services, (3) widespread public diffusion of the ideology, (4) expanding the network into agency and professional practice, _ (5) interdependencies between the clergy organizat1on and established groups, and (6) activities broadened to a wide cross-section of ministerial types and communities. e, for example, Edwin M. Lemert, Human Deviance, Social Problems and cial Control, Englewood Cliffs, N. .: rent1ce- a . nc.,. 3 war 5. Bec er, Outsiders: Studies in the Sociolo y of Dev1apgg, w York: The Free ress, ; o n I. Kitsuse. ocietal Reaction Deviant Behavior: Problems of Theory and Method," §9£iél.££29h§fli (Winter, 1962): 247-257. M. Schur, Crimes Without Victims, Englewood Cliffs, New Jersey: entice-Hall, nc., 17 H. L. Packer, The Linfits of the Criminal Sanction, Stanford: Stanford University Press, 968. Economic sources that were especially useful for my analysis include: Harvey Leibenstein, Economic Theor and Or anizational Anal sis, New York: Harper & Brothers, I960; W1|liam Fellner, Compet1t1on Among the Few. New York: Augustus M. Kelley, Publisher, 1965; Willard F. Mueller, Monopoly and Competition, New York: Random House, 1970. For a good summary of Barth's development of the entrepreneur and social change, see his "introduction: to "The Role of the Entrepreneur in Social Change in Northern Norway,“ pp, 215. For the classic economic treatment of risk, see Frank H. Knight, Risk, Uncertainty apd Profit, Boston: Houghton Mifflin Company, 1921. The problem of legitimacy of institutions is a central concern in the sociology of Everett C. Hughes. See, for example, "Institu— tions," The Sociolo ical Eye: Selected Papers, Chicago: Aldine- Atherton, |§72. ‘ k .131 CHAPTER II THE SOCIAL CONTEXT OF THE ABORTION MARKET: THE TWO FACES OF LAW Introduction This chapter considers the two faces of the abortion law-~formal tes and enforcement apparatus--as the crucial social context for 1 This focuses on izations serving or rejecting abortion clients. deicisions and enforcement machinery as two distinctive, or ate, aspects of the legal order.2 In emphasizing the distinctive s of law, we show how gaps between g§_jurg_laws and gg_j§§tg_ ices generate conditions in which professionals and agencies ruct interpretations, exploit opportunities for intervention, and A innovations. Discrepancies and lags between abortion law and ement, then, are primary conditions permitting, and even facili- , innovation in this health service. It is in the context of a enforced law that clergy entrepreneurs were able to interpose tions and actions that ran counter to traditional legal inter- ions. By calculated risk-taking, the clergy movement initiated erage system that circumvented legal roadblocks for both brokers nsumers. Inconsistencies between law and enforcement practice are teristic of the “crimes without victims“ category. Laws that 18 dim l9 Ipt to define moral behavior between consenting adults are virtually fbrceable. What the "victimless" law can do, however, is generate matic modes of rule subterfuge by both providers and consumers that les a flow of contraband services, but with such services distributed used outside of the control of legitimate community groups. In abortion practice, legitimate health groups face a dilemma: olate the rules is risky, but to uphold unenforceable laws is, my instances, professionally threatening. Physicians are denied Iomy to define patient needs. And when they do operate within the er of the law, they face possible malpractice suits from irate hts who may claim "extreme cruelty" because of "forced" delivery nulti-handicapped child.3 Contradictions for public health groups ding maternal health care for low income women involve an official ol structure they cannot modify, and a clientele whose need for ion as a preventive health service is acute. . The law, then, imposes initial conditions for medical practice is area. Yet, inconsistencies between law and enforcement prac- provide loopholes within which consumers seek alternative services, tors set up "discreet“ hospital abortion services. Enforcement bodies, in confronting these and other overt tions, also must cope with changing public demand and conflicting and professional definitions about the morality of abortion. akes for problematic enforcement or a situation characterized by ic regulation or even withdrawal fromcontrol.4 Another response by health occupations is to g§g_the contra- y conditions fostered by gaps between formal law and enforcement 20 :edures to explain action as a consequence of the law. In other is, abortion demand is met, circumvented, re-routed, or ignored, all me name of organizational response to legal circumstances. The e-law is used to justify different conduct, whether innovating mices or maintaining routines. Formal Rules--An Overview of the Abortion Law In Michigan the performance of abortions is regulated by the final code and Public Health law. The language and intent of the law 0 prohibit any professional, agency or organization from trafficking borthnn either by direct application of drugs, surgery, supposi- es or other mechanical or chemical interferences with pregnancy. e acts are deemed a felony. Induced abortion is also prohibited Infirect means, as in advertising, selling, or publishing information t.drugs that may produce a miscarriage. In this case, it is a neanor. The only legal exception to this proscription is in those 'al (and now medically rare) cases wherein abortion is performed to erve" the life of the woman.5 .CtL. 750.14. Any person who shall wilfully administer to ny pregnant woman any medicine, drug, substance, or thing hatsoever, with intent thereby to procure the miscarriage of ny such woman, unless the same shall have been necessary to reserve the life of such woman, shall be guilty of a felony nd in case the death of such pregnant woman be thereby roduced, the offense shall be deemed manslaughter. n any prosecution under this section, it shall not be necessary or the prosecution to prove that no such necessity existed. .C.L. 750.15. Any person who shall in many manner . . . ad- ertise, publish, sell or publicly expose for sale any pills, owder, drugs or combination of drugs, designed expressly or the use of females for the purpose of producing an abortion hall be guilty of a misdemeanor. % 21 hLC.L. 750.322.- The wilful killing of an unborn quick child by any injury to the mother of such child, which would be murder, shall be deemed manslaughter. M.C.L. 750.323. Any person who shall administer to any woman pregnant with a quick child any medicine, drug or substance amatever, or shall use or employ any instrument or other means, with intent to thereby destroy such child, unless the same shall have been necessary to preserve the life of such mother shall, in case the death of such child or of such mother be thereby produced by guilty of manslaughter. In any prosecution under this section it shall not be necessary fer the prosecution to prove that no such necessity existed. M.CJ" 757.72. An indictment or information fbr manslaughter may contain also a count for procuring or attempting to procure an abortion and the jury may convict for either offense. M.C.L. 338.53 (6) (7). (6) The board of registration in medicine "my refuse to issue or continue a certificate or registration or license . . . to any person guilty of grossly unprofessional or (fishonest conduct. The words "grossly unprofessional or dishonest conduct" as used in this act, are . . . declared to mean: (a) the procuring, aiding or abetting in procuring a criminal abortion. (7) It shall be a misdemeanor for any person to be guilty of "unprofessional and dishonest conduct" as defined in this Act. The creation of such misdemeanor . . . shall not be construed to supercede any existing remedy or punishment, whether civil or 6 criminal . . . but shall be construed to be in addition thereto. Court Decisions Clarifying Legal Questions In court decisions, incremental charges in the statutes npted to clarify continuous legal questions raised by difficulties eprosecution to sustain conviction. Such questions revolved nd theproblems of (l) evidence, or proof required to justify a 'ct of guilty, and establishing (2) integt_on the part of the ed to commit a crime, rather than the facts of the crime itself. th questions, the court resolved the issue so as to simplify cution and conviction of abortion cases. agent :ncti safer: 22 Fer instance, the question of evidence focused on the type of ifs.required, as in showing the defentant's tools of the trade, cal observation of the defendant's perfbrming the abortion by police Its, and establishing certainty that the woman was pregnant. In :tice, police apprehension of the abortionist necessitated that ircement agents not move too rapidly in arresting the practitioner, much as this prevents the prosecutor from establishing a "clear e" and intent" to commit a crime. And, if police delay, the woman d be injured by the catheter, chemical substance, surgery, and so h. Use of policewoman decoys in such instances were declared invalid, much as proof of pregnancy was required. Evidence was often ndent, then, not on police statements of evidence as witness to obable crime, but on the woman's testimony. Even with expert imony from legitimate physicians declaring that certain tell-tale ical signs could be detected, as in instrument punctures, scraping s, and chemical damages, the court could not accept this as ial evidence unless corroborated by statements of the aborted, uld-be aborted woman herself. Evidence thus hinged on the woman e key witness and the main prop supporting the prosecutor's In the event of the woman's death, the court had long held testimony from her lover, husband, or attending relatives was sible, if there was also sufficient evidence that the defendant the abortionist) has told other persons of the intended crime.7 he aborted, or would-be aborted, woman who refused to testify, the eviden 23 could arrest her for contempt. But jailing the woman served er to convince her to present testimony, nor eased the problem of Ice for the prosecutor. Subsequent decisions reduced the problem fluctant witnesses" (i.e. the aborted woman and her relatives), at the same time circumvented the thorny issue of proof that a had been committed. In a series of decisions the court ruled that: The woman could not be held for commission of the crime of abortion, nor as‘ETder and abettor. Thenceforth, she would be defined as a "victim," and could therefore serve as "willing witness" without violating the Fifth amendment by providing evidence against herself.8 Conspiracy to commit a crime was an indictable offense at common law, and such conduct was made a felony in abortion cases.9 Conspiracy to commit abortion is both an easier charge to sustain, and requires simply tracking the third parties to the agreement such that evidence shows "agreemsnt, understanding, plan, design or scheme to abort a pregnancy." The conspiracy decision also stipulated that Michigan does not recognize abortions fer the benefit of the psychological health of the woman. The court rejected the doctor-defendant's claim of the.threatened suidice of his patient, and in doing so empha512ed that legal abortion be restricted to saVing the "physical life" 0f the mother.11 In the opinion of the court: most unmarried women who were about ready to have children are inclined and frequently tell their physician they are ready to take their own life. This does not in my opinion justify any type of a abortion.12 The viability of the fetus no longer was required for proof of crime. "Intent" to commit an abortion, regardless of whether the woman was pregnapg or not, was sufficient to convict on a conspiracy charge. The “intent" clause further stipulated that procuring a miscarriage “unless the same shall have been necessary to pre- serve the life“ of the woman did not require the prosecution to prove that no such necessity existed. The burden of proof in abortion convictions is on the practitioner to prove his innocence, not the prosecbtor to prisent material evidence showing lack of medical necessity. 24 In short, from People v. Marra on (l970) the legalistic arpretation of the abortion law is to warn that any "jgtggt_to procure iscarriage" is in violation of the letter of the law (italics mine). Michigan Medical Society, for example, took this reading of the law :tipulating to members that abortion referral under present legal fitions was both illegal and unethical (April, l97l).15 How can we account, then, for the following apparent structural alies? T. An estimated l,000 "therapeutic" abortions are given in Michigan annually (1970). 2. Metropolitan Detroit hospitals may admit as many as three to four patients per day into emergency rooms to "clean up" the "incomplete" or septic abortions, many of which are criminally induced. 3. Michigan physicians provide an estimated 30,000 pelvic examina- tions confirming pregnancy fbr women planning to get legal abortions in other states or illegal abortions in Michigan. And many physicians refer patients directly to friendly practi- tioners in New York or elsewhere. L A few physicians still give abortions in their offices and are known both to the police, and to other physicians who may ‘ refer patients directly. L Some counseling clergymen continue to refer to illegal sources both inside and outside the state. Although, less frequently used, the "local" resources serve a stop-gap function for ailing or poor women unable to withstand the costs of travel. n An elaborate, although tenuously linked, counseling and referral system spread throughout the state and incorporating a variety of agencies, connects women directly or indirectly to legal abortion sources. The most recent plan to open an abortion clinic is being constructed with a view toward satisfying the local prose- cutor's expectations of appropriate site and situation fOr therapeutic abortions, as well as facilitating "scenery" fbr participation by prestigious physicians. The existence of these diverse fbrms of apparent rule evasions 'olations has as much to do with the inconsistency of the present 25 ation of the law, as with selective perceptions of risk. Not 0 different law firms "read" the law differently for physicians, als, and clergy service for example, depending on what the clientele ;" but variations in local conditions and type of network affilia- tend to generate distinctive structural adaptations. The facts of formal law and rigorous court interpretations of es do not explain these variations. Nor do appeals to medical or hospital licensure laws describe the actual operations of e law is applied in actual criminal cases. In spite of two on the docket charging conspiracy, in one instance against a , and in the other against a counseling clergyman, the rules-in- abortion prosecutions, are increasingly difficult to process. 1 these cases indicated, there are side issues involved, as in publicized malpractice charges, and routing patients to a non- ian in Michigan, for the doctor and clergyman, respectively. The ation of the criminal system, as it relates to abortion, an enforcement structure in which abortion detection, appre- and conviction are increasingly onerous and low pay-off ies. Rules-In-Use;:The Organization of the Criminal Court Appellate court rulings in abortion cases suggest an increasing by the criminal court as rule-makers to shore up the prosecutor's nents. Initiating complaints by police officers instead of s, gathering information and eventually the chief evidence, from g witnesses," and circumventing material proofs of pregnancy 26 the fact that a crime has even been conmitted, all facilitate the ls of bureaucratic efficiency in prosecuting and convicting tion conspiracy cases. Yet law enforcement agents often express tration and dismay in the criminal court procedure itself, which, hold, bogs down at crucial procedural points. From the point of view of the rational-bureaucratic-production el held by police and prosecutors,16 abortion cases are problematic require great care and prudence in decisions to pursue a complaint present evidence for prosecution. According to police informants, e favorable ground rules are all on the other side." The adminis- five tactic of "bargained justice," or negotiations between police, ecutor, judge, and defense lawyer, analyzed by Blumberg and Skolnick17 rprimary means of clearing cases, does not explain the often tenuous, ot devious, courses of action required for successful abortion ecutions. Detroit police informants (Homicide Section) emphasize that not have the rates of successful convictions declined over ten years numbers were provided, however); but that the number of complaints hich warrants were issued (a more adequate indicator of abortion processing) has dropped to negligible proportions. Some pending . extending over two years, show little sign of moving from the rial arraignment to a court hearing. Detroit policewomen (Woman's Section) point to the low incidence reported abortions among minor women for l97l. They say this e was probably closer to l00 five years ago. A few informants bute this to the availability of legal abortions in New York. 27 Enfbrcements agents present various claims and counter-claims runting for these changes in terms of loss of respect for the law, if life itself. Evidence, however, suggests that citizens are 'easingly reluctant to press charges against an abortionist regard- ;of the form of treatment received. Where a warrant has been red, the case is likely to be terminated at one point or another in :essing through the criminal courts. The "Sieve Effect" Modelgjn ’Enforcement ProcedureslB The "sieve effect" or sifting and sorting out of abortion cases rlreports to initial complaint, to pre-trial, to arraignment, and Itual conviction and sentencing, offers a descriptive model for mstrating the constraints on legal agents at various phases of H and conviction of abortionists. The procedural engine that pushes accused from one structural point to another shows in rough don the possibilities of case termination because of legal issues, mtional or administrative exigencies, organizational values, or ic opinion. This is shown in Figure 2. The subsequent problems of abortion investigation and prose- on then, serve, to restrain effective enforcement, while at the time act to block efforts to change the present arrangements. By taining a continuous threat of legal action, if organizations should not flouting the law, the enforcers create a risk environment. law enforcement officials, theoretically, the law stands intact I changed. The business of enforcing it simply is more problematic. the pragmatic rule, is usually a "hands off" approach. Lacking er of Illegal rtions Reported U D —-l a-la O (‘D Pre-trial Hearings cused is ndicted l_—_ Arraignment in District Court I__ ricted after trial 1 felony or mis- ameanor l m l 'rison ____J. re 2.--The Sieve Effect. 28 [no Investigation ] An Abortion nvefiTgafi on , is Committed ~ 1N0 Arrest Investigation, Arrest Accused freed fer lack of evidence; woman and her relatives as necessary for "willing witnesses" refuse to testify; no follow through because of jurisdictional problems, lack of police man-power, or other crimes occupy the department (e.g., homicide and robbery). Accused freed by dismissal, discharge, or lack of prosecution because of no known "probable cause," failure to identify co-conspirators, or reduced from a felony (e.g., conspiracy to commit abortion) to a misdemeanor (e.g., possession of narcotics) and disposed of in lower criminal court. Case may also be postponed because of problems of venure or motions on either side to suppress evidence. Freed by dismissal of indictment, acquittal, or discharged due to any of the following: failure to prove that the conSpiracy could be completed, "no show" of witnesses, divergenCe in legal opinion on use of non-pregnant police- women as decoys, rejection by court of the law as unconstitutional, and/or hung jury. Other Possibilities: Sentence Suspended Fined Probation 29 omplaintants, witnesses, and unified conmunity support, enforcement gencies perform only minimal, routine surveillance and investigative ctivities. For example, the dominant belief by law enforcers that "good bortions cases are rare" in spite. of "lots of abortions going around" trongly suggests that most criminal abortions reported from hospitals, ctors, school administrators, hotel or motel managers, are never vestigated in the first place. And if cursorily investigated, the eport only rarely results in a warrant. In theory, any physician or ealth officer who strongly suspects that a patient has had an induced aortion is required to notify police. In practice, few hospitals ever intact police unless the woman appears to be dying. In this instance, 1e hospital acts to insure itself against liability from the law or "om relatives charging malpractice. In failing to notify police of possible crime, the hospital avoids police harrassment of sick patients. nce few patients actually die from septicemia or hemorrhaging with 'dern medical technology, the hospital routine is preserved without re interference of third parties. In this way, police are denied an portunity to make a complaint in the first place. In jurisdictions with a heavy proportion of Black citizens, there often a reluctance on both sides--the police and populace--to terfere in abortion traffic. In one case of a Detroit Police Depart- nt complaint against a Black defendant and all-Black clients (l97l) e case never went beyond an initial warrant, although the police cured signed statements from all the participants, including attending ysicians on the case. Interviews with Detroit police suggest that 30 cide cases receive first priority in the department. Shortage ney and manpower keep this police department from following ugh on abortion cases unless there is strong pressure from the ty prosecutor. In one mid-Michigan city, a Black policeman infbrmant reported e that the Black community is "left alone" as not "worth bothering" t. As long as suspected abortion activity is confined to this ing, there is little or no enforcement intervention. Instead, surveillance and investigation is the departmental emphasis. s of prosecuting, low bureaucratic priority of abortion enforcement, ompared with other crimes, and few or no citizen complaints are involved in decisions to effectively withdraw from abortion acution. Even when the police strongly suspect a conspiracy case, )w-up may be viewed as unfeasible. This same policeman informant t this way: 've been told on three different occasions that there's a doctor rom who refers to an abortionist, a physician abortionist. ut we couldn't get a case on it. Three different occasions, ut we haven't been able to do a thing. Doctors aren't going to urn him on that. The administration in hospitals support him in oing this. I'm sure that's correct because there are three ndependent reports here. There's no way for us to follow up on his. Police view this as simply not being worth going all the ay on it. It's just not worth doing. These doctors can afford he best lawyers. We can't fight this. r the "local ladies" using illegal abortionists, the department y is hands-off. In the infbrmant's words: he police could detect the local ladies, but they don't care. hey - I mean the establishment - don't care about the poor. hey're less educated, less capable of testifying in court. The olice are much less likely to care about prosecution in these ases. The girl has probably had negative contacts with the law nd she's not interested in getting involved either. It's an area e just don't like to touch. A bla Black enter infer Int i M091 physi police Practi Such p inform indige W hav aborti often Mega 3] Other urban settings have a different pattern of enforcement. tflack woman gynecologist practicing in Detroit emphasizes that lack women have little incentive to report an abortion, or even to nter a hospital emergency room for treatment of uterine bleeding or rflection that may follow an illegal abortion. Fear of police harrass- wn:and investigation of the woman's assumed criminal statuses or annections restrain black women who have received a "bad" abortion nmninvolvement with legitimate institutions. Instead, a "neighborhood" weician may take care of the incomplete abortion without notifying ilice. In Detroit some black physicians with a primarily gynecological ectice, report that police interference is a chronic problem of work. mh physicians not only reject police invasions by refusing to give Iformation, but are also reluctant to attempt processing the medically Idigent person through hospital abortion boards where she is likely have to undergo a non-voluntary sterilization as the price for an ortion. Mutual distrust between police and blacks together with the ten prohibitive costs of legal abortions, serve to maintain the legal abortion route fer most black women. For this black woman gynecologist the modus operandi of police forcement is simply to harass and to humiliate both physican and tient. She said in an interview that in her experience: The prosecutor's office makes a lot of noise. You're forever aware that these guys can move in on something. All the incom- pletes that come in (to hospitals) are reported as criminal abor- tions and admitted as such. The hospital administration makes the report. There are very few patients who will go into the hos- pital and say they've had an abortion, however. In the case of a septic AB, that is an infected abortion, we used to do this regularly (i.e. report septics as criminal abortions). But we 32 have run 'into problems with the police. The inhumane manner in which detectives question patients is very bad. You certainly haven't scared the patient. She's not going to tell. They're going to protect the illegal operator for their own daughter, sister or what have you. Why should they tell the police where they had their abortion? This just shows you how desperate women are to have abortions. The really appalling thing is that the detective comes into the ward where there are a lot of women, and they hassle the woman. They spread her business out. They just tell what her business is on the street. Everybody knows about it. It's inhumane. Just because society has forced them to do something illegal, I'm not going to go to the detectives. Police interference, particularly against black practitioners ds to withdrawal by many of these physicians. In the same informant's ds: The homocide squad is coming to me. They were looking for a Negro woman who gave an abortion (in which the patient died). They're just fishing around. We all know licensed physicians are doing it. I've never seen this other woman who's doing it, though. Some things you just don't delve into. It isn't what you want to do, but it's one of the things you have to do so you don't get involved. One of the reasons that the police don't have infbrmation is that we don't feed it to them. So they must suspect a lot. But they really don't have any information to pin down. One 21 year old black women who has had three criminal abortions, who was in jail for heroin at the time of the interview, said that and her friends avoid the hospital situation altogether. She rted that:19 When you go to the hospital, that is, through the emergency room, the police come in on the case. The detectives come in and ask a lot of questions. They bug you a lot and try to get something on ou. They try to clean the books on you. If police cannot depend on respectable physicians or hospital gency room victims for information, to whom do they turn? One e practice is the surveillance of known abortion sites as a source "getting a good pinch." Yet the dubious activity of observing ubsequently tracking down ostensibly sick women who leave these 33 ises results in few successful warrants. Most women, investigators are unwilling to testify against the abortionist even in such nuating circumstances as bleeding or other abnormalities. The n is reported either to be too ashamed of her act, or grateful he operator, for most to speak openly with police. In many instances, police investigator believes that the type of woman who gets an tion is the greatest drawback to pursuing a case. For example, one e policeman with over ten years experience in abortion investigation ted out in an interview with me that: In terms of getting abortions you're dealing with a moral degenerate who's an unwilling witness. She's probably a swinger or a pros- titute or some kind of promiscuous person . . . Even if the girl is knocking on death's door at the local hospital, we try to get the girl to give you the guy's name so that we can get a complaintant and a witness, and then you're set up. But you end up afterwards with a hostile witness because if she recovers, then there's no witness. You lose both ways. If she recovers there's no witness, because she no longer wants to provide information, because she just wants to get out of there and not be involved. If she dies, there's no witness either. So it's a very difficult case to prove. If witnesses are a continuous problem to the police, even eis the tactic assumption by police departments that public opinion not support prosecution in instances wherein the physician- tionist is tied into a medical network, or has "clean hands" (i.e. atient deaths). In the case of one well-known Detroit physician, with active police surveillance and numerous complaints charging with abortion, the department has not been either willing or able hut down his operation. Public opinion, or community "consent" is regarded by many rcement agents as crucial in successfully prosecuting any crime. lack of community cohesion in the abortion issue, however, serves estrain legal action and promote status-quo arrangements, i.e. a 34 've-and-let-live" attitude toward abortionists until an actual patient 1th has occurred. The now nebulous constitutional status of the sent law further curtails new prosecutions in abortion complaints. a former assistant prosecutor sums up the dilenmas in abortion law ’orcement in this way: The police can't operate unless the community is reasonably cohesive in this matter. Abortion is a crime today and not a crime tomorrow. People must be convinced in the comnunity that something is a crime in order for it to be prosecuted. How can you get a prosecution when the defense attorney can point to legislators who support abortion reform? You can't touch it. That is prosecution- vfise. No prosecutor would operate in this area. No attorney general would prosecute. The problem here is the problem of consent. Until the people at the legislature know what they want, no prosecutor is going to want to touch this. The prosecutor has to be very careful that he doesn't step on the legislator's morals and other functions. You shirk the function that belongs to the legislature. Even a freshman law student wouldn't handle a case i e t is. Exasperated law enforcement officials may, in turn, accuse sicians of neglecting an area that is really their responsibility. forcing what is virtually a medical choice on to legal agents, doctors and hospitals are said to be helping to maintain the impasse enfbrcement. Physicians who give abortions in hospitals for health welfare reasons are operating within their discretionary power, se officials say. There is, however, a counter recognition that sicians who use judgment in those cases that were "absolutely antial," as in medical, psychiatric, rape, incest, or rubella cases20 probably assuming some risks if operating in jurisdictions with fitious prosecutors." The shortcomings of the statutory limitations, iinfOrmants hold, is that the physician is indeed denied judgment Iin his area of expertise. This paradoxical situation is summarized me prosecutor who told me in an interview that: 35 Physicians who give hospital abortions are above the law, in that they are protected by their colleagues, the community, and by women who receive the abortion. This is a situation in which the police are virtually ineffective. They (the police) must bring the case in. There must be a complaintant. It's difficult to do in the present milieu of changing and contradictory attitudes. On the other hand, the prosecutors who must do their jobs and who are _ambitious, are not limited by the physician's judgment. If they think they have a good case, but not enough sufficient evidence that a crime has been committed, they may still move into the situation and prosecute. Generally, though, there is a very low probability of prosecution occurring. For many physicians, however. the threat of prosecution, or en the possibility of a threat is sufficient to circumscribe any forts to use physician discretion in these matters. Values and ideologies of judges are other crucial elements in Lccessfully prosecuting a case. Even if the prosecution makes a easonable case, a "liberal" judge may throw it out at any point, 1ereby jeopardizing the department's production record in terms of (penditure of time, money, and manpower. Flagrant instances of mal- ‘actice or "botched" jobs by non-physicians offer the best chance of muring conviction. Yet, even here juries may be divided because of wal conflicts of the participants. Within the legal system itself, opponents to the present rortion law emphasize the more obvious legalistic shortcomings, as in biguous language, inconsistency in application and enforcement, nrisdictional differences in court interpretations of admissibility of idence, and the more difficult problem of defining the state's terest. In the latter situation, does the state act to protect the man or the fetus in putting abortions within the criminal code? ile higher courts in many states are still considering this issue,21 e legal aspects are strongly influenced by recent inputs of the Catholic 36 hurch. This religious group seeks to articulate state's interests as hat of sustaining fetal life, with subsequent denial of choice to the regnant woman. Opposition frequently focuses on the language of the criminal tatute which permits abortion only to "preserve" the woman's life. he language of "preserve" has been variously interpreted as "to keep live or in existence," “to keep safe from hann or injury,“ or “save," y still other facilities. Changes were not necessarily permanent, 51 ough. Psychiatric complications following a saline abortion created “cause celebre" in one medical community halting the liberalized licy. In this case, a resistant nursing staff supported by Catholic ofessional and lay persons alerted hospital authorities to the contra- nd practice. Interview data on the extent of legal abortions are contradictory. e physician states that the number of abortions are down; another serts that the number of hospital abortions are on the rise. Evidence om three Michigan hospitals providing a relatively extensive abortion rvice (i.e. 100 or more a year) shows a rise in legal abortions from 67 to 1970, but a sharp drop since late 1971 in two of the three milities. In all cases, legal enforcement played a minor or negligible He in the change. Instead, the shift may be traced to three other DHthTOHS: 1. Increased community tolerance for abortion as a method of family planning led to increases in demand for abortion. 2. Legalization of abortion in other states enhanced the medical information flow with regard to technology and patient outcomes, leading to a reconceptualization of abortion by some Michigan physicians. 3. The opening-up of the New York market after liberalization PrOVTdEd an alternative route for abortion seekers. The recent decline in requests for admittance to hospital rtion is explained by this alternative route. Physicians can now oid the hurdle of the committee system by referring patients either rectly to professional contacts in New York, or indirectly through eabroker system. For most Michigan hospitals providing obstetrical ryices, there is a "wait-and-see" attitude. This means that for most cilities little or no variation is expected until the abortion law 5 changed.8 52 In the next section, we consider the structure of medical control urexamining two hospitals, one a metropolitan-teaching hospital (“Metro") nd the other a rural community hospital ("community"). Processing_Abortion Patients: Hospital '“ManagementiinfTwo7SettingsA To delineate the structure of control in these settings, we asked three questions: 1. What are important differences between these hospitals? How do they affect medical practice in abortion service? 2. Who are abortion patients served in these hospitals--their characteristics, type of procedures received, and diagnostic evaluation. 3. What is the relationship between medical control and patient accessibility to abortion service? We consider four features in describing hospital processing of [bortion patients: the settings, professional conceptions, patients :erved, and abortion programs. In exploring rules and practices in ifis service, we also suggest ways in which particular control mechanisms 'elate to: (l) cost-reducing strategies, and (2) problems of patient lccessibility. The Settings--Metro and Community Hospitals Location, size, type of hospital,9 population served, speciali- zation of staff and type of'medical or surgical program are some rganizational characteristics giving shape and substance to hospital (flicy and medical programs in abortion service. Policy and programs, n turn, are also responsive to the kind of supporting or controlling elations the organization has with other institutions-~1egal, hospital, dical, academic, community and so on. In deciding whether or not to 53 rovide abortion services--what kind, what amount and to whom--h05pital taff must wrestle with the limitations imposed on the organization by ‘ts own internal appartus (as in location, size, etc.), and by the kind f relationship it has in the larger medical and social community. hese conditions circumscribe decision-making and strategies in providing bortion service. etro Hospital Metro Hospital is located in the inner-city area of a large metropolitan center. It is a voluntary hospital, one of four other facilities, which has a university-associated status with a major lniversity in the state. It functions primarily as a teaching-research iospital offering a variety of basic research and clinical programs in lbstetrical and gynecological medicine and surgery. Medical departments are relatively centralized. The chairman supervises all research, clinical, and teaching programs, but is rccountable to the dean of the medical school, and through bureaucratic mannels, to the university board of directors, and to the hospital ward of trustees. The staff is a highly specialized one with obstetric-gynecologic :OB-GYN) board certification for all tenured staff physicians, who mrform three roles: professor of an academic specialty, director or :eacher of a residency program, and private practitioner. This hospital, unlike many university teaching hospitals, etains the traditional board of trustees. Metro hospital boards have fistorically been controlled by old-line business interests. The board 8 presently comprised of leading businessmen or their wives most of 54 the latter of whom are older women who perform "professional" volunteer roles in various civic activities. The population served is an urban-suburban one, with a rela— tively high proportion of Black patients drawn from the immediate hos- aital area. The "staff" service which cares for indigents, almost all )f whom are Black, is an essential feature of this hospital organization. lfter initial processing, these patients may be later fonneled into specialized programs, as in "high-risk" pregnancy care, abortion, and/or sterilization procedures. Private patients are admitted into the OB-GYN department through referral by a staff physician, or alternatively, are routed by an outside physician who refers directly to a staff :hysician. The hospital is located in a city of approximately one and one ialf million persons, with a 550-bed capacity. Clinical practice is almost exclusively limited to OB-GYN medicine. This is the only etropolitan hospital specializing in women‘s practice. For this reason, atient admission is restricted byiifbrmal referral system, and more ecently, residency requirements. Linkages with local business interests, the university, and tate and national medical-hospital associations connect the hospital 0 a variety of supporting and controlling groups. This network affects ospital abortion policy in subtle and complex ways. For instance, taff physicians view board surveillance as a conservative influence. hey say that board members are traditionally-oriented and uniformly bject to abortion for social reasons. And, while the university supports epartmental autonomy, top administrative staff and lawyers tend to take heir policy cues from board members. 55 Administrators typically stress bureacratic constraints-~legal risk, costs, manpower shortages--as primary reasons why abortion service must be restricted. Some staff physicians also point to the fact that the president of the hospital is a leading Catholic layman who is highly opposed to "abortion mills" at whatever quantity of service provided. The expectations of the obstetrical department, supported by the dean and professional medicine, oppose this rationale of no service. They hold that in a setting festering experimental, research.clinical, and teaching programs, abortion service should be a standard procedure for training residents and for research on maternal and fetal studies. Local professional connections with organized medicine regarding the legal and medical status of abortion make this a suspect practice unless conducted within the context of other specialized programs (e.g. surgery or sterilization). The negotiated outcome of these contradictory influences is a policy that permits a limited number of abortions, but only within guidelines established by the board and carried out by the hospital abortion committee. Cgmmunity Hospital Community Hospital, by contrast with Metro, is located in a rural, and-Michigan area, and functions chiefly as a general hospital both serving and supported by the local community. There is little medical specialization in obstetrics-gynecology. Among those physicians with OB-GYN hospital privileges, only one is specialized in this medical field. All others are classified as general practitioners (M.D.) or 56 doctors of osteopathy (0.0.). Hospital organization is relatively decentralized. Physicians as private practitioners are responsible, first, to patients, and second, to the hospital administration, who essentially perform facilitating roles for local doctors. The hospital is locally controlled by a community board of trustees, all of whom are business or professional men who share club and other recreational activities with physicians. By and large, hospital control is shared between the administration, board, and staff physicians. The medical entrepreneur in this context can readily maneuver himself into a position on the board. This latter situation accounts for one physician's single-handed efforts to set-up a relatively extensive abortion program. The population served is rural, small-town or students drawn from the two colleges in the area. Referral into the hospital originates from a variety of informal sources--former patients, social service agents, clergy, or college health service physicians all of whom may contact a doctor with hospital privileges. This hospital serves an area of approximately 100,000 persons with a capacity of 146 beds, 16 of which are devoted to obstetrical cases. There are 37 beds for surgical and/or pregnancy termination procedures. The hospital has relatively open admission for citizens located in the inmediate or adjacent counties. This policy extends to abortion patients as well, with some reservations because of necessity to maintain a "discreet" service. Supportive alliances are primarily drawn from local business and professional elite. State political and medical organizational activity 57 y one physician serves as an outside prop for innovative medical programs, .9. vasectomy and abortion. 0n the whole, the medical-hospital system ‘5 based on a laissez-faire orientation. Physicians are expected to erfonm "discreetly" in terms of inner controls, or at least, peer eview, largely free of bureaucratic sanctions. Informal relations between board persons, administrators, staff physicians, and community alite contribute to a permissive medical milieu with high levels of autonomy for individual physicians. Peer review, in this context, tends to be friendly and non-censurious. Figure 3 summarizes relevant differences between the two Iospitals. In almost all respects--location, hospital function, type lthSPltdlorganization, characteristics of staff, population served, ype of referral, extent of obstetrical-gynecological practice, and xternal alliances--the two facilities offer contrasting patterns of tructure and organization. In only one feature are both hospitals imilar. This is control by a board of trustees, largely drawn from he local business or professional community. Although the two boards are imilar in form, they differ in practice. The smaller scope of the ommunity hospital enterprise allows for informal relationships between 0W" and professionals. This facilitates physician infiltration into he control ranks, making board censure of medical practices a socially roblematic activity. In the larger bureaucratic structure characteristic of Metro ospital, constraints by independent hospital board, university board, entralized hospital administration, and the larger body of organized dicine all considerably limit the degree of individual physician 58 Organizational Features Metro Community Location Urban Rural Voluntary Community Type of Hospital Function Size of Hospital (# of beds) Specialized Programs 10. of OB-GYN Patients Served (i.e. deliveries, surgical, etc.) Characteristics of Staff )rganization of Staff leferral into Programs Type of External Control ype of External Alliances University Teaching Hospital; Specialized Programs 387-bed Obstetric-Gynecological Service; Experimental 9,786* All Board-Certified OB-GYN Hierarchical-Dept. Centralized Physician to Physician; (Formal only) Board of Trustees; University Board of Directors Business; University; Medical-Hospital Relations--State and National *Number of patients served is for 1970. All-Community Hospital; General Program l46-bed None l,153* General Practitioners with OB-GYN Privileges; l OB-GYN Specialist Individual Practitioner De-centralized Physician to Physician; Agency to Physician; Patient to Physician; (Infbrmal) Board of Trustees Business; Local Politicos; Michigan Medical Society igure 3.--Summary of Organizational Features in Two Hospitals 59 freedom. In this hierarchical context, medical innovators with "unpopular" values or practices eventually have to seek other outlets fer their activities. Professional Conceptions--Values, Ideology and Rationale'fOr Abortion service In providing abortion services, professionals bring to bear conceptions and meanings about abortion and abortion patients that define preferences. Collective definitions may arise from past experience, or present professional needs. The meanings may have evolved gradually, or may be negotiated outcomes of long-term conflicts. Whatever the source, definitions act to provide values and guides for action. The different set of circumstances within which the two hospitals operate also relate to different values and meanings staff hold toward abortion in each setting. Metro Hospital In keeping with the more elaborate bureaucratic structure and complex exchanges, professional decision makers at Metro tend toward a inaditional orientation in medicine. This is articulated as technical orfippreaucratic requirements for practice, or abortions performed within the constraints of costs, and essential teaching and clinical programs. Only a few reform physicians in this setting actively reject this orientation. While definitions toward abortion vary somewhat between these specialists, the general attitude toward abortion may be summed up as fifllows: abortion surgery is not challenging medicine. This is not flat we're trained for (i.e. obstetricians), and we don't like the idea 60 of having our beds full of abortion patients when there are sick people that need medical care. Moreover, being involved in abotion mills discredits the hospital and the profession. This attitude may be traced to legal, moral, medical, and traditional sources. The association of abortion with criminal activity and the doctor-turned-abortionist-for-profit motive is one source for this negative attitude. Another is the reluctance of physicians to be involved in "mill-like" (or assembly line) medical practice. Some say it "cheapens" the enterprise. Medical school socialization also contributes to an anti-abortion ethic. Training for obstetricians revolves 10 Strong religious on the "preserving“ of fetal life, not destroying it. opposition by Catholic physicians and administrators, particularly, is still another factor contributing to a low evaluation of abortion. Most obstetricians I interviewed, regardless of religion, are reluctant to accept abortion as appropriate therapy for problem pregnancy. Negative values affect conceptions toward abortion patients as well. In working out shared meanings about more or less desirable and legitimate clientele and problems, many physicians view abortion patients as an undeserving client group. They are held to be irres- ponsible and incompetent, and by some traditional physicians, promis- cuous. These attitudes are reinforced by perceptions of the legal risk. The collective definition can be expressed in these terms: Why bring in a possible malpractice suit on your head by a confused or irate patient or her relatives, or incur the wrath of the county prosecutor's office? lfis cost evaluation is also related to a status-quo conception. pranding the present abortion program has no advantages, as this staff hysician pointed out: orir 594‘ Hi! I? he Th plr 6] It's not worth it. Keep the system tight, so we don't have to deal with too many of these people (i.e. abortion patients). I'm already overloaded now. Besides, we're already taking in more abortion cases than anywhere in town. Let some of the others (i.e. hospitals) do it for a change. Low commitment to abortion service together with a program riented toward "challenging" medical specialization in a university atting tend to keep all, but a few, staff physicians from trying to lter the present arrangements. And, while therapeutic abortion has een given in this hospital for over 25 years, the official rationale or service is limited to surgical care for the severely ill. The nofficial reason is that abortion provides an added staff service for raining OB-GYN residents. In this context somewhat less than 1 out f'16 applicants screened for abortion receive service. immunity Hospital 5 Professional values toward abortion service in this rural-based acility have undergone dramatic change over the last four years. Trough the systematic efforts of one physician who holds to a family anning and social therapy conception of abortion, a gradual loosening ’restrictions has occurred.11 In challenging the "strait-jacket" dical mentality that limits abortion to the severely ill patient, is abortion advocate has convinced colleagues that abortion is eventive” community medicine. In this conception surgical inter~ ntion of an unwanted pregnancy "preserves" the woman's health, and aves" the community the often tragic consequences of rejected ildren. Value changes have encouraged organizing an abortion service. naa primarily one-man enterprise limited to one or two patients a 62 week in 1970, the service has expanded to presently accommodate six to eight, or even more, patients in the same time period. If calculated at a yearly rate for 1972 this facility would be providing approximately three and one—half times more abortions than any other single Michigan hospital in past or present years. The ideology of medical practice, generally, in this Republican- Main-Street area is a strong orientation toward private practice in a laissez-faire, permissive political climate. An explicit anti-bureau- cnatic conception toward processing patients facilitates a personalistic- counselling relationship between physician and patient. Values of private practice and community medicine and an ideology of personal fieedom for individual physicians generate the rationale for service. This emphasizes abortion as a public health measure, and a social- medical responsibility for-physicians. The medical leader of this program considers the present medical- hospital arrangement in Michigan as both inconsistent and hypo— critical. It is inconsistent because only a few hospitals in the state are willing to treat abortion patients, thus denying service to most wmmyh It is hypocritical because abortions have long been given for a variety of non-medical reasons (e.g., rubella, rape, mental health, etc.), but called‘by something else. Further, the language of "preserve" hithe present law can be interpreted to mean “keep," "maintain," or "prevent harm," thereby implying that "health" is a Quality of human life, not a matter of merely saving the woman from death. This physician waged a one-man campaign to negotiate the abortion service. As a lone crusader, he aimed to convince colleagues, 63 mspital administrators, local elite,and his legislator-friend that rresent abortion practice should change in the interests of community realth. To build up his credentials he deliberately set out to influence ommunity medical and political organizations. Vigorous activity on the ocal mental health board provided one channel for his claim that comprehensive health care" also included “mental" health. This approach ermitted abortion to be rationalized on "mentalistic" grounds. Effectively competing for elected posts in the Michigan Medical ociety also provided a forum for his ideas, and legitimated his maverick" medical values to colleagues back home. Republican party eadership at local and state levels made the physician relatively mpervious to local prosecutors, who needed his support for funds and nfluential contacts. This situation was reinforced after the local arosecutor brought in a relative with a "problem pregnancy" that was resolved" by abortion. After this event the physician expressed ittle concern for Opposition from this quarter. Moreover, in making bortion available to a number of wives or daughters of local influ- ntials, the physician acquired enough social capital to offset opposi- ion from anti-abortion groups, especially Catholic lay women. Importantly, the physician has maintained a visible abortion tructure in the local hospital. This strategy requires continuous igilance by the physician against possible detractors who could ineaten tenuous arrangements with the hospital board, administrators, nd colleagues. He justifies these efforts on the basis that a clan- estine arrangement could not communicate his message-~need for an xpanded health mandate in which abortion is one medical option for a roblem pregnancy. The Te 15 sh hi ale rel Fig am of 1 m a e a iu the s 64 Although this abortion advocate is willing to concede that most lysicians reject being involved in abortion surgery, ("Who wants to a the abortionist?"), he believes that every obstetrician should be illing to do the abortion "thing." If you accept referrals on hysterectomies, and other things, then accept referrals on abortion. Where's the consistency? If you can give a couple of abortions a year, why not give more? 'he rhetoric, although supporting a limited abortion service, is not eld by most local physicians. Colleagial acceptance of the service is related to positive regard for the innovating physician rather than strong approval of his program. Most observers would also add that the likelihood of this program working in other community hospitals is almost nil. These two facilities--Metro and Community--present a contrast version of medical values, ideology and rationale for abortion service. igure 4 summarizes the differences in these professional conceptions nd definitions of practice. Traditional versus entrepreneurial values 'fnedicine, a bureaucratic-restrictive versus laissez-faire permissive 'deology, a professional versus public health rationale for patient ervice, an impersonal-negative versus personal-positive orientation to bortion patients, and a threatening versus non-threatening perception 'flegal enforcement for Metro and Community hospitals, respectively, re contrasting sets of meaning that provide distinctively different uides for professional action. In the next two sections we see how these differences in meanings are reflected both in the type of patients selected, and the kind of abortion programs available. 65 ganizational efinitions Metro Community dues Traditional Medicine; Private practitioner; bureaucratic, academic Entrepreneur research (”interesting case" deology Bureaucratic-Restrictive Laissez-Faire — ationale for bortion Service onception of bortion‘Service 'erception of ‘egal Control Professional: Experimental and teaching programs; organizational requirements for total OB-GYN care “Exceptionalistic” Medicine; involves risk for hospital and patient. Surgery is alternatively viewed as simple, low-skilled proced- ure (early abortions) or gynecologically complex Threatening Permissive Community service; public health Routine medicine; involves little risk if M.D. is skilled and "discreet" Non-threatening igure 4. --Summary of Values, Ideology, and Rationale for Abortion Service in Two Hospitals 66 The Patients-~Characteristics of Clientele ‘in-‘the Two Setti ngs‘ Who are the patients served in these settings? How do clientele raracteristics reflect differences in settings and medical values? What ind of medical programs and patient screening encourage serving one lientele group rather than another? In the two sections that follow, a consider the issues of selected patient type and organization of bortion programs as outcomes of professional efforts to channel atient demand within the subjectively defined boundaries of legal and aneaucratic limitations. Table 1 summarizes patient characteristics in he two settings. What the data from Metro suggest are that the local, white, 'rotestant woman who is relatively older, married or formerly married, with the preferred number of children is mg§t_likely to get into the irogram.12 Employment status is related to ability-to-pay. This means “hat legal abortions are further confined to (1) those patients who an afford the costs of referral and hospitalization, in the first place, nd (2) those women who have enough sophistication or connections to elping sources, to "play" the elaborate organizational "game;" in ther words, a middle-class clientele. There is one significant exception to these generalizations. hirty-one percent of patients at Metro are black women, approximately 0% of whom are indigent. The reported denial of accessibility to ospital abortions fOr the poor black is not apparent here.13 Instead, igorous social action by some staff, concerned with gynecological care f poor women, opens up a channel, albeit limited, which facilitates ntree for a few otherwise medically underprivileged women.14 67 TABLE l.--Summary of Abortion Patient Characteristics in Two Facilities Classified by Residence, Age, Marital Status, Employment, Race, Religion, Gestation Age, Pregnancy History, and Method of Patient Payment (June 30, 1970-June l, 1971) Metro Community Variable (n=100) (n=100) Residence 77? r an or suburban 95 1 rural or small town 5 99 A e 79"21 or under 36 56 22-30 36 31 31+ 28 13 Marital Status Married (or fbrmerly married) 60 37 Never married 40 63 Em 10 nt Empioyed or housewife 55 50 Student 25 45 Unemployed 20 5 Race White 69 100 Black 31 O Reli ion gatholic 27 23 Protestant or other 73 77 Gastation A e TUnder weeks 51 96 13 weeks 1 4 14-21 weeks 48 0 Ipcidence of First Pregnancy 22 68 ngidence of Live Births l 12 2 2+ 34 31 no infbrmation 34 O [pgidence of FOrmer Abortions 1 10 1 2+ . 7 1 no information 33 l Ethod of Payment Insurance only 74 9 Medicaid only 21 5 Cash or Mixed plan 5 86 r—* 68 Gestation age, or the time period of the pregnancy, extends into a second trimester for 49 women of this group. This requires a more sky surgery, or one that challenges the considerable skill of the acialized OB-GYN staff. "Late" abortion is further linked to surgical d sterilization programs rather than treated as routine practice. emphasizing abortion as an exceptional surgical procedure, medical lues in this setting are reinfbrced by treating such a high proportion complicated cases. Patient records at Community Hospital show a different papulation. ection for abortion service tends to favor young, unmarried, sexually xperienced students, or small town working girls or housewives who ve or go to school in the immediate area. Not shown here is the :idence of reported experience with contraception. Sixty percent of a women had never used birth control. By choice, early pregnancies ly are treated in this setting. The staff gives no complicated gical procedures in abortion. As preventive medicine, moreover, ervention is stressed in the earliest stage of the problem pregnancy, her than delaying the procedure for a "late" termination when the idence of medical and psychiatric complications rises sharply. The ormal referral network also helps to route patients with early gnancy. Overall, the program as set up by the director is a low-risk, -cost enterprise established within the constraints of a community aital setting. If these women can be classified as "locals," who fit the l or small town image of "good" girls, then a benevolent medical ram performs a dual role: abortion restores the woman's status from 69 hat of a morally suspect person to that of a "respectable“ or "normal“ Hrl, and abortion prevents illegitimacy especially among the young, hereby maintaining community "health.“ As a community salvage program, eborthn1nay also eliminate local welfare relief for the unmarried woman end her child. Abortion Prpgrams--Control Features ‘in the Two Settings Patient differences in the two settings are iripart a eflection of the larger medical program in each setting (general ersus specialized medicine) and professional values supporting these wograms. To what extent patient differences also reflect variations n the type of problem pregnancies in these two locales is unknown. hat can be determined, however, is the mode of processing of those atients who do apply and are accepted into the program. We have uggested that most patients who apply are not admitted to the borthnrservice. For Metro, 1 of 16 screened applicants is admitted; Jr’Community 3 of 100 requests are accepted. Organizational criteria ims to match preferred patient type to pre-existing programs. Con- "olling accessibility, an essential condition for regulating patient stake and for providing limited services, enable the facilities to nage this problematic service. Chancey outcomes are reduced by instituting control mechanisms at will assure administrative and professional staff that the program a "legitimate" one, or one that does not jeopardize other hospital professional activities. We identify five strategies used by these ilities to regulate number and type of patients served: pre-intake eening. quota system, program emphasis, diagnosis, and costs. 7O 9 Hospital--Strategies of Control The mode of screening abortion patients at Metro reflects the :conservative political structure within which this hospital operates. man conmittee, plus anex-gfiicig board Observer evaluates. all appli- ions for abortion--whether staff patients or outside referrals. aretically, the only conditions under which a request for pregnancy Mnation is granted include: severe illness, psychotic behavior, less frequently, fetal or genetic disorders (e.g. rubella or sickle cell nia). Concrete decisions, however, take into account other realities, example a letter from a psychiatrist stating the “abnormal" iition of the woman's present psychic state (e.g. hysteria, suicide, J term instability, drug use, etc.). In borrowing the psychiatric lonale used in states wherein abortion is legal (e.g. abortion to 15 the hospital serve the physical or mental_health of the mother), :ects itself legally. Technically, of course, this is still in ation Ofa strict reading of the legal code. Criteria, however, are not hard and fast rules. The chairman of hospital abortion committee admitted to me that if a physician 5 a strong appeal for a patient, he can sometimes get her in. The ittee is "reasonably flexible," he said, when numbers are down. the demand is up, though, strict criteria are used. The quota system is usually expressed in terms of manpower and ating room shortages. But the gatekeeping function actually takes form of an elaborate referral system that negotiates the woman's tion on a physician-to-physician basis. This means that the woman 'sees the committee, nor is whe consulted at any point in the 71 cess. Restrictions, then, involve not only one or two referring sicians, a costly and time-consuming process for the patient, but husband's consent for married women, or parent's permission fbr or girls. Delays are endemic to this mode of screening, according to the ef of obstetrics. He detailed the following roadblocks fbr'the patient (1) initially finding a cooperative physician to request abortion, securing an appointment with a psychiatrist who is willing to write strong" letter of recommendation for terminations, (3) waiting for the thly, or now bi-weekly, review committee, and (4) postponements in pital admittance to surgery because of patient backlogs or staff nitments to other activities. These various delays in processing the pregnant patient may be factor, among others, that accounts fbr the large number of late ninations at Metro. The relatively uncomplicated early abortion (12 s gestation or under), requires early diagnosis of the pregnancy owed by surgical intervention within a relatively short time after nosis. Patient delays at any point of the process can result in a more dangerous procedure that carries a high incidence of post- ative complications.16 The following table shows gestation age of patients by type of ical procedure Ifbr Metro patients. Early pregnancies of the group) are typically terminated by either vacuum aspiration ilatation and curretage (D & C). Reported complication rates are tively low for these procedures. Late pregnancies, varying from eeks of pregnancy through 21 weeks for this group (49%), are T_______h_ 72 erally terminated by one of three procedures: hysterotomy, hysterectomy, saline induction. Complications are reported to be increasingly her fer these latter methods than fer either suction or D & C 17 cedures. Significantly, there are 5 suction-type abortions formed on late pregnancies (14 weeks or over). This procedure is pngly contra-indicated beyond ten-weeks gestation. A large staff, e of whom perform more than a few abortions a year, may contribute lack of experience and, hence, errors in judgment.18 LE 2.--Type of Abortion Procedure by Gestation Age--Metro Hospital (N=lOO) (June 30, 1970-June l, 1971) tation Vacuum Age Aspiration D&C Hysterotomy Hysterectomy Saline Other Total weeks 4 7 2 l 14 J 12 5 3 20 12 7 4 5 1 l7 - - l l 16 4 - l7 1 28 18 - - 5 3 8 20 l - 5 6 12 E:_ 28 16 38 l 16 100 The abortion program is incorporated into a standard gynecological, ical service. Regardless of the specific procedure or length of nancy, abortion patients are similarily processed. Treatment involves ~abortion physical and other related medical examination, general thetic, one or two attendant physicians, with in-patient hospital fer a minimum of two days. This cautious surgical program is ted both to high incidence of late terminations requiring more 73 ensive post-operative supervision, and to frequency of sterilization lowing abortion. For two-thirds of abortions given at this hospital, procedure involves either a more complex, and therefore risky, ical or surgical intervention, and/or tubal ligation (i.e. sterili- ion). Neither abortion counseling nor contraceptive information or atment is part of the termination program. Instead, the committee luates all patients in terms of recommendations for sterilization. ical grounds for this "final solution" to "promiscuous" abortions, le forcefully debated by individual members, typically include sician evaluation of both medical condition and moral character the woman. While most non-voluntary sterilizations are given to ar women with multiple pregnancies, a diagnosis of "mental retarda- 1" or "psychosis" may require a relatively young woman to undergo fl ligation. Table 3 shows selected patient characteristics as ated to incidence of sterilization. Patients are most likely to receive a sterilization procedure, if: 1. the woman is twenty-two years or older. 2. she is, or has been, married. 3. ‘the patient has two or more children, and 4. the woman has a reported history of a gynecological disorder, medical disease, or has an inherited or congenital condition of mental deficiency (4 cases). Patients are least likely to be sterilized in those instances, 5. the patient is twenty-one or under, 6. the woman has never been married, 74 LE 3.--Incidence of Sterilization at Metro Hospital, as Related to Selected Patient Characteristics of Age, Marital Status, Employment, Race, Religion, Gestation Age, Parity, and Medical Indications. (June 30,1970-June 1,1971) Number of hent Variable Sterilizations Sterilized* N l 412-21 4 ll 36 1 22+ 40 5_3 64 1 Total 44 TOO ital Status Marr1ed (or formerly 35 58 60 married Never married _ji g; 49 Total 44 100 10 ent Employed 29 53 55 Unemployed 11 55 20 Student 4 lg 25 Total 44 165 TH ack 12 39 31 White 32 45 69 Total 44' 155 igion Catholic 12 44 27 Protestant 333. it E Total 44 100 :ation Age 6-12 20 39 51 13—21 24 42_ 49 Total 44 156 ty (No. Children) 2 8 25 1 2 17 12 2+ 25 86 29 Total 9 6 ** cal Indications Medical disease, illness, etc. 11 85 13 Psychiatric disorder, (includ— 22 38 58 ing a previous history of psy- 11 §§_ 29 chosis, neurosis or extensive 44 106 drug use) Social/Fetal *Total Percent Sterilized for each Category Equals 44% **No information on 34 cases. 75 7. she is a student, and 8. the patient has had no children, or at most, one child. Finally, there is little difference in incidence of steriliza- an by race, employment status, or religion. A late pregnancy is iewhat more likely to be followed by sterilization. Neither a 'ported psychiatric disorder nor social-genetic indicators, are lcial determinants in staff decisions to sterilize patients. Rubella, German measles, as a maternal disease affecting the cellular system the fetus, is a counter-indication fer sterilization. Physicians a reluctant to sterilize the young mother, who wishes only to prevent a birth of a possible malformed child, not necessarily all subsequent ‘ths. Postroperative follow-up, a significant factor in tracing ertion complications after the patient has left the hospital, is not 't of the program. The woman may return to her family physician, less likely, to a staff doctor. In neither case is a post-operative tory included in the hospital record for purposes of systematic ff assessment or correction of the treatment program. Patient access to abortion service is primarily managed by sician diagnosis. This ostensibly limits abortions to severely ill ients only. But the tentative status of the law and changing medical ception of abortion, generally tend to cast diagnostic criteria a a definitional limbo. What is legally valid, or alternatively, ically equivalent, for instance, in the following diagnostic egories: "drug abuse," "mental retardation," "contraceptive failure," 1istory of miscarriages," "rape," "rubella," "incest," “inability to a," "immigrant," "broken home,"'tardiac failure," "chronic disease," 76 diabetes," "extreme youth,” or "situational psychosis?“ In reducing he non-commensurate diagnostic evaluations, especially for non-medical ndications, into a single category termed, "psychosis of pregnancy,“ he hospital simplifies diversity. In 80% of cases, ”psychosis" was recorded as the reason for the bortion. This category does not necessarily converge with the patient's mychiatric history. Even with a broad interpretation of this condition,19 Lly 54% of medical histories had some reference to psychiatric illness H disorder. The professional myth of abortion service as one confined o medicallysor at most psychiatrically, ill women, is not borne out n these data. High costs are probably an effective tactic to further reduce he number of requests for hospital abortions. Initial entrance fees for rivate patients average $500 for the hospital, with an additional fee f $300 or more for the physician. Hospital methods of payment are imited to insurance and/or Medicaid (95% of payments). The apparent ack of flexibility in this payment program may also screen out patients 10 lack the necessary work or welfare affiliations, characteristic >urces for private or government medical insurance. Screening of patients, then, may be an ag_hgg activity, ependent less on diagnostic criteria as on other considerations. imposition of the committee, the number of requests for service at a ven time, hospital—staff commitments limiting resources, and physicians' aluations of status or social worth of the woman, all influence who is kely to be admitted to abortion service. It? 77 gymnity Hospital--Strategjes of Control Screening abortion patients at Community Hospital under a one-man rectorship of the program has been simplified to one outside consul- tion. The patient, if approved by the directing physician, is then Ferred to one of fOUY‘or five other staff physicians for a counseling ssion. The counseling is a prg jgrma procedure that operates less to termine the woman's needs, than to judge whether the woman fits the iteria for admittance. Basically, these are: local residence, early agnancy, and legal consent for abortion, either by the husband, if rarried woman, or by a parent, if the patient is a minor. The counseling format follows guidelines established by and erned from clergy brokers, and later widely adopted by social service ancies. The approach is twofold. One purpose is to allow the physician evaluate the woman's "real" intent in choosing abortion over against Ier alternative (e.g. no abortion with or without marriage, illegal ertion, suicide, etc.). Another aim is to stress that the patient Lume moral responsibility fOr her choice. Consultation is thus multi- ectional: (1) it acts to legally protect the physician who gives the lrtion by furnishing him outside collaborators who are implicated in :act, (2) it provides a process by which patients may be evaluated in ms of motives for abortion, thereby screening out troubled or trouble- e clientele, and (3) it serves to infbrm patients of the legal and ical hazards involved.. In emphasizing patient responsi- ity for the act, the medical system seeks to inSure that legal risk, any, is primarily assumed by the patient or her family.20 78 Informal quotas are an implicit part of the decision-making :ess. If the directing physician takes in as many as Six patients aek, this is actually only about 3% of the total number of calls for "tion he typically receives in this time period. Management of s risky medical procedure is handled by limiting the number of "tions to fit colleagues' expectations of "appropriate." Too much and for hospital operating room, anesthesiologist, and nursing time Id create consternation in the hospital system. Further, with a >le medical practice to maintain, there is reduced incentive on the : of this physician to expand abortion service. Hospital intake for abortion is explicitly limited to patients I early pregnancies only. Almost all patients (96%) had pregnancies reen six to twelve weeks, with all terminations by the relatively a method of vacuum aspiration. In screening for low risk patients--i.e., :e with early pregnancies, who are medically, psychiatrically, and 11y "normal"--the system aims to limit both medical and psycho-social Jications that are said to follow from "late" terminations. No onsibility is taken for referring high risk patients. Abortion service is a modified surgical program that reflects vation within standard hospital practice. This means that the tion procedure itself is treated as "typical" gynecological surgery. requires an operating room, a physician-anesthesiologist, nurse- ndants, recovery room, and bed rest. Patient use of hOSpital bed lities, however, has been drastically reduced. In fitting all cts of the surgery--pre-operative, abortion, and recuperative vities--into an abbreviated period of six-to-eight hours, instead 79 Fthe usual 24-48 hours of in-patient care, the hospital can accommodate ire-patientsat less cost to both facility and patient. Mode of referral and physician "follow-up" are practices that e consistent with social or family planning rationales for abortion. itree into the system is relatively open with non-medical, medical, or een self-referrals equally acceptable. To reduce the possibility of sortion “repeaters," patients are carefully coached in contraceptive ectice by the directing physician. Although approximately 69% of atients reported erratic or no use of contraceptive devices at the time Fthispregnancy, almost all (91%) of the women had some form of lysician-administered birth control after the abortion. This includes even women whose husbands received vasectomies (i.e., male sterilization) r the same physician. Contraception as “preventive" medicine, is a wcial goal of abortion service at Community. In counselling the atient both before and after abortion, the physician emphasizes pro- assional definitions of moral behavior, i.e., avoidance of abortion. (stematic use of birth control protects patients from future unwanted ~egnancies. By this means the physician secures both necessary and afficient conditions for colleagial acceptance of this questionable adical service. Once the woman has passed the initial screening by two physicians, iagnosis is essentially irrelevant. Almost all patients receive 1bortion on request," or termination for personal or family reasons 32%). Medical or psychiatric problems, when present (18%), are sually viewed as complications related to the present pregnancy. For 1e hospital record the woman's articulated distress due to an 80 anned pregnancy is translated into the psychiatric code of "reactive ession." In doing this the physician follows conventional usage in state university women's hospitals. Legal discovery, if it occurs, d expose not only one relatively isolated hospital system, but a ork of hospitals similarly involved. Psychiatric coding for abortion 5 this local enterprise to more presitgious medical organizations, ein strength in numbers acts to offset local variation in enforcement tice. Even with a relatively simple surgical procedure and a short ital stay, the costs for abortion are considerable for many less uent persons. The hospital charges a standard $175 payment, plus ysician fee of $150.21 The flexibility of methods for payment-- uding insurance, cash, time payments, Medicaid (5 cases), or s thereof--allow even the less affluent to fit budget to payment Abortion patients, generally, are reputed to be poor credit 5 by hospitals. Once the “problem" has been eliminated the patient rtedly leaves the scene with no discernible trace. Falsifying s and residences by patients has been a standard practice, until ntly.22 This situation, however, does not prevail at Community. features of local attachments for patients, gratitude for the physician's ingness to engage in medically risky conduct and a flexible payment all generate a loyal clientele, or at least, one that pays the . Figure 5 summarizes the abortion programs in the two settings. 81 “ganizational Practices )de of Screening Iota system A. Explicit Limitation B. Implicit Limitations 'pe of Surgical ogram me of Abortion 'ogram arcent of Abortions Metro 7-Man Committee plus 1 board ex officio member Hospital bed, operating room, and manpower shortage; abortion for medically or psychia- trically ill patients only; consent forms; service restricted to formal referral Low organizational pri- ority to abortion ser- vice; service restrict- ed to metropolitan pop- ulation; "strong" let- ter from a psychiatrist usually required; moral evaluation of patient as "deserving: Extensive - inpatient care only; general anesthetic; 2 attending physicians; 2 days in hospital Extensive--full range of procedures; early and late terminations (up to 5 month gesta- tion); sterilization frequently follows termination 1%* lTotal OB-GYN Serv. 'pe of contraceptive ogram sts Sterilization No contraceptive education or treat- ment $500 - $800 Community Intake physician; 1 outside consultant Local residence; early pregnancies only; con- sent forms; service restricted to "catchment area" (100,000 popu.) Need for physician "dis- cretion;" moral evalua- tion of patient or her family as legally responsible. Modified--out-patient care; general anesthetic l attending physician; 6-8 hours in hospital Limited--l procedure only only (vacuum aspiration); preference for 8-10 week gestation; no additional surgery 3%* Patients treated with pills, IUD, or diaphram, husbands receive vasec— tomics (91% treated for contraception) $325 gure 5.--Summary of Abortion Programs in Two H05pitals (1970-1971). 82 : 5 (Cont.) lzational ices Metro Community d of Payment Relatively inflexible; Relatively flexible: insurance, Medicaid Insurance, cash, time payments, Medicaid, or mixed method -Operative No systematic program; Systematic program: *1970 Figures (See, also, footnote 23). woman consults her pri- vate physician woman returns to physician who perforned abortion; telephone or interview follow-up 3-6 months following abortion Implications of Medical Control: Access and Social casts The problem of professional dominance, generally, is succintly arized by Freidson who suggests the extent to which medical practices e up organizational exigencies rather than emphasize patient needs. )ontrolling both the healers and healing programs available, pro- ionals define appropriate care and who shall receive 1't.24 icularly pervasive feature of abortion. Despite the historically ' costs of control, as in—patient death and illness, persistence of l { This differential power to define and regulate services is a f l l rrworld suppliers, inflated prices, and poor technology, the medical ession, as a whole, has remained relatively passive regarding attempts hange abortion laws. Rather than confronting law—making or enforce— bodies with these Cost considerations, there has been notable nce by organized medicine. The medical and social consequences in the patient's problem, not the physician's. 83 In accepting the legal status-quo, medical organization of ion has actually served as a regulative arm of the state restricting ces and imposing risk-related costs on to consumers. The implica- s of these regulative practices from the Michigan data may be summar- in terms of accessibility and cost features: 1. Accessibility to abortion service is a function of ”fit" between patient characteristics and organizational requirements. 2. Accessibility to abortion is inversely related to client's social status and/or ability to pay. 3. Accessibility to abortion service is limited to patient's willingness to bear the high social costs of service. From the point of view of physician-gatekeepers, the incidence 1 of abortion and/or recidivism must be severely controlled. This nanaged, in part, by limitations on type and number of services, gnostic labels, delays, consent requirements and "rehabilitation" ‘in sterilization). Some of these strategies (e.g. quotas, steriliza- ) are explicitely used to discourage or eliminate clientele. Still rs (e.g. diagnostic labels) are implicit organizational devices that ect traditional conceptions of abortion patients and etiologies of 'r problem (e.g. psychosis, depressive reaction). Individual icians may or may not personally subscribe to this control order. act, some evidence from interviews suggest that a few practitioners ‘ed in this system strongly repudiate many of the regulative mechanisms the attitudes behind them. Subsequent rules probably reflect a negotiated order, in which )nents of control manage to modify or limit certain of the more tly or punitive tactics. Excessively high costs and involuntary ilization, especially, are regarded by a few practitioners as both 84 assary and illigitimate.25 One solution to control by opponents has the widespread practice since 1971 of referring problem pregnancies encies and counselling clergymen for out-of-state abortion. This 5 the problem of directly confronting medical or bureaucratic :eepers. At the same time, it assures that the patient will ive the desired treatment, however objectionable the referral system be to individual practitioners. In resolving the benefits/cost problem, the medical system as ole takes the position that patients who wish a medically-approved, etate abortion for an unwanted pregnancy must assume the largest e of costs for this service. This is regarded as a small “price" legitimating this still morally suspect medical service. In this over-priced legal market of few abortions provided ar elaborate and often excessively costly control conditions, the sumer is likely to seek an alternative supply source for the 1 9mm l This chapter presented an overview of the legal market. Two ligan hospitals were analyzed to show pre-legal abortion policies )practices. Although no claims can be made for representativeness :he sample, we strongly suspect that abortion service throughout Iigan hOSpitals is similarly characterized by problems of patient as and lack of available, low-cost procedures. Various restrictions edical conduct in abortion are traced to a proscriptive law. It 150 the case that ethical and value preferences among practitioners to keep the system tight. 85 The physician's role in interrupting a pregnancy has typically n assigned to those few involved either in experimental or teaching uations, or alternatively, to "marginal men"--older, less successful, even psychotic practitioners--willing to gamble careers against the s of a lucrative practice. Obstetricians, especially, may evaluate career in terms of the number of healthy babies delivered. mination of a pregnancy in these tenns violates both the physician's ge of appropriate medicine, and even his conception of production-- ., the saving of fetal life. Public shift in values and ideology with respect to abortion 3 been slow to percolate up the social structUre. Even today, many sicians are likely to view the abortion seeker as “promiscuous," itally ill," or otherwise incompetent. Whereas the medical profession increasingly sophisticated with regard to birth control techniques, re is a serious lag in information regarding abortion procedures and :omes. Lack of knowledge contributes to lack of experience and gyprga, The reluctance of many physicians and hospitals to become )lved in the abortion ”business" should be seen from this historical spective of a view toward abortion as “bad," or medicine contaminated 'sleazy“ operators and profit-takers. In this value milieu, the in seeking an abortion is likely to be outright rejected, re-routed in illegal operator, or at the present time to a clergyman broker; less frequently, forced through the delaying, often humiliating iital abortion committee system. Consumer demand for abortion, when l is met, has been primarily supplied from illegal and extra—legal l ices. In this gap between public demand and legal supply the #preneur has flourished. 86 The next chapter briefly examines the illegal market--criminal bortions in Michigan. Although accurate data about these processes re sketchy, evidence suggests that the viability of the illegal market as been sustained, until recently, by an elaborate exchange order etween "respectables" and "deviants.“ CHAPTER III-~FOOTNOTES Data for this chapter are specifically derived from the following sources: A. Formal interviews with 42 Michigan physicians, public health nurses (2), and Michigan Medical Association personnel (4). B. Extended informal interviews, telephone calls, and discussions with two physician infonmants. C. Attendance as an observer at a Public Health Abortion Facilities Planning Committee from October 15 to March 18, 1971 (monthly or bi-weekly meetings). D. Interviews with New York City physicians, hospital administrators, and public health researchers (18), and with Buffalo, New York, public health and city hospital physicians and administrators (5). E. Hospital records of almost all abortion patients from two Michigan facilities for a one-year period, June 30, 1970, to June 1, 1971 (100 cases each). ‘ F. Attendance at medical or abortion conferences (3), and study of unpublished documents by abortion reform physicians. Not considered in this study are abortion sources outside organized practice. Barrie Thorne reminds me that other alternatives are available, e.g., successful self-induced abortions, lay "experts" or women's self-help clinics, and menstrual extraction in doctors offices. Estimates of the number of hospital abortions per year differ, depending on whether the source of the data is re orted or estimated. The only available report on the number of hospital a50rtions in a 1971 survey conducted by the University of Michigan, Center for Population Planning, Department of Public Health, under the direction of Johan W. Eliot, M.D. in an unpublished paper. With 55 questionnaires returned (representing 29% of Michigan hospitals), only 17 indicated they performed therapeutic abortions in 1970. Altogether, these hospitals had performed a total of approximately 387 thera- peutic abortions. I think this figure is too low. With data from three hospitals for 1970, my figures show a total of about 242 abortions. Further, many city hospitals with OB-GYN departments provide some therapeutic abortions (estimated 12-25 per year). Subtracting the 55 responding hospitals from the total of 188 hospitals providing maternity 87 87a service, and giving the lowest possible estimate of therapeutic abortions per year (i.e. 12), the number of hospital abortions in Michigan is at least 1,596. Most refOrm physicians use the rounded figure of 1,000 as the "typical" number of legal abortions. But how many undercover procedures that are masked as "D & C“ remains unknown. A more conservative estimate is offered by Jan Schneider, M.D. who includes the figure of 364 legal abortions for Michigan. (Unpublished paper, Department of Obstetrics and Gynecology, Maternal and Child Health, University of Michigan, Ann Arbor, Michigan.) See, also George LaCroix, M.D. who has summarized these trends in "A Report to the Michigan State Medical Society," Annual Meeting of the Michigan State Medical Society, Grand Rapids, Michigan, October 7, 1971. See 5. M. Wassertheil, C. B. Arnold, M.D., and R. C. Lerner, "New York State Obstetricians and the New Abortion Law: Physician Experience with Abortion Techniques," unpublished paper, Dept. of Community Health, Albert Einstein College of Medicine, Bronx, New York. See John Peel and Malcolm Potts, Textbook of Contraceptive Practice; Cambridge: At the University Press, 1969, pp. 203-204: This belief persists today among some physicians. In a poll taken of physicians in Ingham County, April, 1971, by the County Medical Society, one of the most conservative views of the risk element in abortion was taken by physicians classifying themselves as obstetricians and/or gynecologists. This group maintained that abortion presents a far hi her risk to the mother's life than childbirth. While this risk situation undoubtedly still holds for illegal, or non-hospital abortions, it has been estimated that it is 6-8 times safer (i.e. in terms of maternal mortality rate) to have a hospital abortion than to carry a pregnancy to term. (See Christopher Tietze, M.D., "Mortality with Contraception and Induced Abortion," Studies in _family Planning 45 (September 1969: 6-8). This situation is limited to abortions performed in licensed hospitals. "Clinics" or "hospitals" with dubious legal standing which have been discovered to be giving abortions, are subse- quently closed, and their owners, managers, and practitioners prosecuted. In Eliot's unpublished study from the Center for Population Planning, cited above ("Preparation of Michigan Hospitals for Abortion Law Liberalization"), hospital administrators' or physicians' comments with regard to change emphasize that most facilities are "holding tight" until the Michigan law is liberalized. Some facilities reject even contemplating possible changes, even in the event of liberalization, because of location, type of population (rural or Catholic), "high occupancy,“ or lack of direction from boards. 88 Iospitals are differentiated by their (a) mode of ownership, (b) =unding, and (c) source of accountability. The four major types if hospitals include: ) Municipal or government hospital: This is publicly owned, funded y taxes, an accounta e to c1tizen boards. It is a non- profit hospital. !) Voluntary hospital: This type is privately owned, or associated with a corporation, or university. Funding may be private and some public (as in taxes), but accountability is to a local board. It is non-profit. l) Universit -teachin hos ital: These are associated with medical schools. The hospital may be owned by the university or retain its voluntary, private status. In either event, it is a non- profit organization. 1) Community hospital: This is a combination of municipal and voluntary, with funding primarily derived from local taxes and federal grants, and some donations. Accountability is first, to the local board, and second, to the community. It is a non-profit facility. 5) Proprietary hospital: This is a privately owned hospital that operates for profit. Owners are accountable to stockholders, if incorporated, with no public accountability. lntil recently, physicians have been socialized in medical school to egard abortion as both dangerous and unethical. As late as 1969, 1edica1 students were using the standard Williams' Textbook on lbstetrics which has the following statement in regard to thera- >eutic abortion: Since therapeutic abortion entails destroying the fetus it is a grave undertaking and must never be considered unless there is imminent danger of death of the mother as the result of pregnancy, or of great bodily or mental harm. Neither the law nor medical ethics permits the procedure for sociologic reasons, i.e. illegitimacy, poverty, or rape." (Quoted in Jane E. Hodgson, M.D., "Therapeutic Abortion in Medical Perspective." In Minnesota Medicine 53 (July, 1970): 755—757). fhis restrictive stance has been amended by a recent policy statement if the American College of Obstetricians and Gynecologists who hold that abortion may be given to “safeguard the patient's health or lmprove her family life situation." (Nineteenth Annual Clinical hating, San Francisco, California, May 6, 1971). l l l l l l 89 Physicians provided top leadership in abortion reform movements at both state and national levels. They should, however, ppp be considered as operating outside of their professions, but rather as "segments" or coalitions within the profession opposed to entrenched anti-abortion physicians. Professional segments are discussed in Rue Bucher, "Pathology: A Study of Social Movements Within a Profession,“ in Eliot Freidson and Judith Lorber, (editors); Medical Men and Theierork. Chicago: Aldine . Atherton, Inc., 1972. pp. 3- 7. The pregnancy histories were incomplete for Metro patients with approximately one-third of patient records having no report of previous pregnancies, number of children (parity) or prior abortions. This is attributed to the erratic hospital reporting system wherein individual physicians are responsible for patient charts with no uniform check-off list. The pregnancy rates, undoubtedly, would be much higher for this patient population if data were complete, according to staff informants. This is suggested in a paper presented to the Conference on Planning Abortion Facilities in Michigan (Wayne County Medical Society, Detroit, Michigan, April 23-24, 1971) by Ethelene Crockett, M.D., "Consumer, Consumer Education, and Protection.“ Her point is that Black and/or poor women are shut out of hospital abortions because of prohibitive costs, or restrictive hospital clauses, generally. We should note, however, that all of these women were covered by Medicaid payments. There are p9_free, or low cost, abortions here, regardless of patient need. See Appendix B for a summary of state abortion laws. The American Public Health Association emphasizes that risks to life and health increase steeply with each additional week of gestation after the first trimester (or 12 weeks). They stress ‘that "the factor of gestation age is of overriding importance." 1(The American Public Health Association, Inc., “Recommended 5Standards for Abortion Services," November, 1970.) This element of timing is problematic for the abortion patient. ‘Since accurate diagnosis of pregnancy is usually not possible until the sixth week of pregnancy, the "safe" period for abortion is limited to six weeks or less. Elaborate abortion committee systems in states, wherein abortion is illegal, may prevent a woman from getting a safe, uncomplicated abortion. Table 4 shows complication rates by type and period of gestation. For late abortions, hemorrhage, infection, retained tissue, and even failure of the abortion procedure are endemic hazards. 90 :LE 4.--Complications following Abortion, by Type and Period of Gestation, Numbers and Rates per 1,000 Abortions, New York City, July 1, 1970 - March 31, 1971. PERIOD OF GESTATION 1e of Total 12 Wks. & under Over 12 Wks. plication Number Rate Number Rate Number Rate orrhage 128 1.5 68 1.0 60 3.7 ection 214 2.6 85 1.3 129 7.9 forated Uterus 143 1.7 124 1.8 19 1.2 sthesia 10 0.1 5 0.1 5 0.3 uck 0.1 2 * 5 0.3 ained Tissue 199 2.4 44 0.7 155 9.5 lure 61 0.7 3 * 58 3.5 :erated Cervix 23 0.3 17 0.3 6 0.4 Ier 48 0.6 30 0.4 13 1.1 ,pecified 9 0.1 6 0.1 3 0.2 a1 Complications 842 10.0 384 5.7 458 28.0 al Abortions 83,872 67,520 16,352 Source: Jean Pakter, and Frieda Nelson, "Abortion in New York y." Family Planning Perspectives 3 (July l97l):5-12. ss than 0.05. Complication rates by type and method of termination have been computed for 1,000’abortions in New York City. Saline an. . . hysterotomy are estimated to be three to four times more 1njur1ous to the patient than suction method (i.e. vacuum aspiration). A sunmary is presented in Table 5 (see page 91). The director of a New York City hospital program for saline abortion (for late termination) pointed out to me that physician error 1n . JUdgement in these matters is invariably related to limited exper1: ence. He believes that most practitioners need to work as apprent1ces in abortion techniques for weeks or even months before they are ready to practice alone. Patient records include such items as psychosis (long tenn or "situational"), suicidal, depressive neurosis, extens1ve drug use,- and other related psychiatric ills. These were coded as psych1atr1c indications, although we strongly suspect that cooperating psych1a- trists in many cases manufacture such codes to f1t hosp1ta1 adm1ttance requirements. 91 TABLE 5.--Complication Rates per 1,000 Abortions by Type and Method of Termination, New York City, July 1, 1970 - March 31, 1971 METHOD OF TERMINATION Dilata- Type of tion and Hyster- Zomplication Total Curettage Suction Saline otomy Other lemorrhage 1.5 1.6 1.0 3.4 4.7 0.9 Infection 2.6 1.3 1.2 9.4 16.3 3.4 ’erforated Uterus 1.7 2.3 1.8 0.1 5.8 0.9 \nesthesia 0.1 0.1 0.1 0.3 1.2 -- Shock 0.1 0.1 * 0.3 1.2 -- letained Tissue 2.4 0.6 0.7 12.8 2.3 -- .acerated Cervix 0.3 0.4 0.2 0.2 1.2 0.9 iailure 0.7 * * 4.9 —- -- lther 0.6 0.5 0.4 1.1 2.3 1.7 Mspecified 0.1 0.2 -— 0.3 -- 0.9 'otal 10.0 7.3 5.3 32.7 35.0 8.5 Source: Jean Pakter, and Frieda Nelson, "Abortion in New York Iity," Family Planning Perspectives 3 (July l97l):5-12. 'Less than 0.05. E0. Physician fear of malpractice suits is regarded by many doctors_as a primary condition leading to reluctance to serve abort1on pat1ents, especially under the present law. 0. Compare this to the present (1972) total cost of $125 for a clinic abortion in New York City (early terminations only). 2. This has been a major problem in following post-operative complicat1on rates for out-of—state women having abortions in New York. Sub- sequently, some hospitals have refused abortion serv1ce to non- residents (in interviews with New York hospital admin1strators). 8. Figures are based on 1970 data for the two hospitals. The base_ for Metro is 9,682, including private and staff deliver1es of 11ve births and all gynecological surgery. The number of abort1ons for this time period is 104. The base for Community is 1,115 OB-GYN services, with 38 abortions for 1970. If computed at a base of 7,085 (total number of persons served) the proportion of abort1ons to total service is reduced from 3.4% to .5%. But, if we assume constancy 0f patients served for the next six months with an 1ncrease of 62 abortions over this time, the proportion of abort1ons to overall_ service is approximately that of Metro (Metro - 1.1%; Commun1ty — 92 Eliot Friedson, Profession of Medicine: A Stud of the Sociolo of Applied Knowledge. New York: Dodd Mead & Company, 1972, espec1a|ly Chapter 10. Emotional problems have been noted as being strikingly more common after legal abortions than after other abortions or deliveries. (B. Jansson, "Mental disorders After Abortion," Acta Psychologica Scandinavia 41 (1965): 87-110. While this writer concludes that such emotional trauma is associated with the greater psychiatric vulnerability of women who seek legal, as compared with other, abortions, an alternative explana- tion is that the process of seeking and getting a legal abortion is in itself a humiliating, and problematic experience for the woman. It is response to the immediate situation, rather than a pre- conditional psychiatric state, that may account for the frequency of reported deterioration in the woman's emotional condition after therapeutic abortion. - _,-, CHAPTER IV THE ILLEGAL MARKET: ROLE OF THE MIDDLEMAN IN MEDIATING AND REGULATING TRADE We; ‘ Until 1969, restrictions on legal abortions throughout the United States required most demand to be deflected into illicit channels. In iichigan and elsewhere, a proscriptive law nourished the development of a well organized criminal system which provided these strongly demanded services at a high profit. Part of this profit was used both to improve the services and to insulate the criminal organization from negative "eactions of official agencies. Contraband goods and services, generally, Follow this pattern.1 Studies by Kinsey and others make it clear that a restrictive abortion policy discriminates most severely against women of lower social-economic status, or those whose situations are most distressing.2 he viability of the criminal organization is evident in reports by aolice who consider criminal abortion the third largest illegal enterprise in the United States, surpassed only by gambling and narcotics.3 )verall, the way in which a social need has propelled the development if an illegal abortion machinery is well documented.4 93 CHAPTER IV THE ILLEGAL MARKET: ROLE OF THE MIDDLEMAN IN MEDIATING AND REGULATING TRADE Introduction Until 1969, restrictions on legal abortions throughout the United ltes required most demand to be deflected into illicit channels. In :higan and elsewhere, a proscriptive law nourished the development of Iell organized criminal system which provided these strongly demanded ~vices at a high profit. Part of this profit was used both to improve a services and to insulate the criminal organization from negative lCtTOflS of official agencies. Contraband goods and services, generally, llow this pattern.1 Studies by Kinsey and others make it clear that a restrictive irtion policy discriminates most severely against women of lower - . . . . 2 :ial-economic status, or those whose Situations are most distreSSing. a viability of the criminal organization is evident in reports by lice who consider criminal abs d largest illegal . . 3 :erprise in the United Sta y by gambling and narcotics. erall, the way in whic' ' d the development an illegal abor' 94 Considerations of how this illegal order is tied into the agitimate system is less well documented. This chapter describes the change order between "deviants, or illegal operators, and "respec- ibles"orlegitimate professional and agency persons by describing some dal types of transactions.5 The illegal resources used by helping rsons—-professionals, lay volunteers, and individual clergy--were so essential components permitting the Clergy movement to put gether a network of services. What kind of market existed for these ergy—entrepreneurs to exploit? We try to describe this, in part, by amining (l) the exchange order as this sustains the illicit organization, ) operations of physician abortionists, and (3) mode of professional itrol over illegal business. We also briefly consider the role of e abortionist in change. How he uses efforts to legitimate abortion reform groups, and how he is used by legitimating groups suggests v changes in institutional processes may reconstitute a social role.6 The Exchange 0rder--Sustaining the Illegal System Dilemmas regarding ethical, ideological and professional roles coping with abortion demand or legal violation make for (l) widespread ‘uctance to convict physician abortionists on the part of enforcement nts. (2) tacit acceptance of this order by professionals and agency sons, and (3) various degrees of professional involvement with icit operators. Exchanges involve various mechanisms supporting the tem. For instance.direct or indirect negotiations between professionals abortionists provide a steady consumer input into the illicit anization. Or exchanges may be infonmal arrangements that contain e violators within boundaries of the professional order. 95 We identify three distinct sets of interdependencies between gitimate and illegitimate agents. These include: (l) hospital argency rooms as “back-up” support for medical ”failures," or aborted ien who have been injured by, or who have received "incomplete," :rtions,7 (2) referral networks, or direct and indirect linkages :ween "respectables" and "deviants," and (3) friendship-colleagial ationships that prevent exposure of physician-abortionists. gital Emergency Room Records from hospital emergency rooms in large public and unteer hospitals provide one indication of extent and range of illegal rtion activities. This facility is a chief outlet for "botched" rtions, a situation well established in police and medical circles. se two hospital functions--keeping a check on the number of illegal rtions, and serving abortion patients who received a medically )mpetent operation elsewhere--make this setting a central link veen legal and illegal orders. Law enforcement agents are now only ely called in by hospitals to assume legal responsibility for an ~tion patient, and only then, when the patient is dying. Police are aware of this emergency room function, though. Hospitals in urban ers, especially, are known to have a vigorous illegal trade of ched“ abortions coming in the "back-door" of the hospital, even while "front door" of the facility is closed to such traffic. The extent of the problem often has been buried in organizational gories of "spontaneous abortions" or “uterine bleeding,“ or other ascript terminology. Emergency room records indicating diagnoses for )mpletes" are glosses for a variety of uterine ailments, with 96 legal abortion typically an unnamed entity. Some indication of the mber of illegal abortions processed in two of Detroit's larger spitals with obstetrical-gynecological emergency room care suggests at "septic" or "trauma"8 was associated with 32% of 900 "incomplete" ses in one hospital, and 22% of 1200 similar cases in the other Spital (1970 data). According to the administrator of these services, is means that 522 known illegal abortions have been processed in these p hospitals yearly. The actual rate of illegal abortions, according (this source, is probably f2!£.£ifl§§ the number of all septic abortions torded in the city hospitals. The rate has reportedly remained istant from l966 through l970, with the relatively high incidence of iical "failures" attributed to non-professional abortionists (estimated 95% of all abortionists operating in Detroit) serving the inner-city )ulation. Experienced physicians located in emergency room service keep mental file" on type and source of medical problems associated with ptics." Hospital detection involves knowing instruments, and patterns use by illegal practitioners. In this way, they can pinpoint the idence of illegal abortion (as compared with self-induced, or ontaneous" abortion), and in a few cases, even the operator. Hospital arting of information to police, however, is perceived as a "problem." physician -director of two large Detroit hospital emergency rooms :ribed the strained relationships between hospitals and police lrtment: We've had problems here (in reporting to police). For instance in 1967 we took pictures of a catheter which was imbedded through the uterus into the peritoneal cavity. Taken from every angle, it was pretty obvious there were holes in the uterus. Uteruses 97 simply don't come with holes in them. This instrument was sticking through. We brought it (pictures and instrument) to the police. We asked them to please investigate. The police would not move, because, according to them, there was lack of evidence . . . We know who the good guys are and we're not going to touch them. But we certainly would like to move against the butchers-~only the police don't seem to be cooperating. From the viewpoint of police, though, selected reporting ("bad“ iuys only) discredits the facility as a reliable source of information, lfld leads police to investigate primarily those cases initiated by iembers of their own enforcement staff. Whatever the reason for the communication "problem," hospitals Io inform police in the event of an abortion death. At one time, llegal abortions were the major source of maternal deaths in the state rith the present figure estimated at 30-35 abortion-induced fatalities lyear in Michigan.9 Antibiotics have drastically reduced the number If deaths from illegal abortion, even though the total number of abortion msualties has remained almost constant. There is even some question if "self-induced" abortion is natomically possible. One physician rejected patients' claims of self-induced" or "spontaneous” abortion as defensive statements >rotecting a friend, neighbor, or illegal operator who actually inserted he instrument, packing, or chemical. For these reasons--poor or nadequate record keeping, lack of police accounting, and resistance y patients to state the source of an "incomplete" abortion--the incidence f illegal abortion remains shrouded in guesswork. eferral Networks Referral networks, forged by professional or agency persons inking patients to abortionists, demonstrate the interdependency of the 98 two sectors--legal and illegal. Even before development of the clergy organization, a few physicians, agency and lay persons had "lines into" the illegal system, and routed patients either directly or indirectly to service. Some physicians were dependent on the “good" abortionist to take care of a patient's "problem“ they themselves could not handle. lbortionists, in turn, relied on the informal "grapevine" to maintain a constant consumer intake. In an interview with one out-of-state )hysician—abortionist, I was told that Michigan referrals constituted in estimated l5% of his abortion practice. This figure reportedly Ias varied little over a five-year period. Before the clergy organization emerged as a "visible" structure, eferral was secretive, and preferably, indirect. One former Planned ’arenthood board member located in a university city operated a one terson referral "business" for years with tacit cooperation from a few ocal professors and physicians, and the agency state board director. er referral network, described below, had three phases commensurate nth the mode of operation and “resources" used. They include: (l) in- tate underworld linkages, (2) out-of-state legal and illegal connec— ions, and (3) clergy contacts. Phase 1: Undenworld Linkages The earliest phase of illegal abortion referral that I identi- ied probably dates back to l963.10 From this period until l967, private eferral persons (clergy and lay in this case) were alone as legitimate iddlemen in developing a personal network. Data from this lay eferral person along with two interviews from campus clergymen in two ifferent cities suggest that these referral persons "drifted" gradually l i 99 pnto the enterprise. Accessibility to uniVersity students and resources end commitment to family planning and/or sex counseling seem to be primary considerations leading to this involvement according to infor- tants. We take up the clergy referral network in the next chapter. In this section we show how one former agency board person set up referral arrangements and coped with contingencies of work. The initial problem in setting up a referral practice for this lay person was getting a handle on "good resources.” To secure reliable 1nd safe treatment for clients under hazardous conditions, she used the bllowing procedure. All parties remained anonymous. First names for lient and abortionist only were used. In some cases, the illegal perator was simply referred to as "Doc" or "Doctor," whether he was physician or not. Abortionists were periodically investigated. Most nformation had to come from the clients themselves, as in reports of he safety of the procedure or the emotional impact of the event on he woman. Clients, however, often failed to return after abortion. aluable information about the experience would then be lost. Pooling lient reports did sift out bad operators. But there were continuous roblems in getting and keeping good ones. For instance, she said,the abortionist typically presented imself as a doctor. But if she tried to verify this, she could (pose herself and her tenuous "business" to outsiders. If she lost wst with the operator, this might antagonize him, and eliminate good resource. Then, too, abortionists were not very reliable. Iey were likely to move in and out of the social scene depending on Iforcement conditions. Negotiating the routing was a complex, and l l i lOO i ten frustrating, job as this taped interaction suggests: (Inv. = ! vestigator, Inf. = Informant) ) Inv. Why don't we start with what kind of experience you had in l the beginning--whether you were working with other persons ‘ in the community, whether you were alone, how you made the kind of contacts with the resource man in Detroit or elsewhere. Inf. That's where you are going to have a difficult time because I simply don't remember. It came on kind of gradually, and then somebody told me about this guy and I started sending people to him after I talked to him myself, and then it seemed unkind for me not to make contact with him, so I did. Inv. You were sending them through directly? Inf. Right. I had his name, (illegal organization) but they never ' 'knew it. He would call and say, "This is doctor.“ He would arrange a meeting place. He did all the arranging you know. A motel around here, and he switched around, so he never got caught. Inv. He was operating out of motels then? Inf. Yes. Inv. Now was this a Mafia organization? Inf. I think the guy he transferred the gals that got botched to (sic) looked and sounded like Mafia, whereas he did not. I met him finally. He came to the house and we had coffee and talked things over. He had a very good personality, and the girls would always report back to me. They all liked him. Inv. What technique was he using? Inf. Curretage, D & C. Inv. Was he a physician? Inf. He said he was. I found out later that he wasn't. But he was very proud of his work, proud of his competency. With regards to training, I don't know that he had any. But he was good. We had no problems. But, once I found out, I called him on it. I said you kind of betrayed me (in calling himself a physician). Now I can't trust you any more. And he got mad and he wouldn't take anybody from me. So what I had to do was to go through my listing, which I had as of l968 and here, you see, I have underlined in red, those girls who are willing to act as go—betweens . . . lOl Inv. Did you send any (patients) to Mexico? Inf. No. Have you read that listing? Now, if you'll go on through that list you'll see that it is the actual list of people, which meant that the picture changed so rapidly that if I sent a girl out there she might possibly be picked up looking for the doctor. But, of course, all the taxi drivers in that area were hep, and they'd take them somewhere else without the girl's knowledge of anything. I thought it was much too risky. With the person I was using, every once in a while, the doctor would have to go on vaction because the heat was on, so we'd send them to somebody else. Developing referral options when the regular source was unavail- able, required this referral person to be aware of possible situations clients might encounter. Clients as go-betweens, while relatively effective information sources, were not satisfactory for developing or acting on new linkages and sources. By 1968, she was able to use a boyfriend of a former abortion patient to make necessary business contacts. The "runner system” reduced risk of discovery, but costs for both referral person and client were still prohibitively high. Financing abortions and post-operative expenses for needy clients cost this middleman some $l500.00 in unpaid “loans." For clients, prices ranged from $300.00 to $l,000.00 depending on location and source used. Detroit contacts continued to be problematic in terms of both hazardous nedical procedure and type of connection, believed to be a "mafia“ ring. Even reputable abortionists were "difficult" to deal with, often "harsh." and occasionally "brutal" to patients. Women reported that some refuse anesthetic either because of added medical risk in a non—hospital ietting, or because of additional “trouble“ and costs for the operator. ’igure 6 describes typical network formation during the early phase. lOZ acon< new :omxmm Fmgcmemx :omzpmn mmmmxcwb “emcee mcwzogm :oprELom xeozumzuu.o wgsmwm .umvcow :esm_eemz gmsoege emuuaccou pemw_u pmwcowpgon< Am :omgmm nggmmmm A” pcwaQ seam_eeez 0p toanemwa pcmw_u 103 Phase 2: Out-of-State Legal and Illegal Resources At the earliest phase almost all referrals were to "local" or ichigan abortionists. Later the list included out-of-state legitimate ld illigitimate resources. The "runner-system," which maintained old intacts was still used locally. Through "underground“ sources, she lined lists of abortionists with names and locations of operators, as Al as treatment costs, safety features, and technology. Lists could a purchased from an underground clearinghouse for $5,00, but required equent replacement because of changes in address, orprice and quality of rvice. Contacts, formerly limited to Michigan, could now be made th various practitioners throughout the United States and overseas ngland, Mexico, Puerto Rico and Japan). Previously, most information depended on client feedback. The N system did not require this. Traffic increased during this time, t the system was actually more efficient than in the preceding era. Now concern focused on "weeding out" high risk patients, or )se with medical or emotional problems likely to be exacerbated by frtion. If mistakes were made, responsibility devolved on the referring Tson. Very young "hippie-types," "disturbed," "on drugs" or morally iesponsible, were perceived as threatening the tenuous referral order. ise persons were believed to be more likely to end up in a hospital, ) once there, to broadcast the act to authorities. This seriously 'sed risks of legal detection. Moreover, a "disturbed" girl was also {jeopardy for repeated abortions, a situation viewed as physically iaging and morally degenerating, especially for the unsophisticated. )oling out" this client type could involve referral to a psychiatrist, 1 i i 104 l0 is some cases, furnished necessary credentials for a hospital >ortion.12 Evidence from this informant, as well as early clergy “ganizers, suggest that “problem“ clients constituted an unresolved :sue in referral operations. Figure 7 describes the second phase of network formation based I indirect referral contacts with abortionists. Greater infonnation -d traffic flow together with a reduced risk situation were network atures. Phase 3: Clergy Connectors The referral network up to this time was only loosely and directly connected to legitimate support persons. Moral support from few family planning colleagues and reform physicians was helpful. t this did not reduce personal expenditures of time and energy or 3e this referral person from a full-time commitment to abortion ients. Physicians or agency persons were not contacted directly. 2 client had to make such connections on her own. But fear that "no 2 else could or would do thisg'kept this specialist by default working spite of increasingly excessive personal costs, exacerbated by a ious accident in the family. By late 1968 connections with state- le refonm groups and clergy leaders permitted her to channel clients local clergy counsellors. Despite almost five years of increasingly by abortion traffic, this infonmant was unaware that two other )gymen were also operating similar networks. Secrecy had been so leully maintained that none of the three were aware of each other's l erral organizations. i 7 H. .,_._, A-¢>,. :,-; - i _7”, 7 105 .meoEofi op .528 Stfimm 96 8983.5 82.53 3:55 832:8 c.8562--.“ 95m: “$5.512: mmoesom cowumEoH—E ucaogmgmvca Lassa A :8er Einm A .22 8 c.0330“. :o 52:85 l06 Subsequent attempts by this referral person to move Planned Parenthood groups in a direction of leadership in abortion counseling and referral were unsuccessful. This informant became disenchanted with "proliferation of activities, peoples, lists, no coordination, and a hell of a lot of paper." She finally concluded that such old line agencies as Planned Parenthood were too "professional" and "too damn middle class" to manage innovative programs required for this "emergency health care." Instead, it was a small group of clergymen that created the state-wide brokerage system, connecting women to points of care within and outside the state. Professional Friendship-Colleagial Linkages Tracing this early referral system shows how linkages were forged between legitimate and illegitimate sectors, serving to keep a viable criminal system. Professional ties with physician-abortionists also shored up the illegal order. Some physicians continued to be involved in "old-school" ties with colleagues-turned-abortionists, or with former hospital physician-associates now operating as illegal practitioners. In a few cases, the physician-abortionist was a member of the reform circle and referral to I'our kind," said reformers, was how "we helped women who can't afford to travel out-of—state." Only a few physicians openly admitted that they had had a ”contact or so" before legal abortions were available, who would "take care of the woman's problem." Many doctors, however, believe the practice of physician referral to be widespread, though adding that they personally were not involved for legal and ethical reasons. What constrains most physicians, these informants say, was that regardless 107 f personal sentiments, fear of being sanctioned by colleagues or legal uthorities kept them from making contacts. I was told by one physician, ntagonistic to legal control, but who claims never to have eferred a patient directly to an abortionist, that he advises patients to go find somebody in Detroit. . . I can't give you any names, but f you get an abortion, I'll patch you up." A few physicians who have ried the hOSpital route get discouraged after rejection by the hospital aortion committee. This may lead to withdrawal from further attempts 3 refer. Or it may lead to more "calling around." In three such ises reported by women informants seeking illegal abortion, their rivate physician contacted a colleague willing to give the name of a local" abortionist. Patients then contacted the resource directly. Persistence of colleagial ties seems to endure long after the iysician-turned—abortionist has left the friendship-colleagial circle. t is "remembrance of things past" that contributes to supporting such )lleagues, even when recognizing they have moved "beyond the pale." In 1e case, only after the abortionist was indicted, and threatened to esmear the reputation of a former supporter, did the legitimate pro- essional admit "he was beyond saving.’ At this point he severed ties umpletely, in spite of an active inter-office referral existing for ume years. In a phone conversation with this physician-informant, was told that if the abortionist "continued to use my good name" d those of other reputable physicians and medical groups, this ysician would initiate court action against his former colleague. How extensive these instances are is difficult to determine. at seems evident, however, is that professionals resist disengaging fries—”L4. .24....‘.._._ _.________ . U. 108 l ' from former associates, even when no longer using them as referral )utlets. This may account, in part, for belief by prosecuting attorneys )hat physicians indicted for abortion can rely on former associates as Ntnesses in court to vouch for their medical credibility. Non- Lysician abortionists lack this support, they say, and are much more ikely to be indicted, and in time convicted, for illegal activities. ‘ How do physicians rationalize to themselves and others why some embers of their respected profession turn abortionists? There is no ingle rationale here. Most commonly expressed is a belief that the roblem reflects personality or judgment deficiencies of the man imself, rather than situations within the medical profession or law. I this view, the physician—abortionist is one who has "lost judgment," )vereager in some areas," “only turned bad after he left ," Id so on. Personal fault for ”excessive" types of practice may be aced to a bad medical experience (e.g. less of hospital privileges), ability to live by rules, a deteriorating mental condition, or neral incompetency in medical practice ("hack“). Reform physicians e much more likely to assert financial inducement as the compelling ason physicians get involved in abortion practice. They may add, Jugh, that only l'fools" would get into this business when their :ense is at stake. The abortionist's career, as explained by one physician, is latively easy to move into. For example, an exclusive practice (e.g. inic clientele), relative isolation from hospital-medical groups, llegal entanglements may be conditions initiating abortion practice. m costs of service are justified to pay for legal protection 109 awyers, police pay—off, local community "contributions," etc.), and, turn, expensive legal protection requires charging high fees. gether these work to maintain a relatively constant situation. ile reform physicians may be a "special breed" in that abortion change a primary professional concern, they are most likely to express lerance of the abortionist role ("after all, it could be any of us"), d to reject, not offenders, but the "bad law" that leads to “back- leys" and “butchers." Former colleagueship, expressed tolerance, ’forts to assist patients, opposition to the abortion law, and wsicians' reluctance to bring legal action against other physicians e conditions within the profession serving to sustain the viability of iminal organizations. yket Operatiggs of PhysiciagrAbortionists If certain conditions help to sustain the illegal order, or at fist physician-abortionists, the illicit practitioner.himself, must ten operate in a tenuous set of relationships with medical, hospital, gal, and other agents of legitimate order. Above all, the practitioner st be extraordinarily well skilled as a technician to avoid constant reat of legal sanctions. He must also be adept at recognizing various rveillance devices used by enforcers. Illegal practitioners can make few medical ”mistakes.“ For ike legitimate physicians who are "entitled" to occasional "errors” practice, illegal abortionists who err in work may be discovered and secuted. Competency in his chosen field is both a necessity and a k of pride among abortionists. For example, one Michigan physician orted how he had mastered the abortion craft after initial isolation 110 >m white medical groups and a practice composed mainly of poor, rural, 1thern blacks. In an interview he said: My own background is Indiana. I was a top student in my class and passed the boards in l937. I used to do home procedures (abortion), because I was working with a poor population. I wasn't admitted into the white medical society, and so I wasn't permitted to practice medicine in any of the hospitals in Indiana. Now I've moved into office procedures for abortions up to 8—l0 weeks. But before the vacuum aspiration, I used an extra-ovulary product which was a paste, a gel product. This is a German PPOdUCt which has the same effect as saline (injection). It separates the amniotic sac from the embryo. My father was a pharmacist, and we worked to get the paste perfected. By removing the caustic products, all we had to do was insert this (into the uterus) and she (patient) then expelled the products of her conception. Another out-of-state physician referred to himself as "the idge that carried the Michigan clergy across until the doors were open New York.“ He emphasized shifts in technology over his 34-year story of providing 30,000 abortions as a "master surgeon." In this formant's statement: I've done abortions since early in my practice, and learned the technique by fundamental principles. I've always been a student of anatomy. In the early period, I gave the D & C, or paste, if it was l2 weeks or above (gestation). I've used this with tremendous ' success up to 7 months (gestation). Now I know they're using the salting-out method in New York. I suppose I've given 20-25% salines for these later cases, but I'm not sure when labor is precipitated with saline injection. With paste I know that the woman is ready to deliver in 24 hours. I'm very experienced. Down through the years, I've learned what works and what doesn't work, and I know what I'm doing. I know what the fetus and placenta look like after they're removed . . . I know what the uterus feels like after you've gotten everything out . . . I like to pack my cases. I use a gauze pack with a string (of gauze) 5 yards long with some (?) inches of packing hanging out of the vagina, so she won't get infected. You pull it out yourself. There's more bleeding with a tooth (removal) case. This controls bleeding. I studied in the best clinics-~Japan, England, and New York. Technology then, is an intricate part of tradecraft for rtionists. Another skill is to develop requisite defensive strategies 111 :o avoid legal entrapment. A highly successful management strategy has )een to maintain local community ”respectability." For the black )hysician this entails multiple professional and community affiliations-— ilack medical societies, local hospitals serving primarily a black flientele, and church, school, and civil rights groups. Rapport with latients, too, is an essential feature of practice if the abortionist s to protect himself from discontented or irate patients who could nform police. By keeping open phone lines and by making himself vailable in the event of post—operative emergencies, he contains istakes within spheres of office or friendly local hospital. Anticipating trouble is more problematic, when the woman is an ut-of—state resident, and, for the black abortionist, when she is hite in an almost exclusive black practice. Only an external broker rrangement with clergy or legitimate physicians who assume part of the asponsibility make this patient type a worthwhile risk. One black lysician reports that he occasionally makes arrangements to meet the iman in a different section of town to avoid surveillance. This raises lTQTCé] costs considerably, but protects both woman and abortionist. Most abortionists have had tangles with the law. Some abor- onists are said to have made regular pay-offs to local police (although is practice reportedly did not characterize present operations cording to informants). All abortionists learn to recognize surveillance ants, described as relatively easy to detect since they (1) are ite in a black community, (2) come in teams, and (3) are accompanied a "deputy-woman" acting as a patient, but who is "very nervous." abortionist screens intruders by stalling the procedure-~keeping tinge-raglsgé'égrega— 112 he patient waiting in the reception room and delaying the physical xamination while on the table.13 Even with precautions, abortionists cannot always avoid rosecution, and for some, conviction. One Black physician reported gilgrg to give a medically contraindicated abortion led to his arrest. hen the rejected patient died in hospital as a result of criminal bortion given by a non—physician, the woman's husband blamed the doctor or her death and went to police. A criminal trial followed resulting n conviction and a l4-months jail sentence. The abortionist told me 3w the court effectively discredited him, even with support from agitimate physicians,many of whom had been referring abortion patients )r years. In describing the court scene, he reported: Judge , a Catholic judge was the presiding judge for my case. The trial was a comedy. We had physicians testifying to this whole thing. Doctors verified my character references and my competence. The women (patients) verified this, too. Many doctors had been referring to us (team of 3 physicians and l pharmacist). They sent their girlfriends, wives, daughters and so forth. They (court) brought in 2 black girls and one white woman. They couldn't even get the physician to testify against me. But they trapped the white woman. They said to the white woman on the stand, who was a very pretty blonde: Where were you with relationship to the doctor? I was on the table. Where were your legs during this time? My legs were on the stirrups. Where was the doctor in relationship to you during this time? The doctor was standing at the bottom of the table. Then the doctor was located between your legs? Yes. The doctor then inserted something up your private parts? Yes. What was this that he inserted? I don't know, a speculum, an instrument of some kind. You cannot testify for certain what it was the he put up your private parts? No, I can't testify for certain. 0 3" PPP?P?D>Q>O>O 113 And that was the end of the prosecutor's questions. They charged me with conspiracy to perform an abortion. I had a 14 month jail sentence and lost my license. After release from prison, this informant learned to deal with egal pressure" by turning to legislators and "police higher-ups,” . 3 "I've helped out in the past.” Informal protection was the ggig giggg for "taking care” of their women who need some ”local treatment," a reduced or no fee basis. As technology changes, so have costs conformed to new market iditions. Price for a "late“ abortion—~packing followed by D & C—- merly ran as high as $1,000.00 with early procedures averaging $500. )rtion is still "lucrative," but profits are less inflated now. One icago physician charges two hundred dollars an abortion competitive th the New York market. He claims his service may actually be i ieaper" for Michigan, Ohio, or Illinois women who save transportation ;ts in the bargain. For one Michigan abortionist, "profits“ are in e fOrm of service to the black community. A sliding scale with a high $150.00 to no-cost operations accommodates inner city patients, all whom are black. Three abortionist-informants perceive very few physicians or n non-professionals presently operating large—scale abortion practices. y report that police have a "tap" on all abortion practitioners. 5 requires not only careful maneuvering to enter the market in the st place, but enough capital "to take care of local boys at the tion house" if they should give any "trouble.“ Reform physicians and ‘tionists alike assert that getting into the market now is less fitable than earlier. Medical referrals, they say, are "drying up“ - - — ,‘v—v-,_;._A;_\_7»V<._‘=K gas—see. z;’_ ,——-_‘£.__AF , 114 ' ith competition from legal sources in New York, California and elsewhere. his discourages new operations, but, seemingly, has little effect on ractitioners successfully plying their trade over years of effort. ‘ egitimate Control Over Illggal Practice Legal threat or promonitions of threat are persistent market eatures for illegal practitioners. Even so, well-insulated black hysicians, "respectable" in terms of local black community norms, are nlikely to be prosecuted. If prosecuted, they are less likely to be ndicted. If indicted, jail sentences are token punishments, rarely xtending over a few months or years. This holds for fonmerly "respec- able" white physicians as well, who are even more likely than blacks a have superb legal counsel and a battery of mainline professional ssociations that prevent loss of credibility. Because abortion practice 5 well rewarded, abortionists can pay for long-term litigation, often (tending over many years while the offender continues operations, zaping profits, meanwhile, to payoff costly legal action. In this way, a postpones a court decision, hopefully,until legalization of the law. uth abortionists and defense attorneys believe that once abortion is clared legal, courts will be reluctant to sentence, retroactively, for crime that no longer exists. The "bad" abortionist is a vexing problem, though, especially r the profession. A man, once performing competently, dependable in king referrals and providing safe operations, may, in time, become alcoholic, senile, mentally incompetent, or physically ill. This Bates a dangerous situation, but one which has few professional edies. Turning the miscreant over to police is unacceptable, though 115 ng legal constraints is advisable. The profession prefers to police own as much as possible. Asking the physician to desist operations ks, sometimes, but not very effectively. He usually reappears in a 'ferent community. Stopping all referrals is one control tactic, but utations of abortionists are not necessarily confined to professional brmation sources. Word-of-mouth circulation among former patients :ps clients coming, often long after the abortionist has retired, or en died. In one story told of a senile physician—abortionist who resisted ing up practice, enforcement came first, by way of professional sure, and after that failed, direct action. The control strategy, reported by a former president of a county medical society was as lows: We had a colored doctor performing abortions in his office, which was in his home. He was picked up by the court (and) sent through theprobationary and fining system. They let him go at the time. The Mafia got into this deal. The doctor was 79. And he was starting to get sloppy. One woman who was given an abortion died in the street on her way to the car of an embolism. The way we handled this business was to negotiate an out for the culprit. We took away his tools, burned down his building, and had him legally constrained by putting him under the care of his daughter. There had to be a legal agreement. After all, he was too old to go to jail. In general, physician-informants and clergy leaders say that litions under which the profession is likely to move against an sgal practitioner include: 1. "blatant" display of the illegal abortion practice signifying lack of appropriate professional discretion; 2. failure to link into the on-going local medical community at whatever level of interdependence; 3. personal and social characteristics objectionable to the local medical community (e.g. senility, alcoholism, or manifest mental disorder); 116 4. use of "name dropping" of respectable physicians or associations by an indicted abortionist; and 5. an especially restrictive community milieu forbidding professional tolerance of illicit practice. Other conditions than those mentioned earlier that infonmants lieve sustain the abortion practitioner include: 1. location in a large city with an inactive or tolerant prosecutor; 2. a relatively open referral network, not limited to the local community (one general practitioner in Pennsylvania took abortion patients from a 5-state area); 3. a formerly successful practice as a non-abortionist, which builds up "credits" for referral purposes; 4. a preferably long history as a successful abortionist, or one who has made few "mistakes;" 5. isolation from known undenworld1jigures or organizations (although the myth of the Mafia tends to be a universal one, with any discovered abortionist said to be linked to these suspect persons or groups); and 6. charging competitive prices commensurate with risk and number of alternative suppliers. When costs remain above market price, referral sources evaporate quickly. a Role of the Abortionist in Change Abortionists have assumed new roles in keeping with changing Finitions and practice. Any abortion conference replete with leading ifessionals and researchers, a few Ph.D. candidates like myself, and Ier "truth-seekers? now includes abortionists as spokesmen for the I order. Some are tottering elders, long banished from professional :ieties who state that they are attempting to restore respectability :ore it is too late. Others are "marginal men"--so called "doctors“ unlicensed practitioners from southern states--some of whom are trying "make it" in this new milieu of abortion institutionalization. 117 Recounting "sad tales" of yesteryear when all was lost--practice, community reputations, homes, and freedom-~to over-zealous prosecutors, are frequent private andpublic conference topics. Some abortionists reflect bitterly about the past when they see newly-gained prestige accorded to planners and directors of abortion clinics and hospital services. Others hope that a ready market for abortion will continue, if new sources of referral can be developed. Office abortions in New York, free from local public health board surveillance (except in New York City) is one outlet for formerly prosecuted abortionists. In some cases the abortionist becomes transfonmed from pariah to hero. Here the abortionist takes on dramatic coloring. It is he who forged the chain making it possible for others to institutionalize abortion as a health service. Whereas, other professionals were too timid to rise to the challenge, the abortionist took responsibility into iisown hands. Responsive both to consumer need and to public outcry against restrictive abortion policies, he moved forward when others ield firm to respectable reputations and status-quo careers. The lARAL (National Association for the Repeal of Abortion Laws) Conference in October, 1971, featured one Michigan abortionist openly proclaiming 11S intention to test the law. Public testimony by a Michigan Clergy Service counsellor stressed the heroic proportions of his effort. DF- has been serving the poor and the black. He has struggled and BEEF—agonized in this abortion fight. The abortion law of Michigan discriminates against poor people who cannot even raise money for travel even when the medical fee is waived completely . . . \nother speaker emphasized, even more dramatically, this physician's “ole in change: 118 Dr. has rendered the veil of discrimination by striving forl equaTTEEtiofi'. This is a constitutional issue, then and Dr. '5 decisive act will prove a model for other states to follow. Subsequent events suggest that the doctor in question, while ling his own legal battles, has stirred little significant legal lion either within or outside the state. Instead, his conference role marily was to rally a sundry group of pro-abortion ideologues to ion; but, once rallied, each separate state reform unit went its way. Since that time, Michigan legal action has been stagnating in quagmire of indecision awaiting a U.S. Supreme Court ruling on stitutionality of criminal abortion codes. Conclusions This chapter documented some identified patterns of exchange ween legitimate persons or groups and illigitimate practitioners. interpreted exchange as sustaining the illicit abortion market lby providing tactic support for these actitivities, (2) by generating sumer input into illegal channels through referrals, and (3) by l trolling “excessive" forms of practice through informal means. erlinkages between legitimate and illigitimate sectors help to keep jcriminal system viable, even while it reduces effective enforcement the law. I Gaps in these data, especially with reference to non-physician )tionists and their clientele, prevent a well informed discussion of as of services available for poor, black, and other underdog_groups. Q5 has necessarily been on (1) transactions between professionals or Dnteer referral persons and former professionals-turned-abortionist, 119 (2) ways in which these transactions uphold illegality, (3) operating mechanisms of physician-abortionists, and (4) problems of professional control. The abortion market has rapidly changed. The next two chapters take up the clergy counseling movement, and brokerage system generated by this movement. We trace transformation of market conditions by, first, describing the organization as it developed from individual actions to create a legitimate social role. Second, we trace the abortion referral network--typical modes of liaison and features of agency practice. ii: i FO0TNOTES-—CHAPTER IV Edwin H. Sutherland and Donald R. Cressey, Princi les of Criminolo , 6th ed., New York: J. B. Lippincott Co. ,1969, pp. 225- 226; Edwin M. Schur, Crimes Without Victims, Englewood Cliffs, N. J. Prentice- Hall, Inc. , 1965, p. 39, Herbert L. Packer, The Limits of the Criminal Sanction, Sanford, California: Stanford University Press, 1968. Schur, Ibid., p. 24. John B. Martin, ”Abortion," Saturday Evening Post, (May 20, 1961). The following sources give some indication of both extent of social needs and various modes of meeting needs: Edwin M. Schur, "Abortion and the Social System," Social Problems 3 (October, 1955): 94- 99, Paul H. Gebhard, et. a1. Pregnancy, Birth and Abortion, New York: Paul B. Hoeber, Inc. ,TT958; Herbert L. Packer and Ralph J. Gambell, "Therapeutic Abortion. A Problem in Law and Medicine,‘I Stanford Law Review 11 (May, 1959); J. Bates and Zawadski, Criminal Abort tion, Springfield, Ill. C. Thomas Company, 1964. Data for this analysis is drawn primarily from interviews with physicians, hospital administrators, police, defense and prosecuting attorneys, and persons formerly engaged in referral activities with abortionists. This includes one agency board person and members of the clergy group with additional data taken from clergy documents. Three physician-abortionists were also interviewed. Informal interaction with two other former abortionists at a National Abortion Conference (NARAL) in Washington D.C. in October, 1971, provided further insights to illegal organization. Due to inability to sedure interview data as "privileged communication," I was unable to get interviews with two other "notorious" abortionists now under legal indictment in Michigan. Attorneys for the defense strongly advised in both cases against taking statements from these sources, because of legal jeopardy both to myself and to respondents. Physicians, clergy, and formerly reporters have constitutional immunity from legal injunction in issues of confidential information. The social scientist does not have such immunity. Both abortionists in question have been indicted under the charge of' 'conspiracy to commit abortion. One physician has also been prosecuted for malpractice. Legal counsel for the defense considered it highly conceivable that the court could demand my interview data as material evidence for the record. In spite of months of effort to track these persons down, I decided the risk was too high both for respondents and for the social scientific enterprise. 120 121 We use the term "legitimate" to refer to "respectable” professional, social service, or lay persons or groups engaged in abortion traffic. "Illigitimate“ refers to illegal, criminal or illicit operators or operations in abortion. "Legitimating groups" is a term restricted to persons or organizations involved in supporting or facilitating change in traditional abortion ideology or practice. In this sense, the clergy movement served as one, among other, abortion legitimating groups. The larger abortion reform movement incorporated national and state—wide groups comprised of women volunteers, physicians, nurses, social workers, epidemiologists, clinic directors, former abortionists, “liberationists” active in other causes (e.g. civil rights, ecology), radical feminists, and clergy consultation groups (15 state-based organizations). “Incomplete abortions" cover a variety of medical conditions. The term may indicate (1) failure to remove the placenta, (2) excessive bleeding, (3) septic abortion, (4) uterine puncture, (5) extension of a catheter through uterus or vagina, (6) malfunctioning of the reproductive system due to introducing chemicals (paste, soap, and other materials with caustic compounds), and (7) self-induced abor- tions. These are alternative terms for "illegal" abortion. Public health data indicates a total of 8 reported abortion mortalities for Michigan women in 1970. Four physician informants independently suggested the figure was probably closer to 60, with almost half that number in the Detroit area. In the first few months of fieldwork, I heard of a number of non- clergy private referral operations as in university women located in dormitories, campus-runners for Detroit abortionists, and house— wives who simply passed on their abortion experience to friends. VI was, however, unable to locate these persons (with the exception ‘of one housewife who reported that she had probably helped out 20 10f her friends or their daughters). Change of address, shift in ‘occupation, or simply withdrawal from these activities (especially )after New York legalized abortion) prevented contact with these ipersons. I was able to identify not more than five full-time physician )abortionists serving Michigan residents in 1970 located in: .Detroit (3), Saginaw (l), and Chicago (1). All but one of these iphysicians are black. The Saginaw resource has subsequently closed Edown. Most of the so-called undenworld connections are with out-of- {state doctors brought into Michigan one or two days a week to )perform a guaranteed number of abortions. Almost all other “doctors“ (are either technicians or other para-professional persons, or (someone who "picked up the trade," perhaps in the army medical corps. (There are a few doctors of osteopathy reportedly performing Mabortion as part of their practice. I was unable to locate such ppractitioners. 11 11' 122 The role of psychiatrists in negotiating therapeutic abortions is documented by a study sponsored by the American Psychiatric Associa- tion: “The Right to Abortion, A Psychiatric View," Fonnulated by the Committee on Psychiatry and Law. Published by the Group for the Advancement of Psychiatry, 1969. I waited approximately 3-1/2 hours for this informant. Only after I began an animated discussion with a local clergyman whose daughter was having an abortion, was I admitted to this physician's office for an interview. These precautions, on his part, were seen as necessary screening devices, in spite of two telephone calls from a Michigan physician on my behalf, and my own call earlier in the day. I made some preliminary inquiries in the field regarding Mafia- related abortion activities. Responses were inconclusive. One story is that the Mafia Egg se are not involved in criminal activity, although individual members of the family may put up money or have other marginal contacts with an abortion "ring." One informant, who runs a referral-for-profit business in Detroit, repudiates police claims that Mafia operate abortion businesses. He holds that present Mafia connections with respectable circles would be seriously damaged if they were also running abortion "mills.“ Whatever the facts, both police and media reporting of abortion convictions invariably include a reference to "Mafia-organized crime . . . etc." (from police files of newspaper clippings and documents of closed abortion cases). CHAPTER V TRANSFORMATION OF RISK: RISE AND DEVELOPMENT OF A CLERGY ABORTION BROKER MOVEMENT PART I. Cler Entrepreneurs: Buildigg the rganization In creating a new counseling and referral organization, clergy nsellors broke down traditional barriers--moral, social and economic. y did this by combining features of both legal and illegal abortion tems. This two-part chapter explores some processes by which bridge- ions, or collective efforts to forge linkages between legitimate illigitimate sectors by clergy innovators, were organized into a ial movement} Three phases of movement development are described. In t I we show how efforts by individual clergymen to connect clients to ping sources laid foundations for a collective enterprise. We then ineate how the entrepreneurial, or risk-taking, role created new initions and generated resources previously unavailable to most "tion seekers. In Part II, we describe the broker role evolving n these innovative activities, which sustained the counselling and irral organization. We show this with a description first, of :er arrangements, and, then, of clergy counsellors-~background ‘acteristics, conception of the counseling role, and mode of :icipation. Finally, we suggest how different network forms 123 124 :haracterized the movement at different time periods as movement norms Iiffused in the larger social environment. What were traditional barriers that this broker system altered? 'irst, risk characterized both legal and illegal market phases affecting 0th producers and consumers. For producers, social sanctions, as in 055 of license or professional esteem, fines and psychological strain revented most legitimate professionals from engaging in abortion ractice. This left the market to "hacks," or those willing to gamble areers for profit. For consumers, poor technology, illness, or ossible death, high prices, and frequently, psychological hardship, ere endemic features of the traditional abortion market. In changing his risk structure, the clergy movement mobilized resources from both egitimate and illigitimate sectors to create a new network of helping ources. Costs of action were borne largely by the movement. Second, given conditions of a restrictive law and medical ontrol over legitimate services, the structure of the abortion market emained relatively stable. Movement activity altered this stability y increasing number and type of participants, by eliminating still other articipants (e.g. "bad" operators), and by shoring up this new order ith support from established groups. Third, interdependence between legitimate agents and illegal roducers reinforced the criminal system. Abortions could be had, but Or a “price.“ Market perfonnance, as in use and distribution of esources, price of services, "extra" social and psychological costs 0 consumers, and quality of the product were determined by suppliers, ot by market operations of supply-demand interchanges. In these 125 :ircumstances, consumers were powerless to affect the market in their Favor. What some consumers did, however, was to turn to individual help sources, both lay and clergy, to mediate the market. In confronting this clientele, a few clergymen developed personal referral networks similar to that organized by the lay counselor (described in Chapter 4). There were notable differences. Professional experiences of clergy :ounsellors, the wider range of resources they could mobilize, and eventual move toward a collective effort, all were related to flexibility 1f the ministerial role. Under the legitimating mantle of the Church, some clergymen flouted the law, first, as individuals, then as an Jrganized body of dissenters. Individual Actiog§--Pre-Movement Activitigs Prior to legalization of abortion in, for example, London, Ialifornia, or New York, individual clergy attempted to cope with 1erceived need of "desperate" women with unwanted pregnancy in a totally ‘ndividualistic manner. Most physicians and clergyman believed [bortion to be outside the professional sphere. The definition was :hat abortion was illegal, it was “dirty" medicine, and women harmed 10th themselves and their families by seeking such an operation. For :onscientious clergymen, the options looked grim-—early marriage and |uick divorce, standard outcomes of a "shotgun" wedding, or delivering me victim to an unknown abortionist. In wrestling with moral dilennms, mst clergymen facing a choice between the woman's need and institu- fionalized norms, took the safer route. Abortion counseling and/or 126 referral was simply too “hot“ an item to include in the usual repertoire of clerical duties. By 1965, a new breed of socially conscious clergy, generated from a decade of involvement in civil rights, community planning,and other citizen action groups, were located in strategic positions where resources could be exploited. Campus ministries and bureaucratic positions in the Council of Churches, or in liberal denominations, especially, offered relatively little public surveillance and maximum personal freedom, even without initial back-up support from congregations. With phasing out of Civil Rights and shift to Black Power along with increased bureaucratization of community planning, some activist clergy found their social niche shrinking. For "secular" clergy, especially, with no conventional pastoral or sacramental duties to perform, the search for a meaningful role was a significant catalyst for extra— institutional commitments.2 Sexuality--its uses, abuses, and conse~ ‘quences--became a major preoccupation for some clergy. Counseling women ion sexual problems led some clergy to recognize that "talking the :situation out" did not resolve the problem of an unwanted pregnancy for la vulnerable or frightened girl or overburdened mother. 1 Frustrated with inadequacies of professional services, individual *clergymen sought more direct measures for linking abortion seekers to gmedical sources. By 1965 in two state university religious centers, a ‘series of linkages generated by individual clergy connected women to abortionists, abortionists to clergymen, and clergymen to other social or medical agencies. Operations took this form: --"Local" or illegal abortionists were located by either direct or indirect contact. After an abortion women were expected to 127 report back, providing necessary feedback on quality of medical or personal care. One negative report resulted in eliminating a medical “resource“ from the list. Assault, seduction, unclean facilities, and "hormonal” treatments for “frigidityf and other patient complaints about quality of service were common during this clandestine phase. —-Bargaining with abortionists resulted in agreements to send a stipulated number of women in exchange for reduced prices. --The clients themselves were primary protection and support for clergy brokers. If apprehended by police the woman was told to withhold information on either legitimate or illegitimate contacts. In redefining the situation, movement clergy emphasized that the woman was not a co-conspirator under the law, but a "victim," in which role serving only as "willing witness." Clergymen reported that in spite of some police harrassment, women rarely violated trust. --Clergy organizers informally contacted university health services and community physicians and hOSpitals for “repair" work on post-abortion patients. Because of the primacy of these early organizers' sex or family counseling roles, agencies assumed this activity to be a routine helping function. In one University community, three individual brokers-~two lergymen and one faculty wife--operated private lists, "runner- ontacts" and client feedback system without the other's awareness, or f later aware, without material aid. Police surveillance, an occasional ireat, was controlled by locating physician-abortionists in other tates. Jurisdictional boundaries kept brokers relatively free of legal arassment. Legal risk also was reduced by severely limiting the number of arsons informed of the operation. Legalization of abortion in other states broke the code of ilence, and generated legislative hearings in Michigan on the abortion mu beginning in 1967. Legislators and reform groups contacted )ncerned clergy, many of whom became articulate abortion spokesmen. )mmunication became more open, and referring clergymen began to talk F the possibility of duplicating the Clergy Consultation Service in 128 New York organized by Reverend Judson Moody. This movement served as forerunner for subsequent state clergy organizations. Individual counseling and referral continued as isolated ventures for almost two years. By early 1969, a few clergy leaders recognized that collective efforts would be a better means to reach clients and to promote community support than the current variety of individual approaches. Entrepreneurial Role--Launching a Movement Beginning with a nucleus of 12 men in September 1969, the movement grew in three years to its present size of 300 clergy and untold hundreds of professional and lay abortion counsellors serving a reported 15,000 women yearly. What were crucial decisions and actions taken by these few committed clergymen leading to development of a social movement? How did the idea spread that abortion is a moral choice for the woman with the supporting counsellor assisting her in .this decision? To understand this, we focus on strategies clergy ‘entrepreneurs used to cope with opposition from legal and church authorities, colleagues, parishioners, community and family. This (required clergy organizers to innovate in three areas: construct a moral mandate, define the counselling role, and build a network of ‘health services. In this way, movement actions changed the risk ’structure of the market by transforming meanings and organization of labortion from an almost universally-held, morally problematic event to ?a standard, if still relatively costly, medical procedure. ‘Constructing a Moral Mandate How did early clergy organizers reconcile their illegal or lquasi-legal activity with moral and theological precepts? Before 129 ttempting open recruitment of colleagues, and later social service rofessionals, a mandate for service had to be constructed. The mandate, s a philosophical and theological statement of intent, offered both .rationale for mutual support among participants, and a counter- ationale against legal control. In the first place, clergy drew up a "covenant" stipulating pmmitment as an extension of pastoral and religious duties and as n expression of social conscience. The document reflected an earlier vowal made by Michigan Council of Churches (1967) asserting therapeutic bortion and legal reform as "affirmation of a reverence for life." he Covenant read, in part, as follows: We as Michigan Clergy, being duly ordained by our respective faiths and denominations to serve in those ways fitting and appropriate to our calling, pastoral responsibilities, religious duties and social conscience, and believing that the recognition and alleviation of all human suffering in our time is of paramount importance, do hereby covenant together to establish and participate in the work of the Michigan Clergy for Problem Pregnancy Counseling. Specifically, articles of commitment were concerned with actions elated to "sexuality and human wholeness," changes in abortion atti— mdes and laws, and setting up counseling and referral services. Embers were to share infonnation on all sources, aids and assistance elated to these services. If "sanctity of the pastoral counseling elationship" were attacked, (as in civil action and/or criminal vroceedings), support would be forthcoming from all members by way of financial aid, public statements of support, and voluntary admission of :ounseling activities (e.g. court testimony). Members violating procedures (e.g. which proscribed the use of fichigan illegal abortionists) or operating outside convenant rules 130 (e.g., took fees for service) lost all privileges and immunity. Finally, an executive committee of the Michigan Clergy for Problem Pregnancy Counseling (MCPPC) was formed to centrally coordinate "education, interpretation, staff training and general administration for communication, public relations and functional internal organiza— tion." Coordinators from local centers were presented on this committee. The code, however, included no formal control mechanisms to enforce conduct. Policing improper behavior, an occasional problem, was usually turned over to director or board who handled such matters informally. The next move was to g§§_the mandate as the basis for erecting an interstate abortion referral system. Even before legal opinion clarified the relative security of moving clients between state lines (counseling in one state, abortion in another), clergy worked on the hunch that jurisdictional boundaries were relatively impermeable. This meant that prosecutors were unlikely to follow a case to another state because of costs, legal snarls, and problem of identifying particular persons as co-conspirators. Long-time counselors knew, however, that use of "local resources" could eventuate in prosecution. This activity was especially contraband. Counsellors realized, though,that while the "seal of the con- fessional,“ as a special legitimating mechanism protected them, physicians or other community support persons were in jeopardy and could be charged with conspiracy. For this reason, cooperating physicians almost always referred patients directly to clergy. 131 To further ensure against risk, the movement carefully sounded out legal situations in states or areas in which they referred clients. Interdependence between the 15 or so state Clergy Consultation Services facilitated infonmation gathering. For example, in a message sent to all state counsellors on the Chicago "resource," the executive director pointed out that: You may be interested to know that the Chicago Counseling Service informs me that the police are very quiet and have no intention of doing anything in the city of Chicago in the very near future regarding abortions being performed. Apparently public opinion there is a favorable toward our counseling service as it has become apparent that it is in the State of Michigan. Reciprocal arrangements also included setting up physician abortionists in Michigan for clergy counsellors in other states. The system was not foolproof; but most contingencies could be dealt with. For instance, a crisis in late 1969 implicated a Chicago rabbi indicted 'by Chicago police for referring a woman to a suburban Detroit abortionist. Subsequent outcries by Michigan and Illinois clergy counsellors, Jewish lay groups, and other sympathetic "liberals," together with a favorable press, led to quiet dismissal of the case. As far as can be determined, there was little other overt inter-denominational cooperation. The Council of Churches in large communities continued to issue public declarations supporting abortion. They were, however, constrained in openly participating in the network because of dependence on community- wide funding sources. Working out legal arrangements was one thing. Successfully resolving moral and theological meanings was still another, apparently more difficult process, for early organizers. For some clergy, confrontations with bishop, pastor or senior colleague demanded that the 132 . moral issue of abortion be further articulated in terms of commitment ' to "higher laws and moral obligations transcending legal codes." ‘ In response to my question "How did you personally reconcile ; your abortion counselling and referral activities with moral, legal, ' and theological precepts against the taking of life," the early I organizers I interviewed (6) pointed to precedents established by clergy involvement in civil rights. Civil disobedience, said one ; former director, is "right of dissent“ when a moral issue is involved. 1Another clergy-administrator asserted that ”immoral laws“ can only be 'changed by ”conscientious objectors" willing to take ultimate legal and ‘personal risks. Still another view expressed in a position paper 1emphasized the "radical freedom and radical responsibility" for man to ‘be "intentional about life and death." Moral alternatives hinged on the question of which is the more humane course: enforced pregnancy with a possible dehumanizing experience for the woman and her future child, or terminate the unwanted pregnancy. In a document, written by a clergyman working for an advanced degree in sociologY. a strong pro- underdog position was articulated: Without taking an anarchist stand, it is also important to ask why should "society," through its law and mores, impose particular kinds of behavior and (more important) fates on certain of its members? Should a woman, who must carry and bear and most often spend at least five more years in care of a child be forced by society to continue with an unwanted pregnancy? Women are forced, by a kind of double standard to bear in a primitive form, the fruits of an act which in fact involved another person who, with great ease, may evade or pay his responsibility. 1 identifying with woman as victim, the position paper underscored quuities of male-dominated society. The paper went on to say: It is more tragic and morally reprehensible that women are forced to terminate the pregnancies by seeking out untrained, ill-equipped, 133 dirty, and often abusive persons for the termination. It seems to me that this state of affairs is the final proof of how a male- oriented tradition has managed to make an object of women--first as a source of pleasure, second as the bearer of responsibility for the consequences of that pleasure seeking, and third as the scapegoat punished for the guilt of both the male and herself and the society as a whole, which is guilty of not facing the whole business responsibly in the first place. In concluding, the document emphasized morality of intervention as the only humane course of action: It is moral for us to help women seeking termination of an unwanted pregnancy to avoid abusive, unsterile, non- or para-medical services. It is moral to help them avoid the danger of infection, puncture, sterilization, degradation and self—hatred. It is moral for us to help them in a time of need and crisis to make the Host creative and healing decision possible. Clergy counsellors, coming in after the first movement wave, or 1 those isolated geographically or socially, often did not share in the agonizing moral and theological decisions regarding the "contemporary challenge" of abortion. Ambivalence or confusion about moral issues occasionally led to withdrawal, slow-downs, inability to serve certain categories of clients (e.g. young or "promiscuous" women), or unresolved conflict by a few counsellors. How can we account for this unresolved ambivalence among some later arrivals? While there may be a number of factors here, as in changes of personnel with more older men or those from conservative denominations; the one compelling condition fostering a move away from the early crusader ethic was a change in the mandate itself. As the clergy message spread into the larger environment, requirements for )rofessionalism became more acute. Clergymen with unresolved moral filemmas entered a different value milieu, in which moral resolution 1f abortion was a "taken-for-granted" ethic among old-time counsellors. . -. i...:... .-IJI..1m.....1.ln..l..“ .11.. ..wiw..- . 134 Training sessions reflected the value shift. In the early days, weekly encounters between organizers were largely devoted to working out moral and theological dilemmas, or issues of life and death. In developing a rationale for service, organizers had to confront potential or actual opposition from their own denominational colleagues, pastoral supervisors, and even clientele. Once they successfully accomplished this task, they turned to pragmatic concerns. Training sessions underwent a metamorphosis. All-day sessions held monthly for new clergy recruits, and later agency or lay persons, focused on immediate abortion—information needs, as in medical, psychological, social, economic or public health situations. Knowledg- able professionals, called in to inform members, addressed topics such as ”the status of legislation," "proposed medical guidelines," “psychological effects of abortion" and so on. Medical fact sheets were distributed refuting traditional beliefs about hazards of abortion. 1 Women who had received abortions through the movement route were ‘ invited to describe their experiences. Public health officers presented recent data on abortions from states where it was legal. Especially ‘ after abortion was legalized in New York, extensive materials delineating 1 precise steps in routing women, were handed out and discussed. In developing trappings of a profession, the movement encouraged T recruits to study medical terminology and psychiatric information, now 1 available in hand—outs. Simulated counseling sessions by more experi- { enced clergy counsellors demonstrated special problems and contingencies ) in client care. To foster shared beliefs regarding this special 1 clientele, clergy were asked to fill out information sheets on demographic 135 characteristics. The information had two purposes. One was to ascertain what kind of clientele clergy processed. Overall, women were evaluated as young, inexperienced, "good" girls caught in a situation they could not resolve by marriage or adoption. The other purpose was to use the information as ammunition against opposition groups, who tended to impute unworthy characteristics (e.g. promiscuous) to abortion seekers. Training sessions, then, were multi—functional. They indoc- trinated recruits in a universe of discourse regarding the nature of the service, type of clientele, and kind of information necessary to negotiate this order. Sessions also incorporated established persons and groups who, as sympathizers, endorsed movement efforts. Training further served to normalize the abortion event by removing it from a moral domain, and placing it in medical, psychological, or legal spheres. In this context, a fixation on morality of abortion by a few recruits, could only obscure movement efforts to make abortion a conventional choice for problem pregnancy. The relatively superficial level of this "training“ became apparent after sessions were opened to agency social workers and physicians who were also asked to make "donations" ($20. per person). One agency director told me she found it a "profound waste of time," in that most trained social workers, physicians or counsellors know the information, aHYWay. Hostility between this director and the movement may have contributed to a negative evaluation. Overall, the training sessions, though couched for beginners, were well grounded in specific counseling techniques and situations. Audience participation in simulated sessions and discussion led by a 136 psychologist or clergy staff member were primary teaching tools. In my "class" of agency and lay persons, there was high enthusiasm for both the Service and its mission. This seemed to more than compensate for what critics might call an "amateur” presentation. Regardless of course content, securing information on all out— ofestate routing had to come directly from this source. At one time training sessions offered the only means to get information, with active network participation requiring clergy mediation because of their exclusive control over resources. Defining the Role Defining the counseling and referral role was a continuous problem for clergy organizers in the first months. What do problem- pregnancy counsellors do? What is the scope of their activity? How much time should be devoted to this commitment? What other persons or community resources should be involved? What is the counsellor's respon- sibility to the Service, to the client, to himself. Experience would modify some of these early decisions, but overall, the counselling role took the following form. --Movement clergymen were available on a demand basis. Since there were never enough counsellors during this early period, men were on duty as long as calls came in. The open-door philosophy with no attempt to screen clients made for a low-counsellor, high-client ratio, forcing many counsellors to neglect almost all other pastoral or university duties. Some clergymen literally abandoned themselves to abortion service as a full-time career. One minister reported handling 50 calls in a two day period. Another actually counselled 24 women in the same time period. —-With no source of organizational funds other than those provided by individual counsellors (or movement sympathizers), clergymen were forced to "borrow" resources such as paper, typewriters, telephones, duplicating machines, and office 137 Space from their church, university, or Council of Churches employers. This led to a few bitter exchanges between counsellors and their boards, congregations, or pastoral supervisors. Eventually, one director had to resign under such pressure; another director phased out of the Service after his term of assistant pastor in a prestigious suburban church was over. --After the movement surfaced into public view via media publicity, demand for counseling was so heavy that clergy organizers pushed hard to encourage colleagues to join them. --Countering expansion efforts, however, was a necessity to keep the organization under tight control until "kinks" could be worked out, as in legal matters, physician involve- ment, and type of out-state abortion resources. The dilemma for movement organizers was this: if we open up membership, we spread the work around and reach more needy women. But as work is distributed, so is the possibility of making visible the illegal or quasi-legal activities (e.g. physician involvement was believed to violate the medical malpractices 'act). Yet, limiting the number of counselors prevents some women from getting necessary help. In time, the dilemma was resolved by active recruitment of clergymen, and later, women volunteers and agency professionals. In the gap left by inadequate services, however, women continued to get illegal Michigan abortions, and a flourishing business referral system developed. --The counseling itself was conceived of as "crisis" counseling. The view here was that women were engaged in a moral and psychological crisis which they could not resolve alone. The task for these clergy volunteers was to guide the inexperienced, but basically morally "good girl“ to make the appropriate choice in terms of her life situation. In an open letter in early 1970, the director warned that because the Service was the I'only'I one available, and because the medical profession had ”shied away from such unrespectable and shady practices," counseling had to be carefully conducted to protect both counsellor and counsellee. Legal jeopardy was controlled by the counsellor's empahsis on the woman making her own choice. The Service simply presented the five options: marriage, adoption, keeping the child, abortion, or suicide. Protecting the woman from medical and psychological complications required counseling before and after the abortion, and advising her of the "best availaBle services.“ Medical "information and advice" was never a "recommendation," but only a list of alternative resources, "if the woman re uested such information." This was the official rhetoric. Un- officially, individual clergymen did indicate their prefer- ences, as in pro or con abortion, or used movement lists specifying "positive“ (approved) or ”negative" (disqualified) abortion services. 138 --Boundaries had to be established to define scope of personal involvement in counseling. Exhaustion, family "troubles,“ threatened loss of position, and other complaints related to over-extension of the role, required that the Service attempt to cope with personal problems of counselors. For almost 10 months of open movement activity (September 1969-June 1970), establishing personal and professional limitations was a persistent problem. Counsellors were urged by the director to develop a professional attitude. This meant "avoiding deep personal involvement," and especially, financial entangle- ments with counsellees. Increased membership, a routinized counselling and referral format, and frequent training sessions (as least once a month) eventually facilitated a more detached counseling style for many clergymen. But setting counselling standards in terms of a moral philosophy remained an unresolved problem. In the first place, normalizing abortion by making it a readily available option tended to reduce the woman's moral anguish. In this case she rejected the clergyman's morality focus. Second, the woman's need for information to successfully negotiate the network was so ovenwhelming that moral discourses by the counsellor were often seen by both counsellor and client as irrelevant. Morality and pragmatic issues clashed in this context, contributing to variation in counseling style and in modes of relating to clientele. --The role, as first articulated by organizers during the high risk days, was to provide professional counseling and advisory services for women and their families concerning sexual problems, contraception, pregnancy, unwed parenthood, adoption, and abortion. The word "abortion" however, has never appeared in any titles, nor has it ever been publically expressed as the chief solution to a problem pregnancy.3 In . effect, however, abortion referral constituted from 73 - 95 percent of all Clergy Service activities. One counsellor lamented that only 2 of 900 women he had counselled over a three year period opted ggt to get an abortion! Abortion, supposedly one option of 5 for "desperate” women, was the dominant mode of resolving an unwanted pregnancy by most clergy clients. --The abortion referral focus constrained some potential move- ment participants, particularly in the first year of organiza- tion. Moral objections to abortion ggyise limited some clergymen's activities to first-line contact persons only, with counseling and referral passed on to Service regulars. In doing even this, however, the referral network was extended considerably beyond the few dozen active movement partici- pants. .. IHVAFVEASw .1 ~44 43:1, -_., 139 --At first, arrangements with physicians and social service agencies were handled on a person-to—person basis. Later, a list of cooperative physicians developed by these contacts was assembled by each center coordinator for all clergy counsellors in their area. In an undated letter from the Detroit coordinator, social service professionals were urged to "send on their problem pregnancy clients that they them- selves, could not handle." Despite a one-way flow of agency-referred clients, the situation proved highly beneficial to both clients and Service. Movement activities became more widely known. Women were more likely to be moved along in the abortion routing, rather than having the search curtailed by a reluctant agency worker. And, willingness by the Service to take “problem“ cases showed both agency workers and physicians that the clergy were serious about dealing with their "crisis" patients. For perhaps one year or more after visible operations, movement organizers continued to deliberate on role definitions and scope of counseling and referral activities. Only in the context of organization building, and trying the role out by shared experience did most par- ticipants finally "learn to live with it." As clergy entrepreneurs moved from underground operations to aggressively promoting their cause they were better able to manage the risk involved. Building the Referral Network In accounting for the rise, development and eventual expansion of the clergy movement, one public healthyofficialobserved that only the clergy, of all professional groups, possessed the necessary occu- pational flexibility to "carry it off." For instance, he said, clergymen have no licensing, academic or bureaucratic requirements as necessary components of the counseling role. Once ordained, pastors or campus ministers are relatively assured tenure and can operate under the mantle of the "confessional" to protect themselves and their cause from legal intrusion. No similar security mechanisms exist for licensed or bureaucratized professions. 140 Not all clergy organizers saw themselves as free from risk. Some counsellors expressed moderate to intense anxieties during the early period about their career, their family's welfare, or possible harm to women they assisted. As a whole, early organizers communicated a "crusader's" view of social change. While a few clergymen had advanced degrees in psychology, sociology, pastoral counseling, or community planning, most were attracted to the movement because of previous work either with young people, as in sexual or draft counseling, or with civil rights activities, or had interdenominational political or administrative experience. In this activity, movement organizers developed a new kind of clerical mandate justifying civil disobedience and an activist social role. They adapted bureaucratic and professional strategies learned in earlier roles to abortion network building. Some strategies included: Utlizing on-going networks as a power base. Building a state- wide referral network required local clergy coordinators to identify community political networks. The notion was that by intervening at strategic points in on-going networks, the clergy system could be well cushioned by local community power people. For instance, one clergyman coordinator did a sociogram of his city with special attention to university - community alliances. On this basis, he put together an advisory board composed of local influentials, many of whom previously were linked in town-gown activities. The board, drawn from a variety of professional and administrative groups, included community mental health administrators, a psychiatrist, an associate dean of students, a leading gynecologist, and two university professionals (including a 141 professor of medicine and a professor of police administration). At the same time, clergy counsellors represented 80 percent of church denominations in the community. With support from established groups, clergy had a united front against police opposition with full scale referral services proceeding on the assumption that ”unless we really got stupid, they (i.e. police) wouldn't bother us at all." In Detroit, a similar executive board was put together some- time after the Lansing group had demonstrated the efficiency of winning support from legitimate community groups. Importantly, both these early centers emphasized putting the abortion option in the background. The idea was to avoid antagonizing Catholics, and to bring in as many >ublic-minded persons as possible. The "problem pregnancy“ title :erved to mute the morally objectionable option (i.e. abortion), while lot necessarily eliminating it from consideration. Ugjgg the clerical roleygs a protective cover to innovate luestionable activities. After developing local support sources, clergy- entrepreneurs moved more openly into the counseling and referral ‘business." To reach more clients, they needed both to inform the larger vublic of available services, and to urge agencies to cooperate in :onnecting women to clergy counsellors. Two prerequisites were required hr open network building. First, counsellors had to assume that the lublic believed in the respectability of the ministerial role, even if hey could not accept abortion counselling itself. Here, the concern was o keep citizens from, at worst, publically protesting, or better, to Iain their support. Second, they had to test the strength of the organization by Hrectly confronting enforcement officials. In this case, a favorable 142 4 Presenting press was helpful in developing a sympathetic audience. authorities with the organization as :31: accomplis helped to legitimate this activity. In some cases, police became "silent partners” in the network. A few even used the clergy as referral sources for troubled women they encountered in their rounds. Other centers were less successful. In spite of tacit approval by state-level enforcement persons, the Detroit Center continued to wrestle with a hostile county prosecutor. Close surveillance resulted in eventual indictment of a counsellor who referred a woman to an illegal abortionist in that city. Generally, high public esteem of clergymen and increasing citizen use and regard for the service together with police recognition or a hands-off policy allowed a relatively free rein for the movement, once launched. Learning to live with risk. For a few clergy organizers, civil rights activities provided a crucial training ground for later involvement in the abortion movement. Living under threat and intimi4 dation by community and police, and a jail experience in Mississippi was the kind of ”fire" that prepared one organizer for the abortion venture. Other men had less direct confrontation with such coercive opposition. Instead, efforts to racially integrate local churches or community services had ”stung" a few organizers. This not only exposed them to the rigidities of entrenched political groups, but also revealed the multiplicity of political and economic problems involved in social change. Risk was a day-to-day event for most counsellors during the early period. Clergy interviews suggest that being "troubled," “tense," "apprehensive," "uncertain about resources . . . or role," "having to 143 take a lot on faith,“ or "living on the legal razor's edge,“ typified feelings for those counsellors referring abortion clients the first year of the Service. Most coordinators and new volunteers depended completely on key leaders (perhaps no more than 6 men) for setting up local organizations. These early organizers, apparently, had the greatest range of experience, sophistication in mobilizing resources, and willing- ness to risk personal careers. Carrying heavy burdens, these top leaders were more quickly apt to "burn out," resign or get fired from present jobs, or alternatively, seek other careers (two former directors abandoned their posts for more secure and lucrative, private employment). Utilizing Church Resources. Employed as pastors (or assistant pastors), campus ministers, or interdenominational organizers, clergymen could use available church resources for running operations. In effect, local churches, universities or church councils subsidized the movement. Office space and supplies came directly from these sources. Denominational resources also provided financial and social support, as in legal advice or services, adoption agencies, and counseling services. For example, when threatened by an assistant prosecutor in another Michigan jurisdiction, one clergyman refused to disclose whether he had referred a woman for criminal abortion. Instead, he recommended the prosecutor to take his complaint to the Diocesan office, where it would be handled by "legal staffi" The charge was subsequently dropped, with a letter of apology from the chief prosecutor indicating that the woman in question was "generally unstable." The Methodist Pastor's School,an annual in-service training conference,became a favorite recruiting ground for new abortion 144 counsellors. This was possible, in part, because of the reform "mission" openly espoused by Methodists. The fact that a number of key organizers were also prominent Methodist ministers also contributed to the fortuitious arrangement. Methodists coming into the Service had two movement indoctrinations; one from their own denominational leaders, the others from movement organizers. Relatively high commitment by this group may be an outcome of this double exposure. In spite of some hostility by a few chdrch boards or congre- gations, most abortion counsellors operated in relative security in the privacy of church offices with limited interference from local communities once the movement was undenway. In some parishes inter- vention was an occasional problem. Rarely did it result in a serious confrontation. Most counselors reported they were able to handle complaints on a personal basis. If outside aid was needed, counselors typically turned to movement colleagues or leaders. For a few, 1 sympathetic church boards, congregations, and even denominational ) organizations provided support. Changing perspectives of risk as the movement developed led counselors to make different responses to disapproving groups at different time periods. For instance, confronting a negative congrega- tion in the "early days” could mean, at worst, threat of job loss. But after the movement was established, clergymen could use the privilege of the pulpit to lecture a "recalcitrant" or ”traditional" congregation. Many clergymen report highly favorable reactions from their congregations once issues were presented in this way. 145 Stressing a no—fee-for-service orggnization. Perhaps the move- ment's single most significant legitimating feature was its stress on no-fee-for-service. Early organizers considered this the principle element that made the Service untouchable for most prosecutors and police (“after all, what are the clergy getting out of it?“). Money has always been a problem in the movement. Mainly, there is never enough. Money transactions (fee or loan) were specifically barred in the Convenant between the counsellor and his counsellee, or between the counsellor and physician or social‘agency., "Loaning" money to needy clients was a typical problem for early counsellors, in spite of the prohibition. Only rarely did counsellors demand a fee, although some did request "gifts“ from clients ("to help make this service possible for other women"). The no-fee tradition has thrawted later attempts to make the Service a solvent enterprise. Many counsellors feel uncomfortable about the "money issue! especially if it involves them in what some call "soliciting? clients. In spite of this, the no-fee strategy has been considered the only possible course of action. The New York Courts later outlawed all fee-for—service medical referrals.5 Moreover, most organizers believe this approach convinced the public that the reverend's "mission" was to help "desperate" women, with no material gain on the clergyman's part. Maintaining autonomy of clergy centers facilitated local influence. The clergy movement, as organization, is divided into 7 geographical areas with each area center acting as a distinct political unit. Centers have their own coordinators elected by local members. Typical responsibilities include: setting up counseling schedules and 146 training sessions, distributing information from the Detroit "clearing- house,“ in some cases, setting up physician or agency contacts for members, and representing the center at all-state clergy meetings or local or state abortion reform gatherings. While local organizational structure varied, members aimed to keep their own centers autonomous. This resulted in a weak "superstructure," or one in which control resided in local clergy groups. Decision making took place in terms of local community sentiments and opportunities rather than a larger set of organi- zational goals. This loose structure promoted a more diverse impact than would have been possible if a uniform bundle of activities were the case. For instance, fitting programs to local circumstances allowed some clergy centers to move more rapidly into network building with professionals and agencies. In another community agency liaisons might be hampered by l'old guard" directors. Instead, legal reform efforts would be emphasized. In still another situation, a supportive community sponsored a joint counseling effort by clergy and women in a women's center. Autonomy made for other variations as well. Ideology and commit- ment tended to fit social circumstances. This occasionally led to clashing rhetorics. A Detroit member might call himself an "information-giver“ an abortion referral. Another counselor from the Upper Peninsula viewed the role as "moral adviser of mothers and needy women." The primary liability is that with geographical and organizational separa— tion, "each man does his own thing." Accountability to the movement or to local colleagues was offset by community or denominational loyalties. This generated unanticipated "irregularities." Some men continued 147 to refer to criminal abortionists, others alluded to abortion as "murder" in counseling sessions, and some clergymen never paid their dues, which almost alone sustained the organization. (More extensive discussion of movement structure follows this section.) The Referral Network By early 1970, the network formed a complex linkage of approxi- mately one hundred clergymen, a variety of local medical and social service agencies, and more than a score of approved abortion sites scattered around the state, the nation, and even a few foreign cities. Most well-traveled routes were illegal, as in Detroit, Chicago, Puerto Rico, and Washington D.C. Different clergy centers had different lists and tended to use only a few preferred resources out of the dozen or so available at any one time. Importantly, each resource had to be checked thoroughly. For an occasional counsellor this meant personally visiting the abortionist and bargaining in person. Telephone calls between abortionist and counsellor were more frequent, although counselees made the actual contacts themselves for legal reasons. In making up lists of "resources, counsellors had to balance advantages against disadvantages to arrive at "approved" sites. The proximity of a resource, say Detroit and Chicago, was a sizeable gain, eliminating travel time and cost for clients. Counter— balancing this was illegality of abortion in these cities, and inevitably, threat of legal jeopardy to both counselor and client. London, while legal, was out-of-the-country, and involved passport arrangements, expensive air flight, and complicated travel arrangements. 148 Counselors using London on a regular basis rarely allowed women to go alone. Husband, parent or other adult had to be contacted to ensure the woman a companion for the trip. Young girls, without parent or older relative, had to be teamed up with an "older" woman, also London- bound for an abortion. These arrangements often resulted in delay — an additional cost. By 1970, the price tag for legal abortions (e.g. London and California), remained out—of-reach for all but the affluent (approxi- mately $1,000). Because of "private arrangements" between police and clergy counsellors in one city, only legal resources were used. Women unable to pay were referred to other clergy centers where they could be given alternative lists of lower-priced, but illegal abortions. The cost situation infuriated some counselors who felt that only by continuously exerting organizational pressure and bargaining with nearby abortionists (e.g. in Ohio, Chicago, Indiana), could prices be brought down. The Chicago resource remained a "preferred" one, because of greater medical experience of this practitioner. Yet, the physician held out on price. In time, clergy were able to negotiate a reduced price (from $800 to $500) from the Chicago man by playing off altern- ative resources. In exchange, the Service agreed to refer a large proportion of their clients every month. Chicago continued to be a major outlet for Michigan counselors until New York legalized abortion. A few centers still continued to use this resource (now $200) because of travel convenience (e.g. a 4-hour car ride from Lansing). A “bad neigh— borhood" and the on-again, off-again constitutional status of the abortion law in Illinois, however, were drawbacks. 149 California, which had legal abortions after 1970, was used for about a year until the New York routing was well established. There were other limitations besides travel time and cost for the California resource. Psychiatric consultationandhospital committees, while Egg fgrma, added cost and delay to the operation. Most counselors preferred to use this state for "late” hospital abortions, rather than for the 70 percent or more of early, non-complicated terminations. A few counsellors simply ignored directives from Detroit “central office" or other movement-pooled information, using whatever resources they personally had developed. Apparently, Japan, Mexico, and Puerto Rico, were considered too "exotic" by most to use as standard referral outlets. Counselors were reluctant to use these on a regular basis because of language barriers or costs. Untraveled women were believed to be exploited in these situations, either receiving abortions from the ”wrong" resource, or overcharged for the operation once at their destination. The fact that such sites were available and had been checked out by clergy or their supporters, gave credence to clergy claims that they were only in the business of offering ”lists,“ not recommending specific medical persons or facilities to clients. Regardless of resource listed, its location or legal status, there were some disadvantages in all of them, whether medical, travel, costs, or treatment features. This forced movement organizers to change abortion referral sites frequently, requiring enormous time investments. Maintaining present contacts, gathering additional client information on new resources, continuous negotiating on price and 150 quality of service with practitioners--all were necessary to build up a viable referral system. Figure 8 documents a representative list of abortion sites. Some locations were used frequently by all counsellors. Still others were rarely or never used by clergymen. Because of persistence of personal networks operating outside movement control, Detroit remained a preferred source for some clergymen, despite hazards involved. This eventually resulted in the prosecution of a Detroit counsellor. But the case has never gone beyond the pre-trial period. Thislist includes only facilities checked out as "positive" (or approved) referral sites. "Negative" lists also circulated indicating abortionists by name, location, and reason for disqualifi- cation. Lansing Center, for instance, had one “rumor control informa- tion" sheet, dated January 1970, listing 10 Michigan abortionists rejected on grounds ranging from "dangerous" to “affectionate with clients,“ "unstable," "two known infections, sexual problems," "un- sanitary conditions," and "senile." The same circular also excluded 28 physicians in 10 other states. Information was compiled either by the National Clergy Consultation Group in New York City, or by Detroit which had a small administrative staff to check out "rumors.“ Local clergy groups also kept their own files, as well, based on client experience or counsellor investigation. Who were clients served during the first year of network building? Most are young, white, Protestant, unmarried students or working girls with at least a high school education. 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Low mumou vmquEmu 3:553 woa— .umo-mwm_-.un.um-uu..>..om 9:23.58 .3st ,3 new: muuczomoz cox-.22 m... 3516 2:3“. lSZ typically a first pregnancy, and almost 69 percent used no contraception.7 Informants also emphasize that clients are "not promiscuous," but rather are "good girls,"who are "not yet ready for marriage or a stable rela~ tionship." With data of this kind, clergy-organizers could appeal to physicians and agencies for support of this "vulnerable" and "high risk" population. In time, professional treatment of this client group was termed "crisis counseling," or "crisis medicine." Legal, medical and/or professional risk for those involved are all suggested in this conception. The entrepreneurial phase of the movement succeeded in creating a rationale for abortion counseling and referral, defined the role for participants, and constructed a viable, if still limited network. The broker system that evolved from these movement efforts extended the network across the state, linking an ever-larger number of clergymen, professionaL and agency persons to help-seekers with unwanted pregnancies. How the entrepreneurial, or risk taking role, changed to a broker, or legitimating role, has to do with a series of events. These were induced, in large part, by legalization of abortion in other states, especially New York. Legal abortion, in turn, facilitated a routinized agenda with standardized information. This approach focused on the woman's psychological state and information requirements with referral to New York if there were no obvious psychological or medical contra— indications. Legal referral also encouraged an ever-widening spectrum of legitimate groups and clergy from more conservative denominations to connect into the system, many of whom had resisted on grounds that the enterprise was too hazardous. If clergy-entrepreneurs could be said to have created a movement, then clergy-brokers were those who sustained a new health delivery care system for abortion. FO0TNOTES—-CHAPTER V (PART I) Date for this chapter are taken from the following sources: (l) Formal interviews with 28 different counsellors with four of these providing 2 or more interviews. These average between l-l/2 to 4 hours per interview; (2) informal interviews discussion, and participation in clergy—related activities (e.g., board meetings, training sessions, observation of the counselor-client interaction (4 hours). Informal contacts extended over a l4- month period; (3) four years of documents, organizational letters, and personal memos from two centers--Detroit and Lansing and (4) a mail-out questionnaire to l05 counsellors with 60 returns (57%). A pre-test of the instrument was the basis for the final version of the questionnaire. For a discussion of role problems among campus ministers, see Philip E. Hammond, The Campus Clergyman, New York: Basic Books, Inc., l966. While origins are hazy, the term, "problem pregnancy” probably has been used by Planned Parenthood and other family planning groups long before clergy came on the scene. In borrowing the term, the clergy movement attempted to universalize meanings associated with the abortion event across counseling groups. It is also clear the clergy used the term for rhetorical purposes,as welL to avoid offending professionals and publics. Few physicians I interviewed used the term. Instead, the reference was to "unwanted” pregnancy or baby. Media support was facilitated by a series of abortion articles sponsored by the chief editor of a leading Detroit newspaper. The editor is married to a regional director of Planned Parenthood who has been active in abortion reform for almost a decade. The attorney general of New York ruled against a Michigan "consul- tant" firm referring Michigan and other out—of—state women to New York. In the opinion of the court, all_medical referrals for profit violated "the standards of ethics and public policy applicable to the practice of medicine and . . . professional conduct.” In testimony by the New York State Director of Planned Parenthood, Inc., a case was cited in which a medical director of one referral-for-profit corporation earned as much as $l600 in one day for performing abortions, in addition to which he received $2,000, a month for his services as director. l53 154 Another $19,220 in monthly dividends was also collected by the physician who owned 30% of the corporate stock. The court‘s objections focused on (1) excessive fees for referral, (2) fee splitting, (3) advertising practices, (4) laymen giving medical advice by phone, and (5) charging unitemized fees for both abortion and referral. (In an Opinion, [unpublished document] S.P.S. Consultants, Inc., versus Louis J. Lefkowitz, attorney general and Martin S. Mitchell versus Louis J. Lefkowitz, [United States District Court, Southern District of New York], 7l Civ. 293l, 7l Civ. 2990, October 5, l97l.) This list was assembled mainly from coordinators' handouts to Detroitand Lansing area counsellors. Interview data were also used. These data are provided by Professor Diana Warshay, University of Toledo. l55 PART II: Clergy—Brokers--Sustaining the Organization It is apparent the clergy movement has been an adaptive instrument in building an organization, and in reducing or spreading risks for abortion market participants. This was documented in describing strategies the Service employed to deal with external constraints and. internal problems. In creating a single-function organization, or one whose primary activity was to counsel problem-pregnancy clients and to refer them to medical and social resourcs, the Service performed a unique role. By tying together previously disconnected resources into a relatively cohesive network of helping services, the clergy provided both a routing system and a model of health care that would be adopted by legitimating Public Health officials (discussed in Chapter VIII). What social arrangements characterized this second phase of the movement-—the broker enterprise? How didthe counseling format work as a routing mechanism to move clients through the system, and only rarely, to provide intensive therapy? Who were the brokers, and how did demographic and professional differences among counsellors contribute to different modes of participation? What were individual counsellors' conceptions of the role-—motives, gains and costs? How did agency- professional contacts change over the course of the counseling career? We consider these questions in terms of elucidating the broker phase of the movement. Finally, we briefly document changing movement structure in terms of different network formations over time. l56 Broker Arrangements The single most significant catalyst to transform the risk structure of the clergy operation was, undoubtedly, opening up legal abortions in New York to out-state residents. Until July T970, almost all abortion referral within Michigan was illegal or quasi—legal. Cross-jurisdictional arrangements between referring clergymen and criminal abortionists kept legal jeopardy within bounds for both c0unsellor and client. But there was always the possibility that "something could go wrong.” Psychiatric indications used as a protective code for abortions in California and Maryland, were technically still in violation of those states' abortion laws. At one time, only London and Japan were legal abortion sites. The only conditions limiting abortions were gestation age or severe medical or psychiatric contraindications. These conditions were very liberal indeed (e.g. acute psychosis in London, severe heart or diabetic condition in Japan). Underage girls needed parents orguardian's consent in London. But the expense was con— sidered by some counsellors as discriminatory for those unable to pay the high costs of abortion. Once New York legalized abortion and clinics were open, the shifting routing pattern stabilized. Because abortion was now a competitive market product, the Service could negotiate openly for preferred treatment with New York physicians and facilities. In an effort to shape the market, clergy groups formed a coalition to achieve a high-quality, low-cost medical product. The Michigan Clergy Service, with the largest single referral group, and reportedly, most vigorous of all the state organizations, was 157 apparently very instrumental in determining direction and form of abortion services. Results of the collective efforts were as follows: --Arrangements were made with a New York Clinic (out-patient) to give ”preferred" treatment to clergy-referred clients at low cost (initially $200) with pre-abortion counselling and contraceptive treatment built into the program. --In exchange for treating clergy patients at the regular fee, the clinic agreed to take l0 percent of referrals at reduced or no fee. This enabled the Clergy Service to greatly expand the number of indigent women they could serve. --The clinic was set up for early terminations only (l0 weeks from conception). A vacuum aspiration under local anesthetic took approximately l5 minutes to one—half hour with a three- hour recovery period required by law. The woman could be in- and-out of the facility within five hours or less. Low-risk surgery in early pregnancy combined with high skill of the practitioners have made this facility a model clinic in New York City.8 --The clinic was responsible to the Clergy. Client comments regarding treatment were included on all patient data sheets returned to clergy state offices. In this way the Service could monitor the New York facility without personal surveillance. Patient complaints were attended to promptly, For example, reports of an ”abusive” doctor or unsympathetic counsellor involved letters and phone calls from Detroit coordinator to New York clergy consultation staff and clinic administrators. If complaints persisted, arrangements might be made to retire the offender from the facility. Though the clinic was not always responsive to clergy interpretations of client charges, overall good rapport existed between the New York facility and Michigan Clergy Service. —-The Service also attempted to get alternative clinics with similar regulatory power, but woth no success. A few Michigan clergy centers continued to use their own preferred resources, rather than the sponsored site. Detroit administrators believed that these isolated ventures reduced their overall effectiveness in bargaining with specific facilities. The present cost of $l25 covering counseling, abortion, contracep- tion, and antibiotics was a direct outcome of "hard bargaining" by National Clergy Groups. By setting up a model clinic that competitors would have to emulate if they were to survive in the market, the clergy realized a major goal of their move- ment-~safe, low-cost, legal abortions. 158 -—Clergy arrangements with New York City area hospitals for in-patient treatment for "late" abortions (11 to 24 weeks fetal age) were more precarious. By tradition and preference hospitals are a multi-service facility. Few were willing to provide either kind of service or cost of treatment clergy demanded. Administrators were also reluctant to have the Clergy Service interfere in price-setting or treatment programs, latter domains considered to be perogatives of hospital staff physicians and administrators. --Counsellors were particularly incensed about treatment deficiencies for out—state residents at New York hospitals. For example, despite increased medical and psychological risk of saline abortion (the typical procedure for late termination), there were no supportive services, as in counseling, contra- ceptive treatment and follow-up care. Moreover, clergy staff say they have little or no choice in hospital service. Over- all my observations show that New York hospital buildings are old and unattractive. Poorly designed for heavy abortion traffic, they have few ameliorating features that compensate for multiple deficiencies. Both personnel and treatment are under par. For instance, an unsympathetic, if not often hostile, technical and nursing staff are said to contribute to low patient morale. Racial and religious factors among this group reportedly lead to negative evaluations of abortion on moral grounds, expressed in staff rejection toward patients. --Lack of adequate treatment contributed to an unpleasant patient experience. Patients complained,for example, that beds were often soaking wet from loss of fluid and/or fetus after delivery, bed pans were not brought or removed as needed, and there was no toilet paper or towels. For clergy organizers, treatment complaints reflected a punitive attitude by staff toward patients. Women were insulted by orderlies ("Now, you're never going to screw aroung again"), treated like ”animals" in overcrowded and emotionally unsuppor- tive settings, and forced to watch the ”mopping up" after delivery despite their protests. Other problems intrinsic to an out-of-state referral system continued to plague clergy brokers. Information changed rapidly, especially in initial efforts of clinics and hospitals to tool up for abortion. Some counsellors passed on outdated or wrong information to clients. The reduced fee ($25) or no charge for clergy-referred clinic patients created confusion at both ends-- Michigan and New York City. There was really no criteria for 159 need established by either the Service or the Clinic. Michigan clergy tended to interpret need broadly, often sending on relatively affluent college girls who simply "couldn't tell their parents," and, therefore, had no source of funding. The Clinic complained that they were "running in the red" with this surplus of needy cases, and that the clergy should either severelylimit these reduced fee or free cases, or face elimination of this policy. In other problems cited, some clergymen were reported to be moralistic, ("abortion is murdering a fetus," or "you shouldn’t have made the mistake of getting pregnant"). Other counsellors warned of committing a "felony" or emphasized the possibility of "infec- tion and death." Clients complained that counsellors were overly ”solicitious," in probing the woman's psychological state, when her intent was merely to get necessary information. Common errors were wrong codings from counsellors on recommended price, and failure to get a doctor's statement of the physical examination before New York referral. These delayed the abortion process. A few women even arrived in the city only to discover they were not even pregnant. It was difficult to serve such a varied clientele. Some women complained of over-counseling, some of under-counseling from the same counsellor! Multiple counselling sessions for the ambivalent, frightened, or anxious woman drained time from a hurried counsellor who might be spending as much as 25 percent of his professional time on this activity. Lack of effective sanctions kept on "deadwood" counsellors, and made it difficult to retire the inadequate or poorly skilled. Many problems were intrinsic to voluntary organizations, as in time budgeting and 160 ineffective sanctions. Others characterized organizations operating on the fringes of the social order, as in ethical dilemmas, initial difficulties in getting supportive services from physicians and agencies, and chronic money shortages. Access to legal abortion did break down many of these barriers. Counselors "learned to live with the problem" or switched into legal reform activities. Once the social services sector began to move into the network, work overloads were less pressing. It was still the case, however, that a few counselors carried the greatest part of the burden. Except for one paid coordinator, the Service was totally dependent on volunteer help. And, volunteers shifted in and out of the counseling scene, depending on other commitmentsand personal situations. Despite chronic limitations, the organization established a counseling format that both legitimated abortion referral for clients and professionals and induced many agencies to assume some obligations toward this clientele. The Counseling-Referral Format Counseling is no longer on a demand basis. Nor is it an individ- ualized, precarious undertaking. Most counsellors now serve on a revolving basis, with regular duties assigned on a monthly or bi—monthly basis, depending on location, demand, and number of participating clergymen or agencies. While counseling time varies widely (from 1 - 100 hours monthly) for this sample of 60 clergymen, median time was 15 hours per month (mean = 19.6). For most clergymen counseling itself is a standardized procedure. As one experienced minister pointed out: All the women have already made up their mind. There's no point in going through the options. I've been in this for three years and haven't seen any panicy women. They may tear up as they talk, but they've already made up their mind. 161 For most counselors, routinizing the format did not reduce the importance of pre—abortion counseling. Instead, client contact before abortion serves a number of essential purposes, primarily "screening cases," and giving supportive help and guides for making a moral decision. The Service, respondents say, assists the woman to "sort out feelings,” ”gain confidence in the procedure," "desensitize her to the horror stories,” "clarify her reasons for seeking an abortion," and promotes consideration of "moral and spiritual factors involved.” Typically, counseling is viewed as ”supportive referral" rather than ”deeply therapeutic." A few counsellors believe emotional and ethical consequences of abortion involve "guilt, fear, and deep feelings about relationships with God-self—and sex partner." Counseling is an "absolute necessity" for clarifying these reactions. Some recognize that once the law changes, there will be little need for the present counseling format. Either other agencies will process most cases, or moral problems associated with illegality will vanish once women can get convenient, low-priced abortions. Meantime, most counsellors stress that the Service is "very" or ”immensely important," and should be maintained until the law permits them to phase out gracefully. The ideal-type counsellor, as described by one staff person, is a low keyed, non-moralistic person who is responsive to the counsellee's situation, takes her through the options, but lets her make the choice herself. Excitable, moralistic, "interventionist" counsellors, by contrast, have little place in the program. The counseling session is to be "unhurried," and yet is to communicate the necessary information. This allows the woman to work out any problems she may have by way of 162 verbalizing her feelings and decisions. If the client is ambivalent or expresses serious unresolved emotional or moral questions, the counsellor is expected to proceed cautiously. Guilt and post—abortion trauma are always possibilities (Catholic women are said to be at higher risk here), although clergy believe the incidence of this reaction seems to be declining. The interview lasts approximately 30 minutes to one hour. Within this time period, the counselor establishes rapport, delineates the options, supports the woman in her decision, and provides routing information. He also fills out an information sheet after the interview detailing social-demographic characteristics of each counsellee. The clergy-client interaction tends to be a highly routine encounter with a leading question simplifying the decision ("For you, then, the best situation is abortion?"). For experienced counsellors, leading the woman through the various alternatives requires little creativity or unusual counseling skills. Instead, repetition and uniformity are required attributes of the role. Because counseling usually follows a set procedure, patience and understanding are often more valuable than deep insight into client needs. One three-year participant emphasizes concrete details related to the immediate preg- nancy or impending abortion, as my notes from this interview clarify: (C = counsellor, W = woman) How did you find out about this service? Through Cosmos (journal). I read a lot of magazines. Do you work? Yes, I work in an office of stockbrokers. How much education did you have? Junior year at the University of Wisconsin. That's a college year? Yes. EDZOEOZO 163 Religious background? Catholic. 00 you have a note from your doctor? Yes. Do you mind if I smoke? (She was very nervous.) No, as long as you're using your own. (Laugh Are you the reverend of this church? , No, I'm a pastor on the East Side. No contraception, Sandra? Yes, that's what's so awful. The doctor told me to quit the pills because I was spotting. By the time I went back for a check-up, I was pregnant. Are you getting married? No, he wants me to have this baby, but not get married. I'm going to break off with him. So you don't think you can hack it? No, I don't think so. 15 he going to be any help to you? No, he's not around. Do you think you're likely to have the child? Do you think that you would like to have the child and adopt it out? My sister had a baby last year. She's not married. She's on ADC. I don't think I can do that. As far as you're concerned then, you want an abortion? As long as I can have children later. fifiznznzo in E 0:020 in (A brief discussion of the Service, necessity to consult a physician, and New York arrangements follows.) C: What you want to do is to move quickly. Don't let any grass grow under your feet. You have to move very quickly on these things. Do you know anyone who had their baby? I mean what else can you do? AOC: What else is there? You're asking for alternatives to abortion? Yes. Can you get married. No, he won't marry anyone. Have the baby and work. How? You may lose your job. I can't do that. A zoznzeses A final alternative was then proposed.) Do you know there's a fifth alternative? Did you know that? What? No. Suicide. What? (gag) Have you thought about that? No, never. So many people can have their babies, but I can't do that. That leaves abortion, doesn't it? znzngf? 164 If the clergymen feels the woman is still uncertain about the abortion decision, he may pursue the issue further in the same or, less frequently, a later interview. In many cases, it is the procedure itself that frightens women. Counselling reassures the woman by delineating the mechanics of the operation. The same counselor speaks to another woman, a 22.year old black divorcee with one child, who wants an abortion, but is fearful about the operation: W. Do I have to see it? C: See what? W: See the whole thing? I don't want to see the whole thing. I think it's scary. C Oh, no. Under good medical procedure it's no problem at all. These medical doctors perform abortions and it's not a big thing at all. The procedure they use is a vacuum aspira- tion procedure and you'll have anesthetic. Have you had problems in this at all? No, the problems are minimal. Under good medical conditions there are no problems. The difference here with abortion is that we hear only about the illegal, the back—alley abortions. 02 But when abortion is legal, then we can give good, safe abortions . . . Despite uniformity of counselor—client interactions, individual counsellors express variation in role conceptions and participation. Differences are, in part, a function of demographic and professional variations between clergymen. Distinctions also reflect differences in personal circumstances, a feature which makes it difficult in some cases to identify with the movement and its cause. The brokers-—social characteristics, role conceptions and performance-—are further elucidated in the next section. The Brokers--Who Are They? From questionnaire data furnished by 60 respondents (with 57 percent returns) from a geographically stratified random sample, we present a summary of social-demographic characteristics. 165 1. The highest proportion of respondents are Methodists (48 percent), with so-called liberal denomications (e.g. Unitarian, Presbyterian, or Episcopalian) represented by less than 25 percent of the respondents. No Jewish clergy are presently in the service. 2. The sample is relatively evenly split between rural and small community (20), small city (16) and large city or metropolitan areas (21). Two-thirds are from communities of 10,000 or more with approximately 1/3 operating in large urban centers (no answer = 3) 3. The largest proportion are either full-time pastors or assistant pastors (47 counsellors). Another 11 are campus ministers, who in a few cases, are also attached to a church. The solo-pastor parish is most typical (36 of 58 responding), although 8 ministers are attached to parishes with 3 or more ministers. 4. The sample represents a fairly established ministerial group, with 34 (of 59 reporting) having been in the ministry 10 years or more. This includes 11 who have been ministers for 20 years or more. 5. Over half have been in the movement two years or more (33) with almost 22 percent of respondents participating 3 years or more. 6. Sixty-five percent (36 of 55) serve in moderate or large-sized parishes with congregations of 400 or more persons. Sixteen respondents, or 30 percent, are pastors of very large congrega- tions (800 persons or more). Only five serve in very small parishes (under 200 persons). 7. Recruitment into the Service has typically been through friends (28), or professional contacts (11) with 8 self-recruited because of local demands for service, or perceived social need. A few were directly solicited by movement leaders who were friends or associates (3). The others (10) were introduced to the movement at denominational meetings or training sessions. In sum, this is a relatively established ministerial group from mainly urban or suburban parishes, most of whom are likely to come from "middle-of-the road," or politically conservative denominations. The congregations they serve are relatively large for the 1-2 pastor set-up. Most are recruited by denominational or clergy colleagues, many of whom are friends. 166 While generalizations from this sample to the larger membership must be cautiously made,there is strong indication that almost all active centers are represented.10 The relatively high proportion of respon- dents who have been members of the Service for 2 years or more, while possibly unrepresentative for the larger group, permits a more adequate analysis of role formation and transformation than would be possible with a sample lacking this longer period of participation. We strongly suspect that this is the single most significant bias in the sample. Both questionnaire construction, aimed at delineating changes in role and organization, and possibly greater inducement of "longtime” members to explain themselves and their part in the movement may have contributed to this bias. From interview data and observations, the type of men recruited for broker activities represents a somewhat different social group than leaders or early organizers. On the whole, there is a wider diversity of ministerial types--more older men, more full-time pastors, more denominations represented, and, significantly, more denominationally - conservative and small-community ministers than prevailed in the early days. Whereas, early organizers almost exclusively originated from large urban or suburban centers, this "third wave” of participants entering the Service, often only after the movement publically surfaced, come from a wide variety of Michigan cities, towns and rural communities. Movement orientation and ideology, an almost uniform rhetoric in docu- ments and speech of early organizers, is increasingly replaced by a general service or professional ethic by rank and file members. The crusader's theme, less evident now, becomes -transmuted for many Into a 167 service rhetoric in which lack of alternative help sources creates both the necessity for participation, and an essential rationale for counseling. Part of this is due to the phasing out of old organizers, who were "burned out," or left by choice or by necessity (e.g. transferred out of state). Another aspecttyfchanging ideology is the status of the movement itself, which in more recent months has become a respectable commitment for both clergymen and other professional or service groups. Conception of the Role--Motives, Gains and Costs Clergy-brokers as a group articulate a strong "help" ethic in entering problem pregnancy counseling. For many, counseling is simply an extension of the pastor's role or professional obligations. For others, it is a new service arising out of social changes that no other organization is either willing or able to grapple with. For a few, personal involvement is a "pioneer" activity, a breaking of new ground in an area where legal "repression" has stimulated ”bootleg" operations. Participation aims to reduce costs for women, as well as their families, the unwanted child, and the larger society. Social "need," together with a belief that the Church must take a position ”as advocates for women with problem pregnancies,“ serve as inducements to provide a service that almost all believe is indispensable at this point in time. Perception of ”need," or a service imperative, may be expressed as a religious, I9931, psychological, economic, or organizational obligation, as these statements indicate. I believe that the Church haSan obligation to provide the moral and spiritual context in which consideration of an abortion is done. Also, it is essential to provide the best resource if the decision to have an abortion is made. 168 I'm involved because I want to help girls who have no one else to turn to. Also, I feel thepresent laws favor the rich and discriminate against those without money and contacts. I think unwanted children are not desirable-—to the girl, to society, and probably not even to themselves. This (counseling) fulfills my need to be a helping person. It helps tragically-trapped women and is a useful way to help my church see themselves supporting a direct ministry to non-members. I believe every child has the right to be wanted. I believe every woman has the right to secure an abortion, and should be able to do so where it is legal, medically safe, and as cheaply (sic) as possible. ' I continue to see people in terrible turmoil over the problem pregnancy. The length of time I've been involved, and haven't yet found other clergymen in the area ready to help. I want to help those in need. I believe the option (abortion) should be open to all. I do not believe you can legislate morality. Lack of referral alternatives for women is an overriding consideration for many counselors. Even when the individual feels that the work "gets me down," he also recognizes that ”the job must be done," and that “we seem to be the only ones left to help.” The church and local ministeries, specifically, have an obligation to move into social problem areas as an extension of Christian principles and as advocates for women and the unborn. Professionalism is still another dimension that provides a vocabulary(rfmotives for participation. For instance, many counselors emphasized how they moved into this new counseling area to enhance their professional counseling skills, develop new community resources, get needed experience with a range of problem clients, or work more inten— -sively with local community resource groups. While there is some decline in professional rationales after months of participation, expressed gains from counseling emphasize professional and personal pay-offs from the activity. 169 In one sense professionalism, expressed as increased skills or greater centrality of the ministerial role in the larger community, becomes transmuted into another dimension altogether. The experiential benefits from counseling are seen as altering traditional views and opening up new social meanings and opportunities. From the largely closed social world of the parish, the counselor moves into the community with new insights, a new awareness of the larger social world, more understanding of conflicting values and deviant life styles, and greater tolerance for differences. Enhanced sensitivity, in turn, makes him more responsive to counselees and more adaptive in his larger ministerial role. Compassion, enlightenment, and increased ability to relate to a larger set of persons and circumstances are, then, primary benefits from participation. New counseling techniques, increased status with colleagues, and an enlarged network of professional contacts are byproducts of this enhanced psychological state. From these protocols, we find that inducements for service and gains from participation tend to diverge. Table 6 summarizes variations between expressed motives, or “reasons you are now participating in MCCSPP" and gains, or "positive ways the counseling role affects your life." The table suggests four considerations affecting clergy par- ticipation. First, clergymen who enter this suspect moral domain of abortion counseling are ovenwhelmingly attracted by pervasive social need, as defined by organizational leaders and their own experiences. For those who see "need" predominantly in terms of the woman's "problem," there are two distinct ethics: traditional or liberation. 170 TABLE 6.--Rationale for Participation in Abortion Counseling: Motives and Gains Rationale for Motives Gains Participation (n=60) (% of total)** lfi?867“‘?%’6¥’$6€3i7 Professional 24 4O 15 25 Community Service 30 50 9 15 Psychological/ Experiential 10 17 4O 67 Political/Legal 7 12 O O Concern for Women 18 3O 5 8 Concern for Unborn 3 5 2 3 Theological/Church 5 8 5 8 Lack of Organizational Alternatives 17 O O *Multiple responses **Percentages are rounded 171 In traditional terms, the woman's need is related to her role as mother, community or church member, or "tragically-trapped" victim. Counseling in this sense is an extension of pastoral or professional support and guidance. A liberation ethic, contrariwise, interprets the woman's dilemma as byproduct of a repressive law which forbids medically safe and low-cost abortions. In denying the woman's right to dispose of her body as she chooses, the law and "medieval medical attitudes" generate exploitation and personal stress. Second, experience with the counseling role tends to mute the community service ethic. In some cases, this rationale comes to be viewed as unrealistic, either because of unresolved personal conflicts regarding the morality of abortion, or negative reactions from community or church persons. For some, the helping ethic also loses its potency under pressure from sheer repetition of the counseling situation, and concern that few counselees choose any other option than that of abortion. Professionalism also declines with a routinized agenda, and loss of mystique earlier associated with the role as a “unique“ one. Third, many recognize that increasing agency and lay partici- pation no longer makes the service an indispensable community resource aiding "victimized" women. Instead, clergy are more likely to consider their organization as the only helping resource that offers the woman a moral or spiritual context, rather than merely a secularone,within which to consider the decision. The irony, of course, is that the more successful the movement is in converting traditional public and pro- fessional attitudes toward abortion, the easier will it be for women to avoid confronting the "hard moral choices" and seek only those professional 172 or agency groups who will give the abortion service with no questions asked. For this reason, the more sophisticated counselor tends to take a fatalistic view with regard to maintaining the Service after legaliza- tion. He is more apt to see both the Service as a stop-gap measure, and the counseling role as an information-giving function. For instance, three - year men emphasize clergy withdrawal and take over of the counseling and referral function by family planning services and physicians after legal change. Fourth, most clergy counselors perform the broker role for strangers, who may or may not be "believers." This strongly contrasts with traditional pastoral contacts,with clients typically imbedded in a network of church and community relationships. Again, unlike the more familiar pastoral relationships, problem pregnancy counseling is a one—time encounter with success or failure dependent on the counselor quickly appraising the woman and her situation, and thence guiding her skillfully, and preferably, quickly, through the options. Success implies that the woman comes to a decision, appears to be convinced that this is the right choice, and moves along through the network without difficulty. Failure is more problematic to define, but it typically involves negative feedback from physicians, agencies, or abortion facilities by way of reports regarding the unsuitability of this client/patient for abortion. This could mean the clergyman was too hasty, perhaps unaware of the client's circumstances, or ignored signs of ambivalence, conflict, or less frequently, severe disorientation. In developing psychological skills of "awareness," "sensitivity," or "understanding," the clergyman learns appropriate signs and symbols that alert him to 173 possible areas of concern. (One counselor expressed this as: "I've become more alert to hidden meanings in verbal and body signals.") And in clarifying his own feelings regarding abortion, women, sex, and alternative values and life styles, he is more able to cope with the range of client-strangers he sees without unduly disrupting other commitments and roles. Experiential growth, then, may be as much an outcome of cost-reduction strategies as it is intrinsic gains of participation. If an enhanced psychological state was a crucial pay-off for many counselors, what were costs of participation, expressed as conflicts or negative reactions? Moral dilemmas, "feelings of being used," disrupted commitments in other areas, and resentment over time required for this activity are some penalties incurred. For 41 of the 60 respondents, personal conflict disrupted moral, family, pastoral, professional or community commitments. Time binds, especially, with or without other conflicts, affected many counselors (23). Some question if they are not even promoting "irresponsibility" among women whose motives for terminating a pregnancy are often interpreted as inappro- priate and unjustified. This may be expressed as, "the easier it (i.e. abortion) becomes, the more trouble I have." Referring the very young, the "promiscuous" girl, or the "late" pregnancy for abortion creates tension, and arouses renewed anxiety regarding the ethics of abortion. A few even fear the future career may be in jeopardy once the "myth” of their "abortion mill" activities is known. Dissonance may be especially sharp for the counselor whose own baby is born during his high commitment period (1 respondent),or who finds it difficult to 174 counsel abortion while his own wife "desperately wanted to become pregnant" (1 respondent). That conflict is more likely to be related to particular moral or professional conceptions of the self rather than to concrete social reactions seems apparent for this group. While 38 counselors have experienced negative reactions from their congregations (11), board (2) enforcement agents (2) community (12) and/or other persons and groups (14), such reactions are not necessarily linked to personal conflicts. For 18 counselors who indicated unfavorable church or public responses to their conduct, there was no indication of personal conflict. Twenty men experienced both conflict and negative reactions. These reactions rarely threatened the clergyman's job. For most, it was the threat that ”something couldgo wrong" that induced anxiety. The way in which the counselor resolves or fails to resolve internalized conflict, depends on his own coping ability, and/or his willingness to live with ambivalence or negative public reactions. While some simply "learn to live with it," others adapt by developing schedule priorities, sharing problems with colleagues, reading in the area of abortion and sexuality, or dealing with concrete conflict situations as they arise. Some (16) have never resolved the moral dilemmas. Others manage the strain by viewing ambivalence as a way of achieving personal or professional development (7). Or they come to regard stress as an aid, if not an essential condition,for spiritual development. One counselor who was unable to clarify the ethical issue and time pressure resigned from the service. Still another sought therapy. 175 Overall, most counselors adapted to the situation. Modifications in the counseling role itself (expressed by 42 respondents) were primary strategies used to reduce costs. Counselors learned to be non- judgmental, non-directive, or emphathetic with the woman. This removed the burden of personal responsiblity for the abortion choice. Or, interaction time with each counselee may be reduced, becoming rationalized as an outcome of “improved counseling techniques." Some simply cut the number of problem pregnancy clients they see during any one time period. This permits the counselor to maintain all of his commitments, without severe dislocation incurred by preoccupation with this more problematic one. Still other counselors enact stylistic role changes, as in group counseling or involving other interested parties (e.g. parents and boyfriend). This enables a more intensive exploration of the woman's problem, while at the same time, reduces possibility of mistakes in personal judgment regarding the woman's circumstances. More recently, counselors "fann out" routine cases to agency or lay persons, 'if available, and take only more “difficult" assignments-—clients with moral, religious, or sexual problems that the counselor feels are challenging or fit his area of expertise. Frequent contacts with Service colleagues is another channel for expressing doubts, getting support,or talking over common problems. Only clergymen in more isolated geographical areas fail to take advantage of this opportunity for "shop talk“ and discussion of "exceptional" or even typical encounters. Because most men do not feel free to communicate counseling problems with local friends or associates, colleague involvement is considered essential for 176 re-stimulating interest and concern, and learning new ideas or techniques. For 49 of the 60 respondents, discussing counseling problems with Service colleagues once a month or more allows airing of tensions and working out new approaches to problems. Counseling clergymen, as a whole, operate in a four-dimensional world with a shifting role focus depending on which situation is salient. As counselor, the clergyman has two foci: psychological sensitivity and social resource person. In this capacity he must relate both to clients' needs, and to the variety of social services these needs demand. As organizational man in a new health delivery system, his concerns are pragmatic. Questions revolve on routing mechanisms, time scheduling, availability and costs of services, transportation problems, and other financial and logistic arrangements. As minister, he orients himself to community service and pastoral care of his own congregation. This set of concerns must somehow be linked to his counseling commitment, an often difficult task if local influentials or church persons view abortion as a suspect moral area. And, as professional, he is concerned with the style, techniques and organization of the counseling role itself. Professional mistakes can be costly. For example, an irate husband or parent who hears of the abortion decision after the fact may report him to his denominational supervisor or church board. Or he may suffer reduced esteem among other counselors or staff persons who hear of shortcomings as in inappropriate remarks regarding abortion, or the woman's sexual patterns, or failure to give concrete routing details. 177 Lack of fit between abortion counseling and the ministerial role is a persistent problem for many counselors. The scope of the minister's world lacks a clear definition, perhaps for many clergy- wen, generally. If spiritual responsibility includes all varieties of social "trouble" with no person or place boundaries, the clergyman is free to move into new spheres and develop non—traditional ideologies (e.g. the feminist ethic). This is a more commm15ituation among campus ministers who lack a clear mandate for service in the first place.]] But if the pastor's role is traditionally conceived as ministering, first, to his immediate congregation, second to the local community, and only after these, to the larger community of private troubles and social problems, there is little room left for new or socially-problematic commitments. For the counselor with a negative congregation and community, whose primary role focus is the traditional ministerial service function, costs of participation frequently outweigh gains. While he may rationalize his new "awareness” and social knowledge accruing from the role as beneficial for other professional activities, he is far more likely to hedge on making a full commitment, and instead, limit both number and type of clientele he sees to fit his conception of appropriate obligations. Counseling and the Client Whatever personal convictions the individual counselor has regarding abortion as a morally justifiable choice, there is strong collective belief in the importance and efficacy of counseling. Pre- abortion contact is viewed as particularly crucial whether related to 178 psychology and structure of the abortion choice, or because "no other organization is effectively meeting the demand.” Post-abortion counseling, by contrast, is seen as less urgent, although this senti- ment is frequently associated with counselors' experience of client withdrawal once abortion is over. Follow-up care, regardless of the counselor's personal inclination, is not a standard procedure for most abortion patients. “leaving the scene," and "forgetting the event'l are said to reduce the woman's dissonance, even if conditions that generated the problem pregnancy remain ignored. How clergy evaluate pre-and- post abortion couselling is summarized in Table 7. TABLE 7.-—Counselor Evaluation of Abortion Counseling Pre-Abortion Post-Abortion n= 0 t of total* 5:60———_§Ttfi?7ifi§fr Very Important 36 60 15 25 Important 13 22 15 25 Not Important 1 2 12 20 Optional 10 17 16 27 Undecided O 0 2 3 *Percentages are rounded Declining interest in post—abortion counseling is apparent in respondents' increased choice of "not important" and "optional“ (depends on client) categories. Part of this decline reflects changing conceptions of the client's need-—with different services provided before and after abortion. Before abortion, the counselor supports the woman in making a decision by assessing her moral and psychological 179 situation, and providing information-~medical, travel, costs, and so on. After abortion, immediate moral and psychological needs of the client are less salient with more attention given to the woman's social situation (e.g. return to school, take a job) and even life plan. For some, post abortion contact is a crucial opportunity for client feedback, enabling counsellors to evaluate the quality of services or special difficulties encountered in the routing system. Twelve counsellors see no need for post-abortion counseling because of client resistance or the counselor's belief in lack of utility for either client or counsellor. We indicate variations in the reasons for pre- and post—abortion counseling in Table 8. TABLE 8. Reasons for Abortion Counseling Reasons for Pre-abortion Post-Abortion Counseling n=60* "% of total** 5:60-__—%_6f't6t3T Psychological 58 97 38 63 Moral Client 9 15 5 8 Social Needs 2 3 5 8 Information 18 3O 4 7 Counsellor Information 2 3 10 16 No need 1 2 12 20 Other 2 3 2 3 *Multiple Responses **Percentages are rounded 180 How the clergyman views the client indicates the importance he places on the counseling experience. A psychological rhetoric often explains both client need and provides a rationale for service. Most counselors find that client stress is a typical reaction bgfgrg the abortion choice. How pervasive this psychological stress is believed to be varies with the individual counselor. Half the respondents hold to a "crisis client" conception, or view clients as having "trouble,“ "guilt," “inability to cope,“ "extreme moral or sexual problems, and ”irrationality" as generic conditions of abortion seekers. This conception of the client both rationalizes the counsellor's commitment and is associated with a strong emphasis on psychologizing the woman's experience (e.g. ”I am concerned with people under stress, or ”I want to help those who are struggling with problems created by pregnancy.”) By contrast, counsellors who "nonnalize" the client, or see her as simply inexperienced and lacking necessary information to negotiate the situation, are unlikely to hold this view. The following table shows the incidence of these two client conceptions (as crisis or non-crisis) in terms of expressed importance of the role. We use post-abortion counseling as a more adequate indicator of the counsellor's general view of the client. As already suggested, clergy hold pre-abortion counseling to be uniformly essential (or necessary, depending on the client) because of situational stress and/or information requirements. 181 TABLE 9.--C1ergy Perception of Client by Expressed Importance of Post- Abortion Counseling Importance of Crisis Client Non-Crisis of Conce tion Client Conce tion Counseling n=55* % of total** n=55 % of total Very Important or Important 18 33 ll 20 Not Important 4 7 7 l3 Optional 7 l3 8 15 *Five responses were not coded, either because of contradictory state- ments regarding the client, or the respondent was "undecided“ about the importance of post-abortion counseling. **Percentages are rounded What the protocols suggest, on the one hand, is that where an association is feund between a crisis client conception and emphasis on counseling, the counselor is more likely to view the abortion situation as "traumatic," or one in which guilt, remorse, depression, or negative feelings persist, perhaps long after the event. On the other hand, counsellors who normalize the woman and her situation, while also expressing need for post-abortion counseling recognize either that follow-up is for the counsellor's benefit ("I want to check on the quality of services"), or that women need an opportunity to "verbalize their joy," or "confirm the decision" as a sound one. V An association between a crisis client conception and post— abortion counseling as got important suggests two considerations. One, already mentioned is the fatalistic belief that, although women need counseling, there is little motivation to re—activate the abortion ”distress." Another is the counselor's belief that the woman is 182 reluctant to explore "psychic“ problems related to her emotional and sexual relationships which "caused“ the problem pregnancy. For those who define abortion clients as anxious and abortion as traumatic or "like an illness“ (a view, we believe, more universally held by problem pregnancy counsellors and agency professionals, than this group indicates), post-abortion counseling serves a number of functions. Primarily, it clarifies personal identity and moral values associated with sexuality, contraception, pregnancy, and abortion. Here the counsellor “weeds out problems," "picks up faulty attitudes,“ and works through consequences of the act for the future self—concept. Abortion, in this sense, is held to have long term, possibly a pro- foundly disruptive, influence on the personality and future adjustment. For the ambivalent or confused client, counseling also permits catharsis, a release from fear and guilt in a confessional-type relationship, enabling the woman to gain insight into herself and her problem. Finally, counselling permits exploration of the "re—entry" process--a redirecting of "life purpose" and ”human potential"--that goes beyond the immediate conflict situation. In this view, abortion is seen as possibly the most significant choice a woman will ever make. By linking theeventto a larger set of existential concerns, the woman is able to establish a new identity, and "new roads for the self to travel." The "optionals" among this group (15), whether holding to a crisis client conception or not, are most likely to take the position that counseling is "supportive referral,“ and should be available, if the woman wants it. In recognizing the present lack of an available M 183 support system, clergy counseling is a "bandaid" remedy until structural changes facilitate professional take-over of this role. "Humanizing" the experience requires that the woman have access to warm, consoling and confirming persons. Deeply therapeutic counseling is rarely called for, if not rejected as a counseling mode for the abortion client. Optionals, similar to those who see little or no need for post—abortion counseling, are also more likely to believe that client stress, where present, results from situational contingencies, which disappear once the abortion is over. For a few counsellors, the woman's silence or lack of expressed need becomes a sign of her "deep underlying guilt." For others, the same situation indicates her "great relief," that the ordeal is over with no traumatic aftermath. There is, then, no clear consensus on the meanings of abortion, of the abortion client, or of the counseling role in ministering to this clientele. Despite strong organizational measures to create a universe of discourse in this area (as in mail-outs, training sessions, and informal contacts), clergy counsellors bring into the counseling situation a variety of therapy ideologies. Some of these are inherited from traditional Christian ethics. Others are generated from personal experiences with wives, lovers, friends, or former counsellees. Still others are borrowed from the literature of psychoanalysis or existen- tial psychology. Nor is there an organizational mechanism to separate those healthy counsellees who fail to return because of lack of need from those anxious women with unresolved guilt. In the absence of this information, counsellors make their own assumptions regarding the 184 woman's condition and ways to cope with it, less on the basis of empirical evidence, than on personal beliefs and feelings regarding the abortion event. Role Commitment We have emphasized that clergy brokers perform abortion counseling as a voluntary activity. Cousellors receive no extrinsic rewards such as cash, job promotions, social honors, or enhanced power. There is, of course, enhanced esteem among Service colleagues or social problems- oriented clergymen, but it typically does not extend beyond these domains. Many discover that the work is difficult, the clientele are too demanding, the time taken from home and professional life is disruptive, and the repetitive format is uninteresting and fatiguing. Moreover, the ethical issues generate stress which few outsiders can know or appreciate. Overall, the immediate professional investment is great, while the rewards are often in the long run, and even then, frequently too personal to be translated into professional gains. How, then, does the commitment process operate for these volunteers? How does this part-time obligation to serve a stranger- clientele fit with other dimensions, as in demographic characteristics, social values and definitions--role, service, and agency-professional participation. To explore these questions we used time spent in abortion counseling and related reform activities as an indicator of the commitment process. We then attempted to relate cumulative time scores for each counselor with other items specifying social location and 185 attitudinal responses to discern what differences, if any, could be identified for this group. Figure 9 lays out the respondents time record by number of hours spent per month on abortion related activities (counseling, speaking, petition drive, writing, organizational work, etc.). The graph shows differential patterns of participation by total monthly hours spent on all abortion-related activities. One pattern indicates a relatively high commitment for 12 clergymen, ranging from 40 to 100 hours a month, with 6 working 60 or more hours. Five respondents average 76 hours a month, with one counsellor working 100 hours or more. Another six with high commitment were involved from 40-59 hours monthly with an average of 48 hours. Moderate commitment for 30 respondents entailed a work load of 10 to 39 hours a month, averaging 20 hours. Those with low commitment (15 counsellors) spent less than one hour to 9 hours monthly. Two of these work less than one hour per month, or have fewer than one counselee in the same time period. The remaining 13 average 5 hours monthly. What differentiates clergymen with high commitment from those with low commitment? What demographic or social factors could account for relatively wide variations between these two identified groups? Demographically, the high commitment group look different than the low one, and also diverge in many respects from those with moderate conmitment. For instance, the 40 hour or more counsellor is far more inclined to spend one-quarter to one half of this time on abortion reform or related activities which involVed all 12 counselors. counselor now spends almost all of his 84 hours in this area on 186 High (n=12) Moderate (n=30) Low (n=15) Commitment 14 7 14 12 Number 10 of 8 clergymen 6 4 2 l 2 3 4 5 6 7 lOO-80 79-60 59-40 39-20 19-10 9-5 4-0 Number of Hours Mean = 23.66 median = 20 mode = 20 range = O-lOO *n = 57; 3 respondents provided no clear indication of hours spent, e.g. "as needed" or “on request." Figure 9.--Cumulative Number of Hours per Month on All Abortion- Related Activities* 187 abortion/related women's activities--teaching, counseling, or training lay groups. Another two high commitment counselors are organizational men, who counsel, administer, write or speak in this area as an almost full—time career. Most are older, established ministers with all but three in the ministry 14 years or more. Five are campus ministers devoting almost full-time to counseling as a profession. Three are from parishes or campus ministries with five or more clergymen. Two-thirds of the group are Methodists, the other 1/3 are from liberal denominations (e.g. Unitarian and Congregational). Full-time pastors among this group are most likely to serve large congregations (600 or more) with or without assistant ministers. Nine or 3/4 of the group are from urban or suburban centers. All but three have been in the Service three years or more. Two are early organizers of the movement. Motives for participating typically indicate a movement or crusaders' orientation (9 respondents) related to strong reform or social problem concerns--abortion, women, youth, sexuality, legal change, etc. Some complain that the problem pregnancy counseling commitment overly restricts other concerns such as draft counseling, university consultant in sex or youth issues, or organizational work in the denomination. Sustaining the commitment involves either belief that “no other organization is serving the need" (8), and/or enhancement of the professional role (all) as pastors, consultants, "social resource" persons, or campus ministers. 188 Accessibility to clientele seems to be a dominant aspect of the commitment. This entails a "demand" schedule, or a campus career ministry in which counseling is “a way of life.” Operating in urban centers, they are also more exposed to a larger population of women seeking help, than small community-based counsellors. As strong movement-oriented counsellors, they are far more inclined than the larger group to express disillusionment regarding drain on time and energies or lack of appreciation by clients, or to be frustrated with inadequacies in organization or routing. Shortcomings, however, are not necessarily viewed as a conflict situation (only 4 stated persistent conflicts in the role), so much as a belief that changes in role or organization have not always been beneficial ones. Increased bureaucratization or “secularization" within the service with a subsequent decline in counselor commitment is seen as inevitable, but, nonetheless, disconcerting. Exploitation by public and by clientele (expressed by three counselors) implies that personal efforts are often neither recognized nor rewarded by those persons they serve. One counselor with a strong professional commitment thinks that the public would be more appreciative if they had to pay for services. A plea for a fee-for-service was stated in this way: I believe there should be a way for counsellors to collect pay for their time. This would be great. I get tired of being exploited as a do-gooder. Despite inadequacies, most of which are recognized as outcomes of the movement's success, many counselors assert that the upgraded, more centralized organization facilitates the counseling task. More equity in the distribution of work because of an increase in the number 189 of counsellors, and more vigorous activity in legal reform are major conditions making for an improved organization. With high client contact for this group, three changes in the counseling role have occurred. One is a shift in organization, as for example, group counselling sessions. Another is an altered style. This may involve less probing of the counselee's "real motives" and more emphasis on routing or local resource information. Finally, there is increased professionalism which entails upgrading of skills, more vigorous attempts to follow-up patients for checking on quality of service or understanding the experience from the woman's perspective; even asking clients to keep diaries to share with other women. Those with high commitment are somewhat less likely than the larger group to view the client as a crisis patient (41 percent versus 50 percent), often taking the position that stress is situational, and alleviated by abortion. Not all clergyment with high commitment have resolved the moral dilemmas, which may be particularly acute in tenns of the total contact time with abortion clients. One three—year participant, who is also a campus minister,sought therapy as a way to resolve his "personal guilt feelings." For most, it is apparently the ability to professionalize the role,which includes the weighing of alternatives--no choice for women versus options presented by skilled and dedicated counsellors. Most of this group aim to maintain a "visible" service through an open-door counseling policy, but theirs is not necessarily a one- issue concern. Instead, abortion is related to broader social problems, as in medical care, sex education,or women's rights. And in placing abortion within a larger social context, there is greater willingness to 190 endure the heavy professional investment as part of a larger set of commitments. This entails viewing the role, for example, as the "cutting edge of the contemporary ministry. or facilitating economic and legal change (e.g. consumer advocacy, serving the poor, law reform). Among those with low commitment, there is a different demographic picture. For 15 respondents who spend less than one hour to nine hours monthly, only three are involved in abortion reform or related activities, and this only in a peripheral way (1—2 hours monthly). Demographic features, generally, encourage low commitment. For example, four respondents are ministers in conservative or fundamentalist denominations (e.g. Lutheran, Disciples of Christ, Seventh Day Adventist), some of which are opposed to abortion on moral grounds. Six are from small or very small congregations (lOO-3OO members) with 10 of the 15 from rural or small town communities (1,000 - 8,000). This includes three from the low population area of Michigan's Upper Peninsula. All but two are from one-pastor parishes. Only one is a part-time campus minister. Almost half of the group have been in the ministry under nine years; most (11) have been in thecounselingService one year or less. Motives for entering the Service are most likely to be experi- ential or psychological with such rationales as a desire for "greater awareness," “knowledge,“ “to be more infonned," ”compassionate," and so on. Rolesatisfaction, where indicated, tends to revolve around personal gratification of the counselor, rather than professional or client-influenced experiences. This may be expressed as "counseling allows me to get outside my parish into the real world," or "I am more reality-oriented since this experience.“ Role changes are far less frequent than for those with high commitment, and are almost exclusively 191 confined to different ways of relating to clientele, as in increased tolerance or understanding of the woman's plight. Four indicate that they receive few, and more recently, no referrals. This could be attributed to some of the following: (1) relative geographical isolation of some counsellors, (2) greater possibility of community or congregational surveillance in the small town setting, (3) general lack of availability associated with intensive congregational demands on the pastor's time, or even (4) a decreased problem pregnancy population with greater availability of other services, orgreaterpatient sophistication in negotiating the system alone. (E.g., one counselor said, "Where are all the problem pregnancies? Aren't women getting pregnant anymore?”). Personal ambivalence regarding the abortion choice may also constrain many in this group (8 respondents). Abortion may be regarded as "immoral," but probably a lesser evil than "bringing an unwanted child into the world," or forcing women to experience the "destructive curse of the bootleg abortionist." Even when the counsellor has justified the act to himself, he may perceive negativism or harrassment from the congregation (3). For those who counsel five clients or more a month, there is both more acceptance of the act, and recognition of professional gains. Some, apparently, have little or no counseling experience outside of their immediate pastoral requirements. For these clergymen, counseling provides a feeling of “being useful and needed which is important to me." 192 Rejection of commercialism in present abortion arrangements created strong misgivings for one two-year participant, part-time campus minister and pastor of a large congregation (1,000 members). In a final comment in the protocol, he noted: I have only one area of feeling not already discussed. My calculations lead me to conclude that 800 women a week use Women's Service (New York Clinic). That's 40,000 patients per year at $125 (per patient). The estimated income of Women's Service is Five Million Bucks Per Year! I'm not getting it, and Michigan Clergy is not getting it. So who is? I personally do not feel we are making money off of people's misery, but I cannot refute the argument that we are involved in a profit-making enterprise. I once wrote to New York asking this question and requested a financial statement. I got no reply--that fact didn't exactly build my confidence in “the system." I do not participate in institutions or agencies that practice fiscal secrecy--except my tie to New York. I make this exception because I believe in what we're doing and I want to be able to minister to people in trouble. But I don't have to like the feeling of being used. In this case, movement ideology clashes with an anti-profit ethic to weaken commitment and even to undenmine organizational goals. For example, this counsellor rarely mentions the option of financial contributions to clients. Soliciting funds, though required for main- taining a viable organization, is seen as unethical and inappropriate. Low commitment may also be related to strong objections regarding “abortion for convenience.“ This conflicts with belief that abortion counseling is of vital importance because of client "anxiety," "tension," 'self-doubt, and probable “future hang-ups.“ The low commitment group, regardless of relatively few hours devoted to counseling as compared with others; are more inclined to view counseling “an absolute necessity" or "extremely important," especially for post-abortion clients (L.C.=75%, M.C.=50%, H.C.=4l%). 193 Those defining clients as stressful and abortion as traumatic often have strong morality or religious concerns. For example, a low commit— ment counselor expressed need for a denominational statement of “theological rationale" to clarify his moral ambiguity. Another posited client crisis as one primarily of "spiritual-moral dilemmas." For one counsellor, the "atmosphere of religious (denomination) prejudices” of ministers, unlike agency professionals, is believed to bias counseling. Agencies, he said should take over most problem-pregnancy clientele, leaving the ”confused and afraid" with morality problems to clergy. Certain concerns are not exclusively limited to low commitment clergymen, of course. Moderates and even those with high commitment face dilemmas, unfavorable reactions, and personal conflicts. Counselors rationalize moral ambivalence by emphasizing how significant counseling is in supporting a crisis clientele. Only a few also admit counseling has taught them the folly of client stereotyping for what is, in actuality, a highly diverse population. In this view, the client is nonnal; it is the situation that is abnonmal. Alter the situation (legalization in this case), and you alter the stereotypical reactions. Even more, if the counsellor changes flj§_conception of the event (or abortion as traumatic), the client, who takes her cues from the counsellor, is far less likely to express stress or disorientation. Instead, she considers the situation in pragmatic or medical terms, rather than moral or religious ones. The fact that client-counselor interaction is a negotiated situation is recognized by more sophisticated counsellors. With 194 extensive experience, the counselor becomes more open, more susceptible to client influence, and more inclined to take the woman's point of view even when this clashes with denominational, congregational, or local community sentiment. It is precisely this feature of counselor openness or sensi- tivity to clients that is lacking among some with low commitment. In turn, this is related to the relatively limited counseling and/or contact with persons outside of the pastoral or local scene. Limited social participation extends into two areas relevant to the counseling role: ppmpgp and typ§_of contacts with Service colleagues and professionals or agencies. These circumstances both reflect and, in some cases, reinforce the relative social isolation of this low - commitment group. For instance, contacts with Service colleagues reveal, not only a lower incidence of participation for the low commitment group than others (L.C. - 73.%, M.C. = 85%, H.C. = 83%), but different reasons for contact. They are far more inclined to seek information regarding referral procedures, or to see many of their cases as "extraordinary client situations," than are moderate-or high-commitment counsellors. More experienced or high-commitment counsellors with frequent colleague contact seek fewer reasons for exchange or use the opportunity for "shop talk." By contrast low-commitment counsellors seek information or support for a variety of reasons--extraordinary or typical client situations, procedures, moral or organizational issues, and psychological problems in dealing with clientele. 195 Agency—professional contacts over the course of the counseling career also show a more limited association pattern. Differences between commitment patterns include number and type of professional associations, reasons for contact, and different monthly contact rates. Table 10 summarizes variations in mean number of contacts for commitment patterns over three career phases; before movement participation, the first few months of counseling,and present patterns of association.12 What are different association patterns over the counseling career for these three groups? First, before movement participation, clergymen with high commitment actually have fewer agency-professional contacts than do moderates, although together they average between 3-4 contacts. The relatively high proportion of campus ministers among the high comnitment group (42%) may contribute to this lower contact pattern. Universities and colleges are most likely to have a full range of services accessible to students. This reduces the counsellors, need to personally negotiate this system. Before participation, the high commitment group have been involved in community, denominational, or movement activities--consul- tation or board work for family planning groups, denominational "action groups," or civil rights and draft resistance movements. A few were active in other states. For example, one was instrumental in setting up an abortion clinic in Indiana; another previously served on the Clergy Consultation Board in California. Low-commitment clergymen, by contrast, with less than two service or professional groups they regularly contacted,have about M m.m m.~ Am_n:v 196 N.m m.~ AmFucv a.~ m._ A_Fu5v o.m m.o Aamncv m.m m.m AmNHCV _.m m.m Amwucv m.m Amucv o.m _.s Awucv m.m o.m Anucv coco: cw; mpumpcoo xocmm<\moga mo consaz cam: umpomwcoo mmwucwm<\$oga mo Lmn232 cam: ameucv :owmmmwprLma pcwmmga space can mpumpcou zocmm<\$oem mo Lonasz com: umpuwucoo mowocmm<\wocm to smassz cam: «wwncv :owuwawuwpgmm we mzpcoz 3mm pmgwu coco: Lea muowpcoo aocmm<\wosa to Longsz cam: umpumucoo mmwocmm<\woem we ewnszz cum: Aowncv :o_uw _orpgom mgowwm pamEpwEEoo 304 acmEquEoo wuwgovoz “caspwssoo emu: :orumgwuwpeum ucmmogm ecu .covpmawowpemm to mgucoz zen “mew; .cowwmaw0wpsmm mcommm "muowgma meek emcee Low mpompcoo _mcowmmmmosa\a6cwm< to gmnszz cam: new mesmupwa acmEuTEEoouu.o_ ubm Mutual Influence + (plus) Gains or costs of exchange (potential or actual) - (minus) Pre-existing linkages Figure lO.--The Isolated Cell Type: Variant One 203 + Student -—--——-‘*~*——€> Clergyman - Clients 6 A} f? \ \\ \ \ \ \ \ \ \ \\ \“ \ ‘ - \ — \ X \ \ ‘ \ \ \ | \ \ \ \ \ "runner" \ ‘\ . “ \ \ \\ \ \ Lg * \ [Abortionist l H Abortionist 2 I University Community ' Services Groups Code: —______9 ——————> <_____________ + (MUS) - (minus) Direction of communication Mutual influence m Pre-existing linkages Indirect linkages Figure ll.--The Isolated Cell Type: Variant Two Gains or costs of exchange (potential or actual) 204 Among these were groups and persons opposed to both abortion counseling and legal reform. On the other, cells tended to vary on a number of dimensions. These included: differences in community alliances and law enforcement practices, varying degrees of professionalism and counseling skill, strength of individual commitment, and extent of actual counseling practice. In addition, denominational loyalties differentiated one clergyman from another. In some cases, resistance to abortion reform by denominational leaders generated conflicting pressures for participants. These conditions kept cells localized and fragmentalized. In this way, alignment between cells on movement ideology and practice was offset by opposition between cells (or members within the cell) because of differences in local identifica- tions and opposed interests. Figure 12 plots the "social system" of the Clergy Counseling Service in the model of structural oppostion or cylces of division and cohesion within the movement. For the most part, cells were more characterized by variation, especially in the earliest developmental stages, than by homogeneity. The segmental structure fostered different cell types to fit local circumstances. Three major variants may be noted. Atomistic cell type: Clergymen, isolated geographically or socially, tended to meet local parish and town demand for counseling services by extending pastoral duties to include this extra counseling load. The personal network, whether few or many linkages, was drawn from local groups who provide professional backup. This limited influence to the few immediate support persons and clientele and their families. The cell operated as a single unit unconnected to either other 205 Clergy Community Tri- Lansing Kalamazoo Grand Other Anti-Abirtion County Rapids Cells Groups Phase 1: Disunity of local cells. Cells were localized and fragmentalized. Movement functions loosely unite members of a cell, but identity with the movement as a whole was weak. Primary alliances in this phase were with parishioners, clients, and professional and community support groups. Phase 2: Cohesion of movement cells through resistance to anti-abortion forces, both local and state-wide. Primary allegiance, in this situation, was to the movement. Phase 3: Conflict of movement participants between community, denomina- tional and movement identifications. This created cross- pressure leading to a weakening of movement solidarity. Split allegiances reduced movement effectiveness in the larger society. Figure 12.--"Social System" of the Clergy Counseling Service 206 movement cells or to state abortion reform groups. Geographical isolation, especially, limited alignments to local membership and professional groups. Mailings and telephone contact with the central cell, "clearing house" provided information and minimum assistance. Fear of alienating local support and dependence on local resources made for unbalanced reciprocity in transactions between counselors and outside groups. Unidimensional cell type: Cell activity among participants was limited to a single purpose activity, i.e. counseling and referral. A few individuals within the cell occasionally were involved in speaking engagements to community groups or other reform activities, but there was no systematic division of labor to increase movement influence. The single-stranded net (i.e. single purpose) was loosely knit, with commitment primarily to clientele with the pastoral mission extended to include non—parishioners. Local loyalties played a more significant role than identification with movement ideology or practice. Each counselor maintained his own list of referral physicians and social service agencies. While this created high redundancy, or duplication of efforts, it also served to widen total number of community groups contacted for support. Extramovement linkages and alliances resulted largely in one-directional flows of energy, assistance, influence and decision-making from the cell to outside groups. This "influence flow" was asymmetrical and favored community groups who shifted the burden of responsibility to individual clergymen. Costs for counselors included ovenwork, shortcutting other activities, reduction of time spent with family or on leisure, and expressed frustration. This 207 lowered morale, and fostered high turnover or reduction of counselee load. The loosely-knit cell was also more vulnerable to outside attacks. For example, a clergyman prosecuted for ostensibly sending a client to an illegal, and non-medical source, was virtually cut—off from member support. In violating the Covenant, or written agreement forbidding in-state illegal sources, he exposed all members to legal jeopardy. Combination of a high risk situation and relatively fragile bonding between participants required a higher measure of conformity to movement norms if mutual assistance was to be maintained. Multi-dimensional cell type: For a few favorably located movement cells, established in select niches (e.g. university community or cities with crusading reform groups), movement activities took multiple forms. In these settings, abortion counseling and referral was an added element bonding participants linked by shared religious, professional, ideological and friendship activities. As autonomous professional persons, each movement participant had his own special area of expertise, yet he could also "fill-in" in a colleague's absence. Non-parish clergy were particularly free to innovate. The personal network was expanded to include contacts with a variety of non-movement professionals as in church, school, agency, medical, legal and reform groups. This permitted maximum influence in key establishment or reform centers with wife, protege, or new participant also enlisted to assume administrative roles freeing the organizer for other operations. This cell-type sponsored the highest number of militant, action-oriented, and administrative activities. Cell leadership was 208 a revolving one, with power largely shared among equals. High autonomy of the unit allowed for rapid change in form and function to meet local conditions. For example, one of the larger cells was phased out-of-business altogether. Effective coalition building among local service agencies and women's groups generated a community structure that could stand alone. A type of balanced reciprocity emerged in exchanges between this cell-type and outside groups. Strong support from family planning projects and other agencies and professional groups allowed for more equitable distribution of the counselee load. In this situation, movement participants were most likely to view the movement as a "progressive" and "legitimating" influence. Members tied into this multi-stranded (or multi—purpose) unit were the most successful in maximizing individual and professional goals, while extending movement ideology and practice into a variety of social spheres. Figure 13 summarizes the three identified cell types in the segmentary network. Imperfect Bureaucracy (approximately September 1970-Present). Phase 1: Lack of unity because of local autonomy and cell fragmentation persisted, but a super cell assumed some centralizing tasks. Chief among these was coalition-building on the state level. The modified hierarchy (board, paid director, and state coordinator) became spokesmen for the movement as a whole. Extra-movement linkages and alliances established viable relations with established and reform groups, enabling the movement to negotiate advantageously. 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Boundaries, or social divisions, between “believers, supporters, and participants have been greatly blurred by introducing lay and professional agency persons into the counseling role. ”Fellow—travelers? of both sexes from a variety of occupational groups,rallied to the movement‘s defense against anti-abortion forces. In this way, the extended network may be said to be "unbounded", or one that ramified throughout society. Figure l4 maps the structure of interlinkages between the Clergy Service and other stateand national reform groups at the high point of this organizational phase. Phase 2: A citizen-drive to bypass the stalemated legislature by putting abortion reform on a proposed referendum upstaged the clergy movement. Impetus for reform shifted to political action groups dominated by physicians, legislators, and volunteer women. For sometime, there has been evidence of a slow-down and gradual contraction of movement influence. For instance, during the last few months, (Nov.- Dec., l972) clientele contributions have steadily decreased, a perpetual deficit exists in the state board budget, and movement leaders talk of ”phasing out" after legalization. In triggering abortion refonn, the movement served an essential stop-gap function in providing partial abortion services and alerting citizens to this social need. Final discharging of the mission is being carried through by other state and national political forces. 2ll J: National \ Clergy Federal Consultation -———--———-——-—————9 Courts Service ’5 \ \ \ \ f‘”‘—T\fi / State \ ,I State Reform ‘ ” Reform Courts Organiza- Movement ‘ ----------------- ‘§ Physicians tions 1 --------- . N %_ _ _|.. l r I r 7 I I, ’I’ 'I k! I ’I } State Public ' Health Abortion Planning Groups I I I, ; Reform Legisla- , tion I I I ~ a. ‘~ ‘~ ~ -‘ Women's Lib. Abor- tion Groups (----' Code: State Family '.Planning Projects -------- Mutual Aid Direction of Communication Indirect Linkages Only *National Association for Repeal of Abortion Laws (N.Y.C.) Mutual Membership Groups and Other State and National Reform Groups Figure l4.--Type of Interlinkages Between the Clergy Counseling Service 212 Movement decay may also be an inevitable outcome of the recent Supreme Court decision to legalize abortion. From the New York experience, agency and physician mobilization of resources has led to movement withdrawal from that scene. Among these respondents, there is little indication they are willing to turn to "power strategies," in Morrison's term,18 to coerce changes in client management by private and public sectors. Clinic management, a future role suggested by some respondents (l0),is likely to entail strong conflict with entrenced commercial and professional interests, who may find clergy involvement to be intrusive, if not threatening. Participation strategies (educating and urging people voluntarily tOInakechange), expressed by most respondents as a future role, entails a view of the movement as a continuation of past efforts-- education, training, advisory, counseling and referral activities. These strategies succeeded in the broker phase because movement activities resulted in reduced costs to professional groups,who, heretofore, have rejected taking primary responsibility for this clientele. Participation orientation, moreover, had its most fruitful expression in Michigan Public Health Guidelines specifying counseling and referral require- ments for abortion clinics. In the future, the movement may provide auxiliary support to power—oriented reform groups (e.g. physicians, public health, family planning groups, legislators, feminists) whose strategies aim, less to influence individuals and their families,than to coerce change in both public policy and the distribution system. 213 Conclusions In this two—part chapter, we traced the evolution of the clergy counseling movement from origin, to development, institutionalization, and possible demise. Internal movement factors, in this analysis, were related to extra-movement transactions, and overall impact of the movement on the social environment. The concept of social networks, or links across groups and category limits, clarified these movement changes. Influence between the movement and its public has shifted over time to transform the once clandestine counseling and referral activities to a recognized, legitimate service among most health professionals and a large segment of the public. A transactional model of social movements is useful for process analysis in that: --Structure, or organization of relationships within the movement, is seen as a consequence of social change in the larger environment generated, in part, by the movement itself. --Choices of actions by participants within the movement are depicted as contingent on members' ability to mobilize outside support. Internal movement action is portrayed as a dynamic interplay between the movement and extra-movement factors. --Movement growth reflects participants' on-going involvement in pre-established or recently established groups. There is no "real" institutional division between movement participants and their support groups. This posits that social movements cut across institutional divisions of society and succeed because relationships established in one context are utilized in another. "Non-institutionalized" behavior, a cherished concept of collective behavior theorists, is a redundant category, and offers little conceptual clarity in analyzing change situations. --Entrepreneurial activity, shown in the early phase of the move- ment, 15 one p0551 e organizational outcome of a deprivation situation. The provision of goods and services in an unstruc- tured environment, however, is more adequately explained in 2l4 terms of other facilitating features, a point we made in an earlier chapter. Turner points to ”structural contradictions in the larger society effectively constrgining legal sanctioning of "deviant" behavior or organizations. The deprivation model is, at present, too global and unspecified to be a very useful analytical tool. Instead, deprivation may be considered as part of the rhetorical package used by movement proponents to promote social change. In this case, entrepreneurs used the deprivation thesis to promote new conceptions of abortion, and new distribution patterns in this service. --Broker arran ements, however, were not dependent on either structural contradictionsor deprivation rhetoric. For once the movement made a significant impact in affecting the way abortion was defined and addressed, consequent institutionali- zation transformed ideoloav and practice among professionals and consumers alike. Changing agency practices, consumer routing experiences and public health regulations all show the impact of broker arrangements. We consider these outcomes of the movement in the next three chapters. FO0TNOTES-—CHAPTER V (PART II) For a discussion of this clinic by the medical director of services, see Bernard N. Nathanson, M.D. “Ambulatory Abortion: Experience with 26,000 Cases (July 1, l970, to August 1, l97l) New En land Journal of Medicine 281 (February 24, l972): 403—407. In interviews with New York City hospital administrators. Only one respondent from Grand Rapids is represented out of seven questionnaires mailed out to this area. This center is not an active movement cell. Instead, local arrangements with family planning groups allowed counseling clergymen to phase out. Hammond, 93. £11. Relatively high incidence of no response to some items in this questionnaire may be accounted for as follows: Some men were recently ordained, and lacked any professional/agency contacts; others lived out-of-state, and in some cases, did not indicate pre-movement contacts. Nine reported that the information requested was "too complicated" or the questionnaire "too long," generally. Gradual or total withdrawal from the movement was also related to lack of present contacts for problem-pregnancy cases, and hence "no response" on items related to "present participation." For these reasons data should be considered as suggestive only. What the data may indicate is l) the degree to which many counsellors are integrated into the larger service community, and 2) variations in this integration pattern. The best collection of papers on the network concept and research application is found in: J. Clyde Mitchell, (editor), Social Networks in Urban Situations, New York: Humanities Press, Inc., Distributors, 1969. In one sense, this phase of activity, that of meeting local demand conditions, provides the preconditions for the emergence of a social movement. In Blumer's conception, these changes are part of “cultural drifts“ or the groping, discoordinated efforts that provide the background out of which the movement develops. Blumer holds that, at this stage the movement is unorganized, with neither established leadership nor recognized membership. Individual lines of action based on individual decisions and selections are 215 216 characteristic at this early period. (H. Blumer, Collective Behavior, In A. M. Lee (ed.) Princi les of Sociolo . New York: Barnes and Nobles, 1951, Pp. l67-222). The segmentary structure as a typical mode of organization for many social movements is offered by L. P. Gerlack and V. H. Hine, "Decentralized, Segmentary and Reticulate Organizations in Move- ments of Change . . . ," Journal of the Scientific Study of Religion 7, (Spring 1968) pp. 23— 40. ’The particular network form charac— terizing any one cell tended to change with time, number or kind of participants, and leadership. The segmentary structure typified the movement after it publically surfaced. The structure is thus related to historical phases. How many shifts actually went on within a given cell is unknown. In one large cell, I identified a structure that began with a single member, in time, moving to a uni-dimensional type, and at the high point of counselling and referral (perhaps mid l97l) a multidimensional cell. By September 1972, it had moved back to a unidimensional type. For representative work in this area, see, for example: A. L. Epstein, Politics in an Urban African Communit . Manchester: Manchester University Press, i958; Philip Mayer, Townsmen or Tribesmen: Conservatism and the Process of Ur anization in a South African City. Cape Town: Oxford Univer51ty Press, and P. Mayer, Migrancy and the Study of Africans in Towns.” American Anthropologist 64 (1962): 576-92. The term, lfederated: probably best describes this organizational phase of the movement. According to Zald, the federated organization is more characteristic of voluntary associations, generally. In this type, the major constituent parts precede the founding of the overall organization, and these retain rights and jurisdiction over certain subunit processes and over parts of the total organizational process. Furthermore, in a federated organization (as contrasted with a corporate), the constituent parts have the right to withdraw. (Mayer N. Zald, 0r anizational Chan e: The Political Economyo of the YMCA. Chicago: The Univer51ty of Chicago Press, 1970). We would argue that the official structure of power, especially in non-business organizations, is an outcome of intercell competition, and opportunity to manipulate resources, not otherwise available to other cells. Morrison et al contrast power or conflict strategies with partici- pation strategies. In the latter case, influence tends to be limited to individuals and their families. Denton E. Morrison, Kenneth E. Hornback, w. Keith Warner, "The Environmental Movement: Some Preliminary Observations and Predictions," from William Burch, Neil Cheek and Lee Taylor (eds. ), Social Behavior, Natural Resources and the Environment, N. Y. Harper and Row, l972, pp. 259- 279. Victor w. Turner, Schism and Continuit in an African Societ . Manchester: Manchester University Press for the Rhodes-Livingstone Institute, 1957. CHAPTER VI EXPANDING THE NETWORK: AGENCY LIAISONS AND PRACTICE Clergy brokers pushed hard to get agencies to acceptandtopartici- pate in referral activities.1 To do this, they attempted to persuade family planning agencies, church or public health groups, mental health centers, university counseling and health services and other service units having direct contact with problem pregnancy clients to adopt their program. At first, traffic was a one-way flow from agencies to clergy. Personal arrangements between an agency worker and individual clergyman provided a steady supply of clients for clergy counsellors. But the movement wanted more direct assistance from agencies, asking them to take responsibility for direct client contact and abortion routing. Agencies showed a mixed reception to brokerage participation. Gradually, if often reluctantly, a variety of community agencies became part of the network. We detail some of the processes by which agencies have coped with this new service by considering (1) type of clergy-agency liaisons, (2) some conditions promoting variation in agency practice, and (3) four abortion service settings and their definitions, costs, and program outcomes. 217 218 Clergy-Agency Linkages Before the clergy movement, agencies avoided direct contact with this disfavored clientele on pragmatic grounds. There was neither time nor skills to deal with ”crisis" medicine. Denial of help was also expressed in moral terms. Abortion was illegal and a wrongful act. For the unmarried woman, bearing the illegitimate child was the "normal” consequence of wrongdoing. In a very few cases, the woman might be routed to local hospitals for therapeutic abortion. Most agencies I contacted report that they had little success in trying this option for a "desperate" client. Hospitals are said to have denied almost all requests. In one reported case a 42 year-old,working-class woman with 6 children committed suicide while waiting for the hospital committee decision. Working with problem-pregnancy clients usually involved a minimum of direct services with outside agency routing,as in unwed mothers' facilities, pre-natal clinics, and after-delivery, well-baby clinics. The affluent sought their own medical and social resources. After the clergy movement the moral argument was less obvious, but did appear in a different guise. "Prevention“ of the "problem" was the preferred, and for some agency workers, the only solution. Other reasons stated to clergy for inability to assume responsibility included personnel shortages and other more pressing commitments. To counteract this defensive posture, clergy organizers made direct appeals to agencies by letter, telephone,and personal contacts with directors. In-service training courses for counseling and referring this “special" clientele were instituted. In this appeal, the clergy 219 tried to deomonstrate, first, that the need was ovenwhelming; second, that the clergy could not adequately handle the demand alone; and third, if agencies shirked in this, many women would be forced to seek either the underworld of criminal abortionists or the semi-legitimate paid referral business. Clergymen,I interviewed,complained that agencies at this first contact stage initially engaged in "foot-dragging, refusing or avoiding this "necessary" and “urgent" work. Individual clergymen often had private agreements with local community service or church groups for exchanging legal, medical or psychological services. Overall though, referral activi- ties were sustained primarily by the efforts of a small band of clergymen located in university or urban settings. In the second stage of contact, clergy brokers moved to solicit direct counseling and referral assistance from a few agencies. The strategy was to tie them into the network as equal participants. By 1971, adoption agencies seeking clients in this new era of reduced need for "unwed-mother" care, were first to take on the counselling and referral program as their own. Clergy, overburdened with clients, referred directly to agency workers. They, then.took the client through the counselling routine, and if indicated, referred her to New York for the abortion. Directors and workers,trained by clergy,were expected to avoid pushing the adoption option, unless'appropriate for the client. One agency worker told me that her board had a different view. They saw this clientele group as useful for generating new “business"--i.e. adoptable babies. The reported decline in available babies for adoption suggest that board pressure may have been too little and too late. 220 In other communities, clergy slowly incorporated other agencies or laygroups into the network. In assembling a visible structure of agency support, clergy brokers aimed to spread the work load over as many organiza- tional units as seemed necessary to meet local community demand. They never intended to abandon over-all supervision of the program. They were especially concerned that the Clergy Service act as a single unit in negotiations with New York facilities. Loss of control over local units could weaken the negotiation position. Lacking effective sanctions for “maverick" cells, though, led to a few local groups splitting off from the larger broker structure to form their own autonomous units. For example, in one community Planned Parenthood and clergy counsellors operated as a single broker unit. Here the agency provided medical care and extra—agency referral sources, if the women chose not to get an abortion, with the clergy continuing to hold on to counseling and New York referral. This tightly interlocked operation bypassed the Detroit office, and set up their own referral outlets in New York. Withdrawal from the training sessions indicated that this unit had "gone its own way." Other referral units rejected both philosophy and strategies of clergy-brokers, either supplementing or reducing the original format. Referral-for-profit groups particularly, eliminated the key component of counselling from their service, claiming a saving of time and personnel in the process. Women's liberation groups, typically campus based, were more complexly linked to the brokerage, making them both more dependent on clergy sponsors and more restive under conditions of clergy control. The referral structure for woman's groups took this course: (1) campus ministers gua abortion counsellors drafted concerned women as 221 auxiliary referral persons sending clients on to the clergy for service. (2) After a nucleus of perhaps 5 women or so were organized, the clergy leader trained the small group. Training involved using simulated counseling sessions, discussing medical, psychological, economic or social issues related to contraception and abortion, and recounting personal experiences in dealing with clientele. (3) After training, the women were ready for counseling and referral on their own, with the provision that all information and referral should come from the clergy group. (4) In time, the women set up their own training sessions, first, under the direction of the clergy-organizers, later, with little or no direct contact with clergy counsellors. In interviews with informants from three women's centers, I was told that many now rejected the clergy umbrella on a number of counts. One was the counselling format itself, which the women claimed was “too limited“ in that the clergy did not adequately develop information about the "support figures" in the woman's life. Another objection was the requirement that all New York information be funnelled through clergy, rather than by the women who were carrying a large share of the task. Still another complaint was that males, generally, do not understand women's problems, especially pregnancy. Both Michigan and New York liberation groups have objected to what they claim are clergy assump- tions about the woman's purported guilt. Further, the religious and/or moral ideology was said to interfere with the "woman's coming to grips with her own consciousness." Differences between clergy and women's groups on counseling philosophies could not be adequately substantiated. What the protest reflects, however, are counter claims by women for 222 autonomy in client management. Women's groups now organize their own units, or work in equal partnership with the clergy. The most typical pattern developed during this period and sustained to the present was not a tightly interlocked referral web. Rather, it was a loosely connected net of professionals, agencies and volunteers. Phases of service were divided between participants in terms of expertise, current load, and availability of alternative helping sources. We further describe this network from the point of view of the women who have moved through it in the next chapter. For now, we simply indicate characteristic types of linkages, almost all of which were developed after mid-1970. The most active period of network building occurred during 1971. By mid-1972, there were few or no changes in the brokerage. Agency-Clergy-Physician Linkage Agency-clergy-physician linkage is perhaps the most common pattern. Here the client moves from (1) agency intake to (2) clergy counseling, then to her (3) private physician, and finally back to the (4) clergyman for referral information to New York. All New York- bound clients require proof of a pre-abortion medical examination before processing by clinics or hospitals. Agencies are not uniform in treatment programs. Some offer only pregnancy testing. Others offer pregnancy testing and pre- abortion examinations. Most agencies try to keep overhead low by offering minimum services (e.g. pregnancy laboratory test),moving the client on to other care points for more expensive and time consuming treatment (viz., couselling and medical care). 223 The most problematic feature of this linkage is physician participation. In some cities I was informed that physicians have quotas on pre—abortion "work—ups" or will not take Medicaid patients. Some gynecologocal practices refuse the pre-abortion patient altogether. In still-other instances, the physician charges an “excessive" amount for the physical and pelvic examination with costs ranging from $25 to $40. Clergymen and agency workers must often keep their own lists of "cooperative" physicians. The number of counsellors in some communities is related to the number of participating doctors. A low doctor ratio limits the number of new counsellors who can be brought into the system. Clergy-Agency Linkage One way to bypass reluctant physician participation is to incorporate them into the agency program as in two reported Planned Parenthood groups. This connection is more difficult to both develop and maintain, requiring heavy investments of time and political skills by promoters. Internal agency integration in family-planning settings between medical, nursing, counselling, education, volunteer.and other staff is often threatened by the addition of this new medical program. For most of these agencies, medical directors have the final word in determining type and extent of services for abortion clients. If the physician interprets the law strictly, no abortion-related services are officially given. Informal arrangements, in such cases, must then be negotiated between the clergyman, agency worker, and town doctors. In a few cases, the agency takes over the broker role. Clergymen provide information and surveillance, but counselling and referral is handled by local community resources. 224 University Counselling Service—University Health Service-Campus Movement Clergy Linkage In two large state universities I identified a referral order I that was internally complete, as developed by campus-clergy counsellors. Here the client need not leave the university setting for services, but moves from one resource to another before final referral to New York. The steps are as follows: (1) the patient enters the system via alternative routes: health center, counseling service, or campus movement clergy. (2) She is then given the specialized service of that unit, whether counselling or a pre-abortion work up. (3) Whatever the initial step, all abortion routing is handled by campus-clergy counsellors. Both clergy brokers and university personnel resist having the university assume full responsibility for abortion clientele. For informational purposes and on legal grounds, university health groups prefer to have on-campus clergy counsellors retain the referral function. Since the larger Clergy Service handles information changes in clinic or hospital costs and treatment features, campus clergymen already have access to this. Legal snarls also enter into university reluctance to take over the broker role. Under-age women are considered a poor legal risk for surgical referrals by most colleges and universities, who usually require parents' consent for treatment. Consent clauses for abortion clients are viewed as unrealistic by university personnel and clergymen. 225 Business Referral_§rgups-Clergy Ligkggg Clergy relations with referral-for-profit groups are the most tenuous of all connections. (We detail the background and organization of these businesses in a later section.) These groups are viewed by almost all legitimate professionals and agency workers as "unethical" and “exploitative." This is reinforced by the practice of referring back to the clergy only "problem" cases or those “washed out" from the profit groups—~so-called psychotics, the poor, the ill. Clergy brokers are particularly incensed at what they consider the "inhumane" and "shabby medical treatment“ clients receive. Some clergy men blame agencies for "dropping the ball" and not picking up their share of clients who, they say, are then forced to seek immediate care by "quacks.“ Women Liberation-Campus Clergy Linkage Women drawn from university-based liberation groups were among the first volunteer counsellors used by clergy brokers. The initial enthusiasm of the women to learn the "trade," and the urgent need of the campus clergy to share the load made for a highly interdependent relationship. It is in the context of this shared experience that some of the more militant women rejected what they considered to be clergy "take-over" in abortion counselling. Since the opening of a Women's Liberation Clinic in New York (1972), Michigan feminist groups now maintain their own in-and-out state connections. As far as can be determined, the counselling format retains the basic components of the clergy model with minor modifications (e.g. emphasis on the woman 93; woman experience). In one university city, the clergy have largely 226 turned over counselling and referral to the women. Four clergymen, operating out of the community "Women's Center" in the Y.W.C.A. building, have counselling schedules and attend executive meetings. But the women dominate in determining both shape and direction of the broker system in that community. Lay Volunteer-Clergy Linkage More recent efforts by clergy brokers to extend the network involves bringing in the institutionally unattached--housewife or student volunteers or persons located in informal referral groups, as in "Listening Ear," "Crisis Centers,“ or student-run drug walk-ins. In a few cases, high school teachers or workers in juvenile detention centers have been recruited. Volunteers have the same rights and priv- ileges as clergy counsellors-—information, counselling techniques, referral codes—-but are not required to assume risk for "faulty" client management. For this reason, volunteers are urged to send on their more ”difficult" clients to clergymen or agency workers. On occasion, the volunteer is phased out of the program if deemed socially or psy- chologically incompetent. This is considered an onerous task by clergy sponsors, who prefer to offer continued "guidance" rather than to retire the "unfit" volunteer outright from the service. However tenuous the linkage, agency participation in the broker arrangements is widespread. Abortion counselling and referral resources are now distributed around the state. Map 1 illustrates some of the more well-known abortion referral units in Michigan. Not included are boards of health, visiting nurses, "listening ear" or Code: F= > C) I E l PR= 227 3.5m: agg¢f~fi Family Planning units, HEW-sponsored, Planned Parenthood, other social agencies (e. g. adoption agencies Clergy, (Michigan Counselling Clergy Service for Problem Pregnancy) Women‘s Liberation Center Walk-in Clinic, or Free Clinic Paid Referral units Map l .-—Map Depicting Abortion Referral Units in Michigan 228 other "crisis centers, university health or counselling units, drug centers, or other informal groups. The latter, typically, do not operate as autonomous units with abortion referral a significant part of the practice.2 On the whole, the broker structure portrays a disjointed delivery system with relatively adequate services clustered at some points, and virtual absence or a paucity of services at others. Lack of coordination between care points is a pervasive feature of the system.3 Agencies tend to make their own adaptations to client demands. Sometimes this results in a well organized program; mainly, there is an gg'hgg_response by workers, or "emergency" services conducted outside board or director control. What conditions promote conflict and dilemmas for settings serving abortion clients? How do they cope with this new program in a structure often ill-adapted to serve the immediate care needs of a one-time clientele contact? What cost-control mechanisms are insti- tuted, and in turn, how do cost-reduction efforts affect program outcomes? We consider these questions in the next two sections by treating first, some conditions that influence agency variation in abortion service, and second, four examples of practice, definitions, costs, and program outcomes. Agency Variation in Abortion Practice Agency response to participating in the brokerage has been uneven. Contingencies within the agency and/or local community, constrain many settings from making more than a superficial commitment _ghk—zr T l I 229 to this clientele. Some conditions that impose limits on the range, quantity,and quality of services are the following: gggtradiCtiog§_in the Legal Order. A pervasive feature of abortion practice, regardless of setting (clergy, agency or physician). is the ambiguous and conflicting nature of the present legal situation. (Is abortion counselling against the law? Referral? Or is it only the medical procedure itself?) Clergy brokers have clarified for their purposes the issue of in—state counselling and out-state referral as legal. They also managed to convince a few agency directors that legal risk in their program is nil. But, generally, there has been no consistent reading of the law across social service units. On the one hand, agencies are constrained by federal, state or public health regulations. On the other, problems revolve around medical treatment for “unemancipated” minors without parent's consent, and scope of agency responsibility for out-of-state referrals. Even more, conflicting directives by different levels of the same government agency make for different interpretations of the law--state public health groups urging abortion counselling and referral, federal clauses stipulating against serving abortion clients at any phase of service. Lack of consensus regardigg_gbortion by agency persogggl. The role of abortion in family planning practice is net clearly delineated. National groups, as in Planned Parenthood or Zero Population Growth, have spoken forcefully for abortion as a necessary, if less preferable, mode of family planning.4 Many local agency directors and workers, however, are reluctant to take this most recent view. Abortion remains objectionable for many on moral, medical, 230 and psychological grounds. Recently trained public health "types“ may find this traditional view incomprehensible. The subsequent struggle over definitions often effectively halts program planning. Absence of a public mandate supporting pggpcy involvgmgpp. Lacking a public (and, of course, legal) mandate for abortion practice means that agencies must tread carefully to avoid offending community sponsoring groups. In seeking public support and funds for their programs, agencies often must turn to groups strongly opposed to abortion--Catholics, trade unions, Black leaders. Community Chest affiliation, especially constraining, includes Catholic donors and board persons,who react negatively to a visible abortion service funded by community resources. To avoid censure, agencies need to maintain a "low profile" in broker participation. This means that services, if available, are often the product of individual case workers or nurses, rather than a coordinated effort. Social agencies have differgpt social geographies--location, functionf'type of community relations, mode of accountapility, and so on. Variations in social placement are most dramatically illustrated by two types of family planning agencies--one, agencies sponsored by public health and funded by Health, Education, and Welfare; and two, valunteer or Planned Parenthood groups. Contraceptive treatment and sex-related counseling are primary functions for both groups. But a variety of federal, board, community or professional constraints affect range and type of services. For instance, HEW-funded agencies are expressly forbidden to treat abortion patients at any phase of service. Actual practice, 231 though, is inconsistent. Some reject any service. Others offer a phase of service (e.g. counselling pregnant teens). Still others provide some counselling and referral with the largest proportion of clientele sent on to the clergy. The Public Health director of the maternal health program confided to me that all HEW agencies are doing "some" abortion counseling and referral. The extent of services is up to local directors or boards who take their cues from the professional conmuni ty. Planned Parenthood groups are far more likely to fashion programs in terms of their funding groups' or board's expectations. But local elites are often conflicted in this area, and may not provide clear policy direction. A subterfuge structure,organized by individual social workers or nurses,may be one outcome of this ambiguity. In other situations the medical director may be the chief obstacle to expanding services. In one case, the administrator ignored negative community sentiment to set up an extensive counseling, referral, and medical program, jeopardizing her position to do so. There is differential perception of risk. Different interpre- tations of the same law produce varied "subjective" responses to "objectively" similar conditions. In most settings, agencies read the federal law to mean that medical services are contraband for the woman announcing her intention to seek an abortion. Pregnancy testing, and physical and pelvic examinations, in this view,must be handled by private physicians. Counselling and referral, on the contrary may be defined as part of the agency's "ordinary practice," if the structure is visible at all. The reasoning is that if the woman chooses to have an 232 abortion, the agency simply provided options (in the clergy model). This out-agency medical service and in-agency counselling and referral is reversed in one reported case. In this instance, the law is defined as specifically prohibiting counselling and referral activities. Instead, pregnancy tests and medical work-up for pre-abortion patients characterize the practice. Costs in counselling and referral vary from one organization to another. Program costs depend, in part, on type of staffing, number and characteristics of clientele, extent of volunteer help, if any, and competition of abortion service with other agency programs. Cost differentials are most apparent in mental health settings, as contrasted with family planning units (these do not include medical costs). Mental health settings typically have an all-professional counselling staff (M.A. and Ph.D.), limited volunteer help, largely middle-class clientele, and treatment programs necessitating intensive client evaluation. Family planning units, by contrast, have more semi- professionals (B.A. or R.N.), a large volunteer staff, serve a large number of medically-indigent or working-class persons, and typically do not require in—depth client evaluation. Differences for the mental health setting are reflected both in total number of clients served (relatively low) and in counselling costs per client (relatively high), as compared with family planning units.5 Perceived opportunities for apgrtion sgrvice vary by aggpgy definitions of profit apQLloss in serving client . The recent entry of adoption agencies into the referral system suggests an organization in search of clients. "Profits" in this case involve a steady clientele 233 flow in a diminishing market of adoptable babies. In other settings, commitment to a preferred clientele mitigates the likelihood that the agency will offer additional programs. For example, in two large Planned Parenthood groups, vasectomy clinics are high pay-off operations. Abortion counselling and referral, by contrast, consume an inordinate amount of staff time with little expressed reward for staff or directors. We explore other contingencies of agency practice in case studies. These show variation in range and typesof services with four different program orientations: (l) patient-advocate approach-- medical, counseling, and referral, (2) crisis-client conception-- counselling and referral, (3) therapy orientation--counselling focus, and (4) profit model—-referral only. Certain agencies (e.g. family planning units, adoption agencies, mental health settings) fit more appropriately into one category than another (e.g. family planning units in category 2). But this is not always the case, Local liaisons, on-going programs, definitions of service,and cost features largely influence type and extent of abortion services. Patiept:ggyocate Approach--Medical, Cogp§elling apd Referral The only exception to an organization-centered program is the "free-Clinic" setting,typically run by university students, and staffed by volunteer physicians, counsellors, nurses, and other para- professional personnel.6 In providing free medical service to "street people," "freaks," or other school or job drop-outs, clinic founders establish an alternative structure to standard private or bureaucratic services. Rejecting what they believe are inadequate and inhumane 234 services to poor persons, free clinics emphasize admission of social "rejects, or those with multiple medical problems--unwanted pregnancies, venereal disease, malnutrition from drugs or personal neglect—-that ordinarily require the client to move from one agency to another for remedy. The client atmosphere is informal, oftenraucous, and typically disorganized. Staff and clients alike move from one conversational unit (or "rap session") to another. "Talk soothes the troubled soul,“ is a prevailing definition guiding interaction. Counselors are expected to take the client "where he is," without judgmental bias or predis— positional assumptions about his "needs.“ Organizers recruit staff from various academic disciplines-- public health, education, counselling and medicine. Medical staff, alone, are fully professionalized; others are usually students. The common element binding volunteers is strong adherence either to medical reform or counter-culture ideology. Sometimes, the excitement of being involved in an innovative program is incentive enough. Free clinics face almost insurmountable problems in (I) initially launching a program, (2) funding the various services, (3) maintaining staff, and (4) reducing conflict both within the organization and between the organization and established groups. For these reasons, free clinics phase in and out of the social scene. “Open City," a clinic set up by Wayne State University students in Detroit, was forced out of business after two years of operation. A former staff worker reports that financial problems led to the organization's collapse. Observers in the family planning field also pointed to 235 unresolved in-group conflicts, especially between medical and technical In one Detroit suburb, a staff as contributing to the breakdown. clinic opens one night a week only to serve a total estimated load of 40-50 patients. Staffing problems limit both number of services and 7 patients. Setting-up the clinic and routinizing the procedures often present ovenwhelming problems to student organizers. Initially, they must locate an available house or storefront, get volunteeer physicians, coordinate different staff activities, and find adequate outside Funding is always a precarious stiuation. financial and social support. Neither student volunteers nor "hippie-type" clients appeal to standard funding groups. If organizers are careful in charting their course of action, and succeed in developing outside alliances, the operation may take 8 the following fbrm, as this successful clinic shows. 1. I“ To acquire funding sources, outside groups are contacted for donations or fees-for—service. Planned Parenthood or the Board of Health, fbr instance, may reimburse the clinic for standard tests (e.g. pregnancy test or venereal disease test) or gyneco- Patient contributions, while infrequent, logical services. do serve as minor financial aids. A relatively large number of physicians are recruited. This limits the amount of time any one physician has to contribute and reducespossible turnover. Even with this provision, most physicians move in-and-out of clinic service fairly rapidly. Out of a master list of 33 volunteer physicians, approximately only 6 to 8 doctors perform as ”regular" staff clinicians. On paper,staff are divided by role function (nursing, sex or drug counselling, patient advocate, etc.). This is to cut down on interpersonal conflict produced by overlapping work roles between specialists, especially pervasive in the crowded quarters. But separating work spheres more often turns out to be a theoretical concern than a practical outcome of management. Individual staff tend to respond to immediate situations, whether the work is in their area of expertise or not. 236 Friction between staff and general commotion is one result of this overlap. An ideology of client need goes along with an advocacy approach to patient care. Staff are supposed to attend to the patient as a total person, not merely a ”crazie," a disorganized student, or an abortion seeker. Organizers complain, though, that doctors often tend to be "moralistic,” or "overdirective" in treating patients. On the whole, free clinics aim to develop experimental medical- This concept, as applied in practice, seeks to counselling programs. reverse the burden of costs from consumer to those most able to "pay"-- i.e. the staff or support groups. The image of the patient, as one who must be protected both from the technical control of physicians within the clinic and from the hostility of established groups outside the setting, implies that the "cost“ burden must be primarily absorbed by staff organizers. This results in a patient-advocacy approach, or active intervention on behalf of clients. To achieve this, the clinic bends or stretches the health and legal regulations to fit client needs or expectations (as in prescribing oral contraceptives For for under-age girls). The advocate approach, however, has built-in problems. instance, advocates participate in all phases of service to interpret This disturbs physicians, client need or to protect client interests. who protest that the addition of a third party in the examining room disrupts "normal" and necessary control of patient care. Patient advocacy is also strongly rejected by some health groups (e.g. local board of health),who now require proof of parent's consent for treatment To circumvent this, counter of minors as a basis fbr reimbursement. strategies are used which include lying about the patient‘s age, 237 seeking non-governmental sources of support, and making arrangements with other, more friendly, agencies, who refer their backlog of patients in return for funding and supplies to the clinic. Management of problem-pregnancy clients is handled as a "package deal." In moving the patient from one phase of service to another in approximately two hours, instead of days or weeks, typical of public agency processing, the clinic saves patients both time and anxiety. Pregnancy test, pelvic examination, if the test is positive, in-depth counseling before and after tests and physical examination, and referral of the patient to a New York City clinic, if desired, are all activities dispatched in the context of an extended "rap session." The format appeals to many clients. Local students who find the university counseling and health services inadequate, non-confiden- tial,g or otherwise "costly," may turn to the clinic as an alternative helping source--for medical or counseling problems related to drugs, venereal disease, or pregnancy. By and large, however, conflicts between staff, excessively crowded conditions, physician dominance, interference by established groups, and lack of systematic funding make this a marginal program. As a model for a newly devised medical care facility for emergency health needs, the clinic suffers from too many clients, with too few staff, and lack of continuity between specialists. Services tend to be restricted to white students or ex-students (estimated at 80%), with both poor and black groups underrepresented as patients. . . 13..--.. 11.. ...|.l14.._i...rii.w.. .1111..- 238 Crisis Client Conception-—Counseling and Referral The Department of Health, Education and Welfare sponsors 9 family-planning projects distributed by county around the state. Agencies may be newly developed, as in the Family Planning Clinics, or former volunteer organizations partially funded by HEW, as in the Planned Parenthood Leagues. Whether a new organization or a continuous one with an additional funding source, the purpose is to assist clients in all phases of sex and family planning--information, education, and counseling. Clinical services include pregnancy testing, pelvic examinations, male sterilization (vasectomy), and hospital referral for female sterilization (tubal ligation). HEW-funding requirements, however, specifically stipulate that no financial assistance may be used for apy phase of abortion service p§[_§§, Pelvic examinations for the woman planning an abortion are especially contraband. Abortion counseling and referral, if required, take place with reference to a "problem pregnancy" only. This means that if the woman announces her intention to get an abortion at any point of treatment she loses all claims to service. Counselor assistance in exploring viable alternatives for the help-seeker, which may include abortion, are not explicitly proscribed. But the federal directive makes clear that Family Planning Projects are not in the business of providing help to abortion seekers. The family-planning theme is a dominant one in managing patients and services. The preferred image promotes an interventionist role in providing “helpless" clients with contraceptive protection ("direct service to desperate but hopeful people“). In national 239 media advertising campaigns one metropolitan agency conveyed their message of both rationale and function of the organization: Every child should be a welcome addition. Not an additional burden. Children by choice, not chance. An unexpected child can really rock the cradle. People are not just the cause of the population problem. They're also the victims. Patients with unwanted or "problem" pregnancies create difficulties for the organization. There is really no mandate to support services dealing with this contingency. Instead, pregnant patients are referred-out for care-~physicians, prenatal clinics, homes for the unwed, church or other social-service agencies. Agencies prefer to manage ‘ patients by focusing on prevention of pregnancy or contraceptive treatment piggy delivery. In this context abortion is not viewed as an appropriate option, especially by traditional board members or case workers. For some agency personnel, abortion actually represents the antithesis of sound, rational family planning. Rather, it is the woman's failure to plan that often necessitates the abortion choice as an "emergency measure for the immediate situation." An emergency concept is linked to the notion of the "problem pregnancy" client as one "in crisis," or one for whom the unwanted pregnancy creates a rupture in the routine order-~for the patient, her family, and the organization processing her. The opening up of the New York route in July 1970, the surfacing of the clergy referral movement, and a changed public conception of abortion all contributed to increased public demand for agency response 240 to this clientele. The dominant organizational principle--prevention of unwanted pregnancies--collided with the common sense reality of the client--rejecting the present pregnancy and seeking immediate relief, not deferred assistance after the “crisis" has been resolved by a term delivery. Despite client pressure, HEW-funded agencies lack consistent policies. Constraints are many. There is no mandate for systematic abortion counselling and referral. Prior agency commitments and goals interfere with new programs. Moreover, anti-abortion ideology hampers rational planning. As a result, programs, often inarticulate or partial, tend to be fitted to director or staff preferences. Directors are more inclined to meet expectations of middle-class contributors than of this objectionable clientele. Abortion services, some hold, jeopardize delicate political alliances. Turning away clientele is regrettable, but necessary, if present programs are to be maintained. Adding or expanding services, in any event is very expensive. In one Planned Parenthood unit, average yearly cost for clinical patients (i.e. medical, gynecological, counseling and contraceptive services) is $50 a visit. Many staff executives confined by budgetary requirements, fear that the sheer number of abortion patients would pre-empt all other more "deserving“ programs. Subsequent decisions to serve clients usually represents a compromise between these considerations and pressure from abortion clients or clergy groups. We map contra- dictory influences that affect one agency's program outcomes in Figure 15. The network shown is "partial," or one that relates to abortion service only (i.e. counseling and referral). On other dimensions of -—--———-----------------r11111 Apecgwmwx w mcwpmmcaoo .m.vv ou_>ewm :owpeoa< ouw>ocm op :owmpomo Aocwm< pomm$< amuse we mwgsmmmga m Aeouuwgwo An wo_>cmm mvw>oga op :owmwomu mmwsogasou gov mELo: xgopuwueepcoo to mmsoopao 241 .upm .mcovca memeh.$:ogmemw: :oszco .mmwcwmsm .mcmqumzzm m>wpm>emmcou masocm Egoeoc a case: voncemLo .zmemru |—-—_..__. 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In this agency network, immediate requirements of satisfying federal requirements, local board, and Detroit influentials tend to mitigate against counter influences of the National Planned Parenthood Board, consumers, Clergy Service.or other reform groups. Services, when provided, are unevenly distributed with different programs for three clientele types, as in the following: Abortion—seeking clients: Clients requesting an abortion referral only are primarily handled by telephone referrals. This involves giving the local number of the Clergy Service, or alternatively, the Planned Parenthood number in New York. This Planned Parenthood agency processes 54,601 patients a year (1971). Abortion telephone referrals reportedly include 2,424, or 4% of the total patient contact, or 42% of a reported 5,753 telephone referrals.10 "Regular" Clients: Women listed as regular agency patients, are those previously treated for birth control or other gynecological services, are likely, but not necessarily, to receive a full array of services--pregnancy test, pelvic examination, counselling of alternatives, and abortion referral to New York, if requested. "Teen" Services: ”Sexually active" teens already involved in "education and rap sessions" have access to pregnancy tests, and a full array of medical, counselling,and referral services. Indeed, all phases of pre-and-post abortion work-ups are available to this group, gfiggptgdirect referral to New York. Here the agency demands parental consent for direct referral, or if unavailable, the girl is transferred 243 to the clergy. Girls not previously connected to agency services are given a different orientation. In an information sheet distributed to teens, the agency stipulates eligibility for pregnancy tests and other related services as follows: Pregnancy testing is also available for any teen in the area who wishes to avail herself of the service. Teens found to be pregnant are counseled in the full range of possible decisions and referred for earl renatal care with the ho e that this will reduce-Thfhht The agency rationalizes the dichotomy between marginal clients (or abortion-referral caller or "outside" teen) and regular clients on grounds of political risk and financial cost. Political struggles for control have been waging between this Planned Parenthood group, the largest family-planning unit in Michigan, and the State Board of Public Health. Public health forces, in attempting a managerial take-over of the agency with its 11 clinics located in three counties, wants to consolidate government family-planning programs in that area. Add to this,the agency's shaky coalitions with local support groups who could go either way in the struggle, and you have a political tightrope situation. In balancing consumer pressure against political obstacles, the agency avoids a visible abortion practice, while maintaining current services to regular c1ientele—-abortion counseling, referral, and medical care. High costs of serving additional clients in already overburdened clinics put limits on an expanded abortion service. In a significant sense, the abortion issue--or demand for a different conception of the client and her needs--is related to the more basic problem of what the organization is, or will be, and of what the staff directors can do within the self-imposed limits of this conception. When abortion is defined by directors as a poor, if not 244 inmoral, substitute for birth control, they refer to the ideology of some community groups, overlooking others with a pro—abortion rhetoric. For example, to demonstrate community opposition to abortion, directors point to conservative physicians, genocide issue-centered Black Power groups, "Right to Life" movement, the Catholic hierarchy, and trade union organizations. Counter proposals by clergy and other abortion reform groups to extend abortion service to the larger public, by contrast.are viewed as leading to the eventual demise of the organization. In this conception, the organization would become transformed from one that assists clients in planning and spacing children to one that "eliminates" children. Abortion services for “regular" clients with "contraceptive failure" entail a somewhat different moral order. Here the agency is committed to working with the client in advising, directing, admonishing, or otherwise steering the woman into accepting the agency's idea of appropriate family size. There is an expressed obligation to serve on-going or former clients. Staff goals are thwarted to the extent that contraceptive failure reflects shortcomings in managing clientele. Program continuity--that of regulating fertility among clients--may be maintained for regular clients by "occasional," "necessary," legal abortions, but only under the condition of staff assessment of patient need. In two other family-planning projects studied, the organizations cope with built—in contradictions, on the one hand, by (1) individual staff response to "crisis“ clients without director or board approval, and on the other,by (2) an individual staff-director coalition in which 245 abortion patients, (especially married women) are served, but without express board knowledge or approval. - In the first case, official policy states that "no pre-abortion counselling service is provided." Unofficially, however, abortion counselling goes on. Conflict regarding the extent of these services may be especially acute at the individual case worker level. Abortion counselling must be maintained at a "low profile," for fear of antagoni- zing the director who rejects visible involvement. Confused, ambivalent, adolescent, unmarried,or otherwise vulnerable patients, are Special problems for the case worker,who is expected to transfer such clients directly to local clergy. As a sex and marriage counselor, the worker feels that such cases legitimately fall within her expertise. Failure to adequately deal with these patients may be viewed as a personal loss in terms of professional expectations. Yet these clients encroach on time and other commitments beyond "reasonable" limits. In an interview one case worker said: Abortion requests are constantly increasing here. It's getting out of hand. That's all I'll be doing if I don't watch it. Fifteen a month problem pregnancies! And I see the teens. I'm afraid they're pregnant and aren't married. "Teens," especially, take a great deal of time, but yield little professional return. The pregnant girl, described as usually "hysterical,“ may connect temporarily with the counselor, but often fails to return for a second referral interview. Because pelvic examinations may pg; be given for pregnant patients by clinic physicians in this HEW-sponsored setting, the counselor may find that time invested in exploring options with the adolescent,who believes 246 herself to be pregnant, is simply lost effort. Inability to provide comprehensive medical and counselling care inevitably leads to high patient loss (estimated at 35-50% of gll_first contact patients). The degree to which individual staff perceive these clients as "trouble" reflects the differential position and role requirements of the worker. In this HEW-agency, intake of new patients, regardless of the number eventually "lost," counts as increased "production" by executive staff. Administrators use the numbers game for negotiating with funding groups for additional support. Responsibility, and hence "costs," for processing such patients, is pasSed on to lower echelon workers. Actual intake counts show an estimated twenty pregnancy tests a week with about 29 counselling sessions for problem pregnancy patients in this time period. Two case workers share the load making an estimated 40 "crisis“ clients a month processed by each worker.12 Typeof population served generates "trouble“ for workers. Women tend to beypung (32% are under 19 years of age), white (about 80%), with a high school education or less (65%). The likelihood that help seekers are unmarried is relatively high. Clinic records show that, overall,approximately 50% mpg; unmarried clients than married ones are treated in this setting. Staff persons view this patient category as a "high-risk" one for problem pregnancies. And, once pregnant, they describe the younger, unmarried, working-class girl as unable to cope with pregnancy or to get psychological or financial support from family and boyfriend. The reporting system reflects the gap between publicly stated practice and private case worker activity. Contraceptive-related 247 treatment is the primary focus. Yet, in a one month period (Feb. 1971) of treating 245 patients, 106 patients, or 44%,were reported to be seeking “other" types of care. Counts of problemrpregnancy patients are buried in this category. Conditions, then, of high patient loads, a vulnerable patient type, lack of program continuity, and failure by the executive staff to recognize both the extent of need, and the special problems related to serving this c1ientele,all contribute to worker dissatisfaction. Inevitably, the consumer absorbs the high "cost" of abortion service in being pushed from one referral point to another. In another Planned Parenthood agency, counselling and referral occupied slightly over 37% of work time for one staff person. This informant admitted that client records were only haphazardly maintained and unavailable for board scrutiny. Organizational "saying" and ”doing" become unrelated activities. In this context of subterfuge activities, board members can only guess at the extent of abortion service. One board person associated with the agency for 25 years emphasized the discontinuity in the present inarticulate system: In an interview she pointed out that: I'm not sure what they're doing (i.e. staff). Are they responsible fbr filling our clinics (i.e. abortion clients)? I'm not saying that those girls don't need help. We should build clinic loads, however, on the basis of what's happening. If we have no data, then there‘s no way to get the workload balanced out. Abortion I'm not counselling may be more extensive than what we know. really sure what kind of counselling goes on there. It takes more expertise than our staff has. I have a feeling that they (i.e. staff) may be inclined to make up the girl's mind on abortion . . . I wonder if these girls are getting physicals in our office. I wonder if these girls are interfering with our birth We can't even get second calls from our patients control program. after they‘ve been given birth control because we have these girls coming in requesting abortion, and are interfering with our program. 248 Board members not only express bewilderment at what appears to go on, but never acknowledged; even more, they are concerned that program responsibility has been taken out of their hands. The same informant said: We got into the abortion counselling in rather a half-assed way. Once the law changed in New York, the staff changed as well here. They were eager to do this. I think that we probably should keep records, but no records are kept by with regard to abortion counselling. This puts the person doing it in a peculiar position. They're just getting away with it right now. Abortion clients, as ”crisis“ patients, generate stress and disrupt family-planning agency routines. Communication gaps between staff or hierarchical levels further complicate client management. This results in gg_hpp_programs, or emergency measures to meet immediate demand. Or contradictory pressures yield a clandestine structure only tenuously attached to other functions and goals. Therapy Orientation-Counselling Focus Mental health centers, in contrast to family planning groups, receive few problem pregnancy clients.13 Initial patient screening by receptionist or therapist eliminates most persons whose problem is restricted to an unwanted pregnancy. Instead, the approved routing is referral to the clergy. Generally, staff are convinced that most women do not see their pregnancy, even a so-called ”problem" one, as requiring therapeutic attention. Pregnancy, as such, is not a psychiatric crisis. In the pre-New York era, therapists occasionally facilitated a patient's receiving a Michigan hospital abortion by "rubber-stamping" the necessary documentation. But ”writing the stuff up“ was an act 249 often disconnected from the patient's actual psychiatric history.14 For this purpose any therapist would do (whether clinical psychologist, social worker, educational counselor, etc.). Subsequent "diagnosis" was a collective organizational product. This process simplified connecting patients to hospital abortions, while also reducing as many of the “dehumanizing" experiences for the hospital-bound abortion patient as possible. Generally, the agency constructs therapy for patients with "dysfunctional" behavior problems. They refer elsewhere those patients with a continuous history of mental illness or obvious psychotic behavior requiring extensive or long term treatment. This therapeutic regime serves three purposes: (1) It reduces patient dependency on individual therapists, (2) it facilitates rapid patient turnover, and (3) more patients can be treated without expanding staff personnel. With high and rapid turnover, relatively high patient loads, and a view of pregnancy as "normal'I behavior, the staff view abortion counselling as consuming too much time and, inevitably, contributing little to professional production. The Center recognizes, however, that pregnancy for a few women involves an "emotional factor." Pre-abortion or post-abortion depression is not uncommon. In diagnosing the source of the distur- bance, therapists hold the notion of "underlying" or deeply-rooted problems. For perhaps ten to twelve patients a year with pregnancy- related depression, therapy focuses on pre-existing conflicts. Diagnosis involves a distinction between the pregnant or abortion patient with a psychiatric crisis, and the unsophisticated girl who has 250 a temporary “problem" pregnancy. The director clarified these categories in this way: These women (treated here) had basic conflicts long before the pregnancy or abortion episode. The woman may become pregnant as an attempt to validate her feminity, or as an extension of herself. It may be anger directed toward the parental figure. In any case, you're dealing with a lot of neurotic guilt in these types of cases. I think that the kind of people we tend to see are carrying heavy baggage anyway; that is, heavy emotional baggage. There's a vast difference for the girl who's having a conflict with authority figures and the sweet little thing who didn't know how to take care of herself. In the latter case, she'll bounce back. We don't have to worry about her if she gets pregnant. But the ones who have the neurotic guilt and conflict are ones that we will deal with. Type of patient processed, that is, the psychiatric "crisis" client, influences this reasoning. Even more relevant is staff recognition that additional responsibilities would cut deeply into on—going commitments. To be "overwhelmed with abortion patients" needing special counselling and referral information takes resource not now available, and not likely to be so in the future. In hedging on the possible loss of some psychiatrically- disoriented patients, the Center makes "investments" in both time and contacts with other referral units. Staff maintain active alliances with individual clergymen and family planning counselors. Referral and re-referral of clients between agencies attempt to fit patients to one or another program. If the agency fumbles in pushing a disturbed client through the standard routing, there is always the possibility of another round. Physician, agency, clergyman or New York clinic may pick up the troubled patient and refer her back for psychological counselling, either before or after the abortion. 251 In this therapeutic center, the practice of dichotimizing pregnant patients,as either "at—risk" with respect to psychological crisis or suicide, or ”normal" persons,eliminates almost all abortion client requests for service. This maintains agendas with minimal costs to staff or existing programs. By interpreting their mandate as psychiatric counseling these agencies define abortion referral out of the picture. By contrast, Planned Parenthood groups are still debating whether their-service focus should include abortion referral. Profit Mode1--Referral Only If "Free Clinics“ are in the business of absorbing most of the social and economic costs of abortion service, paid referral operations have a counter effect. Clients pay--and often pay well-—for agency connection to an abortion source in New York. Costs of referral service range from a low of $25 to a high of over $100, with the average agency charge estimated at $50—$65 for referral only. Abortion referral businesses, almost exclusively located in the Detroit Metropolitan area, include 12 groups serving an estimated 2,000 women a month, or 14,400 customers a year.15 Referral-for- profit has been an integral part of the abortion market in New York, Michigan,and other states since availability of legal abortions in New York. They have since been outlawed in that state because of "profiteering" and other fraudulent practices in connection with interstate commerce in medical services. Recently, they have changed their legal status from "profit" to'hon-profit" finns, with little or no change in practice, however. Instead, a "business-as-usual" 252 rhetoric conforms to an image of abortion referral as a "public service“ activity in a scarce supply market. In this view, the business referral agency meets the needs of those women, ignored or denied by family planning groups or even by Clergy Service. Women need assistance, they say, and need it now. Otherwise, they are liable to turn to an illegal and, by definition, a dangerous source. In an interview the director of one referral business gave this account of his participation, stressing the similarity between social service agencies and his own set—up: I'm a non-profit organization. For the first time in history, we're getting involved in something that is really important. I knew it was coming. It's the first time and I want to be in on the ground floor. That's why it's a non-profit organization. The reason that I'm in for non—profit is that illegal abortions were taking advantage of women, and this isn't right. I'm incorporated as non-profit, and that means that we have to do the same thing as Planned Parenthood. We get donations or contribu- tions. The principle here of paying for service is the same as that for the YMCA. After all, if you go to the YMCA for swimming for a season, they charge $75. I'm giving them a serVice, and they're paying in the same way they pay the YMCA. Rejecting the counselling function characteristic of all other referral groups, the businessman holds to a principle of minimum service, or giving the customer only what she wants--the abortion. He considers ”frills," especially counselling, both unnecessary and hypocritical. "Soul-searching” sessions by clergy and others, including signed consent notes by the client, protect the organization, not the woman. Moreover, he claims, by focusing on the woman's "problem" Pregnancy, clergy and other referral groups create the very situation they aim to eliminate. One successful referral businessman states it this way: 253 The clergy aren't doing the girls a favor. The whole idea of soul-searching is no good. I don't have people coming through on mental problems. The clergy report that the women need this (i.e. counselling) because they're having all these problems. The women are not having all these problems. The clergy are giving them a chance to think about it. But they just need that abortion. The word abortion already has the word "illegal" in front of it. When the clergy puts this in the woman's mind, this creates a problem afterwards . . . This is Mickey Mouse stuff to protect yourself. The clergy in Ohio, for instance, have the girls sign a paper saying that they made the decision themselves. Already, this makes it seem like there's something wrong, when they have to sign a paper. Entrepreneurship, in this quasi-legal activity, depends on playing the non-profit "game" with a stripped-down referral model (i.e. minus the counselling). For some businessmen developing opposi- tional principles proves useful for fighting competition from public agencies or clergy, or for battling legal suits. An anti-reformist, anti-Church, and even anti-establishment position, provide rationales against multiple group attacks. In still other cases, the anti-establishment rhetoric is muted or non-existent. One manager defines the enterprise as a standard business practice, another as an extension of medical services. With a ready market Unexploit,business referral agencies have few of the nagging problems that constrain public or clergy referral agencies. With no conflict of goals or priorities, referral businesses usually take whatever the market turns up. They will, however, transfer the psychiatrically disturbed, or otherwise, "problem“ patient to the clergy (probably under 5% of cases). Setting up the business requires relatively little capital. A small room unth telephones, perhaps two receptionists, a cooperating outside physician to give pregnancy tests and pelvic examinations and, 254 in some cases, arrangements with private airline companies to fly clients to New York,all require more "know-how” than capital outlay. For some enterprises, arrangements may be more complex. Referral to an abortion facility may also include direct control over the New York operation. Ownership of doctor offices or other abortion facilities involves a complicated transfer of payments between the physician.who pays rent for using the facility, and the businessman,who takes profits from this medical service. The owner pays physicians on a per-patient, or "piece-work” rate, with no profit—sharing in this scheme. In one case, the businessman has "spots" for depositing clients in Buffalo, Utica, Rochester, and New York City. The Buffalo connection includes three different groups of physicians in two offices. Price of service is a trade secret. But one informant, who admitted to handling approximately 60 women a week for referral and air connections to New York, said he charges $300 for the total service. In this way, he grosses approximately $18,000 per week. If the New York physician receives, at most, $100 an operation, this would leave approximately $12,000 for payment of airfare, Michigan physician examining fee, secretarial and office expense, and personal profit. He maximizes profit by picking up air shipments of goods (e.g. flowers and shrimp) on the return trip to Michigan. Another standard operating cost is legal fees. Abortion "infonmation" advertisements are illegal in Michigan. Local communities in and around Detroit have pushed hard to get courts to rule against abortion ads on billboards or other media. In spite of community 255 censure, court cases are most often won by the referral businesses. In claiming the constitutional right of freedom of speech, referral groups argue that abortion is a medical tenn, and in itself carries "no clear and present danger." The New York State Attorney General's office, too.presents a continuous threat since profit businesses have been banned from medical referrals. This requires at least one owner of a large enterprise to maintain extensive legal counsel with subse- quent high costs of operation. Overall, with profits greatly exceeding costs in an expanding market, the paid referral groups do very well. Standard program outcomes include abortion, birth control information or treatment, sterilization, if requested (with added costs), and occasionally, medical follow-up. The "package deal" is explained by one businessman infonnant as a "real bargain." The girl gets to see Niagara Falls, rides in an airplane for the first time, and she gets an abortion. That's quite an excursion for the money. Don't you think so? "Clinics,“ however, often include unapproved or unlicensed facilities. Especially outside of New York City, local board of health control does not extend to physician offices, a typical setting used by paid referral groups. The State requires fetal death certificates as proof that the woman was pregnant, and as a regulatory device for tracking down "bad" operators. These are filled out only irregularly by office-clinics. Primary control is by the business owner himself, whose chief concern is to maintain a high flow of patient traffic, rather than to regulate conditions under which abortions are given. Only after two patient deaths (including one 256 Michigan woman) by a Buffalo physician having extensive contacts with Detroit referral businessmen and legitimate physicians, did these agencies stop using this physician. Client "need," interpreted in moral and psychological terms by clergy and social service agencies, has been transformed by paid referral groups into the rhetoric and practice of the marketplace. Maximizing individual advantage is the primary goal of these enterprises. In eliminating what they consider to be redundant or unnecessary services, as in pre- and post-abortion counselling, paid agencies reduce costs, while holding price constant. In this essentially caveat emptor trans- action system, the consumer has neither public protection by laws, nor personal concern by brokers. The risk, in this situation, is completely assumed by the buyer. Conclusion In expanding the referral network, clergy brokers along with client demand have pushed agency participation at all phases of service. Lack of an over—all regulatory body, as in public health directives for practice, tends to generate an indeterminate referral structure,or one that takes different forms depending on conditions within the agency itself. Clergy brokers and paid referral groups remain the major referral points for women seeking legal abortions in New York. In the present fluid abortion market situation, these two distinct referral forms act as structural alternatives in this phase of selecting and sorting demand. Clergy brokers, on the one hand, couch transactions in terms of moral, psychological, and social requirements 257 of women. A protective-counselor and dependent-client relationship characterizes interaction. To ensure that this mode of relating will be a relatively standardized one, the clergy organization aims at tight internal control. Training sessions and infonmal contact between members stress the requirements of personal commitment, regulating the counselling format, developing uniform moral definitions of the woman, and her "trouble, and maintaining strong links with the "central office" in Metropolitan Detroit. Women routed to legal abortions in this network enter a well explored field of medical services. Paid referral agencies, on the other hand, calculate referral transactions in economic terms. Abortion is viewed as a market commodity, whatever the rationale, with women simply the purchasers of a service. A buyer-seller relationship is the dominant form of inter- action in this scheme. Economic competition between business units encourages individual maximization of advantage. "Sharp” business practices that occur in a largely uncontrolled legal framework are directed into an expanding market. Social links between "respectables" (clergy and social agencies) and "marginals" (business referral groups) are tenuous and characterized by separation, antagonism, and mutual exclusion. This separation of spheres facilitates market freedom and, hence,profit-taking for business groups. The frenzy of commercial activity tends to obscure, if not exclude, considerations of medical and professional propriety. Physicians are transformed into paid employees; patients undergo a medical service in the absence of conven- tional social and legal regulations. 258 The structural similarity between the profit-referral groups and the "old-time" criminal abortion system may be noted. A "cash-and- carry" economic exchange, an absence of social and legal protection for patients, and market conditions of scarcity that allow medical services to flow where there are temporary or long-term gaps in the care system. tend to typify both the illegal and the quasi-legal operations. The next chapter describes the referral network from the experience of women who have been routed from one point to another for abortion services. Consumer values, and lack of sophistication and experience create costs for abortion seekers. Lack of an articulate referral structure is still another condition that has consequences for the patient. We trace the effects of these conditions by examining five essential features of client movement through the network: defining the problem, constructing alternatives, contacting help, terminating the pregnancy, and evaluating the experience. _l O \l o FO0TNOTES—-CHAPTER VI Data for this chapter include: formal interviews with public health officers (7), agency or clinic directors or medical staff (7), agency or clinic workers (22), University counselling service (3 interviews), and 2 University Health Services (4 interviews), directors of referral-for-profit (3). The Public Health Director of the State Maternal and Child Care Division provided helpful infonnation on HEW agencies. Other sources are observations and informal interviews averaging 4-12 hours in 8 settings, including 3 Planned Parenthood offices, 1 HEW agency, 1 Free clinic, 1 Mental Health Center, 2 Women's Centers. All but one were located in three cities: Detroit, Ann Arbor and Lansing. One Women's Center was in Kalamazoo. Detroit Planned Parenthood newsletters and records from 1 HEW agency were also used. A list of non—profit abortion-referral services by state, type of service,and telephone number is found in Robert E. Hall, M.D. A Doctor's Guide to Havin an Abortion, New York: The New American Library, Inc., Appendix, Table IV, 1971. The author includes 16 locations in 11 Michigan cities among recommended sources. For analysis of this general issue of agency and professional coordination in one city, see for example, E. Cumming, Systems of Social Regulation, New York: Atherton Press, 1968. See, for example, the National Planned Parenthood Guidelines, 1971. Published by the Planned Parenthood League, New York, New York. In an interview with the Director of a Tri-County Mental Health Center, Lansing. There are 4 identified "free—clinic" organizations that are presently on-going concerns. These include Drug Education Center in Lansing handling clients with drug and "related problems,” including pregnancy, and 3 Walk-In Centers in Ann Arbor and Detroit suburbs, Ferndale and Birmingham. All units have counselling, medical,and technical staff and services. Referral to New York is a direct one for clients here. Information is by courtesy of Judy Law, volunteer, Ferndale, Michigan, Walk-In Center. The followingdata areprovided by observations and interviewing of staff directors, physicians,and volunteers in the Free Clinic, Ann Arbor, Michigan, July, 1971. 259 10. 260 Social agency staff, regardless of setting, complain that their organizations are required to handle local university students, who they believe, should rightfully seek services from university counselling and medical sources. Agency staff suggest that the reason for this influx is the expressed reluctance of students to use these university facilities because of lack of confidentiality of records. This data is taken from the organization's Annual Report, 1971. In an interview with a staff executive, it was suggested that calls from women specifically seeking abortion service have been running about 250 a week (or approximately 22% of total patient contact). There is no way to resolve the discrepancy Between reported figures and interview data. The organizational perception of demand, whatever the actual number of contacts, is suc t at it tends to often arouse a strong reaction against present or even future service for abortion patients. Statement from Y.E.S., Teen Center of Planned Parenthood League, Detroit, Michigan, 1972. The figure of 15 patients a month given by one counselor are those recorded cases with completed diagnosis, remedy, and termination. Most patients counselled are given a brief initial session only, and then sent on to an outside physician and/or clergyman. Cases are considered incomplete until the client returns for further counseling or post-abortion care. In interviews with eight staff members and director of one mental health center, August, 1971. Generalization to all Michigan mental health centers is obviously a tentative one. Most therapists interviewed felt that the situation of low abortion:client contact was a characteristic one for this type of setting. The role of psychiatrists in negotiating therapeutic abortions is documented by a study sponsored by the American Psychiatric Association: "The Right to Abortion, A Psychiatric View," formulated by the Committee on Psychiatry and Law. Published by the Group for Advancement of Psychiatry, 1969. Estimates are difficult here. I computed this on the basis of an average of 100 clients per month for the 12 identified agencies (documented by clergy informants). The most successful and well advertised enterprise is reported to refer 175 women a week to New York. Two informants, operating what they claim are "standard“ size services do an estimated 60 referrals per month in one instance, and 240 referrals in the other in the same time period. The actual number of businesses and the extent of their operations largely remain, a Speculative matter. The business may have as many as four or five incorporated titles under one ownership. 261 Or, owners may exaggerate, or even underestimate client intake, depending on the desire to impress the observer, or reduce the possibility of investigation by income tax officials. Informants also report that there is approximately a one-third drop-off rate. Whether the total number of calls, or the actual number of patients referred, is included in the business "totals," remains unknown. CHAPTER VII THE CONSUMER: MAKING IT THROUGH THE NETWORK The now extensive epidemiological and medical research on legally-induced abortion procedures and result; has little to say about how the woman herself perceives, enacts, and reacts to the experience. The structure of abortion services has changed drastically since soci- ologists Nancy Howell Lee and Peter Manning described network features of the illegal routing in search of an abortionist.2 Under the impetus of the abortion reform movement, a variety of legitimating groups-- counseling clergy, cooperating physicians, public health groups, and women's liberation counsellors--came together under the clergy mantle to promote abortion services. Counseling, pregnancy test, pelvic examina- tion, and referral became routinized practice in many family-treatment agencies or professional groups. The woman going through the movement route now finds that a major part of the search activity is created and shaped by the helping professions and/or agencies.3 Secrecy, anonymity, and privacy,all features of the illegal system, have been transformed. The new system encourages openness, discussion of options, and rational evaluation of decision-making among concerned parties (viz,) woman, husband, lover, parents, intimate friends). The abortion event, defined by the legitimators of service, has been altered from a 262 263 clandestine act to a "maturing," "sobering," or even emancipating experience within the rhetoric of respectable medicine or mental health care. The demographic situation, too, has changed since liberaliza- tion of abortion laws in New York and elsewhere. A larger proportion of pregnancies are terminated by abortion, rather than "resolved" by marriage or adoption;4 most abortions are performed on gigglg, 5 rather than married women; and the younger and older woman is more likely at present to terminate a pregnancy than carry the child to term.6 Multiple routes have been opened for abortion seekers. But personal and social dislocations persist even in the present system. Trouble for clients has its source in traditional values, fear of discovery, loss of a love relationship, agency backlogs necessitating delays, high costs, out-of-state travel, and medical and psychological complications. Some features linger from the illegal past; others are products of the new system. Together these make abortion a fearful and anxious experience for many women. This chapter traces the natural history of the search for an abortion. We take the perspectives and strategies of the women to describe entrance into the network, the abortion experience, and aftermath. Using retrospective data from 42 interview schedules, only 36 of which have all items completed,7 we focus on essential features of five stages of client movement: (1) defining the problem, (2) constructing alternatives, (3) contacting help, (4) terminating the 8 Pregnancy, and (5) evaluating the experience. This report of the 264 abortion search, resolution, and outcome, while not representative, suggests patterns and trends of consumer involvement in the abortion "market." (Other sources of data for this chapter include observation of clergy counselling sessions, taped discussion group of twelve women who have had abortions,9 unstructured interviews with counsellors and abortionees, observation of New York clinics and hospitals and hospital observation of abortion procedures.) Backgroppd Information--The Sample Forty-two interviews, with 36 completed protocols, were conducted by three college students and myself on three college campuses,10 and are limited almost exclusively to present or former college students or their friends. Women are predominantly college age or older, although the women's ages at the time of the abortion range from 14 to 30. Most of the women have never been married (83%). and were students when aborted (82%). Only two are not white, with one Black woman and one Chicano. Almost all respondents are Protestants, except three who are Catholic. All but three lived in a college comnunity. The three lived in a Metropolitan area when involved in the abortion search. Overall, the group interviewed were previously known, either by the interviewers, or their immediate helping contacts. Our collective interviewing experience in seeking women who had previously had an abortion clarified two issues regarding research in this area. First, women were often reluctant to admit to their abortion. Even so-called "emancipated" women,who were known by intimates to have had the operation,resist being "scientifically" studied. 265 Second, many leads evaporated upon closer inspection, because the aborted woman preferred to conceal details of her experience on grounds that it was too "personal" or possibly stigmatizing to openly discuss. Place, time, type of abortion (whether legal or illegal), and popula- tion investigated (i.e. primarily college students) may be factors in these "lost" cases. For these reasons, the sample is biased in an unknown direction. Whatever the stated reason for reluctance of some women to be interviewed (although we have no way of tracing actual numbers here), this situation underscores the persistence of the "old" ethic still prevailing in the new structure (i.e., traditional values and conven- tional sex role identifications). The trial and error circumstances of finding willing interviewees greatly helped to sensitize me to the meanings of abortion, especially for the younger, single woman. Participation in this "consciousness- raising” experience, hopefully, is reflected in this report of the abortion search. Defining the Problem Premarital or unwanted pregnancies are probably the result of what Lemert calls, "primary deviation, or behavior that is polygenetic in origin, diverse in meaning, and widely distributed in a given popu- lation, with little significance for the self and role of those involved.]] There is little reason to assume that women who have unplanned pregnancies differ in any way from other females of similar . . . . 1 age. class, ethn1c1ty, or soc1a1 Circumstances. 2 266 For the woman who finds herself in the predicament of an unwanted pregnancy, there is a period of crucial assessment revolving around three questions: Physically, what is happening to me? Psycholog- ically, how did this happen to me? Socially, what are the conse- quences of this now and for my future? While these body-mind-social questions may never be openly articulated, they provide a start for sorting out the meanings of the pregnancy, and constructing solutions to the "problem." For most women, a missed menstrual period triggers the first phase of the assessing process. A few women report that they knew they were pregnant, although only two or three days "late.“ Others drift for days or weeks until a second "missed" period forces them to recognize that this is an "abnormal" situation, or a situation in which they must take positive action of some sort. Fear, anxiety, and expressed feelings of confusion date from the awareness that a missed period is the first significant sign of pregnancy. For some women, nausea, fatigue and a bodily state defined as "generally sick all over," are other signs of a likely pregnancy. For a few women with irregular periods, there is the additional apprehension of "how far along am I?" Confirming the suspected pregnancy by a urine test, if an early preg- nancy, and a pelvic examination, if at a later stage, is the first action taken. If the findings are positive, (i.e. the woman is medically defined as pregnant), the next action is to construct alternatives. In the process of recognizing and dealing with the signs of a probable pregnancy, the woman also reconstructs ppy_the event occurred, the meaning of the sexual relationship(s) she is involved in, 267 and the conseguences of the pregnancy. These assessments precede the construction of alternatives. “How it happened" may be sorted into five patterns:13 (1) the "snow-white syndrome," (2) "everywoman's problem," (3) unplanned sexuality, (4) rationalized sexuality, and (5) contraceptive failure. These suggest the degree to which the woman is aware of or recognizes the possible outcomes of routinizing a sexual relationship. Snow-White Syndrome: Although termed as such by a physician- informant, the young woman who fails or refuses to perceive the impli- cations of intercourse is a common clinical phenomenon. Clergy- counsellors and physicians alike report that the girl most likely to get pregnant, apparently, has little awareness that sexuality carried certain risks. The "syndrome" includes a perception of the self as innocent, a "good" girl, denial of wrong-doing, and expressed love for the boy she is currently dating. Planning sex, as in the use of birth control, is to recognize a deviant act. Unplanned, spontaneous sex, by contrast, legitimates the love relationship. After confirmation of the pregnancy, the girl may report, "It can't happen to me, I don't believe it," or "I never could accept the fact that I was pregnant.“ Everyyoman's problem: For many women, married or unmarried, who are regularly engaged in sex relations, there is routine recog- nition that pregnancy is a likely outcome. A pragmatic definition of the situation includes the notion that "if you're doing it, you're liable to get caught.‘I These women may or may not use contraceptives, but once pregnant, there is a move to contact someone else who has also had the experience. Pregnancy is perceived as non-catastrophic, 268 and perhaps, even expected. As one woman interviewed said, “I'm Joe average. If it happened to me, it could happen to anyone." Unplanned Sexuality: While unplanned sexuality is the most common reason given by most women for the pregnancy,14 the significance for the self varies, depending on whether she is married or not. The first pregnancy, whether planned or unplanned, is rarely a “disaster" for the married woman. Instead, economics is the primary consideration influencing whether the married woman views the pregnancy as "untimely" or not. For the single girl, aware of chance-taking, a definitional gap often exists - between sex and pregnancy, and between pregnancy and having a child. Unplanned sex simply involves short-term affairs, postponing an appointment with a physician for contraceptives, or the belief that "if anything happens, we'll get married, anyway.“ Rationalizing the Sexual Relationship: A few single girls express the sex act as a rational expression of love, experimentation, or emancipation. An assertion of “this is something I wanted to do, and I thought a great deal about it," implies that the girl has considered not only what the sex act means, but what to do if she becomespregnant. One now-married woman.in reporting her first love affair and subsequent pregnancy.said: We had discussed the possibility of my getting pregnant, and decided that if anything happened, I'd just get an abortion. These women are most apt to refer to their abortion experience as "emancipating.” Contraceptive Failure: Gynecological problems, illness related to the use of pills or the I.U.D. requiring discontinuance of these 269 techniques, or becoming pregnant while on physician-prescribed contraception was a problem for twelve women in this group. Some report that physicians advised going off the pill because of adverse effects, but suggested no alternative birth control. These women are least likely to impute self-blame regarding the unwanted pregnancy. Since they had taken precautions, they feel justified in following through their intentions to avoid having a child. Reconstructing the meaning of the sexual relationship(s) occurs at all phases--defining the problem, constructing alternatives, seeking contacts, and post abortion evaluations. Considerations generating mild to extreme anxiety for many women include: uncertainty about the love relationship, fear that it will end if the lover discovers the pregnancy, indecision about feelings for the lover, and recognition that marriage is probably impossible because of youth- fulness or financial incapacity of the parties, or that the relation- ship is a casual dating one only. Thus, while the woman almost alwaysconsiders the preferences of the involved man, if he is still in the picture at all, her primary concern in constructing alternatives revolve around conse- quences of the pregnancy for her future. Frear of discovery by parents, expressed by six women, strongly contributes to a narrowing of options, and a definition that abortion may be the only choice. Other reasons stated for the decision to have an abortion are reluc— tance to jeopardize school or career plans, or an already tenuous love relationship, and perceived inability to carry an unwanted child to term for adoption. 270 Constructing,Alternatives For most women retrospectively reporting an abortion, there is an ambivalent period before making contacts and arrangements, in which the woman finds herself unable to cope. “Panic," "alienation," ”worry," "frustration,“ "nervousness," or even "suicidal“ feelings characterized the experience for 17 (of 40) women. During what may be only a brief time period of a few days or weeks, she "tries out“ solutions in her mind before consulting with the involved man, her friends, or professional contacts. Although most women who eventually get the abortion very early struck on that option as the ppLy possible alternative in the circumstances, others contemplate the possibility of marriage or adoption, or fantacize about having the baby alone (2 cases). Rejection of these solutions by friends, lover, or parents may prove shocking, but often relieves the woman of the burden of responsibility. Contacting Help The construction of alternatives is no longer completed by the time the woman begins her search for an abortion.15 Regardless of whom she initially turns to for assistance——friends, the lover, or professional workers—-the woman often undergoes a re-definition of the situation. This replay of options is particularly acute for the largest proportion of women who were routed through the legitimate network by established groups (i.e. clergy, physicians, agencies). Women report that clergy and physicians, especially, spend "too much time“ discussing "unsuitable" options (e.g. marriage or adoption), and 271 notenoughtime on information about problems of out-state travel, expenses, and medical complications. Unplanned contingencies, such as the boyfriend's rejection of marriage, or for some, his opposition to abortion, may create confusion and indecision. For a few women, options shift depending on point of time, and who they consult with, as in this sequence: T]—-—-girlfriend urges illegal abortion; T2—--—boyfriend decides marriage after physician confirms pregnancy; T3—--- clergy advises against marriage, suggests adoption; T4—-—-boyfriend and woman decide abortion best option. Ambivalence and guilt even after the final decision has been made are frequent outcomes of these shifts. Indeed, it is the rare woman who does not express some confusion at one or another contact point regarding the course of action to take. Only four women (of 36 reporting) expressed no fear or anxiety at any time regarding the decision. Of these four, three were abortion repeaters (one woman had two previous abortions). For many women, of course, it is primarily the "trouble,“ of getting "through it all,"--making contacts requiring telephone calls and appointments to clergy, agency, or physician, eliminating false leads, getting funds, informing parents, and/or the biological father, and traveling to a strange city (New York), often alone; there to be served in a typically large, impersonal setting by unknown physicians. Twenty—four (of 38 reporting) women characterized the pre-abortion experience as "worrisome," “fearful,” or "traumatic," with excessive concern expressed by some, as in fear of sterility 272 (3), a panic state (3), continuous weeping (2), generalized guilt (3), or suicidal (2). Whether the professional helper reduces or exacerbates this general anxiety state is not completely clear. For some women, contacts with two or more professionals actually heightened awareness that abortion is an extraordinary event. For many single women, the “normal" physical and psychological symptoms associated with pregnancy tend to subjectively increase as time delays and number of contacts multiply. Fiften women linked pre-abortion stress to difficulty in establishing contacts. Two essential features in securing a safe abortion are availability of medical care and time. Yet, the present structure of abortion referral services, at least from the experience of these women, is one often perceived as time-consuming, repetitive, disconnected, and expensive. In one sense, the former sub—rosa, or illegal, system, wherein abortion information is "private, personal,“ "unshared,“ and of "little use to moral friends,"16 is still operative. But, imposed on this “shadow world” of private knowledge learned from friends or personal sources, is the new structure of counselling and referral services. Clergymen, physicians, referral businesses, women's liberation counsellors, and other professional contacts complicate the search activity. The abortion search now extends contacts into spheres formerly unavailable or unknown under the “old" system. This has had three consequences in terms of number of resources contacted and time spent. 273 1. The number of intermediaries, or contacts, to secure an abortion has increased. Lee found in 1967 that half the women found an abortion within a chain having less than two intermediaries (mean - 2.82, median = 2.0).17 In my data, under conditions of a "mixed" system, private information among friends, and public information among brokers, these 36 women located an abortion within a chain typically having 4 intermediaries (mean = 4.14, median = 4.0), with a range of one to eight persons contacted pgfppg_locating an abortion source. Thirty-one percent of this group had 5 contacts or more, while only 17% had 2 contacts or less. Table 11 summarizes the number of contacts used by this group before an abortion was located. Social chains may be as reduced as this one-step process used by a woman seeking her second abortion. 1. Paid referral business----New York source or, the more characteristic type of chain which involves contacting two friends and two professionals: 2. girlfriend—---boyfriend----clergy----physician---- New York source. This chain actually involves an additional step, although we have not "counted" it accordingly. After clergy counselling, the woman has the pregnancy confirmed by the physician. The woman then returns to the clergy for specific information and referral to New York. In still another pattern, the woman's search involves contacting friends who then connect her to a local women's liberation "counsellor." Physicians often reject the women's groups as legitimate referral 274 TABLE ll.--Number of Persons Contacted Before Abortion Source was Located (Data taken from a non-random sample.) Number of Number of Persons Cumulative Percent Who Contacts* Involved in Search Secured Abortion by x (x) n (x.n) Contacts or Less 1 1 l 3 2 4 8 14 3 5 15 28 4 15 60 69 5 4 20 80 6 5 30 94 7 l 7 97 8 1 8 100 36 149 *Contacts: Persons used for information, service,or routing. Mean = 4.14 Median = 4.0 275 persons (unless operating under the clergy umbrella). Instead, the woman is sent to the clergy counselling group for a repeat counselling session. The process may include six links before a final New York referral. 3. Girlfriend]-—--girlfriend2----boyfriend----women's liberation counsellor—---physician--——c1ergy----New York source. For two women, the initial effort to locate a "local“ (or illegal) abortionist resulted in two different chains in two time periods involving six different persons. 4. girlfriend}----girlfriend2--—-"Dr. X.” (rejected)---- (4 weeks delay) girlfriend3-—--clergy—---physician----New York source Or, the chain may be a continuous one in time with links from one route connecting to an illegal abortion, and links from another route leading to a legal source. 5. (Route 1) male friend]—---male friend2----bartender---- midwife----(Route 2) male friend3--——clergy—---women's liberation counsellor—-—-physician----New York source Despite the very extensive length of this double chain, the woman succeeded in getting an early termination (9 weeks) in that she resumed her search almost immediately after the initial illegal lead was rejected. Undoubtedly, it is not length of the chain (or number of contacts),or even time involved that alone determines the woman's subjective experience in the abortion search. Sometimes the woman's ambivalence or fear may be magnified by the number of contacts. At other times, the number of contacts really expresses the woman's 276 ambivalence or reluctance to make a decision. "Being in love,“ planning marriage, using pregnancy as "revenge" against a former lover, or moral objections to abortion,all constrain the woman from taking the decisive step. Counselling clergymen, recognizing this ambivalence, may request that the client return for further counselling, or send her on to a woman counsellor with this session including parents, and/or the biological father. Extended counseling often resolves the problem, but in a few cases (2), creates greater confusion for the woman, particularly if the involved man deserts during this time. 2. The number of professional, or para-professiopal persqu contacted greatly exceeds helping family members, and is somewhat greater than contacts with friends. In Lee's data connections into the criminal abortion network occurred through the woman's close female friends with the father often an important helping source.18 The women in my sample, by contrast, had few family support sources, with male and female peers almost equally involved in the search. The greatest §jpglg_structural change, of course, is the number of professionals involved. Table 12 shows the number and percent of types of persons contacted. The network, in large part, is created and defined by the variety of professional persons who process the woman at various phases of service. Unlike the illegal "system, which is re-created with each individual search,19 the present structure exists independently of individuals processed through it. Professional control of services. because of legal restriction of access, however, limits information to those women,who have either passed through the system, or who are ideologically or politically committed to the abortion movement. 277 TABLE 12.--Type of Contact Secured in Search for an Abortion Percent of Total Type of Contact N Number of Contacts Friend Male 25 Female 28. Total 53 35.6 Family Father (or older male relative) 5 Mother (or older female relative) §_ Total 11 7.4 Professional (or business contacts) Clergy 24 Physician 31 Women's Liberation Counsellor l3 Soc. Service Agency 6 Paid Referral 3 Other 9 57.0 278 Contacts typically follow a 2-step process. First, the attempt to get information from friends leads the woman to confide in intimates, her boyfriend, or a male student known to intimates. Second, moving through the legitimate network requires phases of service, as in urine test for pregnancy here, clergy counselling there, physician's pelvic examination at still another point. Lack of unity between phases of service is the single greatest complaint about the organization of services. Some women felt that the situation exposed them to a variety of possible censuring agents they would prefer not to face. Figure 16 describes the "typical" movement of women through I the abortion network. ! Charting clients' decisions at different points suggest a mpg21_network and its alternatives. Not included here are the “deviant“ cases for this group, as in use of one intermediary only, or six to eight contacts used by a few. No woman in this group connected directly (i.e. without intermediaries) with clinics or hospitals. After four contacts, the boyfriend of one woman secured a telephone number of a New York clinic from the Playboy Magazine. Even where direct contact is made without counsellor—mediation, the woman must still rely on local medical diagnosis and appropriate papers stating period of gestation and general health condition. Neither freestanding clinics nor hospitals wish to take sole responsibility for an out—of-state woman, who, moreover, may have unanticipated medical conditions that contraindicate an abortion (e.g. diabetes, overweight, cardiac problems, etc.). From discussions with New York clinic counselors and college students (both men and women), it is the rare woman who does not first negotiate the options 279 . o Locuzo—mv Ampcwoa ucoeommwo we mmow>eom :owmw>oea we» owe? oocmeucm .mcowmwuma m.pcoepo m u 11. ogamw mo>Fpoccoup< mu_ use xcozuoz Poggmmom cowugon< Foooz < mp m ow . . 3 mm. c2355....» 33 mm "w ”F3331. "w .M . 1. m u_oowume Lo mocmesm:_ ..oo :oo_ ta + omcao .n. w, xmeopu v: Jr” ”W :2. £253 .852.— mmalulpiom c9222 Tagger—a copueoofiillw w xoomuwfloopoom "mm .mdoohnomwm ” o mpmmo opococp mm . . . . a me p w P . .e x m m an op =o_mm_se< 1a ”vowgoa mezuouoga pmoa “mm r1 w . 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E g + . . copoou mom . e 1 . + a tam . umwmfizuem mo>_»oceou < 1111 meowuoo ow cowowm ; ouo>we co m=w_omcaho ooxmmmmwwmm op :owmwmmn .moow>gom Fowoom H mmocmv aungQ . . . .muw>eom xmgopo s s Ann. ewe xowm op "mcwpomczoo e0\a Epkonw 0>m£ Cu. :mewomo _ . w>wpwmwz twp—2.0 nfip m 0: :melwogx DCPCCGFQ >._._.Edu_ . + l 3 emwemwé : 3.385 1 H11 1, H m . p megs: 1111111 . 1 eommwo w~m_go copm sucwopemoca. m>+u_moa amok .111. wcwmoo oowcoa » cpwumuomo unocwwuma ..owgmowswucH :eoo mcvcwumwp= 1Poou mppxoz . to worsen. eH aucocmmga oz oseumcoe asp moon u .ou a e u . , mucowem w a o .oo xpwsmm :. p z x m 280 with friends or involved man. While abortion may not necessarily be a crisis decision for some women, it is certainly not among the standard encounters of everyday life. The event, surrounded by myth, medical rituals, and for some, identity-transgressions, seems to demand strong social reinforcement. 3. The amount of time involved to secure a legal abortion may actually be as great, or even greater, than under the illegal order. With the demise of the "friendly neighborhood abortionist“ or the metropolitan physician who provides abortions ”for a price," most women now must go through the referral system. This involves time delays, because of client backlogs on the part of professionals or agencies, a 2-step process in procuring pre-abortion medical services, different personnel and/or agency processing for counseling and medical services, repetitive services, and so on. Compared with the "therapeutic" hospital abortion route, though (see Chapter IV), the present structure is more medically efficient. Almost all of these women had abortions before the tenlor eleven-week deadline, allowing for the vacuum aspiration or D&C procedure. Only one woman (with 42 reporting) had a ”late"-abortion (18 weeks), requiring a saline injection. The period from time of first contact to date of abortion underscores the relative efficiency of this routing system, as compared with the Michigan hospital route (mean = 3.0 weeks, median - 2.5 weeks). The range varied from one day (or no time delay) for the woman who went through the paid referral system, to four months for a fourteen- year-old girl who received an illegal abortion. Thirteen women, or 281 approximately 35% of this group, had a delay of four weeks or more. Table 13 summarizes the time period required to seek an abortion. While inordinate time delays (5 weeks or more) may reflect indecision for a few, lack of funds was the major hurdle for almost all late-comers. Denied credit facilities because of student status or unemployment, fearful of informing parents who could have provided money, and desertion or non-support by the father (21 or 42) make the abortion enterprise a hazardous undertaking. Fourteen women cited money “hassles" or indebtedness as the primary difficulty in securing abortion. This required extending the search, this time for securing loans. Three women found it necessary to contact anywhere from eight to twelve additional persons before funds were available. Women's liberation, or related campus radical groups (e.g. Peace Coalition) were sources of financial support for some. Terminating the Pregnancy After completing the movement through the friendship-professional chain, the woman connects with the abortion source. For most women (36 or 42),this was a New York clinic or hospital. Abortion sites vary, depending on 31mg of abortion and location of helping sources. Before 1970, the abortion was likely to be illegal, with tennination in Detroit, Chicago,or other out-of-state location. Not shown in these data, but a characteristic pattern, are some Michigan clergy cells which continued to send women to a Chicago source, even after legalization. Proximity, familiarity with the physician,and favorable feedback from former patients are some features that keep the old routing going. 282 TABLE l3.-—Period from First Contact to Time of Abortion Time Period (Approximate) Number Percent Under 1 week 2 5.4 1 - 2 weeks 5 13.5 2 - 3 weeks 12 32.4 3 — 4 weeks 5 13.5 4 - 5 weeks 4 10.8 5 - 6 weeks 3 8.2 6 weeks or more __6_ l§;g_ n = 37 100% Mean Time = 3.0 Median = 2.5 Agencies, clergy, and women's liberation groups, while sharing information on New York abortion sources, often have preferences. By far, the largest number of out-state women are served in a clergy- sponsored, non-profit clinic, perfonning an estimated 26,000 abortions a year, 92% on women from outside the state.21 Clergy clients are most likely to have the abortion terminated in this setting. Women's liberation groups also refer here, but are increasingly turning to their own source in New York City. Depending on type of agency-clergy alliance, professionals may rely on the clergy source, or may develop alterna— tives recommended or sponsored by Planned Parenthood or other groups. Invariably, physicians prefer pg§_to refer directly because of presumed legal or professional jeopardy, but use clergy or agency brokers. Table 14 summarizes type of abortion (legal or illegal) by year and location. 283 TABLE 14.-—Type of Abortion Received by Year and Location Type of Abortion Year Location Illegal (6) 1964 (1) ‘ Detroit 1967 (1) Detroit 1969 (3) Chicago 1969 (1) Windsor Legal (36) 1970 (5) New York* 1971 (19) New York 1972 (12) New York *New York includes primarily clinics in N.Y.C., although suburban and upper state facilities were used by some. Costs are also contingent on time, place, and type of abortion. Certainly, the most expensive abortion is the illegal one that occurred in the pre-New York days. Although this, too, varies from a low of $25, for an office D&C (one case), to a high of $575 in a Chicago "clinic," median costs for an illegal abortion among these six women are $500. New York abortion prices have gone down with increased competition since legalization. The following table shows the change in costs for a clinical abortion over a three year period, as reported by this group. TABLE 15.-—Average Costs for New York Clinical Abortion and Travel Expenses Abortion Travel Expenses Average Total 1970 (n = 5) $173.00 $61.00 $234.00 1971 (n = 19) $158.65 $75.00 $233.65 1972 (n = 12) $143.00 $70.00 $210.00 284 Late terminations (including saline procedure, hysterotomy, or hysterectomy),requiring hospitalization,remain expensive procedures ($350 - $450 in New York City), but are still less costly than in- patient abortion care in metropolitan Michigan hospitals (see Chapter IV). Even clinical abortions may be expensive for many women. The rela- tively low travel expenses,reported by this group (averaging $61-$75» reflect the large number of women who travel to New York by car (averaging $50—$60), rather than by air ($98). The clergy-sponsored or women's liberation clinics offer the lowest-cost abortions ($125 and $110 respectively), but additional medication may run as high as an additional $50 before the woman returns to Michigan. In response to the question, "Did you experience any economic hardships due to the cost of your abortion?", 14 women replied that either they or their boyfriends were "very much in debt," or "having trouble" repaying loans borrowed for the operation. Abortion-related money "troubles," while not an enduring problem, forced occupational changes, including dropping out of school for three women. One woman, i who postponed the abortion beyond the "safe" period because of inade- quate funds, emphasized the inequity of high abortion costs. Her expenses included $350 for saline injection plus $132 for trave1,totaling $482 for the abortion. She found these costs exorbitant. In her words: I think the cost of this abortion was out of reason. There are very few women, myself included, who can afford it. Abortions should not be a luxury for the rich. The termination procedure itself is a relatively simple matter for most women receiving a vacuum aspiration.22 The woman enters the clinic on an appointment basis. Since there is usually an hour-or-so 285 wait,with women processed by groups of six to eight for contraceptive information, counselling and medical work, a universe of discourse soon develops among each time-cohort of clients. Having the same counsellor and undergoing the same four-stage process--counselling, pre-abortion examination, termination procedure, and recovery-—at approximately the same time, the women share with each other the pre-operation apprehensions, and later, relief, following the abortion. Counselling in model clinics is usually conducted by young para-professional women,who themselves have had an abortion, and is aimed at opening-up feelings regarding sex, pregnancy, contraception,and abortion. The counsellor urges the woman to accept the pregnancy, and to recognize the meanings the experience has had for her. Abortion in this context is viewed as a viable option, rather than a ”mistake" for wrongdoing. The counseling repertoire excludes the language of morality, pain, suffering or guilt. In fact,the counsellor may look aggrieved if a woman mentions these "objectionable" topics. Abortion is articulated, not as atonement for sins, but as a rational medical procedure, somewhat safer than tonsillectomy, and with far less complications than child- birth. Since local anesthesia is given?3 the counselor must have the full cooperation of the woman. Fearful, tense, or hysterical patients, not only are unable to take the "local," but they can also greatly disrupt the smooth flow of events in a typically crowded and tightly- scheduled setting. Counsellors, then, perform a dual role. They orient the woman to the setting, and provide her with a vocabulary of motives—-how to feel, how to think, how to express the experience. And, the 286 counsellor acts as the chief support person throughout the various phases of service. Physicians, nurses, secretaries, and administrators are transient functionaries who play only specialized roles. The counsellor, by contrast, is a relatively permanent feature of the 4P6 hour experience. She often holds the woman's hand or head during and after the operation, and gives strength by her compassionate atten- 24 Patients' reports from New York clinics emphasize the strategic tion. role the counsellor plays in making the abortion experience a "good" or even "memorable" event. Post-abortion evaluations among this group studied show the extent to which a standardized rhetoric has developed. In asking respondents to describe the feelings they had immediately following the abortion, 30 (of 38 reporting) women used the term "relief" (or a related term) associated with "thankful," "happy," "good feelings," "extreme high," "never felt better," "felt fine," or "relaxed." It is interesting to speculate why the women almost uniformly used the term "relief," which suggests deliverance, alleviation or ease through the removal of pain, distress, or oppression. In view of the official avoidance of the concepts of pain, sin, burden, or wrong, the word "relief" may summarize many of these taboo subjective feelings, while providing a neutral cover term in keeping with the controlled milieu of respectable medicine and mental health. Again, "relief“ may also express the before-after contrast. Before the abortion, most women (30 of 36 reporting) express a moderate to highly anxious state, as in "worried," "scared,"'guilty," "mental anguish," "alienated," and so on, much of which expresses situational 287 stress. Once the procedure is over, and the woman finds herself still physically intact, conscious, and sharing the experience with others who have undergone a similar ordeal, the feeling of freedom from former fears and concerns brings the expressed relief. Finally, after a 2-3 hour recovery period spent either in a large room filled with cots, or a reception-type room with easy chairs and sofas, the clinic releases the woman with antibiotics or other standard medication. Most women return immediately to their homes by car or air. A few (3) report that they make a "weekend of it," with their boyfriends, either visiting New York nightspots or friends. Evaluatipggthe Experience Sociologists, analyzing the criminal abortion experience in the framework of labeling theory, emphasize,that while the abortion decision and search may be a negative experience, the overall impact of abortion has few, if any, long-term consequences for the role or identity?5 This normalization is attributed to neutralizing techniques, or justi- fications for the act, which are said to render social controls inopera- tive, and shield the self-concept from blame. Neutralizing rhetorics, as in rationales of "the lesser evil,"or "the only solution," eliminate or reduce guilt for persons who have internalized conventional norms.26 The psychiatric literature tends to take two contradictory positions regarding the abortion experience. On the one hand, early clinical data suggest that abortion is tantamount to denial of the woman's role, and indicates underlying personality problems. Long- range consequences for adjustment are presumed to follow the abortion 27 experience. On the other hand, more recent data show that most women 288 have few or no psychological problems,either before or after abortion, 28 A straddling except insofar as these may be situationally-induced. position is also apparent in some findings. Women are said to experi- ence a sense of lp§§_associated with the abortion, a condition absent among the controls. Expressed deprivation is reported to be related to pre-existing stressful life situations, with the unwanted pregnancy an attempt to resolve the crisis. Fear of the abortion procedure further exacerbates the psychiatric problem.29 How do these Michigan women in our case study define the experience? Is there a single set of perceptions that can be said to characterize this relatively socially homogeneous group? What conclu- sions can be drawn regarding psychological consequences of abortion? And, what role, if any, does the present broker structure play in facilitating a normal versus deviant identity? First, definitions vary by previous social experience, con- tingencies encountered in the search, and point of time in the abortion process (before, during and after the operation). Second, there is pg§_a single set of perceptions that hold across this group. Except for the official rhetoric developed at the abortion site itself, most women who have had an abortion do pg; share this experience with other abortionees, and thus lack a common neutralizing rhetoric. This means that in the absence of continuity in medical and supportive services following the abortion, the woman is left to "work it out" herself unless she has maintained the relation- ship with the biological father. The frequency of male desertion, or lack of effective support by the involved man for almost half of this 289 group, implies that the follow-up period may be less than satisfactory for some women. For still others, translating the experience into an ideological or political event links the woman to radical or reform groups that may be highly supportive of abortion. For eight women, only one of whom was previously ideologically committed, involvement in abortion reform, the women's movement or counselling activities trans- formed the event into a positive act: Third, in tracing the expressed psychological experiences of women before, during, and after abortion, we find, roughly, fbur patterns, or cycles, of psychological states. We label these the "30 indicating not only shifts "differential cycles of expressed stress, in feelings at different points in time, but also the patterned differences in these mood—shifts. These psychological variations are illustrated in Figure 17. Cycle 1 (8 cases): No or low expressed stress in the pre- abortion period is followed by rapid routinization of everyday life-- return to school, job or family life. The abortion itself is a "relief" to be over. It is primarily the inconvenience, as in cost, out-of-state travel, and interference with study or work, that concerns the woman. Both married women and abortion repeaters (3), who are also likely to be somewhat older, tend to experience low stress. Neutralizing rhetoric for the married woman emphasizes that the "personal crisis" was pregnancy, not the abortion. The well-being of the family was a paramount consideration with husband and wife jointly agreeing on the decision. The relationship with the husband is reported to be either better or "greatly improved" because of the 11. oesawu mmoepm oommmeoxm to moFUAU _owueocomwwo NF emote :owpeon< Lopeo 1mg; Loewe F to 2:82 o 2:82 m 5%: _ not. 2 “V w M . m o—oxo . \\\111111111111 m opoxo m ooze < maze 111111111111111111111111111111111111111111111111111 cow: mmmsum $0 Fw>04 291 shared experience. Divorcees are also positive about the decision, but for different reasons. Pregnancy, without marriage, is not viewed as a viable choice. Interference with school or job, or in two cases A.D.C. requirements, makes abortion a pragmatic decision. For some women processed by women's liberation counsellors and clinic, the experience is both "good" and "emancipating.“ For at least three of these women, abortion was symbolic of a newly emergent self, or a person who gained confidence and strength through the experience. As one woman said: It marked my life. The experience was so good. I'll never I'll always think about it as good. I wanted to go forget it. alone. Even though he wanted to go with me, I thought that I'd be stronger alone, and I wanted to do it myself. It was fantastic! Everything run by women. They anticipate everything. They (clinical staff) gave me so much confidence. I couldn't have asked for a better experience. The whole thing was an emancipating experience. Going to New York alone, I felt so independent. It was my experience, and mine alone. And I handled it. I haven't talked to anyone else who's had an abortion. The big thing with abortion is that it's still hush—hush. It's against the law. Many people are insulted when you ask them about their abortion experience . . . I was impressed with myself. Here I was brought up a staunch Catholic--all Catholic schools, and no guilt! I almost felt guilty about pg; feeling guilty! Cycle 2 (22 cases): Moderate stress in the pre-abortion period is followed by intense relief at the point of the abortion, with normal activities resumed within a month after the abortion. Although this includes women who have had legal as well as illegal abortion, apparently there is little difference between them regarding expressed fears or anxieties about the operation. Both illegal and legal routings seem to offer an equal amount of ”trouble" or "problems“ in the abortion search. There is somewhat more medical concern felt by women who had an illegal abortion. Fear of sterility or other gynecological problems were common worries here (although not actualized in these cases). 292 How the woman comes to conceptualize the abortion provides a clue to the way in which she handles the decision process, the operation, and the post-operative evaluations. Both for women characterized as having low or moderate levels of stress (cycles 1 and 2).neutralizing techniques involved four strategies justifying the act: (1) the lesser evil, (2) the only solution, (3) altruistic concerns, and (4) a positive 23:1. Defining abortion as less stigmatic than a “forced" marriage, an unwanted child, or dropping out of school or work, enables the woman to subjectively weigh the "costs" of other options. Abortion, while a "regrettable incident," has fewer long-range consequences than other alternatives. The woman is aware of conventional beliefs regarding the act, but eventually comes to feel that abortion is a lesser evil than marriage with an unwanted child, or adoption. For example: I feel I did the right thing. I wouldn't have married him because I was pregnant. I didn't want to bring an unwanted child into the world. I couldn't have given the child away. I don't care if people tell me I murdered it--that's ignorant of them. Specifying abortion as the only solution implies that other alternatives have never been seriously considered. There is neither moral equivocation nor taking account of conventional views. For example: I've always believed in freedom of abortion and knew that if the time came that I needed one, I'd find a way to obtain one. My life would have been greatly changed if I had pg; received the abortion. And: This was my first guy. We really cared for each other, but I couldn't live with him. I had no regrets, no feelings of guilt. I had sorted these out a long time ago. Sexuality and having children are not necessarily related, and I carried this through in my decision to have an abortion. 293 Altruistic concerns for the well—being of the marriage rela- tionship or children also helps to reduce guilt or dissonance regarding the act. One married woman with three children believes that the abortion was "necessary" to preserve their marriage: I had no qualms or hesitations at any time. There were never any problems about the decision. The personal crisis was being pregnant. We love our children, but we feel that we've been tied down too long. I got pregnant right after marriage, and we have a need to spend some time now with each other. Current doctrine among women liberation groups holds that abortion is a positive pp; that carries benefits to the user,though not one to be sought out or volunteered for. Self-assertiveness, autonomy,and emancipation from conventional ideology with improved human relationships are presumed outcomes of the abortion decision. The crucial feature, of course, is that the woman herself decides, rather than depending on husband, friends, or clergy to make the choice. For three women of this group.abortion transformed the identity in spite of relatively intense pre-abortion fears. As one woman recalled: I stood up and said 'no." I'm not going to have that baby. Now he (husband) treated me more like a person and recognized that I have a brain. It's much better for Jason (child) . . . . Suddenly, a decision had to be made real quick, and it was my decision. I knew the whole rap (i.e. clergy counselling). I knew I didn't want to have someone asking me, 'Do you have to do this?‘ Overall, most women are not exposed to the women's liberation rhetoric, or if exposed, not influenced by it. Most reported "some" or "many" regrets that abortion seemed the only viable alternative “in the circumstances." Cycle 3 (7 cases): abortion followed by relief at the time of abortion with persistent The woman expresses moderate stress before 294 or even increasing anxiety after the act. For 7 single women, abortion did not immediately resolve the “problem“. Instead, it exacerbated pre-existing difficulties in sexual or relational spheres, or in personal Loss of the cherished man, frigidity, feelings of inade- identities. " or chronic worries about the potential “baby," quacy or "inferiority, are conditions associated with depression, guilt, or confusion for one month or more after the abortion. These women are most apt to question their decision, particularly if they see the loss of man and potential child as demonstrating personal incompetence, immaturity, or immorality. Extensive number of contacts and time involved in the search, money and man "troubles," dependence on disapproving relatives and perceived medical complications following the abortion,all contribute to post- abortion depression. As one woman with this configuration of experi- ences remarked: My feelings are mixed. I'm doubtful about the moral act I've done. I'm glad it's over, but as time goes by, my feelings of doubt increase. The abortion solved the physical problem and the mental anguish, but I still have doubts and concerns about the potential child. Cycle 4 (5 cases): adjustment to the abortion experience characterizes all phases of the For some single women, extreme lack of event, as in: a high level of expressed stress prior to abortion with shock, guilt, or depression at the point of the abortion, and subse- quent inability to resume a normal life. Five women required medical and/or psychiatric attention for acute physical and/or mental disabili- ties with seven years of psychotherapy in one instance. A "late" illegal abortion at fourteen years of age with medical problems necessitated a hysterectomy before the age of 20 in this case. 295 One or more manifestations of the maladmustment include fear or hatred of men, a strong desire to have the “lost" child, extreme feelings of inferiority, a self-conception as "obnoxious," rejection of sex, persistent fantasies about "killing the baby,“ "worrying about everything," indiscriminate sexual relations, and suicidal wishes. While there is no single pattern identifying the possible source of the expressed mental strain, certain features characterize one or more of these cases. These are: l. Inability to face up to the decision, as in tactics of repression and suppression of the meanings of abortion for the woman's life. 2. Lack of a justificatory rhetoric neutralizing the guilt. 3. Severe inferior feelings that are activated by the event leading to a defined self-concept as worthless. 4. Expectations of carrying the pregnancy to term, and inability to alter expectations after a "fOrced" decision. 5. Lack of a supportive person during and after the abortion. 6. Acute medical complications, requiring extensive medical or surgical attention (2 cases). Although abortion has been officially redefined from deviance to a medical or even ideological matter, a few women continue to define the act as deviant with negative implications fer the self. Almost 29% of this sampleexperienced some psychological difficulties following either illegally induced (n l) or legally-induced (n = 11) abortion, with 5) having serious impairment, and 5% (n = 2) approximately 12% (n incapacitated for some months or years (1 case).32 For most of the 12 women who failed to immediately neutralize labels of deviance, the return to "normalcy" was a slower, more 296 agonizing process than for those who could early neutralize the effects of the act.- For most women, experiential or cognitive mechanisms operated to reduce strain, as in finding a new love, marriage, a subsequent pregnancy, re-integration into school or work, blaming the economic order for personal suffering, and "learning to live with it.“ The final and fourth question was raised earlier: how do the present broker arrangements contribute to, or reduce labeling and subsequent self-recrimination? Developing protective mechanisms may be related, in part, to the type of abortion network itself. In other words, the ease or difficulty of making it through the network may account fOr later reactions to abortion. As presently organized, the abortion network is a "mixed" order--normative prescriptions against abortion are blended with availability of resources, if the necessary “trouble" is taken. Whereas, the illegal order promoted secrecy and anonymity, the broker order requires openness and exposure to established representatives, as in clergy, social workers, and physicians. The greater the number of these professional contacts required, the more likely the woman will be subjected to possible re-interpretations of her conduct. Shielding the self-esteem from moralistic implications becomes difficult with forms to be filled out, questions raised about marital status, and the woman asked to reconstruct the past to discover "why she became preg- nant," or what kind of social and sexual relationships she has had. As a whole,clergy have altered their approach greatly since the "early" days of "problem pregnancy" counselling. Morality tales now are eschewed by most counselors to be replaced by agendas of time, 297 place, type and cost of abortion,and travel arrangements. Complaining clients, however, point to the delay in getting appointments with professionals, the moralistic posture of some clergy and doctors, the absence of infionnation about the medical procedure resulting in unanticipated physical discomfort or pain, and the burden of repetitive Out-of-state travel is a ubiquitious counselling performances. The lack of continuity in problem, both in cost and inconvenience. medical and supportive services requires clients to seek medical and/or agency care removed in time and place from the abortion procedure. Clergy informants estimate client ”loss" in the context of these arrangements to run as high as 25% of all abortion-seekers. Some women, fearful of discovery, may choose an illegal abortion as an easier way (Four women of this group out than negotiating this complex order. tried the illegal route, but found that "good" abortionists were impossible to locate, or if located, the women were rejected because of "emotional" or "physical" problems.) Conclusions In tracing the movement of abortion seekers through the referral network we draw tentative conclusions regarding consumer participation in the abortion market. 1. Client routing through the legitimate network is somewhat more complex, both 10 isticall and s cholo icall than movement through the illegal structure.3g And, while the number of contacts has apparently increased leading to greater public exposure of the woman's "problem,” the time required to negotiate service is probably similar (average 2-3 weeks) for both abortion routes. Surgical costs for clinical abortions are significantly lower than fer illegal abortions, or for hospital abortions, whether If total costs for the service are in New York or Michigan. computed, however (i.e. pre-abortion lab tests, pelvic 298 examination, car or plane fare, limousine and taxi costs, motel, restaurant, and post-operative physician fees), the cost of a legally-induced clinical termination begins to approximate, but still does not equal, illegal abortions or Michigan hospital abortions. The "high" cost of abortion continues to be the emotional experience itself that is compOundedbysubjectively expressed delays, "trouble" with the involved man, difficulty raising funds, and reluctance to travel out of state for the procedure. 3. Gaps and redundancies in the referral nezwork, noted by Cumming for social services, generally,3 are most acute in the follow-up period. Discontinuity between phases of service implies that social support before the abortion received at point A (e. . clergy counsellor) may be unavailable or lacking at point B (e.g. social service agency or physician). Client postponements or evasions in contacting professionals after the operation are commonly reported. Physical or psychological disabilities that are relatively easy to modify after initial onset of the disturbance, may develop into more serious problems if left unattended. A chief factor in client reluctance to seek post-operative treatment is lack of a local, central referral system, incorporating pre- and post-abortion counseling and medical services in one setting. 4. Persistence of nonnative constraints on abortion,1eading to temporary or extended self-definitions as deviant,may be facilitated by the relatively elaborate rituals of counseling, physician advice, or agency processing. The term “counselling,“ itself, developed within the therapeutic ethic, implies "opinion," or "instruction" in "directing" the judgment or conduct of another. Most persons seek professional counselling when they experience an impasse in their everyday lives, perceived as too ovenwhelming or problematic for self- correction. Abortion infonnation and referral, covered by the presumably neutral term, "problem pregnancy counselling" could undergo a corresponding change in title, in keeping with a medical definition of the event with counselling an optional service. Labels of deviance, learned in interaction with professionals, will probably remain a persistent feature of present arrangements. Until the broker system is replaced with locally-available, low—cost, legal abortons, the procedure will continue to be a risk commodity for many consumers. We consider efforts by established groups to reconstruct the meanings of abortion for consumers and producers alike in the next chapter. Current myths, contradictory images, and opposing rhetorics of abortion provide alternative models of what abortion means, and how to 299 treat "it." In describing the transformation of models, we show how a series of negotiations over the meanings of abortion resulted in a new set of emergent rules connensurate with a conception of abortion as "nonnal," preventive health care. CHAPTER VII—~FO0TNOTES See, for example, Christopher Tietze, M.D., "Early Complications of Abortions under Medical Auspices: A Preliminary Report," Studies in Famil Plannin 2 (July 1971):l37—l43; S. M. Wassertheil, C. B. Arnold, R. C. Lerner, "New York State Obstetricians and the New Abortion Law: Physician Experience with Abortion Techniques." Unpublished paper. Department of Community Health. Albert Einstein College of Medicine, Bronx, New York; and Bernard N. Nathanson, M.D., "Ambulatory Abortion: Experience with 26,000 cases (July 1, 1970 to August 1, 1972)," New England Journal of Medicine 286 (February 24, l972):403-407. Nancy Howell Lee, The Search for an Abortionist. Chicago: The University of Chicago Press, 1969; Peter K. Manning, "Fixing What You Feared: Notes on the Campus Abortion Search," in James M. Henslin (ed.) Studies in the Sociolo of Sex New York: Appleton- Century Crofts, I971. Rains demonstrates this point well in the case of maternity care facilities for unwed mothers. (Prudence Mors Rains, Becoming an Unwed Mother: A Sociolo ical Account. Chicago and New or : Aldine . Atherton, Inc., 19715. Clergy-informants suggest that the rationale for not marrying among couples-in-love who discover an unwanted pregnancy, is the desire to avoid starting the marriage with what is perceived as a liability (i.e. a child). Further, the reduction in white adoptable infants is a consistent complaint of adoption agencies. Subsequently, some agencies are redefining their roles to include "problem pregnancy" counselling (in interviews). Demographic characteristics of patients are discussed in Tietze, 22. a. The ratio of abortion to deliveries rises very steeply among the very young and among women approaching menopause. See, Malcolm " Potts, "Legal Abortion in the U.S.A.: A Preliminary Assessment, The Lancet (September 18, 1971):651-653. This includes 36 completed interviews and §_incomplete protocols. In the latter Ease, there is an absence of qualitative data regarding the search, but demographic characteristics, place, . time, type and costs of abortion are indicated. Also included in these incomplete schedules is the post-abortion evaluation. . Throughout the report, the numbers of responses for each item Will be shown. See Appendix E for a copy of the interView schedule. 300 8D 16. 17. 301 These stages are adapted from Lee, 0 cit. , and Manning,_gp.c cit. In large part, this chapter is a rep icated study taken after this earlier work. Courtesy of Reverend Owen Akers, Center for Religious Affairs, Western Michigan University, Kalamazoo, Michigan. I am indebted to Keith Pattison and Mary Walker of Central Michigan University, and Kathleen Gerhard, Michigan State University for their careful tracking of persons believed to have had an abortion, and their conscientious work in interviewing. Marilyn Bell and Stacia Robbins, Women's Center, Kalamazoo, Michigan, provided both interviewees and insights to the referral network in that part of the state. Edwin M. Lemert, Social Patholo . New York: McGraw-Hill, 1951, pp. 75-76. See, also, Manning lgp, 213,, p. 139) who suggests that sexual intercourse is a "routinely" occurring event in the context of college student interaction. Clark E. Vincent, Unmarried Mothers. New York: Free Press, 1961. Rains (_p_. cit. , pp 32- 33) emphasizes that commitment to conventional moral standards characterizes most unwed mothers. These categories are constructed by the observer, rather than the actors, although the aim was to develop the category in terms of the expressed experiences of the women. Clergy data show that fbr approximately 69% of women counselled, there was pg or very irregular use of contraceptives. Before the emergence of legitimate brokers, abortion alternatives and decisions were largely resolved before the search. (See, Lee, Chapter IV). Manning, pp. 912., p. 155. Lee, pp. cit. Table 17, p. 69. My data on social chains is presented in a someWhEt different manner than that of Lee or Manning. Whereas, they “count" each unit (person) as a link in the social chain only when the chain was successfully completed, (i.e. an abortionist was located), I include all contacts made as inclusive of a linear movement through the quasi-private, quasi—public structure of abortion communication. My approach, while not completely comparable, seems warranted by the present arrangements. My aim is to show that in spite of relatively high incidence of abortion among college women, the number of persons required to reach an abortion remains approximately the same, or even greater, than under the illegal structure. 18. —-l 21. 22. 23. 24. 25. 26. 27. 9. 302 Lee, op. cit. Table 14, p. 55. Manning (pp. 515., p. 147) holds that under conditions of a abortion system," the infrastructure is both "unknown" and "invisible" until a search begins. I am indebted to Joan Mulligan, R.N., Assistant Professor of Public Health, University of Michigan, Ann Arbor, Michigan, for the original outline of this flowchart. I have added, primarily, the abortion social services network to her scheme of "alternatives and decisions in the pregnancy cycle." Nathanson, pp, £13., pp. 403-407. Approximately 25% of the 26,000 abortions a year performed at this clinic are done for a reduced fee based on recommendationsbythe referring clergyman (p. 404). Sources of data here also include observation of New York and Washington D.C. clinics, observations of the procedure, and women's reports of the clinical experience provided by the Michigan Clergy Counselling Service for Problem Pregnancies. In an unpublished paper reported by the New York Times, June 8, 1972, Tietze shows that a higher incidence of complications follows from the use of local rather than general anesthetic. This is attributed to the probability that doctors "operate in a hurry" when the patient is under local anesthetic. Freestanding clinic counsellors report that after 8 months or so on the job as a counsellor-circulating nurse, the pressure is frequently unendurable. Absenteeism or high turnover is said to be one way to resolve the strain. A good discussion of this issue is found in James M. Henslin, "Criminal Abortion: Making the Decision and Neutralizing the Act,“ in J. M. Henslin (ed.), Studies in the Sociology of Sex. New York: Appleton-Century-Crofts, . This notion was first developed by Matza and Skyes in their analysis of delinquent boys. (”Techniques of Neutralization: A Theory of Delinquency," American Sociological Review 22 (December):664-670, 1951. F. Dunbar, "Psychosomatic Approach to Abortion“ in H. Deutsch, Psychology of Women, Vol. II., Motherhood. New York: Grune and Stratton, 1945, pp. 179-201. Valid studies in understanding of psychological sequelae are said to be largely absent in this early period. (See, N. M. Simon and A. Senturia, l'Ps chiatric Sequelae of Abortion: Review of the Literature, p. 9 5, 1964," Archives of General Psychiatry‘ 15 378-389. October 1966). 28. 29. 30. 31. 32. 303 J. D. Osofsky and H. J. Osofsky, "The Psychological Reactions of Patients to Legalized Abortion." Paper presented at American Orthospychiatric Association Meeting, March 1971 (to be published). Lawrence A. Downs, M.D., David Clayson, "Unwanted Pregnancy: A Clinical Syndrome Defined by the Similarities of Preceding Stressful Events in the Lives of Women with Particular Personality Characteristics." Presented at the Twentieth Annual Meeting of the American College of Obstetricians and Gynecologists. Chicago, Illinois, May 3, 1972. The presence or absence of stress is indicated by statements taken from the interview protocols. No stress includes the absence of negative statements regarding involvement in abortion before or after the operation, or positive statements only regarding the abortion. "Low" stress is inferred from statements such as "some worry," "mainly afraid that my parents (boyfriend or friends) would find out," "no major problems," and so on. "Moderate" levels of stress are inferred from statements such as "very worried," "scared," "continuous hassles," "trouble," "afraid of being sterile," "what a mess - pressure from school, parents, and being sick," and so on. "High" levels of stress are indicated by assertions such as "I felt guilty all the time," l'cried all the time," "I had nightmares about it," “severe depression," "I killed my baby,“ and so on. These statements, of course, are suggestive only. It is only in the context of the total interview that we attempt to interpret the woman's mental state. See Henslin, (pp. pip.1 pp. 120-122) for similar categories of neutralization techniques. Significantly, I found only one differ- ence between my sanple and Henslin's in this regard. While rhetorics are similar for both groups in most respects, my sample included clients routed by women's liberation groups. These persons are more likely to eschew personal guilt, and instead, to assign "blame" to outside agents--the law, culture, political order and so on. Gebhard found 9% of abortionees with psychological difficulties following illegal abortion (P. Gebhard, pp. al., Pre nanc Birth and Abortion, New York: Harper, 1958, pp. 208L210). Swehish data show that 26% experienced self-reproach following legal abortion, 14% in mild form, 11% seriously so and 1% to the p01nt of impairing working capacities (Martin Ekblad, "Induced Abortion on Psychiatric Grounds: A Follow Up Study of 479 Women,“ Acta ngchiatrica Et Npurologica Scandinavia, supple., Vol. 99, 1955 (Donald Burton, translator). By comparison, somewhat over 50% of the group analyzed by Lee report either moderate or severe depression and/or nightmares following their abortion experience (Lee, pp. £13., Table 37, p. 105). 304 33. We base this comparison on Lee's (pp, pip.) data. 34. E. Cumming, Systems of Social Regulation. New York: Atherton Press, 1968. ‘ CHAPTER VIII RECONSTRUCTING THE DOMAIN: INSTITUTIONALIZATION AS A NEGOTIATED ORDER PART I: What Has Changed? A Summary Statement This study documented and described changes in shape and direction of the abortion market. This involved considering altera- tions at different time periods in amount and kind of abortion services available, cost and technology of service, type of providers, and distribution patterns. We interpreted change as an outcome of entre- preneurial, or risk-taking, activities made possible by efforts of a relatively small number of concerned clergymen who launched a movement specifically to defy the law, and to change the health delivery system in abortion. By using resources from both legitimate and illegitimate sources to create a broker network, clergy entrepreneurs linked consumers to various points of service. This chapter has two parts. First, we summarize changes in the abortion market. This serves as a prelude for the second part which considers a crucial meeting in the history of Michigan abortion reform. This was a Public Health sponsored Abortion Facilities Planning Committee which met over a six—month period (October 15, 1971 - March 18, 1972). The Committee, composed of representatives of 305 306 health occupations (i.e. hospital administrators, physicians, nurses, Public Health officers and university professors, a social worker and clergy), were asked by the Director of the State Board of Public Health to prepare a proposed set of guidelines for abortion facilities. With abortion reform on the November 1972 ballot, Public Health groups believed that voters would approve legal change. Along with promptings from the clergy and other reform groups as well as from organized medicine, they wished to be prepared for what they saw as an "emergency" situation, once abortion was legalized. This meeting is a crucial one for discussing institutional change in abortion practice because it illustrates: 1. The problem of legitimating abortion as a "normal" medical procedure, 2. the struggle by health occupations to impose rules that reflect their own interests in abortion practice, and 3. the way in which the brokerage model (i.e. counselling and referral) was used by some committee planners to legitimate this new health service. To summarize the study, we raise three questions: 1. What was the organization of the market-—both legal and illegal sectors--into which the clergy moved to generate resources and social support? 2. What market components changed as a result of the brokerage system? 3. What were crucial changes in the environment pennitting clergy entrepreneurs to open up untapped channels of exchange and to stimulate a new economic organization? In the first place, abortion market organization was split into two sectors-~the legitimate medical and social services sector, and the illegal, underworld of criminal resources. Both market forms 307 reflected organizational response to legal constraints, but with each market sector responding in a different way. Providers in the medical market, in attempting to partially meet consumer needs, supplied a limited, highly controlled service. Local community expectations and pressures, type of setting, andiprofessional beliefs and ideologies determined whether or not services would be available, and if avail- able, the number and types of persons provided service and mode of treatment. Clergy entrepreneurs regarded problems of consumer access, maldistribution of services,and high costs to be paramount deficiencies of this order. In pointing to perceived inequities, the Clergy Counselling Service pppp these deficiencies as a rationale for building a network of medical, counselling, and referral services that they believed would more adequately cope with unmet needs of women. Members of the Clergy Service individually recruited physicians, social workers,and other agency personnel. In this way, they tapped legitimate resources without really altering the official structure of the established system. Providers in the illegal market, in responding to consumer demand, offered services--but at a price. Lack of quality control of treatment, high costs, geographically scattered facilities, and "doctors“ who shifted in-and-out of the abortion scene were typical problems for referral persons. Interdependencies, both subtle and complex between professionals and abortionists, and between other helping persons and abortionists, tended to keep the system going in spite of strong reluctance by some referral persons regarding their 308 role in this hazardous "business.” Greater accessibility of illegal resources.as compared with hospital abortions.encouraged widespread use by referral persons even with legal risks for professionals and medical and social risks for patients. Changes in the abortion market involved three phases. In the first phase (1963—1969), clergy entrepreneurs linked legal and illegal sectors by tying together community health resources with illegal resources. Here the individual clergyman served as middleman linking consumers to different phases of service. No direct connection existed between legitimate and illegitimate providers. During the second phase (late 1969-1970), referring clergymen, who up to this time had been operating as loners, came together to form a social movement with the support of reform elements in the legis- lature, family planning leaders, and other concerned conmunity profession- als. Experience during the early period in negotiating prices, treat- ment, and facilities with underworld operators demonstrated to clergy leaders the malleability of an economic structure, once competition between providers could be developed. A competitive marketplace, in turn, enabled the Clergy Service to intervene in the newly legalized New York clinics, demanding services in keeping with the ideology of patients' needs. In attempting to adjust costs and to revise treatment programs, the National Clergy Movement stepped into what was fonmerly the exclusive sphere of physicians and hospital administrators. And, in furnishing a health care model that linked patients to counselling and referral service, clergy brokers altered conceptions of traditional medical care far beyond technical requirements. 309 In the third phase (1971-present) referring clergynen expanded the network to incorporate a variety of helping agencies, lay counsellors, and other community resources. "Problem pregnancy" counselling and referral, formerly viewed by agency workers and board persons, as extraordinary, or "crisiS" counselling, became a routine (if often questionable) part of many agencies' agendas. Despite reduced risks, agency response has been uneven. Lacking an official mandate for service, and constrained by costs and community and board opposition, agencies coped with this additional program by offering only partial services or by selecting a preferred clientele. The Clergy Service, beginning with an original 6 members expanded to almost 300 counsellors, and succeeded in diffusing their counselling model to dozens of agencies across the state. Outside competition from more "efficient" business enterprises is a recent threat. Paid referral agencies.moving into this potentially profitable market,offered a "stripped-down" service connecting women to New York physicians' offices without benefit of counselling or public health control of medical services. Overall, the brokerage was characterized by contingencies in out-of-state routing, gaps between points of care in the health network,and financial and social costs for "producers" and consumers. Changing conditions in the environment permitted widespread manipulation of legitimate and illegitimate resources by clergy entrepreneurs. These also inhibited tight enforcement of the abortion law. Some conditions were: (1) changing public opinion, (2) legis- lation of abortion, (3) reconceptualization of abortion from immoral 310 and "bad" medicine to a medically sanctioned health service by some physicians and family planning leaders, and (4) legalization of abortion in other states. These afforded one set of environmental conditions constraining enforcement agents in systematically prosecuting offenders. Problematic conditions of enforcement within the legal system itself were still another set of circumstances that made for a hiatus between law pp_jpyp_(or formal laws prohibiting abortion) and law pp_jpppp_ (or enforcement practices). For example, in 1963,a changed legal definition of the aborted or to-be-aborted woman as victim, not co-conspirator, eliminated this category from standing trial. The almost negligible number of citizen complaints in recent years, court problems of getting willing witnesses, costs of prosecutions, and competing agendas in enfbrcement bodies (e.g. drug violations or homocides) also contributed to inconsistent and weakened enforcement practices. Drawing on a legal review and opinion of the present status of the law, clergy acted on belief that counselling Michigan women to have abortions is ppp_illegal if abortion occurs in a jurisdiction where the procedure is legal. By geographically separating processes--coun- selling in-state and medical procedure in out-state jurisdictions-- brokers remained virtually immune from legal sanction. The remainder of this two-part chapter traces the process of norm-making--definitions, negotiation, and consensus-~by representa- tives of health occupations in a Public Health Committee, setting up proposed rules for abortion practice. Our method is to take selected messages from the Committee corpus that we interpret as crucial for 311 understanding institutional transformation. First, we present the content of transactions. These are the debated issues that had to be settled before proposed Guidelines could be distributed to hospitals or clinics. The issues were: (1) defining abortion, (2) determining how services would be organized and distributed, and (3) regulating services. Next, we show the politics of reform in terms of (l) contrasting ideological models of health care, (2) changing structure of the physician's role, and (3) alternative rules for abortion practice. Delineating critical issues and political transactions reveal the process by which subjective intentions, ideas,and beliefs become transfbrmed into objective plans for action. In this way, we show how "naming" the object allowed for increasing advances in objectifying the problem, and permitted negotiations over proposed rules and occupa- tional interests referred in these rules. And, in interpreting the changing structure of the professional role as a feature of the varying contexts of abortion practice, we show how legitimating abortion is also related to a larger set of issues regarding institutional crisis and change in the health field.1 Sample and Methods Attendance at a PublicHealth sponsored Abortion Facilities Planning Committee meeting over a six-month period (October 15, 1971 - March 18, 1972) provided the major source of data. Nineteen repre- sentatives from medical or health-related occupations and organiza- tions were included as permanent members of the working committee. 312 There were physicians, public health officials and professors, nurses, hospital administrators, a social worker, and one official representa- tive from the Clergy Counselling Service who had permanent membership. Two other visitors“ representing the Service attended almost all meetings. There was pp consumer representative in the group. My role was that of a "passive" observer. I took verbatim or nearly verbatim notes for approximately six meetings.2 Later meetings tended to be repetitive or even cyclical with "old" issues brought up in a different guise. Fieldwork notes tended to reflect this, increasingly becoming more sketchy during the last few meetings. I conducted formal interviews with 11 of 19 full-time members, including extensive or outside committee contact with 8 of the 11 persons. Almost all members knew each other ppfpyp the Committee formed. This promoted friendly interaction on a first-name basis. It also contributed to verbal moderation (for the most part), and efforts to resolve apparent disputes, or "table" them until the group felt that they had adequate infonmation to move ahead. The practice of tabling or evading issues made it difficult, if not impossible, to segment the "natural" speech flow. Discourse took a zig-zag pattern with issues appearing, disappearing,and re- appearing weeks later. I had to reconstruct meanings out of what often seemed to be irrational and inexplicable utterances at the time they were spoken, and present these as a coherent message. To do this I tried to discover the logical connections between disputed issues, opposing beliefs.and contending authority claims. Undoubtedly, I neglected issues considered strategic by some Committee members. I 313 touch only briefly, for example, on plant requirements and room space; despite whole meetings dedicated to these issues. I try to convey some of the substantive content that was exchanged, although I cannot capture the various moods of humor, seriousness, pettiness, altruism, anger, and by a few opposed to change, genuine anguish. To discern salience of issues, I used repetition and time spent on each issue as indicators of problem areas. Dispute required little investigative subtlety. After a few meetings, it was comparatively easy to read cues, and to detect significant ideological differences. Key informants, also present at these sessions, helped to bridge persistent gaps in my understanding of the proceedings. In sum, the methods of analysis for this section include: (1) nearly verbatim transcription of most meetings, (2) analysis of documents (7 drafts of the Guidelines and minutes of meetings), (3) follow-up interviews clarifying meanings, and (4) linguistic techniques used in anthropology for mapping semantic domains.3 A qualifier is in order. Structuring the domain of meanings is related to two conditions. The vocabularies any investigator selects to represent the "real" psychological dimensions reflect, to some degree, the particular speaker's idiosyncratic views of the world, as well as his ”collective images." In selecting only certain meanings from the total message, I also interpret these domains in theoretically- relevant ways. Bailey's programmatic paper on the study of conceptual systems in politics was adapted to my analysis of occupations as political entities.4 The substantive task was to investigate the problems of institutional legitimation by showing how planners tried 314 to construct guides for action in an ambiguous and conflicting situation. Defining the Object--What Does Abortion Mean? At the outset, the working committee, many of whom participated in constructing the first draft of the Guidelines, assumed that theirs was a "rubber-stamping“ function. In other words, most members believed that they had primarily a supportive role in approving an already established set of Public Health regulations for proposed abortion facilities. The task, as it turned out, was far more demanding than anticipated. A series of working drafts served as a catalyst for evaluating, differentiating,and defining the problem: what is abortion, and what does it mean for different occupational groups potentially involved in this service? In time, members representing their respective occupations developed clear-cut ideological differ- ences. These differences, however, were not initially recognized by the group. For the immediate problem that appeared to most was the nomenclature itself. How the object (i.e. abortion) is defined, indicates or evokes certain organizational and technical responses, which the Committee wished to control for political reasons. In the view of some, "abortion" evokes a set of meanings that are medically and publicallyobjectionabie, For many persons, the term, "abortion“ is linked with such related terms as "abortion mill," "charletans," "butchers," "back—alley,“ a "business," “medically hazardous,“ "catheter," "criminal,” "medically-uncontrolled“ and so on. In the appropriate context, the use of any one of these terms (e.g. catheter, 315 charletan, septic) could "stand for" or be identical with any other term. The prevailing myth of the "evils" associated with the old order was juxtaposed against the medically appropriate terminology. This suggested at least five sets of oppositions (or contrasts) used by members to clarify which concepts are to be eliminated from use, and which concepts are to be activated for rule-making purposes. The contrast sets are as follows: criminal order : legal order abortion mill : hospital charletan (or butcher) : physician catheter : surgery sepsis : antibiotic control sterilization : .planned pregnancies' For some members, inability to distinguish which contrast set was to be activated for rule-making purposes led to repeated misunder— standings and tension. For a few, "abortion" invariably implied "abortion mill" which in turn, has these additional implications: Abortion mill 1 Business for profit y x Warehouse $ High cost Rule of large numbers 1 Assembly line treatment l Patient exploitation Figure l8.--Connotations of Term "Abortion Mill." 316 If the term, "abortion" was presumably identical to the nomenclature of the illegal structure, this required changing the term to fit the new conception of abortion associated with licensed facilities and medically controlled procedures. Subsequently, the official language was changed from "abortion" to "termination of pregnancy" or "termination procedure." By draft 3 this terminological shift was complete, but the document continued to retain the "old" language, "abortion mill." This conceptual holdover subsequently provoked a dialogue between some members. Physician A: What is an abortion mill? Public Health Professor: The "abortion mill" is a loaded word. It means cranking out illegal operations in mass numbers. In time, the word came to mean any facility giving large numbers of abortions. I would hate to see the term metamorphasized to mean any facility that provides large numbers of abortions. It's important that we give safe, low-cost procedures. This is the most important thing. Chairman: I want to avoid the word "abortion." I used "miscarriage" to mean abortion in the document. But what we're talking about is termination of pre- viable fetuses. We could call it "removal of the products of conception.” That's the definition given by the College of Obstetrics and Gynecology. Physician A: ACOG (American College of Obstetrics and Gynecology) uses the word "abortion." The opposition will say that this whole guideline says nothing about abortion, and that's what we're talking about. Public Health Professor: We're concerned about language. We want to make sure action is not being directed against contra- ceptives . . . This whole issue may be a spook. That is, the opposition may use this factor. Many. of these contraceptives interfere after fertilization. (emphasis by speaker) 317 Defining the object, then, required two other related terms to be differentiated. Abortion and contraception were to remain distinct semantic domains, even if in medical terms, abortion and some types of contraceptives (e.g. intrauterine devices and chemical abortifacients) perform similar functions (i.e. removal of the products of conception). Separating terms into distinct spheres avoided lay and scientific recognition that abortion was_pl§p_a form of birth control. Terminology, the group recognized, has dramatic impact for an audience. Political considerations demanded that such impact be taken into account in constructingplans of action. In clarifying different sets of meaning associated with abortion, the group eventually distinguished appropriate levels of contrast. In shifting categories from a I'lay'I classification (or "what everyone knows about abortion") to a "medical" one, distinctive features of each were identified. Salient features of discrimination include: the operation, the operator, rationale of treatment, type of treatment, and conseguences of the act for patient and institution. Figure 19 summarizes this contrast set. Social Or anization of Services What abortion means also became associated with site, or location, of the operation. “Site" evoked an entire range of related meanings, including features of time (i.e. length of gestation), procedure used, setting, mode of care, organization of staff and service, and cost. After repeated discussions over kind of facilities Public Health Guidelines were supposed to regulate, consensus focused 318 Dimensions of Contrast Features Contrast Set Lay Medical Operation Hazardous X Safe X Operator Disreputable, Incompetent X Respectable, competent (Board certified OB-GYN) X Rationale "Mental" reason X for Illegitimacy X Treatment Social reason X Preventive health X Treatment Catheter X Sterilization X Procedure X Vacuum aspiration X Consequences for Psychological reaction X Patient Sterility X Illness X Health X Contraceptive use X Consequences for Legal liability X Institution Malpractice X Loss of licensure X X Legally controlled Figure 19.--Defining Attributes of the Contrast Set of Abortion on Two Dimensions 319 on freestanding clinics (non-hospital—associated facilities). Hospitals, hospital out-patient units, and hospital-based clinics were, in large part, covered by hospital licensing acts. Freestanding clinics, by contrast, represented a new concept imported from New York, possibly threatening many old-line hospital administrators and public health officers. For over two-thirds of the sessions, the Committee reviewed some phase or other of this new conception of abortion service. Conflict centered, not only on innovative elements of freestanding clinics, but on discontinuities between standard hospital procedures and “free- swinging" or presumably loosely-structured clinics. Figure 20 illus- trates contrasting features of the two facilities. Misunderstandings and disagreements over setting generated controversy regarding which set of rules were to be applied to which medical situations. With hospital administrators demanding that the integrity of the hospital be maintained with restricted rules of access and tight hospital "standards," and with reform elements insisting on open access and low cost, there seemed little hope of resolution. Only after determining relevant distinctions between the two facilities in terms of time, type of procedure,and mode of organization was this issue temporarily resolved. In effect, almost all debate, once no- menclature itself was reconstructed, was on some aspect of this contrast set. From patient restrictions (e.g. residency), to equipment, to optional services, issues generated from clinic ppg hospital, or clinic g§_hospital distinction, provoked continuous dispute. Key issues revolved around four areas, though appearing to have little in common, actually were symptomatic of a continuous need to Features Tennination Procedure in Two Settings Referent New York City Freestanding Michigan OB-GYN Hospital Unit Clinic Location Clinic Hospital Time of l l Gestation Early Pregnancy Late Pregnancy Type of l l Procedure Vacuum Aspiration Saline, Hysterotomy, Hysterectomy 1 Tubal Ligation Type Of ' l Patient Care Ambulatory patient Resident, patient Length of i i Treatment Short—term (4-6 hours) Long-term (24-48 hours) Type of l l Setting “Mental-health" type Surgical—type Organization l ' l of Staff Team Unit: Physician- Hierarchical Unit: counsellor-nurse physician + nurse 1 4 counsellor (if any) 1 ancillary personnel Organization + of Staff Team Unit Hierarchical Unit: Key Staff l + Person Counsellor Physician Organization of + i Supplementary Minimal Maximum Services + + Record-Keeping Simple Complex Figure 20.--Contrast Sets of Two Abortion Facilities and Implications for Organization 321 structure the domain. These issues included problems of blood supply, mode of referral, identification of fetal remains, and scope of the Guidelines. On all four issues, latent questions of abortion were raised. What is abortion identical to? What is it different from? How is abortion similar to other medical experiences we have had? These questions, in turn, were related to the medical domain in this way. In abortion a special type of medical service? Is it the ppmp as a medical service? Or is it similar to something else--for example, oral surgery in a dentist's office or out-patient mental health therapy? Alternative views toward abortion were crucial for these had direct implications for organizing services and staff. We identify three variant meanings of abortion as (l) exceptionalistic medical service, (2) standard medical service, and (3) non-standard medical service. On the three dimensions, abortion is viewed, respectively, as medically special, medically non-special, and medically unlike other services known. Figure 21 charts these alternative views. Social Control of Abortion Service On four issues--blood supply, referral, fetal residue, and regulatory scope-—the clash between diverse occupational conceptions became apparent, revealing another latent point eventually brought to the floor. This was the issue of who controls, and conversely, who benefits from institutionalizing abortion. 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Public Health officials and c1ergy,especially, expressed concern with private laboratorys' practice of selling placentas and other blood residue, in this way implicating health organizations in what they considered questionable market transactions. Hospital adminis- trators also believed that policing this activity could be an over- whelming administrative task. Moreover, they said, facilities primarily devoted to abortion service lack built-in controls available in more elaborate hospital bureaucracies, with profit-seeking in blood a very real possibility. Since most terminations would take place in freestanding clinics, questions of both administrative costs and supply had to be dealt with. Countering this.reform physicians and public health professors attacked the assumption that abortion be identified with enormous blood loss. If,indeed, only minimal blood requirements for "early" abortion (i.e. low complication rates) were involved, clinics probably did not need to handle these products in the first place. Once it became apparent that all facilities would ppp.be handling the same type of procedures, blood supply could remain a specialized service for facilities with technical capacity to manage the commodity. In separating domains--clinic abortion for early 326 (safe) abortions and hospital abortion for late (risky) terminations-- members considered the blood issue, first as analogous to the blood bank, where blood loss is socially acceptable, and, then, as a problem of bureaucratic management. Hospital Administrator A: Chairman: Hos. Adm. A: Public Health Professor B: Speaker B resumes: Public Health Professor C: Hos. Adm. 0: Where did you get the idea of two persons to a room? I'm thinking of the mental and physical trauma associated with this procedure--hemorrhaging, and so forth. I'm with you here. I think we are considering two different things here. One is the freestanding clinics where you don't have serious complicated procedures; the other is the hospital situation. That's a.different matter. (Change in topic) There's a good analogy with the blood bank. They've lost a great deal more blood in the blood bank situation than in this procedure. The patient must be on the table for ten or fifteen minutes. This is a critical point right after the procedure. This is where equilibrium, that is, body homeostasis, is occurring. If patients will follow directions, there are going to be very few who are going to have any kind of repercussions. We simply have to orient ourselves here to a different concept. How practical is the storing of blood? Blood can be a very severe problem in terms of the amount of actual supplies you have to keep on hand. The typing and matching ladies in the pregnancy age class is very complicated. You have to be aware of type and cross-match reference. You need a great deal of supply here. You also need an alarm system, and you're probably going to have to consult a pharmacist. The storing of blood by modern technological requirements is very complex. If you're going to have an effective blood service, you need a more involved business than a freestanding clinic would be able to provide. A medical dictum is that if a person needs blood, he probably needs more than one ‘. -~.‘.- ass. 327 unit. The transfusion requires full scale equipment and technology. Why have this done in a second- rate facility? . Public Health - Professor B: I agree. Once planners related blood loss to a particular type of procedure and setting, freestanding clinic opponents (primarily hospital administrators), could then get down to the business of preserving the hospital order from possible infringements by way of this newly proposed medical service. Mode of Patient Referral Mechanisms of patient referral, examination of fetal tissue, and facilities to be covered by guidelines related to two unsettled matters. What is the responsibility of the facility in providing treatment programs, and hence, physician responsibility to patients? What are likely problems of medical control generated by a still indeterminate clinic organization? In each case questions were posed, on the one hand,as a dilemma between physician autonomy, and on the other, as threats from outside interference. Controversy over professional prerogatives versus patients' referral rights took the following line. If physicians have pp_ responsibility fer interagency referral, and yet are legally and morally responsible for controlling patient care, who, then, is responsible for referral? Is it professional control without responsibility? Or is it professional responsibility without power to control the situation? Further, if providing abortion depends on first organizing an inter~ agency referral system, both costs and administrative complexity of 328 liaison-building could prevent any service from developing. For some the broker arrangements--clergy counselor, agency,and physician linkage--had to be legitimated in the new structure. A model of health care as a community enterprise was contrasted with a professional model of occupational claims. We analyze the two models in the next section. For now, we give the content of dispute, expressed in the contestant's language. This suggests how members shaped the boundaries of this domain. Public Health Dr. W. (presidnet of OB-GYN Assn.) believes that Professor A: any patient not given complete information on pro- tection of family planning at the time of abortion is not receiving good medical care. Physician B: For the freestanding clinic, the main function is to provide abortion and to take care of all the rehabilitation (i.e. post-operative) cases. Public Health But the clinic must have the means to hook the Professor C: patient up for health care. The clinic is not responsible for being saddled with all the health care, however, Liaison with referral agencies must be maintained for follow-up of abortion patients. Yet, I'm scared to death that the rules and regulations for licensing are getting to be too much. If we have to preve by the document that we have established liaisons, we never will open up the freestanding clinics. Clergyman: The issue here is whether we are going to give abortions or give social services as well. Public Health I would like the social services concept built Professor C: into the clinic service. (Discussion of language of "should" (i.e. recommended) or "shall," (i.e. mandatory)for organizational referral) Physician D: I don't have to refer if I' m busy. I just say, "I can't take you.I Public Health Professor C: Physician S: Physician B: Chairman: Public Health Professor C: Chairman: Public Health Professor C: Physician B: Public Health Professor C: ‘329 But there's a time limit here. And how are we going to handle this? For instance, women are running around New York now. They can't be taken in by one facility and they may be wandering around trying to get a termination. (Reading from the document, relating to referral, and pye- and post-operative care, one physician said: What do all these things have to do with abortions-- referral, physicals, and so on? What does checking the woman's ear have to do with sucking out her uterus? It' s not a uestion of what I do, but what we're goi_ggto reg_ire y law. (Discussion of physical examination.) Who's going to make the referral out of the clinic-- not the counsellor? The physician is captain of the ship, and he has to know the counsellor's evaluation. The physician properly makes the appropriate referral. Who should make the appropriate referral? The counsellor may know more about the patient than the physician. Doctors are legally and morally responsible for patients throughout their contact in the facility. We're talking about a larger set of issues--marital counseling, sex counseling, and other social needs. The natural childbirth pe0ple try to take over the physician fucntion. But I want to know what's happening to that patient when I'm responsible for an institution. My name and reputation are involved in this. I want to know what's happening in this referral business . . . The doctor has to have the word on everything. After all, he may be sued. The physician, in controlling the referral, is taking on a domain outside his control. The physician awareness of the community resources is involved here. Welre concerned with patients who can't get care because the doctor does not grant permission. 330 Patients' rights, from subsequent discussion, hinged on the autonomy of the counselor, or at least, the counselor in a viable team relationship with the physician. Physician S: The counselor-circulating nurse role is most important. This is the support person for the patient. A model that we have is the counsellor as the doctor's helper. Social Work The counselors in New York are unionized. They are Professor: not only doctor's helpers, but doctor's critics. The doctor can be fired if they don't like his style. Physician A: This is the doctor as technician? Social Work Yes. Professor: Physician S: We have a model in our minds of New York, and that's the one we want! Chairman: I don't question what's going on in New York, but I question if Michigan should initiate this. The committee eventually resolved referral and control issues in favor of physicians. They declared referral to be non- mandatory with counsellors to work through practitioners on any referral matters. (We take upphases of rule resolution in a later section.) How to Control the Controllers? Yet, committee physicians, whether private practitioners, or public health officers and doctors, recognized that boundaries must be placed on physician autonomy and control. Borrowing imagery from the criminal abortion system, doctors were held to be susceptible to "profiteering" in the lucrative abortion trade. "Charletans" could ruin it for everyone, eSpecially,if they moved into this potentially 331 open market and set up unregulated clinics and abortion programs. How to keep physicians "in line" without encroaching on occupational rights was a crucial problem. Discussing tissue examination of fetal residue brought into focus the dilemma of professional control versus regulatory action. The interchange took the following line of reasoning: Physician A: We shouldn't put too many controlsv< opnwmcoammm AFFmeoz Asuweeuaav spw_waawo Pumas Apcmspmwgkv zpwrwnmwg _mme newsmuso chowmmmwogm emet_oaao eaaom z>w-mo afioeg z>w-mo =_ eactaau wmcoowg _muwvmz umecoeueoa< _ama__H Lmuwmmo sppmm: QWFnzm qumnmoz ago—_mmczoo mmesz ecumeumwcwse< :mwowmzza soe>epo< Lo mopgnwauo< a_oa 356 Figure 25.-~Cont. Code: Attribute present Attribute absent Attribute may or may not be present Claim disputed in committee Attribute present, but illegitimate Not applicable vvll+ +oo \AA + n Second, there are two other professional claims asserted to be essential requirements for performing abortions. These include surveillance (or judgment) by peers only and legal responsibility for treatment. Peer control in abortion has been typically problematic, whether under the old criminal system or the new clinical organization. In effect, hospital-administrator review and Public Health regulation of facilities have been necessary regulatory devices to assure that professional judgments are in compliance with the law. Committee sentiments, however, support this claim as an jggal, rather than a universal attribute of medical practice. As for legal liability for treatment, this is undenwritten both in Medical Practices Acts and in hospital and professional norms. This means that the physician can be sued by the patient if treatment is unsatisfactory. Or he can lose hospital privileges if his performance is judged as grossly under par. Expressed fear of malpractice suits was a crucial consideration in keeping guidelines tight to insure physicians'protection from mal- content or disturbed patients. Almost all committee members were willing to honor this claim, broadening the physicians' rights considerably. A few dissenters thought the issue to be a "red herring,“ really serving to obscure the problem of consumer protection. But 357 theory and practice supported this claim, despite lack of unanimity as to political implications. Consensus held peer judgment and legal liability to be probable (or ideal) attributes, not necessarily obligatory aspects of the physician's abortion perfonming role. Yet, critics also recognized that from the physicians' viewpoint, these claims had to be accounted for in the guidelines.if a state-wide abortion program were to be launched at all. We label these maximal role components to differentiate their relativistic status from other consensually-held obligatory attributes, licensing and special medical knowledge. a Three, professionals asserted still other role attributes as necessary to perform abortion, but that may or may not be present in any individual case; or that may be shared with other occupations. Board certification, legal responsibility for the facility, moral responsibility, advisor-counsellor, referral person, and medical treatment--all are optional role features in that they are neither necessary nor sufficient for abortion service. In some cases, the attribute enhances legitimacy of abortion; in other cases, it complicates or reduces legitimacy; in still other instances, the abbribute is irrelevant to physicians performing abortion. For example, board certification, while hardly necessary for giving abortions, is standard in New York City clinics and hospitals.13 One committee physician fought this for proposed Michigan clinics on grounds that it would raise costs and force many patients to travel great distances into hospital centers with available board-certified physicians (this physician is a general practitioner). 358 Obviously, moral responsibility for treatment is an assumed requisite for any physician performing medical services. This requires the physician to act in the best interests of his patient. In abortion and related family planning services, however, a gap between rhetoric of health care ("It's the doctor's job to safeguard the health and well-being of his patients") and practice of withdrawal or denial of services has been a controversial subject. Some committee members felt that physicians tend to impose their own values.which may or may not coincide with those of their patients. When women have been denied contraceptive protection, or have been given inappropriate birth control that leads to pregnancy or illness, the physician does pg§_ regard himself as morally accountable ("after all, if they want to play, they have to pay"). For purposes of the Guidelines, challengers felt that moral responsibility could be neither legislated nor recommended. Instead, rules specifying the domain of patient care would more adequately delineate available services and types of treatment. As for the attending physician effectively juggling all the medical-counselling-advisor-referral roles, this could not be taken seriously. Early procedures in abortion entails large numbers of patients with rapid turnover of clientele. Why slow the process down, challengers asked? The role of para-professionals in abortion clinics was crucial (e.g. in New York clinics, nurses give pelvics and local anesthetic). Weren't clergy and agencies now handling almost all counseling and legitimate referrals? Clergy-agency participation, while not strongly endorsed by professional medicine, certainly was not opposed by physicians who had little regard for this "dirty work." 359' Many viewed physician take-over of counseling and referral as returning to pre-clergy days, as once again professional roadblocks create barriers to consumer access. Not only would fewer patients be accommodated, but increased cost inevitably follows this greater demand on physicians' time. Or worse, counselling and referral would never be an essential part of the abortion program. Overall, this could lead to complications and delays in legitimating processes as citizens once again are prevented low-cost, efficient abortion service. In a move to incorporate facility-control claims into the Guidelines, physicians demanded that unless they could determine what was going on in the abortion facility, they could not properly assume legal responsibility for that treatment setting. This presumed physicians invariably plan to serve as directors of freestanding clinics, in this capacity supervising all program phases. Most Comnittee members rejected this claim, for here physicians perfonn administrative roles independent of perfonning or legitimating abortion service. New York clinics have medical directors, a position that involves supervising professional personnel and treatment programs. In model clinics policy-makingis ajoint decision between administra- tors (often non-physicians) and medical director, who also share authority with other professionals and non-professional staff. Finally, there was one strongly disputed claim, largely unspecified, but that had sweeping implications for organizing abortion service. This was the assertion of autonomy or, as stated in this Committee,”professional perogatives." In one sense, professional perogatives was not a separate category at all. Rather, it was a summation of claims that could be construed as the following: 360 Physicians performing abortion service must not be constrained by legislative, administrative, public health, or citizen bodies. Rules for practice must reflect physicians' interests and professional needs. Professionals cannot and will not enter this problematic health area unless their traditional rights are preserved. Above all, professionals gg_gp£_§pgpg medical responsibility with non-physicians or patients. Counsellors, nurses, administrators,and public health officials serve to assist, to administer, and to mediate with professionals. To disrupt this pattern by sharing authority could reduce the physician to an employee or "technician" hired only to perform the repetitive abortion technique. "Abortion-on-demand," the code used by consumer-rights advocates, was an equally pernicious doctrine. This assumed that patients buy medical services in the same way as other market commodities. In extreme form, a few professionals considered only the physician as competent to make the abortion decision in the first place; whether on medical or moral grounds. While not yet a committee consensus, a pattern of role components clearly emerged. We show this pattern-—minimal, maximal, optional and disputed charac- teristics--in Figure 26. In short, members conflicted on a number of issues. Rule resolution required that planners link professional claims to the social context within which those claims "made sense." Planners needed to differentiate those circumstances within which one set of rules should be activated (e.g. pre-legalized hospital practice) as compared with another, even contrasting, set of rules (e.g. legalized clinical practice). Questions of professional autonomy and authority had to 361 .mowumwempoeemso eopsamwo ecu .chowuao .pmewxm: .Pmewcmz “masocanoo mpom mo :Lmupmauu.o~ mgamwu soe_wnemcoamae esteem u up AsowPVUaev »o__mnawp _a=o_mmacoea u o Pmcgwwom u pp AucmEpmmsuv zuwpwaewF chowmmmmoca n m “cospmweu Pwowemz u op acoEmuzn chowmmwmoea n e xsocop=< u m eavewpgmo eeaon,z>uimo n m go—Pmmcaooxeomw>n< u m mcwcwmgp z>wumo u N minmcoamoe >Fpmeoz u m omcmow_ n F "once NP m nu .ll.mucm:oqsou umuznmwo m .. s I S w m N o ... mAIIII mpcmcoaeoo flog 228.53 . . . (limpcmcanoo wFom peewxmz mucmcoaeou mFom FmEvaz 362 be reconsidered in terms of setting, time period, type of services, type of practice,and role incumbents involved. The mode of political inter- action--whether equal/unequal, cooperative/competitive--depended on , how these other variables were combined to produce a particular medical program. Figure 27 describes seven identified variants of modes of political interaction. In some settings, (e.g. pre-legalized hospital. setting) all professional claims are honored; in other settings some or few claims are respected; in one proposed setting ( the committee lacked direct observation), the physician lost all but two exclusive claims (license and medical knowledge) serving as technician or employee. Professional claims are most likely to be honored in pre-legalized, hospital settings, where traditional medicine still views abortion as exceptional. Professional claims are least likely to be honored in the post-legalized, doctor-office setting run by a business entrepreneur (physician or non-physician). These settings are also least likely to offer ancillary services--counselling, referral, and contraceptive treatment. Professional claims are modified by shared authority in New York City's model clinics. Here, physicians work within a complex division of labor, wherein counsellors, nurses, administrators.or sponsoring group (e.g. clergy, Planned Parenthood, or Women's Liberation) team-up to mobilize and to sustain an innovative health program. We summarize situational variations in professional authority in Figure 27. 363 mpconE:ochFom ecu .wowpomgm $0 maze .nowemm wave .mcwupmm an wow>eom cowugon< :_ :owuomgmch Fuowpvfiom eo mono: eo mpcewem> cm>omnu.- mezmwu cawo_mm;a Cowpeoaa mmuteeo m>vapmaeoo .szcwca .cwsu< mmmcemzm mZmz . voww—mmwpuumom m_gopooo =a_owm%;a Aocaeoaapsov Loppmmcsoo :owpeoam owcwpu w>muwpwaeoo .Fmscocs -Lopmepmwcw5c< mzmz + umuwpmmm—uumom wave: model cmwowcnuop Apcmwpmapsov mFecowmmmwoem :owpeonm ow:w_u m>_pwpmanu .va _mzcm -mgmmucmvowm>:m mzmz N umNPchwFIpmom mcwucmpmwocu Apcwwumauzov wmgsz sewpeonm owcwpu m>wumemaooo .Fmsom lea—_wmczooucmwowmzcm mZmz + uwNVmew—upmoa mcwucmpmmwed epmwcowucwn< :owpeonm .Em zocmmemEm w>wuwpmqeoo .Fmscocz :mwowmzsm mzm I cmNPFemmpumga _mpwamo: goFFomcwoo mmuaz :owpgonm pcmvpmach m>wuwpquou .szcmca :mqumzza mzm . vw~wpmmmp-pmom mFmpmamo: Azcm ewv LoFmecon wflzz + cowpeoam ucmwumach m>_weewaooo .Fmaumcz :mwowmzzm m2m . meWmempumLm qumamo: :onLone Apcmwpmach m>wpmeoaoou .szcm :mwowm>;mucwwuwmzcm m2m - umNWmempuwea Fmpwamo: meowpmazqu mpcmn5302H opom mowpomgm mmow>gwm nowgwm meek mcwpwwm :Hme: mcoe< we maze Lefi_wuc< cowooaeapeH Paoepmpoa ea one: xgopmucmz Figure Code: -—I II N H (A) ll 01 -5 II II 364 27.--Cont. Mandatory ancillary services refer to counselling, referral,and contraceptive treatment as built into the treatment program, and are coded plus (present) and minus (absent). Type of practice discussed in an earlier section includes: EMS - Exceptionalistic medical service; SMS - Standard medical service; NSMS - Non-standard medical service. Identified in New York. Indirect interaction only. Proposed in Committee. Members had neither experience nor obser- vation of this interactional set. If we construct a formula showing how claims relate to particu- lar treatment settings, we see more clearly how professional dominance (or major claims honored) is a function of the situation. Figure 28 summarizes the rules of combination for appropriate political interaction. The formula links situation to political interaction and yields the following set of rules for abortion practice: 1. An abortion procedure that is judged as difficult and dangerous, involving extensive hospital services, is a claim for profess- ional authority. Ancillary services are optional and are determined by the attending physician. An abortion procedure that is judged as moderately risky, but takes place in a hospital, is a claim for profeSSional authority. Ancillary services are infrequent. An abortion procedure performed on a hemorraghing or septic. patient in a hospital emergency room is a claim for profeSSional authority. Ancillary services are determined by the woman's private physician after referral from the emergency room. An abortion procedure such as vacuum aspiration or other low risk surgery that takes place in a clergy-or agency-sponsored freestanding clinic is a claim by contributing occupational groups (e.g. nurse, clergy service, counsellor, administrator) for shared authority with physicians. Anc1llary serVices are mandatory and are built into the structure of the treatment program. 365 .m_om chowmmmwocm on» we wuoz Fwowww—om Low cowpmcwasou wo mmpzm mewNwLw553m aF=ELodnu.m~ wgzmww .mow>emm Fmowvoe ugmucmpmlcoc . mzmz mmuw>ewm Fmowuos wemecmgm u mzm mmUw>me _mowems owwmwpmcowpamoxm I m2m ”mmuswocw mowpomga wo maze u . wowwwo m.;ouuou u . N ucmem> owcwwo n O (‘0 Q‘ LO Q P “camem> owcwpo u 500; >0cmmLmEm Fmpwamo: u .N _aowamoe u ._ "wuou :owpwcwueonzm Fecowmmwwogm u m< . mzmz + mos .m :owumcwceoasm chowmmmwogm u m< + mzmz + «u .m xuwgogpaw umemgm u m< + mzmz + mo .e mocmcweou chowmmmwoga u m< . m2m + Nam: .m mucmcwsoe —m:owmmmwoea u m< - m2m + I .N mocwcwsoe Pecowmmwwosm u m< . mzm + FI .P ovoz FmUwuw_oa wow>ewm xgmppwoc< wowpumea wo waxy mcwppmm 366 5. An abortion procedure that takes place in a freestanding clinic organized by non-medical persons, is a claim by organizers for authority over the physician's task. Ancillary services are mandatory and are determined on ideological grounds (e.g. women's liberation clinics.) 6. An abortion procedure that takes place in a doctor's office lacking public health control, is a claim by business organizers for authority over the physician's task. Ancillary services are optional (if available at all) and are determined by administrators' assessments of added costs, competition with other facilities,and market conditions. Rule Resolution--Phase I Actually, we have stepped beyond the boundaries of immediate Committee concerns in interpreting professional claims in terms of these varied contexts. The key dispute was over formulating ground rules for clinical practice in what most planners considered a con- servative, if not often hostile, medical environment. Counter claims by rival occupational groups were muted, or were accorded secondary attention mainly in reference to how these ancillary roles would fit into the overall medical program--a program created, supervised,and maintained by physicians. In what most considered to be the final Rules Document, planners bowed to professional demands. In this context the community model has all but vanished, though remnants of the ideology'wereexpressed in ”good will" statements, as in "the patient's general welfare and safety" are of ”paramount concern," with "privacy and emotional concern of the patient to guide all phases of termination performance." The document had a pronounced adminis- trative-physician orientation with approximately 94% of those paragraphs denoting prescriptive clauses having to do with technical or medical organization. Patient care provisions were subsumed within these categories. 367 Collision of health models, expressed in opposing ideologies, resulted in exposing latent conflict earlier unrecognized or ignored. Conflict, symptomatic in the issue of physicians' rights versus community claims for service, was resolved in Committee in favor of professionals. Despite reluctance of organized medicine to exert leadership in changing laws or practice, a point established by planners, medical terminology, interests, and claims became the set of values coalescing moral meanings for planners. Committee minutes nicely record this collision and resolution: . there was lengthy discussion of planning in facilities in accord with community needs with particular emphasis on this potentially leading to ultimate franchising of facilities by the Department of Public Health, thereby interfering with the rights of the physician to practice when, where, and as he pleases. Also the development and achievements of regional comprehensive health planning bodies and their less than impressive history to date were mentioned. After lengthy discussion and assurance by Doctor that the Department has no intent of attempting to interfere with the private practice of medicine and that the licensure considerations are directed toward facilities, equipment, and services and not the individual physician's professional perogatives, it was decided to delete the last sentence of C, 4,_ relating to cooperation with regional comprehenSive health planning bodies and to retain the first sentence emphasizing community needs. "Community needs" in this document, however, are phrased in recommended (i.e. I‘should”), not prescribed (i.e. "shall”),terms and have a total of twenty words, including the provision, "insofar as this is possible." In the final analysis, the document skirted the controversial issues of abortion service as a generic problem of health care organization, and, instead, represented the special interests of a relatively small group--medical directors and entrepreneurs setting up abortion clinic practice. Rule Resolution--Phase II In a reconnaissance meeting held one week befbre the l972 elections, the Committee reconvened to pool information and to plot strategy for combatting the increasing strength of the anti-abortion Legal change, to be decided by ballot, had been considered a forces. Now it appeared to be in profound fiait accomplj by reformers. trouble. High Public Health officials, absent at previous meetings, conducted the final session. officials proposed a revised set of "Emergency Rules," reflecting Without prior Committee approval more clearly the special interests of the State Public Health Depart- ment in regulating this new service. The modified rules clarifying the treatment program had these major changes: -- A provision for counselling and referral was included, making Patients, however, these services mandatory fOr facilities. may use services as needed," and "without coercion." -- Counsellors were recommended to consult with the responsible They were no physician concernihg counselling or referral. longer obliged to work under the physician's supervision. -- Liaisons with a range of.social services were reguired for all facilities "to assist in medical care, social,or'vocational rehabilitation." An inter-agency network, however tentative, was built into the structure of abortion treatment. -- Financial exploitation of patients was explicitly fOrbidden. Since Guidelines have the same constitutional power as law in regulating licensing fer facilities, commercial operators over- charging fbr services,theoretically;could be closed down. -- Contraceptive instruction and supplies were re uired as part of the tenmination program with appropriate referral for subse- ' quent attention. -- A special section of the Guidelines dealt specifically with patient care as one of eight units of concern (including general provisions, licensing, personnel, laboratories, trans- portation services from clinic to hospital, plant facilities, and records). 369 Although the patient care section is somewhat less than 10% of the total document, a language shift from recommended to required on many provisions demonstrated a strong Public Health commitment to patient protection at all treatment phases. The intent of this section written under the direction of the Public Health Director, is exemplified in the opening statement (Rule l7): A woman applying for termination of her pregnancy or seeking infor- mation at the facility concerning any aspect of the procedure shall be received in a kindly and sympathetic manner. (Italics mine) Clergy and abortion refbrm advocates could not have said it better. What is missing from this document and largely bypassed by the Committee is the unresolved question of consumer costs. Denial of'medical treatment because of inability to pay or lack of available public services are outstanding issues to be taken up now that abortion has been recently legalized.‘4 Conclusions This chapter began with a summary of the abortion market in Michigan. Changes in market organization were triggered by a clergy social movement and sustained by a state-wide brokerage system of clergy, agency, and volunteer counsellors. To legitimate this change, however. two additional steps were required. One was to legalize The other was to have ready a set of rules fOr Refbrm by ballot failed. abort ion reform. medical practice once abortion was legal. Instead, a Supreme Court decision in February l973 legalized abortion. the rules remain as "guidelines" or "suggested courses" of action without legal power or enforcement machinery. Undoubtedly, the 370 battle for safe, humane, low-cost abortions will be resumed. In the meantime,women entering the marketplace confront a system of scarce, .expensive hospital abortions and unregulated clinical services. Whether abortion continues to be a problematic and costly health service for consumers can only be determined after the new order is more firmly established. The chapter also explored rule-making processes in regulating abortion service. We considered these efforts to legitimate abortion by way of a transactional framework adapted from the anthropologist. F. G. Bailey. This approach explored the conceptual categories and terminological domains used by representatives of those health occupa- tions most likely to be involved in abortion service, and therefore, most affected by its organization. To understand what issues were being negotiated, and how negotiators related issues to beliefs in efforts to realize claims fbr power and solidarity, we used the following procedure: 1. We took three issues, based on repetition and time spent over the course of the hearings, and interpreted these as the most salient concerns fbr planners. Befbre rule fermulation was possible, the Committee had to wrestle with a redefinition of abortion (or renaming the object), the type of social organi- zation they would be regulating, and problems of social control in those facilities regulated. We then showed how reference terms for abortion vary by setting and kinds of practice. Legitimating abortion required that appropriate terms be connected to specific contexts of use. 2. Having described these domains, the next step was to link the disputed issues to variations in conceptions of health care. we identified two contrasting ideologies in terms of political vocabularies used by participants to assert claims and organi- zational preferences. The professional model of health organization emphasized physician solidarity and control of ,medical resources. The community model stressed interdependence of'health occupations and community control of resources. 37l 3. To discover the rules for relating content domain to political domain, we showed how claims for dominance by one ideological team (i.e. physicians) take place with reference to changing professional roles in abortion service. Professional dominance, or legitimate recognition of these claims, was realized in some kinds of contexts, (e.g. hospitals) but not in others (e.g. new clinics). Rule-making reflects the ambiguity generated by these varied medical situations. Until the newly legalized system is more firmly established, any attempts to create conventions for connecting the variety of health occupational roles into a workable political structure must be tentative. We can expect future shifts in rules with perceived changes in public opinion by rule makers, revised strategies for delivering abortion services, changes in composition of the legislature and other regula- tive bodies, and reactions of Public Health officials and health occupations to new forms of practice. Competition and conflict in this area seem unavoidable, and to some observers, undesireable and unproductive. Prior to legaliza- tion, anti-abortion forces are said to have spent millions of dollars to defeat the Michigan abortion referendum. The ranks of this counter- movement swelled by its success. Intensification of pro-abortion activity--perhaps with a tighter, better funded organization--may destroy the few links still evident between contending groups (especially anti-abortion Catholics and pro-abortion Protestants). Some health- care organizations, caught in this struggle, may renege on any commitments to abortion-seeking patients. Or they may continue to hedge in making a fUll commitment to this clientele. What price politicization? FOr abortidn crusaders, there is hope of a new structure.more adapted to the needs of'women who seek services. For ‘_.._-- 372 traditional physicians, there is resistance to fitting medical practice into citizen demand for what many still consider high-risk medicine. For anti-abortion groups, there is renewed dedication to keep abortion in tight boundaries imposed by legislative, public health, and professional control bodies. Whatever the effect of renewed political activity for various interest groups, the conflict over abortion has raised some serious questions for many citizens regarding such problems as health care organization, consumer rights, and legal-medical control of high-demand Whether abortion becomes a fully legitimated medical resources. It is safe to say, service in the near future is hard to predict. though, that whatever structure evolves from this struggle, it will reflect the discontinuities and uneasy authority relations prevailing among health occupations today. A Final Note--Institutions and Legitimagy How institutions come into being and survive or fail to survive is a central question guiding Hughes' study of occupations and the moral division of labor.'5 In Hughes' analysis, institutions serve as distributive systems defining what is proper demand, and the kind and type of legitimate resources available. But distribution is never "complete or perfect," Hughes notes. Deficiencies in institutional distributions (e.g. art, education, food, shelter, public services, etc.) tend to encourage new collective fOrms. These may arise out of collective protest or'may reflect chronic long-term deviations. They may operate without benefit of law, 373 although often with the connivance of the legal establishment. Such "bastard institutions," while arising from different sources, have the same social processes as are found in legitimate institutions. These may be illegitimate distributors of legitimate goods and services. Others satisfy wants not considered legitimate as in gambling, prostitution, the rackets, black markets (e.g. adoption, abortion, "quack" medical practitioners), professional crime, and bootlegging. All take on organizational forms not unlike legitimate institutions. Bastard institutions are often directed against the law, or the declared moral values of society. While they are equivalent to institutional forms in many ways, we suggest some differences: l. They are "corrections of faults in institutional definitions and distribution" (Hughes). 2. They entail high risk (costs) for participants. 3. They are more likely to be unstable, and/or change organiza- tional forms and personnel to adapt to new conditions and demands than are established systems. 4. Unmodified by collective protest, bastard institutions are unlikely to influence legitimate distribution because they lie outside the realm of respectability (the major claim for legitimate distributors). 5. Because of lack of legal control and efforts to maximize profits, bastard institutions are more likely to have inferior products, lower standards of production, and to involve "marginal pro- ducers" than are products distributed by legitimate organiza- tions. Bastard institutions endure so long as they give expression to values and wants of a particular population and can insulate themselves from competition with other institutions. Changes in institutional life probably reflect a cyclical pattern. This may take the fOrm of: (l) deficiencies in institutional distribution, (2) collective protest _..—— ' " ' ’ ' _""""'“""" ' ' 374 or chronic deviation (at time l), (3) rise of bastard institutions. (4) collective protest (time 2), (5) legitimation of former bastard institutions. The crucial feature of survival, whether legitimate or illegitimate, is that institutions adapt through specialization, or by orienting themselves to the limited populations they serve. Once formerly illegitimate exchanges become legalized (i.e. legitimate),new institutional roles, a new division of labor,and new control problems for role incumbents arise. What was once devalued and illicit now becOmes reputable and respectable, although there is probably some time lag between legitimating an institution and accep- tance of this new state of affairs by institutional groups. For the new institution to survive, occupational groups must maintain control over activities, define problems it will encounter, and devise and justify ways to meet the problems. In other words, continuous adap- tation is required for any institution to survive. What implications does Hughes argument on problems of institutionalization and legitimacy have for the abortion case? Survival of a newly legitimate abortion institution in the reform image is by no means assured. Like other medical "products," it may well become the exclusive property of professional control groups who will be aided and abetted in this activity by other insti- tutional groups,such as the legislature, public health, and hospital administrators. Women will be served, but only in the context of a physician-dominated service. Professional adaptation to this population will probably take a number of organizational forms (e.g. hospitals, regulated clinics, unregulated clinics, office abortions, etc.) to fit expectations and budgets of different clientele. 375 Institutional groups used the clergy.broker model at earlier stages of legitimacy. It is unlikely, though, that counselling and referral in an interdependent health network will become a mandatory part of abortion service unless other conditions change. This means that, while abortion as a bastard institution may become legitimate, there is no necessary association between the process of legitimacy and the final institutional product. This is so because institutional routines, unlike voluntary movement activities, involve full-time committed occupational groups. Institutional practice, moreover, tends to conform to pre-established agendas and interaction patterns. Movement charisma.furnished by leaders and their innovations,attracted believers. This, too, is replaced by traditional professional-client: relations in a bureaucratic or professionally controlled setting. In a word, discontinuity prevails between legitimation processes and institutional practices. New forms of collective protest seem inevitable if abortion is to'become a prototype of a new health delivery system. At this point, that prospect appears bleak. 10. ll. 12. 13. 14. 15. CHAPTER VIII (PART II)--FO0TNOTES For an excellent discussion of the role of ideology in political systems see Clifford Geertz, "Ideology as a Cultural System," in David E. Apter (ed.) Ideology and Discontent, New York: The Free Press, 1964, pp. 46L76. This notion of myth is taken from Bo Anderson, “Revitalization Movements," Acta Universitatis Upsaliensis, Skrifter Rorande Uppsala Universitet 17, Uppsala, Sweden, p. 361. K. Burke, Permapence and Change, Los Altos, California: Hermes Publication, 1954 Edition, Chapter 8. For treatment of this general issue, see Eliot Friedson, Professional Dominance: The Sogjal Structure of Medical Care, New York: Atherton Press, 1970. A related concern, implicit in my discussion of the symbolic world of the physician, is the view of "profession" as an ideology. See Robert W. Habenstein, "Critique of 'profession' as a Sociolo ical Category," The Sociological Quarterly, (November,lg63), pp. 291-300. This analysis of role attributes with accompanying figures summari- zing the data is taken from Bailey, pp, 513, In interviews with New York City clinic and hospital physicians and directors. A general discussion of changes in the health institutional network is found in Harvey L. Smith, "Crisis in an Institutional Network: Community Health Care," in H. S. Becker, B. Gear, 0. Riesman, R. S. Weiss (eds.), Institutions and the Person,_Chicago: Aldine Publishing Company, 1968, pp.7157L164. Changes in the conception and economics of health services are also evaluated by two economists. They consider the "normative shortages" inducing "inequity in the distribution of the consumption of health services" a major force for reorganization of the medical "market place." Howard R. Bowen and James R. Jeffers, "The Economics of Health Services," General Learning Press, 79 Madison Avenue, New York, New York 10016. Everett C. Hughes, The Sociological_§ye: Selected Papers, Chicago: Aldine-Atherton, 1972, Chapters 1, 2,710. APPENDIX A METHODS OF INQUIRY: SOCIAL ENTHNOGRAPHY IN COMPLEX SOCIAL SITUATIONS 377 - “Nat—H -A==-. —- ‘-.__,-—:::...._~ . ._ APPENDIX A METHODS OF INQUIRY: SOCIAL ENTHNOGRAPHY IN COMPLEX SOCIAL SITUATIONS Researchers in the social sciences typically view research designs as "steps" procedures. The process of inquiry is said to logically proceed from a substantive problem to a theoretical framework that generates hypotheses: the problem, the theory and the derived hypotheses are seen as gUiding subsequent research decisions such as the sampling schedule, the data gathering techniques, and finally, the analysis of the data. However, the processes of fieldwork (or all research for that matter) in complex social situations proceeds in a less clar-cut manner than the reconstructed logic. There is, instead, constant interplay between theory, conceptualization and data, and between methods and stages of the research. The experiences of. fieldworkers in putting together a picture of a complex social structure have been less systematically analyzed that the more rigorous, idealized sequence of decisions and commitments outlined above.1 As a result, the whole area of methodological skills in naturalistic settings--such as "grounded" theory,2 purposive sampling, changing tactics of data collection, the role of the moral-political identities of the researcher, use of multiple perspectives, and re- visions of the descriptive mode1--remain to a great extent unspecified. 378 gun—‘- ;——~~ ~ __._~,__. 379 Admittedly, the anthropological tradition provides sound guidelines for addressing many field problems, but the limitations are many. For example, the sociologist often cannot translate the experience of those anthropologistsworkingln relatively homogeneous settings with a non-Western people over a relatively extensive time period, to his own research situation. Unlike the investigator entering a small, well-defined community where everyone seems to share the same culture, the ethnographer studying complex societies confronts a maze of overlapping cultural groups. Distinctive, geographically- bounded groups, characteristic of the culturally-homogeneous setting, are the exception. Instead, the fieldworker finds interdependent populations with multiple subgroups occupying a large, ill-defined territory.3 The sociologist or anthropologist doing social ethnography in urban social settings requires multiple research strategies, entry into a variety of groups and organizations, access to "secret" documents, and ability to negotiate relationships of rank incongruency (or those in which the investigator has negative statuses or less power than his informants or respondents). Add to this the following constraints in which: (1) the project is a one-person enterprise with limited research funds, (2) the study operates under time limitations becauSe of the rapidly changing nature of the subject, (3) there is a need to maintain diverse informant relations over many months, while at the same time, (4) the ethnographer attempts to build a picture of a social process in which even the informed participants and relevant issues must be discovered in the course of the study. 380 This Appendix documents problems of my fieldwork in the changing organization of abortion service within the framework of a cumulative research strategy.4 This shows the developing phases of research that methods, data, inferences,and conclusions took in the course of 18 months of field study. At each stage, particular methodological issues were more salient than others. At the same time, the logic of discovery required continuous defining and redefining of the problem. In a word, methodological issues, seemingly resolved at one phase of the study, loomed up again in a different context because of problem re-definition or new evidence. Moreover, in the cumulative strategy scheme, neither methods nor techniques are "fixed" before entering the setting. The advantage of this flexible, multi-method approach is its adaptability to the various situations and settings facing the fieldworker. The rationale for ordering the methodological issues varies by both the nature of the problem and the investigator's fieldwork experience. The sequence below summarizes the research phases in terms of identifying and resolving problems, and integrating data, concepts,and theory. 1. "Fishing expedition"--search for a model 2. Formal and informal interviewing--discovery of who, what, where, how,and why 3. Participant-observation--identities and ideologies of the researcher 4. Structured techniques--quantifying cases and generalizability. 5. Appraising the evidence--reliabi1ity and validity 6. Revising the mode1--final data analysis and writing the study .. .— v --. --_ n-u—rzv—Tz- ‘— t - -- ' _ .- _ - - . - Wx . .c ,._. _,_.. , _' 381 The following sections take up these phases by focusing on the particular problem at that phase, alternative solutions, and the research strategy chosen to "solve" the problem. Phase I--Fishing Expedition Undoubtedly, the most agonizing stage of the fieldwork involved getting the initial research “hook" into the abortion situation. This demanded that I develop a working model, or theoretical framework, for guiding the inquiry. Preliminary "pictures" of the social world of abortion came in three versions: medical, political, and journalistic (especially sensationalism). Surveys of the literature, documents, abortion-reform organizational newsletters, and preliminary interviews expressed, almost exclusively, the views of proponents or opponents of legalization of abortion. Separating "fact" from ideology seemed impossible. As it turned out, this proved advantageous for ridding myself of older methodological notions that “truth" was “out there, somewhere." The investigator simply has to "look for it.“ Instead, I took the controversies, ideologies, and contradictory explanations of events as ggpg_without determining, at least for the time, why or how to resolve the inconsistencies. Interviews and documents collected during this early period primarily aimed to uncover the boundaries of participants' beliefs and actions, useful for generating preliminary categories and hypotheses. While I attempted to remain open to the diversity of meanings, I did have some theoretical preferences that served as an initial set of fieldwork directives. Even before entering the field, I had been 382 working with a social control theory developed by Lemert.5 This approach considers social control, or institutional definitions and sanctions, as a product of differentiation. Because power to enact norms is concentrated among certain established groups often against the interests of less powerful social categories (e.g. blacks, women, young, etc.), social control has, as one effect, reaction by "under- dogs" as in rule violations and alternative social organizations (e.g. deviant careers). Lemert illustrates this by citing cases of systematic rule violation built into the structure of normative economic or social arrangements. Review of available literature and of abortion reform documents seemed to ”confirm" this situation with respect to abortion. Women of moderate means or less have historically lacked access to legal abortions. Instead, they have sought "alternative“ sources available from marginal or underworld practitioners. The control thesis appeared to "fit" the empirical case,,but propositions generated from this broad-based conceptualization seemed too general, if not even commonsensical. It was apparent I had to narrow the problem. Redefining social control as a problem of political economy required a shift in perspectives. From issues of rule violation I turned to sources of power, type of control of resources, and cost consequences for women and the public. The political economy approach strongly favored an exchange focus, or delineating interdependencies between established groups. This directed me to transactions of controlling occupations and organizations, which affected supply, distribution, use,and regulation of abortion as a social resource. 383 While this perspective would be modified later, it continued to inform data collection throughout the study. Readings in economic theory led me to narrow the problem further. A market concept, even more specifically than institutional approaches, could delineate political processes and mechanisms of exchange. The market.by definition, involves transactions in a specified commodity with actions of buying and selling, prices and profits, gains and losses played out in a supply-demand field. With a market concept, I could show concrete economic and political relations, and by representing these relationships in network form, show the organization of production and distribution of power. From this point of view, abortion "looked" different than the control or political economy approaches. 0n the one hand, a control perspective considers abortion as a deviant act created, defined,and maintained by more powerful social audiences (e.g. physicians, law enforcers, legislators, etc.) against less powerful persons (the poor, the young, the unsophisticated, and so on). Study of rule innovation, violations, and enfbrcement follow this conception. On the other hand, a political economy perspective directs attention to abortion as a controlled resource, with use and distribution regulated by legal, medical,and administrative groups. Institutional arrangements, in this analysis, are p_pyigpi_events or sets of interdependencies existing prior to regulation of this resource. The focus would be on types of interdependencies of regulatory bodies as these influence supply and distribution of abortion. 384 The market concept took me a step further by specifying abortion use and distribution, not only as interdependencies between producers, but as exchanges between producers ppg_consumers. Regulation, in this analysis, is an outcome of legitimate producers' efforts to contain a demand situation over which they had relatively little power to control. The various strategies used to restrict supply only served to generate alternative market forms (e.g. "black market"). The market model underwent certain modifications. Some of these were theoretical, as in including all forms of value when considering gains or costs of transactions (a point further clarified below). Another modification, stimulated by preliminary interviews, was to consider the conditions (legal, values, etc.) that constrain choice. In other words, I needed to place economic activities in a social context to make sense of specific decisions and actions. For example, physicians do give "therapeutic," or hospital abortions even with prohibitive laws, but they act continuously in terms of possible costs--1oss of licensure for hospitals or doctors, loss of community financing for the hOSpital, colleagial censure, and possible stigmatized identity. The notion of "costs" in risky ventures, as these influence actors' choices, was a final modification. The paradigm, focusing on the production side of exchange, took the following ferm: l. The social context for occupations or organizations that opt to become involved in abortion transactions (or phases of service) includes a "constant" demand for abortion services coupled with legal constraints. 2. Contradictory features of incentive (demand fur services) and constraint (prohibitive law) provide two initial conditions 385 requiring actors (e.g. doctors and hospitals) to juggle a a costs/gains assessment. 3. The advantages/disadvantages calculus results in few organiza- tions willing to take the necessary risks, inasmuEfi-as costs outweigh gains for most legitimate producers. 4. The collective choice of non-involvement in abortion services affects market organization by severely limiting the number of suppliers, and by creating induced scarcity with subse- quent high costs of service, and other market conditions characteristic of a monopoly (control by one producer) or oligopoly (control by few producers). The paradigm shows expected relationships in this way: _ Market r Constant fiStructure 1. Demand _ +774 1 ' Organizational Market Incentives Choice (or *7 Conduct _ and Evaluation + 5 . Market Constraints of Options) - lOrganization Canalizing r- Market Choice 3 Performance Legally- . a l. Induced + F Risks Distribution J 2 7 ' Figure 29.--Paradigm of the Abortion Market. The model assumes the market to be one entity with legal and illegal structures operating simultaneously to produce a concen- tration of market power. In turn, this condition of market power accounts for supply, distribution, and differential use of the resource. To operationalize this conception, I planned to do the following: I took the consumer demand situation as a "given" (#1). Most of the documentary evidence emphasized that this was high. I would, however, 386 look at the legal conditions by talking with law enforcement persons, legislators, defense attorneys, and so on, to understand how control agencies actually operated to maintain the law (#2), against what I took as the growing tide of change in this area. I presumed that these two contradictory conditions (#1 and #2) would be perceived by various "producing" units--hospitals, physicians, agencies, university health centers, and so on--as limiting and defining the possible options available (#3). In other words, I expected to find few legitimate organizations providing abortion service in any form, because of the high ”cost" of "production," as in legal and professional sanctions. I assumed that shortages of the legal commodity encouraged risk- takers, or criminal abortionists, willing to gamble personal costs for potentially high profits. A market structure characterized by only a few sellers (#4), provided the "causal" condition for market conduct, or sets of inter- dependencies among legal producers and between legal and illegal suppliers. In other words, hospitals could collectively "afford" to avoid giving abortions as long as they operated emergency rooms to take care of "botched" abortions from criminal sources. With few sellers and tacit cooperation between producers, market "performance" operated for the benefit of suppliers. Price, quality, quantity of service, and other market features (#6) were outcomes of the "oligopo- listic" market. Distribution of services was restricted to selected populations and areas of the state (#7). Some early interviews "tested" these market conceptions. While there was no direct fit between model and evidence, I began to 387 recognize how such diverse events as "market shortages," high price of the commodity, "costs" of service, maldistribution of resources, and other market components operated outside, so to speak, the direct control of any individual practitioner or agency. The "market" itself was an outcome, or consequence, of individual decisions and specific transactions by persons, often unaware of what the rest of the "picture" looked like. An interview with a University health service physician helped to clarify this situation. Investigator: Do you see any women here asking for abortion? Physician: I really can't speak for my colleagues, but I have two or three woman a day in my practice asking for abortions. Frankly, I feel overwhelmed with personal responsi- bility. I think I'm really one of the few at taking on this responsibility. Investigator: Is there a policy here at that covers this abortion situation? Physician: No, there's no policy. In the professional system there is a tacit understanding that each man in his individual practice does his own thing, but not visibly. Investigator: Are there any physicians with whom you talk about this part of your practice? Physician: No, it's a difficult problem.‘ There is little or no medical communication in this business. Investigator: Do you have any idea how town doctors handle patient requests for abortion? Physician: I really don't know what's going on. I'm frankly confused. I don't get any information from professional associations, journals or organized medicine. All I know is what I hear from the girls I deal with. The whole thing (abortion referral) seems to be handled only by indirection. Investigator: What kind of problems does the abortion issue create for the practitioner? 388 Physician: (Snide laugh) Some are making $100,000 a year take-home pay in New York. There really seems to be little sharing of this kind of burden. At the present time, there's a 50-50 split in the profession on the pros and cons of abortion. Professionals like to play God, and this makes it difficult to have any kind of rational discussion in this area. The way it's operated is (that) before New York there was the psychiatric route . . . that's the rich people's way out. The kids went to holes and came back with perforations and allied problems. That's when we saw them here at for post-abortion care after the damage was done. lhings are safer now. It's still illegal to give abortions in Michigan, and, of course, it's unsafe for any doctor to be involved in this . . . . Seems like a strange word, abortion. From these comments and other early interviews having a similar tone, I could only infer that (l) scarce legal abortions contributed to profit-taking by a few, (2) most professionals really were unaware of how colleagues handled abortion seekers, and (3) referral persons had no clear idea of the abortion structure. Three months of fieldwork using this model to generate questions and hypotheses convinced me that I was on the right track, but the situation was far more complex than I had originally thought. "Insiders" spoke repeatedly of a referral "system," of an elaborate trafficing of abortion clients across state lines that operated, at least in its earlier phases, in defiance of the law. How to integrate the idea of a referral model with my conception of a "scarcity" or "black“ market seemed impossible. The two threads would not join. Meanwhile, I continued to interview within the guidelines of the "old" model--abortion as a risk venture carrying high "costs" to producers, but with costs primarily absorbed by consumers and the larger public. . 389 Phase II--Formal and Informal Interviewing_ If the first phase of fieldwork was to "fish" for a model as a general guide for'fieldwork, the second phase was to generate data allowing for an evolving picture or revision of this preliminary model. This required tapping those occupational groups (viz., physicians, clergymen, social service professionals, etc.) first in line in handling consumer demand. In this way, I hoped to get a more concrete idea of the transactions, whether among producers or between producers and consumers. In a very significant sense, initial interviewing was a process of discovery. I needed to know'ypg_saw abortion clients, ppg£_occupations or organizations they represented, pgp_participants viewed the abortion issue, pppyg_they routed clients, pg! the mechanisms for regulating services operated, and ppy_some professionals and agencies were involved intensively in phases of service, while others rejected this clientele. At this point, I needed to explore alternative strategies for generating more productive data. These boiled down to three possible "solutions" to data collection: (1) "snowball" sampling technique, (2) participant observation, and (3) interviewer-selected sample. I could, for example, continue interviewing in the "snowball" sampling style,6 with respondents furnishing names of colleagues, associates, or local agency persons. In turn, these persons, once interviewed, provided still other names, and so on. I found this approach highly fruitful, especially, during the first months of fieldwork, when I had little notion of where to go or how to get contacts. But it rapidly had become a respondent selection of the population, instead of an investigator's sample, or so it seemed to me. 390 Although, I could trace the personal networks of a few pro- fessionals, the method had serious shortcomings. Solo physicians or agency workers have a few outside colleagues they turn to for medical consultation, most of whom have little or no experience with abortion policy and practice. They may, however, express strong opinions on the political and moral issues of abortion. Accumulating professional opinions eventually reaches a dead-end, when for instance, you repeatedly find that most gynecologists state resistance to abortion practice, while most pediatricians strongly favor medically-induced abortion for gggg_patients., I also found I could not pick up policy makers or centrally-located physicians who had direct experience either with abortion clients or with regulating this resource. Another alternative was to drop the circuitous, and as it turned out.inefficient means of seeking respondents, and instead, join the "political camp" of refbrmers. I could acquire, not only names of persons and organizations handling the bulk of abortion seekers, but also eliminate my own "identity-crisis" as a pro-abortion supporter forced to mask my own beliefs under the protective guise of an "objective" investigator. This was a tantalizing alternative, but not very practical. If I pursued this course, I would end up with a study of the "refonm movement," not an investigation of the abortion market. I confirmed this in repeated interviews with a "radical~refbrmer" physican, who later became a sympathetic informant. He convinced me that his view of the world, though similar to my own concerns as a citizen, was simply too "restrictive" and "political" to adequately understand and analyze change and multi-group conflict in the abortion market. After 391 wrestling with my own research identity, I opted for an autonomous base for operations as preferable, at least until I had established myself in the field as an independent investigator. One other solution to productive sampling existed. This was to interview some leading medical practitioners and researchers in Michigan. Instead of gaining access through friendship, possible through the "reform routeJ’but which committed me to a point of view, I presented myself as a "neutral" observer (a position, I believed to be the only tenable one at this time), writing a doctoral dissertation in an area where documentation was either inadequate or lacking alto- gether. I was both amazed and gratified at the results of this decision. For example, a leading public health professor, and a chairman of a distinguished university department of obstetrics, in each case,provided key information about the "state of the field," including various contradictions of medical practice in this area. On the basis of these data drawn from highly knowledgeable and influential persons in their fields, I re-entered the agency and practitioner scene with both a larger picture than formerly, and greater appreciation of the subtleties of medical control of abortion. I had another reason for interviewing prominent specialists. By this time I needed political capital, since as a "free" agent I lacked group or association sponsorship through the thicket of political thorns. My university credentials, while honorable, still did not place me as a particularly credible person for handling organizational "secrets" or verbal admissions of less-than-ethical management of this service. 392 Moreover, as a woman, I had at least three strikes against me. First, most informants held the assumption that as a woman, I, ”of course“ favored abortion and abortion reform. Negative statements tended to be muted to fit this imputation. Second, most physicians and agency directors (with a few exceptions) make no distinction between a woman "sociologist" and a woman "social worker," or between researcher and practitioner. The difficulty of establishing a professional identity became clear when I requested access to patient records from a hospital chief of staff (a point I pursue later). Third, apparently, there are relatively few folly professionalized women in medicine or medical research. "Para-professional" staff, as in nurse, technicians, counsellors, and so on, are "helping" personnel for most hospitals, physicians, and agency administrators. As a "para- professional," I could be an ally, "useful" for listening to the practitioner's "problems" in dealing with this "troublesome" client group (i.e. abortion consumers). But this is not the same thing as collecting data on concrete strategies of office or hospital manage- ment. To bypass the identity block, I used data generated by influ- entials and posed the interview in the following way: Investigator: Dr. , president of the OB-GYN Association mentioned to me last week (month) that he has altered his fbrmer policy of having decisions lodged in a hospital abortion board. Do you think your hospital (or colleagues) would be willing to try the consulting system that he recommends for hospital obstetric departments? Physician: Incredible! He can do something like that. Look at the situation he has there--a university teaching hospital insulated from the community with complete freedom to experiment in these programs. If we tried that here, the board would close us down tomorrow. 393 Investigator: Why does the board have this kind of power? Physician: It's not merely the board. It's the whole community. There's a resistance here to that sort of thing. We'd have the Catholic hierarchy on our necks. They'd get their lawyers and shut the hospital down. Investigator: But don't physicians react to this type of external control? Physician: Most don't want any part of that kind of medicine. Those that do can go elsewhere. We're running a clean hospital here. How could we possibly control some of those people (physicians)? They would abuse the freedom. We'd end up running an abortion mill for country (non- community) doctors who don't have the credentials for determining these kinds of decisions, much less giving this type of surgery. Using this interviewing strategy, attitudinal responses declined, and statements of patient management increased. Despite the additional information using this approach, I was still frustrated with the inability to "pin" down such issues as techniques of hospital screening of abortion seekers, number of patients served, professional rationales for service, and other specific data on patient processing. If I were to assess how the system operated, I would need other kinds of observations, fer instance, patient records, hospital abortion board proceedings, and surgical procedures. With this in mind, I began an extended series of negotiations with physician-gatekeepers in one hospital. After four months of letters and evasive tactics ("I'm sorry the doctor isn't in (again) for your interview. Try next week."), I insisted through the phys- ician's nurse that a decision be made. The interview turned out to be the stormiest scene of my entire fieldwork. After the doctor repeatedly denied that abortions were being given in "his" hospital, 394 I responded that his office colleague had told me differently. With that, he leaped to his feet, pounded on the desk, and shouted, "We're not having a bunch of lady social workers snooping around our hospital! and "besides, you don't know a damn thing about it." I agreed I had "little specific information," but "the reason for this was that physicians refused to share this knowledge with researchers or the public." While the interview finally concluded in an amiable inter- change, based on other researcher identities (educated, mature woman, possible patient, and so on), the hospital route apparently seemed closed. I felt that my data would be little more than impressionistic observations, or an "exploratory" study that went little beyond the first stage of exploration. During the formal interviewing phase, I did accomplish three crucial fieldwork tasks: (1) coding, (2) developing multiple perspec- tives, and (3) delineating network boundaries. I had worked out a plan for coding relatively early in the fieldwork. This involved setting up categories that reflected theoretical indicators and empirical issues. My purpose was to facilitate on-going analysis, or building-on these earlier materials for subsequent questions and hypotheses. I wrote up the interviews and fieldnotes during or immediately after contact with infbrmants. (Eventually, I mastered the technique of writing notes while keeping almost constant eye contact with the informant fOr "normal" interaction.) I then taped written materials to ease the recording and typing problem. Taping fieldnotes also permitted a second review of field materials, with interpretive comments added at the same time. 395 Ten copies of each page of the field notes or interviews were then filed and cross-filed with coded items of interest circled in red for easier reference. I found the categories developed during the fourth month of fieldwork extensive enough to handle most of the later fieldwork with some deletions, additions, integration of categories, and shifts in emphasis within a few of the categories. While coding contributed to on-going analysis, as well aslx> reliability and validity of the study, interviewing had an even more basic purpose. This was to understand the diverse meanings, or multiple perspectives, of those persons and groups participating in abortion service at whatever degree of involvement. Putting together an abstracted picture of a social structure required "seeing" the various parts from the points of view of many differently engaged 7 For example, if I was to generalize to the category of actors. "physician adaptation to consumer demand," I first needed to under- stand how physicians differ in terms of social location, type of practice, and previous experience with abortion patients. This situation held for social agencies and clergy groups as well. The theoretical framework required understanding the diversity of possible events, actors, mechanisms, and processes rather than the extent or degree to which these operate. I found that theoretical saturation of certain social categories enabled me to move into other areas of concern. I now began to place less emphasis on studying individual physician's strategies, directing more attention to "unit" analysis, or interviewing a variety of professional and administrative persons within a given organization. At this time, I also completed -.»— ..fi _ —. .. ..-._._ 396 intensive interviewing of key clergy organizers, who provided a history of the movement. Letters, documents, and "house" newsletters over a foureyear period clarified and enriched the spoken histories. Extending the unit-interview strategy into a variety of settings helped the referral network take shape. What once seemed to be a formless, uncoordinated set of individual professionals and discrete organizations having no connective ties, began to coalesce into meaningful patterns. Social agencies, for instance, began to "look alike" in having similar terminology and strategies for managing the "crisis" (problem pregnancy) client. Alternatively, other agencies "looked different" than these in developing evasive techniques to avoid abortion clients. I discovered that clergy counsellors have been mobilizing physicians and agencies, as well as routing consumers to medical and counseling services. Hospital emergency rooms have been picking pp_the medical wreckage of patients, risking health and life to get an illegal abortion. And police have become plggfi_in enfbrcing the law against the growing tide of change. The enforcement lag, especially after 1970, apparently accounted for the assertion by clergy that the days of "risky" ventures were over. The new system was working, but exactly how could not be determined yet. While I had identified two market forms--the legal and the criminal-~I now discovered three with all seemingly operating simultaneously. With this evidence, I revised the model to include referral activities, later termed the "broker" phase of the market. 397 With the parameters of the market structure assuming different values depending on which professional or organizational unit studied, I decided that more immediate involvement in the abortion "scene" might resolve the apparent inconsistencies. Phase III--Participant Observation The problem now was to focus on filling-in details of the market pattern, and to discover what conditions, causes, consequences, and social units existed for each market phase, and how these discrete phases connected together. With the closing of official doors to my proposed study of hospital abortions, I had reached a terminal point in re-plowing interview ground already covered. Moreover, I lacked both political contacts and professional credentials to get "inside" the system. Identifying the referral network revealed a skeletal shape, but it lacked substance. The theoretical threads--market and broker processes--seemed as disconnected as before. I had no data on or even access td.either the legal or illegal markets. Conversely, the broker arrangements seemed to be operating in a separate sphere. At this juncture, I could only infer that the processes of legal- hospital control limited "therapeutic" abortions drastically, and that criminal abortionists and clergy-agency brokers picked up the slack left by legitimate medicine. In other words, stringent regula- tion of a high-demand resource generates alternative channels of exchange. But what evidence could be brought to bear to either support or refute this hypothesis? On the surface, the solution seemed simple. Go out and find cooperative informants who could link me into the “established" order. 398 and use these observations to clarify my hunches. I earlier had established relations with a key physician in the reform movement, but resisted joining the friendly pro-abortion camp on two grounds. One reason was my reluctance to be tied into a specific network. This, I believed, barred future access to neutral, but especially hostile, professional and agency persons. The other was apprehension over my tenuous identity in the field, and frankly, fear of not being able to handle what seemed to be a premature role commitment to the "cause." For weeks, I dangled between identities--"believer" or "scientist." The entire episode appears almost in a mythical context as Ireview it months later. Staying aloof allowed freedom; but being free kept me from data sources. This paradox generated much agony. Even with relatively sophisticated fieldwork training, there are few sure guidelines for decisions of this sort. But fieldwork is a crescive process that has its own built- in "logic." I was devoting full time, seven days a week, all day and even late into the night "getting where the action is." The geo- graphical scope of my study, while necessarily limited, was still enormous for a one-person project. Michigan is a large state with a number of urban centers. I had early decided to delimit the terri- torial scope from my heme in the center of the state (Mt. Pleasant), south through Alma, Lansing, Ann Arbor, and including Detroit; in all, five communities of different degrees of rural-urban organization. (I later added a Southwestern city, Kalamazoo, to the community sample). My aim here was to construct local referral networks and compare and contrast the different types. Clergy, agencies, university health 399 centers, physicians' offices, clinics, and hospital administrators were some units sampled within each community. The job was a lonely and burdensome one with no apparent boundaries. While interviewing, I had made friendly contacts who told me of state-wide meetings, abortion conferences, a class-action suit (Women against the State of Michigan), or simply infonnal get-togethers of concerned "reformers." In time, a subtle shift in my public identity occurred. I became "known" as a person who seemed to appear at any and all gatherings, always with a bundle of notes and a huge handbag with assorted literature and documents picked up at the last interview or conference. As I became publically known, I, increasingly, found the alienated role of "neutral" observer not only inappropriate, but ethically wrong. It was not a question of my own convictions, of course. Even before deciding to do an abortion study, I had been committed to free choice in this matter. Now I was exposed to persons who were totally immersed in abortion reform as a way of life. In this context any and all topics of the day, inevitably, transformed into value and action commitments to the abortion cause. By no means, though, was the refonn movement a homogeneous one. The most intense factionalism occurred between, on the one hand, certain feminist groups whose platform concentrated on “repeal" and "abortion on demand," and on the other hand, the "moderates," whose position involved "refonn" through ameliorative legislation and medical and public health control. In eventually siding with the "ameliorators,” I antagonized the "radicals," who as women believed me to be a traitor, or worse, a nuisance. I seriously felt that they were right at the time. Reform would shore up the professional and 400 legal system, that has maintained inequitable health and welfare services for many citizens. At the same time, I also had to make a pragmatic decision. I had a dissertation to do, and this required that I sgpgy_the established order, not change it. But I found myself conflicted. In studying and teaching deviance, my sociological reference group was clearly of the "senti- ment-for-the-underdog" school in Becker's model. Yet, my allies included persons who were, without doubt, "racists," "sexists," (you're different, though), and "anti-welfare," ideologues. This situation forced me to construct a rather elaborate personal account of my field— work, justifying coalitions and participation in established spheres as a matter of "understanding the system to more effectively change it.“ In short, the ”reason“ for involvement was moral, but the decision was actually a pragmatic one. The ideological compromise allowed me to pursue fieldwork, and sort out social meanings, less in ideological terms, than in philosophical ones--or viewing society as a bundle of conflicting groups generating contradictions, paradoxes, and dilemmas, that no specific political structure would ever resolve. A rationaliza- tion, perhaps, but it was one that I could live with. Resolution of my ethical-ideological dilemma took some months. Meanwhile, I had become a “hanger-on" in the reformer network. During this participant-observation phase, lasting approximately nine months, or the second half of the fieldwork, I engaged in a variety of obser- vations, including hospital abortion procedures, clergy-client counselling interaction, clergy-lay professional training sessions, and patient processing at various stages of care in New York City hospitals and 40l clinics. Fieldwork allowed for varying degrees of participation, as in attending an abortion workshop, a National Abortion Conference in Washington D.C., one local and one state-wide medical symposium, and a state Public Health planning committee (where I was a "passive" observer), Lunches, cocktail parties, dinners, and extensive telephone and person- to-person contacts gave me the opportunity to establish political connections necessary for gaining access to confidential records and setting up a survey study. Even more important, I could build up a reservoir of informants necessary for cross-checking of data, for questioning in cases of "missing cells," for references, or for contacts to other persons. In this way I was able to penetrate the relatively closed system of the hospital abortion order, and with less success, the criminal system. One note on the ethnographic method is in order. The "par- ticipant" phase of much fieldwork observation may be something of a misnomer in social research. The term usually implies that the researcher "gets to know" his informants as persons and sees them "in-the-round"--at the job, at home, with colleagues, and at social events. Certainly, this was the case for me. But this cannot be construed as "participating" in the sense of taking a direct role in organizations or activities. Instead, I defined participation as the act of commitment to the ideology and efforts of reformers and clergy counsellors. While I shared in the agonies and joys of the reformers, there were few moments when I was not consciously aware that my purpose was data collecting, whatever else I did. Even so, some contacts made earlier in the fieldwork expressed surprise at my 402 open avowals of commitment made after I resolved my own dilemmas between "neutrality" and "attachment," and once attached, between "radical" and "reformer" factions. The participant observer phase had rich research "pay-offs." Hypotheses, only tentatively formulated, could be checked against a variety of field sources. EVen the descriptive model altered to fit new evidence, furnished by on—the-scene observations. In the following discussion, I show how the participant-observer role clarified meanings, enabling hypotheses to be "tested" against new data, and provided model reformulation. ' In an earlier section we considered how well-planned interviews can sensitize the fieldworker to various participantsI perceptions and expressed actions. Interview data, however, also leads to errors of inference, errors arising from the necessity of making assumptions about the relation of interview statements to actual events. These state- ments may or may not be accurate. Reports of behavior require the analyst to bridge the gap between words and deeds, a gap bridged by the investigator's interpretations. Now, interpretation in the absence of observation and of first-hand experience, or of intimate contact with participants, can produce two types of errors. In type 1, the inves- tigator depends almost entirely on what is said, operating on the premise that the interviewee, as a concerned, reliable person, is reasonably forthright. Resistance to questions, as in hedging or ignoring items, provides cues to the interviewer that this is a sensi- tive area. The question may have to be reworded, or dropped, until a more "cooperative" or expressive respondent can be found. On the basis 403 of this restricted communication, the investigator limits inferences to the minimum, and builds hypotheses on what little grounding of descriptions of events the informants supply. In some instances, the investigator's interpretations are really little more than rephrasings of his informants' statements. Timidity, lack of field experience, and limited knowledge of the social context, restrain the analyst from rejecting what appear to be universal assumptions of informants. In type 2 error, the investigator, faced only with accounts or transcriptions of interview data, takes analytical leaps from sketchy, incomplete, or even discrepant data to attempt forming deductions, explaining a range of disconnected statements of events. In the absence of observation or immediate involvement in the social scene, what procedure can be used to check the efficacy of data in decisions to either support or discard hypotheses? Subsequent inferences and interpretations may be constructed to fit the investigator's time and budget allowance, or more likely, his/her theoretical preoccupations. Both the naive fieldworker and the investigator using interviews as a sole method in a complex social situation are prone to commit these two types of errors.8 Participant observation both clarified and corrected pro- fessional descriptions of abortion organization and client management. In this way errors of inference made at earlier stages of the study could be rectified at a later research period. This process of recti- fication is described below by way of extended exampleS- 404 Type l Error--Limiting Inferences to Fit the Informants' Model Abortion, like any medical procedure, has a special technology, mode of operation, set of meanings, and group of specialists. The physician, whose primary business is to know the objective risks and outcomes of any procedure, theoretically, is the most able source for assessing the patient's medical condition. Decisions for surgery constructed with available information and operating experience follow this patient assessment. This set of expectations provided my working assumptions for interviewing physicians. When physicians consistently reported, for example, that abortion is more medically "risky" or dangerous than a full-term delivery, I took this datum as "fact." If twenty independent sources repeatedly emphasized that (1) abortion has a higher complication rate than childbirth, and is likely to (2) cause sterility or other gyne- cological abnormalities, and further involves a (3) great loss of blood, and characteristically, (4) post-operative mental trauma, this appeared to be a consensus of judgments. If I had terminated my investigation of medical aspects of abortion with these conclusions, I would have been left with a very distorted view of the situation. In actually observing hospital abortions by an experienced practitioner, I discovered that blood loss in an "early“ abortion (within three months gestation) is less than that drained by a blood donor in a modern blood bank. Further field involvement in Michigan and New York hOSpitals,and New York City and Washington D.C. clinics indicated that abortion patients have far fewer complications than 405 full-term delivery patients, with sterility a rare occurrence, and with mental "trauma“ an unproved assumption. I had to deal with this discrepancy between physicians' perceptions and this new set of evidence. As a participating researcher collaborating with physicians on a legitimate medical study (i.e. two-hospital study of therapeutic abortions), I now could ask questions informally. The following example is typical of the new set of responses once entry into the physician network occurred. Investigator: "Why do doctors believe that abortion is such a dangerous procedure?" Physician: Because most physicians don't have any experience in giving them. Their experience is limited, when they do give them, to one or two a year, often on medically, very sick patients. Also, they are fearful of probing the pregnant uterus, now stretched and thinned like a blown-up balloon, with instruments in an area they can't see and haven't developed a touch for. Investigator: But don't we know that a very large number of women receive illegal abortions every year, and return to have normal pregnancies and deliveries? Physician: Yes, but our physicians see only the wreckage of botched abortions in their offices or hospital emergency rooms. They see the gynecological cripples that result from this experience, and they want nothing to do with it. Investigator: Doesn't this finding lead to a demand by physicians for reform of the present law? Physician: Not necessarily. Doctors don't like the idea of using - abortion as a back-up for sloppy birth control use. Besides, giving abortions is not interesting medicine. It's too routine, and would limit their practice to a repetitive procedure. Once the word got out, they'd be running an abortion mill. Further discussion made it clear that many physicians regard abortion patients as either promiscuous or mentally ill. The abortion patient takes up hospital space and resources, as well as physician time, 406 that is better spent on "sick" people. Not only are resources wasted on the undeserving, but the association of abortion with underworld operators or unethical physicians has contaminated the procedure. "Respectable" physicians reject involvement in a dubious activity that has such little professional or social merit. This discovery explained why so few physicians actively engaged in legal reform, or with testing the law by openly giving abortions. In turn, understanding the reluctance of physicians or organized medicine to participate in change efforts or patient advocacy led to hypotheses concerning the role of the broker system at whose boundaries the physician stood. Type 2 Error--Limiting Inferences to Fit the Observer's Model Some fjeldworkers' protests to the contrary, every investigator begins his study with certain theoretical predispositions and set of hypotheses that he hopes will provide meaningful guidelines for the research. The concepts he uses are not meant to be fixed entities, but an evolving set of meanings to be checked against the informants' beliefs or experiences. Some periods of fieldwork, though, lack precise cues. Informants'statements may be inarticulate or inconsistent; or interviews appear inadequate to cope with the complexity of the situa- tion. In these circumstances, it seems more reasonable to impose order on the data than to SUSPGDd judgment, the latter required for building up a case based on interplay of theory and data. 407 I faced this situation in my early insistence on linking any and all client management tactics that informants used to the notion of risk. Risk, as a "terministic screen" in K. Burke's analysis,9 directed attention to action as stressful or chancy. I presumed that every organization or professional dealing in contraband acts experiences strain of some sort. I had enough supporting evidence to posit risk as a significant factor in abortion transactions. The language expressing risk differed, of course. Sometimes, it referred to the clients themselves, as in "crises" clients, "traumatic" experience, or the economic hardships for the woman with a "problem pregnancy." Statements also referred to organizations or professions, which take on abortion clients as a ”losing proposition," or as "bogged down" with hysterical women," or whose abortion services "jeopardize" other programs. After I began interacting frequently with "reformers," or other informal contacts, a number of fieldwork observations made it clear that the risk situation had complicated time and setting dimensions. For example, physicians, clergy,and social workers with routinized client management for one year or more, no longer defined activities as hazardous. Earlier fears about legal sanctionim;or community censure no longer concerned experienced professionals. No one they knew had been harrassed by enforcement agents. Instead, many had received encouraging letters from former patients or clients grateful for their services. If individual participants differed in their per- ception and management of clients, could this be attributed to personal background, social experience, social location, or another 408 dimension? Further investigation partially supported these hunches, but the evidence remained inconclusive. To fill the data gap, I began reconstructing the retrospective interview histories and together with available private and public documents checked these against the informants' experiences. Reports of the "earl y days" before any state had legalized abortion contained "horror stories"--accounts of patient catastrophes or severe pro- fessional impediments because of the restrictive law. With the greater flow of patients routed to legal abortions in New York, the emphasis shifted to statements of the "inconvenience," "discrimination," or "added—costs" of sending patients out-of-state for this procedure. This suggested a time dimension as a primary condition affecting how participants perceived and responded to risk. These considerations led to reformulation of my original proposal of abortion transactions as a uniformly "risky" enterprise, to a search for conditions under which risk influenced transactions. The search resulted in a change model that follows the transformation of risk as market conditions alter. Participant observation, then, is invaluable for getting "inside" a complex social situation. The opportunity to "test" impressions, to uncover new information, and to generate propositions in a larger experiential context gives an extensive base for gathering and interpreting data. As yet another consideration, the researcher as "expert" in knowing a wide range of persons, events, and actions, en- hances his value to participants. This results in more open discussion, and occasionally, requests from participants wishing to be interviewed for the study. 409 Phase IV-—Structured Techniques10 Interviewing, participant observation,and document study--these were my tools for analysis. But, somehow.these seemed inadequate. Like so many sociologists facing the possible "slings and arrows" from colleagues embued with the rigorous methodology of hypotheses testing and statistical analysis, I wanted more "precision." An unworthy motive, perhaps, but it did provoke strong discontent with the state of my data. At this point, the problem revolved around finding samples and settings to ‘yield suitable data for quantifying the evidence. Solving this problem required: first, understanding what would be accessible to rigorous study, and second, what would be theoretically feasible for more intensive analysis. Originally, I planned to do intensive observations of two or more hospital abortion boards. This turned out to be impossible. Even friendly physician—informants thought the idea "outrageousfl' They cited the matter of "confidentiality" of the patient's "medical status." I interpreted this statement as a "rationale" for preserving professional secrets. Lacking access both to the professional dialogue, and to the physician-patient interaction, I settled on a compromise solution. Study of patient records (names ngt_included) offered some professional typications of control strategies, as in meChanisms of selecting clients, issues of "medical indications" (or rationales) for abortion, costs of service, and professional patient sanctions (e.g. psycho- logical labeling and sterilization). As it turned out, the study became a two-hospital sample. 410 Examining patient records is a task surrounded by mystique. To avoid the possibility of being discovered an “imposter,” (i.e. non- hospital related), I had a male student, assisting me on various phases of research, dress up in a borrowed white coat to do the "digging" in one hospital record department. Since the facility provided medical training as well as services, young men in white coats go unnoticed. This saved me from visions of being publically expelled from the premises. Such tactics were unnecessary in the other hospital. The abortion service, operating almost as a one-man show, involved super- vision by the attending physician, who collected the records himself with a nurse filling out the categories I indicated. Observations of the abortion procedure, as well as the physician-patient and colleagial interaction in the "clinical field," further enriched the bare-bones record data. Studying the clergy counsellor movement proved fascinating and rewarding both as occupation and preoccupation. I had been interviewing this group for almost six months before I had a term for their activi- ties--i.e. brokers. Early in the fieldwork my intention was to put together a "natural history" of the organization, a task encouraged by clergy-organizers. Some men had devoted years to this effort. They hOped that before the abortion law changed, and their organization disbanded, someone, either within the service or a "sympathizer," would write the history of those initially tentative, and later successful,efforts to legitimate abortion as a health service. The clergy themselves fostered the notion of their activities as a "social movement"--as a wave of protest against social injustice that society -— . __.—:-~--—o - 411 perpetrated in denying women the right to choose in this matter. One long-time clergy-leader compared the Service to the Civil Rights move- ment; another to the long struggle of Margaret Sanger to legitimate the birth-control movement. I was eSpecially curious about the "early" days when the clergy negotiated almost exclusively with criminal abortionists. I could find no Michigan records, either public or private, that clarified the legal and protective mechanisms the Service used before they became "visible." Access to four years of correspondence clearly laid out this pattern. I strongly felt that the movement's efforts to transform definitions andactions of established medical and agency groups, certainly deserved the most intensive analysis I could give. But I was becoming fatigued. Fieldnote processing, coding, preliminary written analysis, preparing a collaborative article with my physician-informants, and recently, teaching duties, made state-wide interviewing, even on a randomly-selected basis, an impossiblity. Mailed questionnaires seemed the only solution to the problem. That decision I now believe was a mistake, at least for the theoretical purposes I had at hand. I learned little more regarding the broker network than I had gained from interviews and l2 early returns on the pre-test questionnaire. What the mailed questionnaires showed, though, were significant changes, as in type of personnel (e.g. older, more established pastors, increased number of conservative denominations,and so on).and in mode of commitment from the early risk days to the present. This provided a profile of the brokers, who operated-for the most part, not as crusaders, but as community resource persons. w.mfl-n~~-‘—hn- “a“... .. .. . _- 412 I faced two more methodological issues in collecting data from hospitals, but especially from clergy. This was representa- tiveness of the sample, and the use of the extended care method itself. Unlike the "snowball“ interviewing technique, and later, participant observation, I had more "control" over my data with sampling decisions no longer on a spontaneous, or first-come, first- serve basis. In the hospital case, how could I justify talking about state—wide hospital practice when I was limited to two facilities? How comparable were these two settings, one located in a major metropolis, and the other in a small town? Both hospitals could be characterized as "exceptional" in that they had a visible abortion service in the first place. What could I generalize to? Did data from these facilities really "say" anything about medical conduct and practice? Did I have to pursue interviewing into the community- at-large to assess the sources for these apparently anomalous struc- tures? While I cannot vouch for the adequacy of the sample, the data demonstrated some peculiar features of hospital abortion practice. First, these were uncommon hospitals. Only very careful "local arrangements" permitted physicians to maintain a visible abortion structure at all. Second, by concentrating risk in a few facilities 413 apparently able to control potentially high costs, other facilities could hedge on serving abortion clients; instead referring-out "problem“ patients. Third, other evidence (viz., documents and interviews) emphasized that abortion remained a special and proble- matic health service, limited to few patients only under elaborate control conditions. In a word, the two hospitals were highly unrgp;_ resentative in performing over 50% of all reported hospital abortions in this time period (June 30, 1970 - June I, l97l), or ggg_of 387 cases. Representativeness in the clergy case turned out to be more complicated. I had used a geographically, random-stratified sample, but only discovered after the questionnaires were in,that sampling individuals did not adequately identify local networks. For this, I needed unit sampling of local cells to determine degrees of organiza- tional cohesion or division. Network sampling, especially in a conflict area, simply cannot be done in questionnaire form. Some men still viewed their conduct as morally suspect. I could hardly ask them to give me the names of their friends and colleagues when their own position was so ambivalent. Further, one has to §g§_the nature of the interaction close-up, not from the distance of a mailed "instrument." The extent to which the clergy data is representative, then, is a moot point. Follow-up conversations with a few old-timers regarding the adequacy of my "picture," makes me "feel" that I am on the right track. In any event, I believe that I captured some of the high points, even if the sketch lacks the "precision" originally aimed for. In trying to get the woman's version of the abortion routing, I spent months tracking down false leads or broken promises. Later, I 414 tried to interview clients processed directly by clergy informants. But I discovered that the clergy kept no records by client name. To use this source, I was told that I would have to participate as a lay counselor, requiring training, and of course, more extensive fieldwork. I finally decided to use three university students I knew, who in each case, had friends or associates who had had abortions. In turn, these friends furnished other leads. During the search we found far more women who refused to give an interview (or failed to show up at the appointed time), than those actually interviewed. We attributed this to the persistence of stigma associated with abortion, particularly for the younger college student. This reason was further substantiated in discussions I had with students in my Deviance class. They felt that women are more open about revealing their sexual and abortion experiences to friends than was the case a few years ago. But they still resist: discussing these experiences outside the immediate friendship circle, because of what "others might think of them." Undoubtedly, there are other factors that could account for this interviewee reluctance. Whatever the unknowns, the sample is a biased one. The second methodological issue was the use of what Gluckman calls the “extended case method" or "situational analysis."n Gluckman says, with regard to this strategy, that the investigator studies the concrete choices that actors make in situations with the focus on change, or social process. The idea here is to avoid the notion that ethnography is simply a collection of static"illustrations" tacked on to an "abstract formulation." I take him to mean by this 415 that the multiple situations,_the particular behaviors,_the concrete choices of actors are to be examined in detail on their own merits, or as integral social factsyielding their own regularity. Gluckman is really quite vague about showing how this strategy works (his own empirical work demonstrates the theory, it does not elucidate it). What Gluckman is really addressing is the issue of the whole- parts problem in his situational analysis. This methodological problem of piecing together events, actors, processes,and so on to form a whole picture is what I call a pattern-search. The pattern itself is a changing one as new pieces of evidence are added, others removed or rearranged. Unlike children's puzzles, though, the methodological "game" of matching events or acts into equivalent or different sets to construct a social situation, has no definitive boundaries or even "right" pieces. Some elements in the puzzle may never be discovered or are "lost" to the researcher. Inferences, in this case, are drawn not from direct (i.e. observed) evidence, but from putting together those pieces already known. The final pattern or construction of events, then, approximates the "real" situation. It is not intended to represent it. In concrete terms, I have "discovered" an abortion "market: or situation composed of a variety of groups with some of these groups equivalent on some dimension (e.g. extent of legitimate services), and other groups different on still other dimensions (e.g. specific coping strategies). I know, for instance, that the criminal abortion phase of this market has a wholly different set of actors than those in the legal organization, but I draw most of my conclusions regarding 416 the specific market activities from my knowledge of other market phases-- legal, broker, and institutionalizing arrangements. I am not satisfied with the incomplete pattern, but researcher fatigue, slammed doors, and necessity to complete the task restrain me from further pattern- search. All of this leads back to the problem posed at the beginning of this section. Which settings and which samples should the ethnographer of the social situation intensively study given the exigencies of personal and resouroelimitations? The solution, I found, lies in the pattern of discovery itself. The "vmat:goes with what" search is constructed in the research act. The combining, separating,and reordering of acts and events (or elements) make for a cumulative pattern. When the investigator recognizes that some feature is "missing" he makes a judgment about the importance of this feature for understanding the larger picture. Without my intensive treatment of the two hospitals and the clergy movement, the market pattern could never have been put together. I would have done a different study, of course, but not this one. In deciding to include a study of "consumer participation," while not basically altering the production focus, did provide a modification in the model. I found the risk element, noticeably transformed for producers, remained a pervasive feature of the broker structure for users of this service. I learned one lesson to pass on to my "technocratic" sociology friends. Regardless of the intricacy of the research design used to test hypotheses, or degree of precision aimed for, we are all in the 417 same “business" after all. Research may start with a pre-existent pattern established by previous work, or it may end with one. Who can say which is the most fruitful route? Phase V-—Assessing_the Evidence In brief, I used an evolving fieldwork strategy. This entailed multiple methods adapted to my own experience and ideological commit- ment. Stage of the study and developing theory were other considerations in sampling and techniques. The idea of induction, or pattern search, is to build up cases--episodes, events, incidents, and informants' meanings--and draw inferences allowing for tentative hypotheses through- out all phases of the study, Evidence supporting or negating the hypotheses are then gained by further questioning, observation, and documentation. At this phase of evidence assessment, the problem focused on clarifying the two distinctive “pictures" of the empirical world-- one, the "emic" model or evidence provided by the informants' statements, and two, the "etic" model, or the interpretive construct provided by the investigator.12 The multiple perspective approach is especially demanding in this regard. In studying a multiplicity of occupations, organizations, settings, and social categories, I discovered markedly different viewpoints. Even within the same social unit, rhetorics varied or were contradictory. This seriously complicated the job of sorting out evidence. What alternative routes could be taken to simplify the ordering procedure? One approach involved taking the perspective, or "model? —>—_—_—-——. .— . .- . ..fi. -_ M.fi 418 of one, or at most two, producing sectors, say physicians and clergy, to trace market organization and change. I found this a compelling choice in that data were most complete for these two groups. For a brief time, I also considered taking the consumer point of view as a frame of reference for analyzing the market structure. I was familiar with the "underdog" perspective in deviance research, and the strategy appealed to me on ideological and moral grounds. Increasingly, I realized how this perspective overly restricted the scope of the market "picture" I wished to draw. For instance, most abortion seekers have only superficial ties with clergy counsellors and physicians. Even more informed persons or movement activitists have, at best, an ideological involvement, rather than an organizational one. Moreover, how could I check out the women's experiences unless I had access to a broader data base? The third alternative--to present each major market unit (viz., legal, medical, clergy, agency, consumer) from the perspective of the various role occupants--required wrestling with the disparate evidence and attempt to develop a multi-dimensional image of the structure. My own sympathies, ideological preferences.and theoretical orientations could then reflect still another part of this social order. In other words, I took the viewpoint of different groups to portray the abortion market and joined this to a critical view. This considered implications for underdog groups or the public of definitions and actions of those organizations or occupations processing clientele. An earlier draft of the study taking the multi-perspective approach showed me its weaknesses. I had "captured" the market phases 419 (i.e. legal, illegal and broker) revealing some of the intricacies of this changing system, but the study lacked coherance. It needed a central focus to pull together the still-disconnected elements of hospital activity, criminal operations, clergy innovation, and agency participation. In reconceptualizing the problem, I took the clergy as the principal set of actors, who, in combining features from both legitimate and illegitimate sectors, forged a new delivery system. The multi- perspective approach could be salvaged by treating different organiza- tional actors in terms of how they constructed the situation. But I tied the narrative together by describing how these other market activities (e.g. hospital or agency processing) affected the clergy movement, and in turn, were influenced by the movement. Choosing a model also relates to other methodological issues, that of reliability and validity. Indeed, kinds and sources of evidence, interpretive construct, reliability,and validity, all should be considered interrelated entities having to do with the process of translating data into theory. Reliability, or consistency of data, refers to modes of data collection and analysis. Theoretically, data are reliable to the extent that they meet standards of intrasubjectivity and intersub- 13 Intrasubjectivity ideally requires the same researcher jectivity. to have repeated observations of the same phenomena, thereby yielding the same data. Intersubjectivity, conversely, requires adequately coding and categorizing incidents, events, and statements to allow other researchers using the same fundamental premises to draw the same 420 conclusions. Another test of reliability is whether a study is reproducible, or repeatable, by the same researcher, who,in retracing his steps, remains convinced that later observations are consistent with earlier ones. As with most ideal formulations, data reliability has built-in limitations. Criteria must be modified, or even abandoned, if they do not fit the research problem. In situational analysis of a changing event, the fieldworker, in time, becomes a part of the social scene he studies. As he develops commitments to specific persons and ideas, he may re-evaluate evidence gained at an earlier point in time in terms of his new state of consciousness, and his more recent observer's model. Reproducibility of the same study by the same researcher is even more hazardous. For after months of fieldwork involvement, the researcher establishes an identity and location in the social setting. Informants' statements of events necessarily take into account that the researcher has been seen with, or is active in, certain groups. On these grounds judg- ments are made, assessing the person either as trustworthy, in which case, confidential matters may be shared, or oppositely, as unreliable or undependable, in that case, not to be entrusted with organizational secrets. Add to this that search situations rapidly transform. Because fieldwork has special problems in this regard, does not imply that the investigator neglects the scientific task of rigorously coding and categorizing data. What we are saying is that intrasub- jectivity and reproducibility, "normal" methodologial tests of reliability, cannot be transposed to the ethnographic strategy, or one which requires the researcher to define and redefine the problem as he moves along. 421 Regardless, then, of the completeness of field notes or inter- views, there is no procedure that can duplicate events after the study is completed without involving extensive differences in the way infbrmants, or the investigator himself, both relate to and respond to the research situation. As for the criterion of intersubjectivity, this is as much concerned with the communication process to colleagues as it is with reproducibility by other investigators. Certainly, the essential "test" of evidence is that colleagues are convinced that the data supports the interpretations made. Intersubjectivity is also related to validity, or corres- 14 A pragmatic test of validity, pondence, between data and theory. of course, is the purpose the data are designed to serve. Data are always valid in gpmg_context with regard to some theoretical dimension. This need not weaken the concept, but qualifies the various forms of data as more or less valid, or informationally relevant, for hypotheses and theory development. Reliability and validity, then, should be considered primarily in terms of the specific research problem. In the abortion situation my aim was not to assess the truth of statements, but the different accounts and interpretations of abortion service from a variety of participants, rather than search for the gigpt_account or interpreta- tion of events. A strategy employing multiple perspectives means that there are no right or wrong views, but only different views representing different interests, groups, statuses, social identities, and so forth. We aimed to record the context of cases by specifying particular actors in concrete choice situations. We did this by a variety of 422 techniques in attempting to close the inferential gap between the informants' infonnation and the observer's interpretation, between the informants' expressed statements and "underlying" beliefs, and from the infonnants' expressed statements and actual behavior. A preoccupation with "Jevels" of infonmants' meanings versus actions, however, does not adequately account for the observer's model. In this sense, the theoretical picture the analyst draws is independent of the different accounts of “reality" provided by infor- mants. Informants' accounts or "models" provide data, which in turn, is used for evidence in making interpretations. Credibility of the theory, or observer's model, a point we re-emphasize, depends less on the criteria ofreliability and validity than the integration and clarity of the theory, the latter established in the communication process itself. For the most part, the research categories are built on verbal accounts, rather than direct observation. We attempted, within this technique, to get the necessary flexibility, refinement, and nuances, that could provide indicators for the theoretical dimensions. These, in turn, contribute to the validity of hypotheses. The interrelated concerns--indicators, theoretical dimensions, hypotheses development, and substantive theory--are illustrated below. Contradictory statements by physicians as well as women's groups regarding the frequency of sterilization following ”therapeutic" abortions could not be checked out by accumulating more verbal state- ments. Instead, patient records were analyzed,together with interview data from physicians and administrators, to detennine both incidence and conditions under which sterilization procedures actually occur. Prior 423 to this investigation.the working hypothesis regarding professional control of abortion service could be stated roughly as fellows: Physicians and hospital administrators respond to legal control by developing working codes and mechanisms that restrict patient entry to abortion service. This notion specified neither concrete codes or mechanisms that medical groups used, nor the conditions or conse- quences of use. The more tenable hypothesis generated from patient records and interview data enabled me to compare facilities in terms of differential treatment of patients, and the presence or absence of particular control tactics. Sterilization, as a property of the medical- control system, could then be linked to other related properties of medical-control mechanisms, as for example, psychiatric referrals, abortion committee or consultation, and high costs of service. With these data I integrated the theoretical categories of (1) medical values toward abortion, (2) perception of personal or professional risk, (3) cost-reduction mechanisms, and (4) client costs to a more focused statement of processes and mechanisms of medical regulation of abortion service. This linked the "control" hypothesis into a substan- tive theory, or set of propositions, that explained causes and conse- quences of the distribution of hospital abortion service. Phase VI--Revisipg_the Model and Writing_the Study By now it should be clear that "model" building is an on- going process involving an interplay between problem discovery, data 15 collection, and theory construction. Initial fieldwork attempted to uncover the nature of the research problem. Then, decisions 424 revolved around types and sources of data, fermulation of hypotheses, checking of hypotheses against evidence, and reconstructing the theory. These processes go on throughout the fieldwork, but do not stop with it. Only after the final writing of the manuscript is the job completed. The relationship between theory and data, in this analytical mode, is not a static entity. Instead, what is considered relevant phenomena itself undergoes re-evaluation in terms of new incoming data. The.interpretive constructs, with indicators used to translate data into theory,are adapted to fit the changing conception of the problem. This means that the final revision of the "model," or the logical organization of hypotheses stipulating--causes, conditions, consequences, dimensions, events, types,and processes--offer a plausible, not a necessary or sufficient, explanation of the abortion market. No attempt is made to ascertain either the universality or the proof of suggested causes or properties. Our aim is to proliferate as many properties of relevant categories as seemed reasonable to understand the conditions and consequences of abortion market organization. Finally, ”proof of the pudding" is inevitably expressed in the final writing and publication of a study. The success or failure of any research enterprise is resolved, not by the analyst, but by the reader. My hope is that the extensive discussion of these methodo- logical problems and strategies of fieldwork clarify and illuminate the conplex, often intriguing, and invariably problematic activities, we call the "abortion market." 425 Conclusions This chapter assesses the methods of inquiry used in this study. We call this method a cumulative research strategy, an approach designed to allow for a battery of alternative tools and tactics commensurate with the experiential world of the investigator vis a vis his informants and data, and the stages of the investigation. The method is a continuous growth process with each phase after a time transforming into the next. Previous phases remain in operation throughout the analysis and provide continuous development to the following stage until the analysis is terminated. A cumulative strategy, moreover, contributes to the interplay of data, concep- tualization,and theory. In thus emphasizing discovery, the strategy allows for both flexibility in methods and systematic data collection. Urban ethnography in "home" locations permits, if not necessitates, on-going contact with infbrmants. This situation both complicates and simplifies the research writing. Continuous contact with infbrmants complicates analysis in that data collecting is never a completed act, for with new evidence changes in emphasis is inevitable. (E.g., I rewrote the conclusion fOur times to reflect continuous changes, as in public health rules, Supreme Court decision legalizing abortion, public reactions, and other recent events.) It simplifies analysis in facilitating a running check of inferences or in filling-in "missing" cells. This implies that the processes of supporting and negating hypotheses is a never-ending one. Even though the final write-up represents an intensive analysis of a phenomenon in one or more time periods, future events can alter past meanings and experiences. enterprise. 426 But this, we assert, is the nature of the sociological APPENDIX A--FO0TNOTES Exceptions to this lack of systematic codification of sociological fieldwork include: William F. Whyte, Street Corner Seciet . Chicago: University of Chicago Press, 1555, Appendix B; G. J. McCall and J. L. Simmons (eds.), Issues in Participant Observation. Reading, Mass.: Addison-Wesley Publishing Company§71§5§s and“ W. J. Filstead (ed.), Qualitative Methodology. Chicago: Markham Publishing Co., 1970. ' B. Glaser and A. Strauss, The Discover of Grounded Theory, Chicago: Aldine Publishing Company, 1 67. Increasingly, anthropologists have taken up analysis of urbanizing societies, an approach which requires research strategies more similar to those used by urban sociologists. Explication of problem areas and su gested fieldwork techniques are discussed in: A. L. Epstein (ed.), The Craft of Social Anthropology, New York: Barnes and Noble, Inc. *For selected urban studies in social anthropology, see, M. Banton (ed.) The Social Anthropology of Complex Societies, London: Tavistock Publications, 1 Glaser calls this sequential and multiple methods approach for generating and suggesting properties and hypotheses about a phenomenon, the “constant comparative method of analysis." See, Barney G. Glaser, “The_Constant Comparative Method of Qualitative Analysis," Social Problems 12:463-465. l965. Edwin M. Lemert, Social Pathology. New York: McGrangill Book Company, 195l;and Human Deviance,_$ocial Problems and_Soc1al; Control. Englewood Cliffs, New Jersey: Prenticéifiall;flnc., 1967. A good discussion of sampling techniques and models is found in: Norman K. Denzin, The Research Act. Chicago: Aldine Publishing Company, 1970, pp. 81-96. See, R. Nicholas, "Rules, Resources, and Political Activity," in Marc J. Swartz, (ed.) Local-Level Politics. Chicago: Aldine Publishing Company, 1968. Rosenhan also uses this notion of errors in inference. In clinical practice, he refers to these as "false positive" (Type l) and "false negative" (Type 2). D. L. Rosenhan, "On Being Sane in Insane Places," Science 179 (January 19, l973):250-258. Another way to clarify the inference problem is offered by Garfinkel. He takes collected items of information fer 661 cases and classifies 427 1]. 12. 13. 14. 15. 428 them as fellows: (I) there was no information, (2) infbrmation was obtained by uncertain inference, (3) information was obtained by certain inference, and (4) information was obtained by inspection. (Harold Garfinkel, Studies in Ethnomethodology, " a Englewood Cliffs, New Jersey: Prentice-Hall, Inc., 2 Table 4.) Ideally, the researcher should begin the fieldwork with this approach. In my case, a ost hoc classification of items did not seem feasible. Much of my fieidwori‘fihs based on what informants said about events, actions or personal beliefs. Checking each of these information items would have necessitated another study. My "solution" to this inferential problem was to spend more time in the the field than seemed warranted by the amount of new data I was getting. I used those last months primarily to check on previously acquired assumptions and information. When new facts or information items came up, my "test" was to determine if they fit into the picture I had. While I was reasonably satisfied with this checking procedure, it was really too impressionistic. Fieldworkers would benefit from a more rigorous scheme, such as that used by Garfinkel. Kenneth Burke, Lan ua e as S mbolic Action. Berkeley & Los Angeles: University of California Press, |§38, Chapter 3. A discussion of quantification in fieldwork methodsisr found in: J. Clyde Mitchell, "On Quantification in Social Anthropology," in EpStein (ed.) 920 _cj-EO’ pp. 17-450 This approach is discussed in detail in: J. Van Velsen, "The Extended Case Method and Situational Analysis'in Epstein (ed.), pp. cit., pp. 129-152. See, also, the "Introduction" in Epstein e .l'§p, 913,, pp. xi-xx by Max Gluckman. For analysis of these two distinctive models-and their use by social scientists, see S. A. Tyler, Co nitive Anthro olo . New York: Holt, Rinehart and Winston, Inc., |§5§; BaFBara Ward, "Varieties of the Conscious Model," in M. Banton (ed.), The Relevance of Models for Social Anthropolo . New York: Bafnes & Noble, Inc.,ffiistributors, l§65, pp. 1 - 37. J. Galtung, Theory and Methods of Social Research. New York: Columbia University Press,*l§37, p. 2§, 85, 121-128. The concept of validity if taken from Galtung, Ibid., PP. 29, lZI-lZB. This refers to explanation as the interplay of theory and data. See, Glaser and Strauss, op. cit.; N. Hanson, Patterns of Discovery, London: Cambridge, 1958; and G. Sjoberg, and R. Nett, A Methodology for Social Research, New York: Harper & Row, 1968, pp. - . APPENDIX B STATUS OF ABORTION LAWS T0 APRIL 1, 1971 4I3() .am: .<:zm: .maofl>aom wewaaaaa sfieaaa how nouaou Haaofipmz "OUHSOW a... ............ i . . .mx . mx. . mva manomsgommmaz .é; :mGsx ....... x. x x x .x x122 . $2 ecfig ........................ x .ova mafia: UH ......... x. efimfi aaeamfisaa .x onH xxozpcoa .0m. x, .mmfivix. x x x x . x nx x, moma mmmcdu .x mvwa «zom .,x. .wme mcmwncm x eawfi mfioewfifiH x mow” ocwuH o.mxv om x . . . a ........ c _ .. . x ...x ...onma wfiazmm x mm-u~ Ammu,x x x x x x x . mama mamaoau x wowa mvwaoflm x x Homa .Hou mo .umwo m.mos a x nmxoozv HMMMW 09mm xv“ guano: nuamom . Haw awao hocovwmom noumm< afieflq umooaH know man“ nanomoo Hap Hmo nuflao: owed uwmmom nwmwna Mao» ouaum .o.z. oeflh uzumum nouom Hmpom Tao: iflmxnm A.vommwuomm m:oauwvcoo can have: vqa wouaownam webmmou any you woupMEuom one meowunonm was» oefi>oum mopsumumv m x~ozumm< a«_Nm— aumacawunmzeg :owugon< mo magnum u:mcg=u--.o_ m4m

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N :...0w.«. .0 0.50» m: 05 503 003000: 0< :...0:05:.~0>0w ow 28000.“ 05 .3 000050;: 0:0 4300: m0 0:05.530: 05 x 002.5: :00 :0 23300: 0 5 00558509.: .05 50.0 00 00:5 53:92 A n m 3:03—00:00 . u 0m x $2 wcefilo : x wme :wm:oum«2 x i mvwa macaw: .96 00 _x 33 x x . . 0> 082 059 n H x on a." :oum :wzmnz 50> 3.005 053. 0:0”. .3: 5:00: 5000: i. >0:00flmom ioumm< was“: 0000:H 5500 0:0: -5How0: H00 H00 cu~00z 0mHa ~00 50:0 5.: 8:. -33.... -28... .305 -5: -5955 . . -558: -0905 so» 83m e......ou--... 0...: 433 TABLE l7.--Major Categories of American Abortions Laws United States - April I, 197l MAJOR CATEGORIES OF STATE ABORTION LAWS STATES HAVING SIMILAR ABORTION LAWS I. Abortion allowed only when necessary to preserve the life of the Arizona, Connecticut, Florida, Idaho,l|linois1, Indiana. Iowaz, Kentucky, Louisrana3, Maine, Michigan, Minne- sota, Missouri, Montana, Nebraska, Nevada, New Hamp- l shire, North Dakota, Ohio, Oklahoma, Rhode Island, Sputh Dakota, Tennessee, Utah, Vermont, West Virginia, pregnant woman' Wyoming. ll. Indications tor Iegal abortion include threats to the pregnant woman's Mississippi. life and toroible rape lll. “Unlawlul” or "unwstihable" abortions are prohibited. Massachusetts, New Jersey, Pennsylvania. IV. Abortions allowed when continuation of the pregnancy threatens the Alabama. woman's life or health‘ Arkansas, Calilornia (does not include letal delormityl, Colorado, Delaware, Kansas, Maryland Idoes not include incest), New Mexico, N0rth Carolina, South Carolina. V. American Law Institute Model Abortioo Law, "A licensed physICian is iustilied in terminating a pregnancy il he believes that there is sub- stantial risk that continuance of the pregnancy would gravely impair the physical or mental health of the mother or that the child would Virginia. be born wrth grave phy5ical or mental delect, or that the pregnancy resulted from rape, incest or other leloniOus interCOurse" VI. Abortion law based on the May,1968 recommendations of the Ameri- Oregon. can College of Obstetricrans and Gynecologists Allows abortion when the pregnancy resulted Irom IBIOnlOUS intercourse. and when there is risk that continuance ot the pregnancy would impair the ohysmal or mental health of the m0ther. "In determining whether or not there is substantial risk Ito the woman‘s physical 0r mental health), acc0unt may be taken at the mother's total envnronment, actual or reasonably foreseeable" VII. No legal restriction on reasOns for which an abortion may be obtained Alaska, Hawaii, New YOrk, Washington prior to Viability ol the fetus Vlll. Legal restrictions on reasons for which an abortion may be obtained District oI Columbia, Georgia, Texas. Wisconsm4. were invalidated by c0urt deCision. I. A Federal District Court decision, Doe v5, Scott , 321 F. Supp. 1385 (ND. lll., Jan. 29, 1971), holding the Illinois abortion statute unconsti- tutional has been stayed pending appeal in the United States Supreme Court. 2. In State vs Duakiobayggy' the Iowa statute which is couched in terms 0! saying the life of the woman, has been interpreted to suggest that Preservation of health is sutIiCient. 221 N.W. 592 (Iowa, 1928). 3. Although the Louisiana abortion statute does not contain an express exception to the "crime ol abortion" the Louisiana Medical Practice Act authorizes the Medical Board to suspend or institute court proceedings to revoke a doctor's certificate to practice medicrne in the state When the doctor has procured 0r aided or abetted in the procuring of an abortion ”unless done for the relief of a woman whose tile appears imperiled after due consultation yvith anather licensed physrcran." La. Rev. Stat. Ann. 37:1261. 4. The abortion law of several other states have been ruled unconstitutional by lower state trial courts; however, these decisions are binding 00W in the jurisdiction in which the decision was rendered. 434 TABLE l8.--Chronological Record of the Status of Abortion Law Changes, 1 Abortion Reporting, and Abortion Ratios in the United States 1969-1971 197T‘ Cumulative No. of States with Abortion Laws Enacted Since 1967 9 l6 16 16 No. of States Which Reported Statewide Abortion Data 4 13 17 16 Additional States with l or more Hospitals Reporting 1 6 + D.C. 6 + D.C. 6 + D.C. Total No. of States with Partial or Complete . Reporting 5 19 + D.C. 23 + D.C. 22 + D.C. Total No. of Abortions 2 Reported to CDC 12,584 180,119 99,721 88,474 . 112.3543 National Abortion Ratio (Abortions per 1,000 3 live births) 3.5 48 110 102 3 130 1 Source: Taken from Center fbr Disease Control, U.S. Public Health Department, Atlanta, Georgia. (Fami1y Planning Evaluation Abortion Surveillance Report.) 2Number of reported abortions and abortion ratio calculated with no data from California. 3 Number of abortions and abortion ratio which result from assuming that 28,880 abortions (number reported from California January-March 1971) were performed in California during April-June. APPENDIX C RATIOS 0F REPORTED LEGAL ABORTIONS TO LIVE BIRTHS 435 436 ABORTIONS PER 1,000 LIVE BIRTHS O '50 I00 I50 200 250 300 350 400 NEW ENGLAND (102) New Hampshire Vermont Massachusetts Rhode Island necticut MIDDLE ATLANTIC (276) New York PeNew Jersey nsylvania AST NORTHP CENTRAL (45) Indiana Illinois *- Hichigan .Wisconsin TEST NORTH CENTRAL (50) Minnesota Iowa Missouri North Dakota South Dakota Nebraska Kansas SOUTH ATLANTIC (65) Delaware Maryland Dist. Columbia Virginia West Virginia North Carolina South Carolina Georgia Florida EAST SOUTH CENTRAL (17) ntucky Tennessee Alabama Mississippi «1551‘ SOUTH CENTRAL (13) Arkansas Louisiana Oklahoma Te MOUNTAIN (41) Montana Idaho Wyoming Colorado New Mexico Arizona PACIFIC (243) Washington Oregon California Alaska Hawaii Source: Center for Disease Control: 1972, U. S. Dept. of Health, Education and Welfare. Abortion in state of Residence Abortion performed in another state Data not available for above time period. Ratio for abortions performed in state of residence shown for July - December 1970. EA Flgure 30. --Ratios of Reported Legal Abortions to Live Births, By State of Residence, in Geographic Order, January - March 1971 *Note: Reported legal abortions to live births for Michigan women are all performed out of state. Abortion Surveillance Report, March 437 Figure 30.--Continued Reported legal abortion ratios for women in each state and the District of Columbia for January - March, 1971 are shown in Figure 1. The white bars represent abortions (per 1,000 live births in state) performed in state on residents of the state; the black bars represent abortions (per 1,000 live births in state) performed out—of—state on residents of the state. Only six states reported either a decrease or no change between the overall abortion ratio (in-state plus out-of—state) for the first quarter of 1971, as compared with the ratio for July - December, 1970. The ratio for Alaska stayed at 120, with virtually all the reported abortions performed in the State of Alaska. Oregon was the only state which showed a decrease, from a ratio of 232 to a ratio of 208, due entirely to a decrease in abortions performed in the state. Maine, Massachusetts, and Nevada maintained practically identical ratios for the two time periods, based only on abortions performed out-of-state. The 45 remaining states and the District of Columbia all show higher legal abortion ratios for the first 3 months of 1971. The increases shown for Arkansas, California, the District of Columbia, Kansas, New York, and Washington result primarily from abortions performed in-state. In Arkansas and Kansas, better data on in-state abortion were available for the first quarter of 1971 than was available for the July — December, 1970 period. In all, 99,721 legal abortions were reported for January - March, 1971. Of these, 73,718 were performed on women in their state of residence; 26,003 were performed on women outside their state of residence. Of the out-of—state abortions, more than 23,000 were performed in New York; more than 1,300 were performed in Kansas, and 62 were performed in Colorado. The overall abortion ratio for the country (i.e., reported abortions per 1,000 live births in the United States) for the January ~ March, 1971 period was 110 abortions per 1,000 live births. LEGAL NOTES No significant legislative changes in state abortion statutes occurred during the period covered by this report (January 1 - March 31, 1971). However, there were important decisions by federal district courts in two states during this period. A. Illinois: Doe v. Scott, 321 F. Supp. 1385 (N.D. 111;, Jan. 29, 1971). On January 29, 1971, a three-judge federal court in Chicago, ruling on the case of Mary Doe versus the Illinois Attorney General, the Cook County State's Attorney, et al, held unconstitutional the Illinois abortion statute which prohibited abortion except in cases where necessary to preserve the life of a pregnant woman. The court ruled "that during the early stages of pregnancy—-at least during the first trimester-~the state may not prohibit, restrict or otherwise limit women's access to abortion procedures performed by licensed physicians operating in licensed facilities." On February 2, 1971, however, this U.S. District Court decision was stayed by order of U.S. Supreme Court Justice Thurgood Marshall, pending appeal. The Attorney General has not appealed this case; however, it has been appealed to the United States Supreme Court by the State's Attorney of Cook County. B. North Carolina: Corkey v. Edwards, 322 F. Supp. 1248 (W.D.N.C., Feb. l, 1971). In this case a three—judge federal court upheld the constitutionality of the 1967 North Carolina abortion statute, concluding "that there is a sufficient public interest in protecting the embryo to permit limited statutory intrusion into what would otherwise be a protected zone of privacy." At the same time, however, the court declared the residency requirements of the North Carolina law to be unconstitutional on grounds that it limits the right to travel. This court also applied the principle of presumption of innocence, stating that the burden of proof in a prosecution is on the state to show that an abortion did not come within the exemptions of the law. APPENDIX D SURVEY QUESTIONNAIRE 438 10. ll. 12. 439 Appendix D MICHIGAN CLERGY COUNSELING SERVICE OR PROBLEM PREGNANCIES Survey Questionnaire Church denomination Geographical area (Tricounty, Lansing, etc. Length of time in MCCSPP Length of time in ministry (since ordination) Size of your present congregation Number of clergy serving in your parish Campus ministry (please check) Yes__ No Size of community in which your church is located Please indicate if you now have other involvements in abortion reform or related activities in addition to your counseling (e.g.,petition drive, speaking engagements, etc.)? a. What are these activities and far which groups? 0' How much time do you devote to these activities a month? 9) 0 Approximately how many hours per week do you give to problem pregnancy counseling? b. What is your usual counseling schedule? How were you recruited into the MCCSPP? a. Personal contact with a member who was a friend? b. Personal contact with a member who was an acquaintance? c. Newspaper article? d. Other? Describe. please. Please indicate the primary reasons, in the order of their importance, that you are ggw_participating in MCCSPP? l3. 14. 15. 16. l7. I8. 19. 440 Have you experienced any personal conflicts in regard to your work in the Counseling Service? a. Yes No Undecided b. Please describe: In what ways, if any, does your MCCSPP counseling role affect your other commitments? Please indicate the ositive ways, if any, in which your counseling role has affected your life. Please indicate the negative ways, if any, in which your counseling role has affected your life. Please indicate the ways in which you have resolved the problems, if any, created by your participation in MCCSPP. If you have been active one year or more in the Service, please comment on the following questions: a. Have you detected any changes in the Service? Yes No Undecided b. If you feel that there have been changes, could you indicate what these changes are, and your reactions to them (favorable, unfavorable, etc.) c. In your experience as a counselor for one year or more, could you indicate any differences in your attitudes or practices that may have affectedyour relations in MCCSPP. For example, your relations with the public, colleagues, counselors, or others. Please indicate these experiences in the time categories below: Early period (first few months): Middle period: Present: Has the way in which you counseled changed during the time ybu've been a member of the Service? Yes No Undec1ded l9. 20. 21. 441 Cont. a. In what ways has your counseling role changed? b. What influences or which persons facilitated this change? How important is counseling for the woman who seeks an abortion (i.e., preaabortion counseling)? Why? How important is follow-up counseling for the abortion patient? 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Did you ever have any harrassment, pressures or negative responses from: Legal enforcement agencies Yes___ No____ Local community persons or groups Yes____No____ Members of your own church board Yes____ o____ Members of your own congregation Yes____ 0 Other (whom?) Do you ever talk with other Clergy Counselors about problems you meet in your counseling? Yes____NoL___ a. Approximately how frequently each month do you talk with other Clergy Counselors? b. What are the most typical problems you discuss with other Counselors? » What limitations, if any, should exist in a proposed abortion law (e.g.,gestation length, place of abortion, husband's or parent's consent, etc.)? What role should the MCCSPP play in the event of legalization of abortion? How do you think a liberalized law will affect your relationship with your abortion counselees? Please describe. In the event of a liberalized law, would you recommend that family planning services or other special agenmes assunethe largest share of abortion counseling? Yes No Undec1ded____ Why? What suggestions for change in the present organizational structure of the Counseling Service would you recommend? What suggestions for change in the counseling format or service to the counselee would you recommend? Do you have any further suggestions, recommendations, or comments? THANK YOU FOR YOUR COOPERATION IN FILLING OUT THIS QUESTIONNAIRE. APPENDIX E INTERVIEW SCHEDULE 446 447 APPENDIX E Interview Schedule The fellowing reseafch questions are aimed to understand background characteristics and personal experiences of women who have had abortion. Your response to these questions may provide necessary infbrmation for understanding the complex medical, psychological, and social factors associated with this procedure. You may be assured that any information you provide will be held in the strictest confidence, and that your name will never be associated in any way with the research findings. The field worker will answer any questions that you may have with regard to the research or the specific questions asked in the interview. Thank you for your cooperation and participation in this study. N. J. Davis Michigan State University Department of Sociology East Lansing, Michigan 48823 Subject's Code Number 448 Interview Schedule I. Background information. The following questions are of general concern for both an under- standing of patient's characteristics, as well as medical and cost factors associated with abortion. 1. Age 2. Marital status __1 3. Occupation __ A!_ 4. Level of education , _g_ 5. Religion ___ 6. Ethnic Group or Race ,_# 7. Residence _., l__ 8. Date of abortion w_ 9. Place of abortion ___ ll lO. Gestational age __fi 4. 11. Type of procedure __f A__ 12. Type of care (inpatient, outpatient) ___ __ 13. Type of facility (hoSpital, clinic) __, “ office, other 14. Number of prior pregnancies _fi _g_ 15. Number of prior deliveries (20 weeks or more) _w ¥__ 16. Number of prior abortions (under 20 weeks) spontaneous _fifi induced __f #_ 17. Type of contraception before the abortion __r (_H_after the abortion _—_ _‘_ 18. Cost features: (a) procedure - doctor ___ _#_ hospital __7 _#_ other medical _l. #__ (b) travel (specify kind) __ _A_ (c) hotel and meals __» ¥A_ (d) other _fi_ A_* II. 19. 20. 21. 449 Method of payment (please check) (a) cash delivered before (b) cash delivered after (c) installment plan (d) Blue Cross/Blue Shield (e) free (f) Medicaid (g) other llllll How was the abortion financed? Describe. Did you use a paid referral agency? yes no If yes, please estimate the amount you paid to the agency . Referral information. The you 22. 23. 24. 25. following questions explore your experiences with persons whom contacted both before and after the abortion. How many persons were contacted by you after you discovered you were pregnant? ‘ What were their relation to you? Which one of these contacts had a part in helping you to get an abortion? (Specify each contact and the role he or she played.) contacted for In all, how many different persons were . h regard to an abortion? information, referral, or counseling wit 26. 27. 28. 29. 3O 31. 32 33 34. 450 Describe what happened at each point of contact. As far as these contact persons are concerned, what were their respective occupations? If the contact persons were friends, were they men or women, same approximate age, older or younger? Which points of contact did you consider difficult or problematic in any way? Why? Describe. What was the approximate time period between each contact? What was the approximate time period from the first contact to the date of the abortion? How long after the abortion did you see a physician, counselor or other professional? How many such post-abortion contacts with professionals did you have, if any? What tyne of professional help did you seek? Please describe each professional contact, the reason you sought help, and the type of help given. III. 451 Fol low—up information . The following questions are of concern for understanding the post-operative experiences of abortion patients. 35. Are you presently using any contraceptive? If so, what kind? 36. Have you ever discontinued contraceptive use? If so, please describe. 37. Have you had any subsequent pregnancies since the abortion? ‘If so, was it planned? 38. Did you haVe any medical complications following the abortion? Please describe. 39. How did you take care of such complications? 40 Was there any change in your occupation as a result of your abortion?_ If so, please describe. 41. Did you experience any economic hardships due to the cost of your abortion? Please describe. 42. Did the abortion have any effect on your relationship with your husband/friend? What kind of effect? 452 43. Did the abortion have any effect on your relationship with your children, if any? What kind of effect? 44. Did you experience any interest with regard to social problems or action related to abortion (e.g. abortion law refbrm, ‘ population-planning, etc.). Describe. 45. What were your feelings before the abortion? 46. What were your feelings immediately following the abortion? 47. What were your feelings one month later ? three months later _fi_ ? six month later ? ? one year or more 48. Do you feel that this decision was right for you? 49. Did you at any time have any regrets about this decision? 50. Would you make this same decision again? either before or after the abortion, that 51. Was there any time, . hiatric attention? you felt you required psyc 453 52. Have you ever seen a psychiatrist or mental health worker with regard to your abortion? Describe. 53. Has the abortion, in any way, changed your life? Please describe. 54. Are there any concerns you may have with relation to your abortion that are not covered by these questions? Please comment. 55. What is your personal reaction to this interview? 56. Would you suggest any changes in the questions or the general format of the interview? BIBLIOGRAPHY, 454 BIBLIOGRAPHY Books Ash, Roberta, Social Movements in.America, Chicago: Markham Publishing Company, 1972. Association for the Study of Abortion, Abortion in the Changing World, New York: Columbia University Press, 1970} Bantbn, M., (ed.) The Social Anthropology of Complex Societies, London Tavistock Publications, 1966. Bates, J. and Zawadski, Criminal Abortion, Springfield, Ill.: Charles Thomas Company, T564. Becker, Howard S., Outsiders: Studies in the Sociology of Deviance, New York: The FFee Press, l964. Blumberg, A. 8., Criminal Justice, Chicago: Quadrangle Books, Inc., 1967. Bowen, Howard R., and James R. Jeffers, "The Economics of Health Services," General LearninggPress, 79 Madison Avenue, New York, New York. Burke, K., Permanence and Changg, Los Altos, California: Hermes Publica- tion,71954edition. Language as Symbolic Action, Berkeley & Los Angeles: University of California Press, l968. Callahan, Daniel, Abortion: Law, Choice, and Morality, New York: MacMillan, 1970. Cumming, E., Systems of Social Regulation, New York: Atherton Press, 1968. Denzin, Norman K., The Research Act, Chicago: Aldine Publishing Company, l970. Dickens, Bernard M., Abortion and The Law. London: MacGibbon & Kee, l966. Ebon, Martin (ed.), Everywoman's Guide to Abortion. New York: Pocket Books, 1971. Epstein, A. L., Ed., The Craft of Social Anthropology, New York: Barnes _ and Noble, Inc. 455 456 Fellner, William, Competition Among the Few, New York: Augustus M. Kelley, Publisher, l965. Filstead, W. J. (ed.), Qualitative Methodology, Chicago: Markham Publishing Co., 1970. Friedson, Eliot, Professional Dominance: The Social Structure of Medical Care, New York: Atherton Press, 1970. . Profession of Medicine: A Study of the Sociology of TApplied Knowledge, New York: Dodd'MeadT& Company, 1972. Galtung, J., Theory and Methods of Social Research, New York: Columbia University PressITl967. Garfinkel, Harold, Studies in Ethnomethodology,_Englewood Cliffs, New Jersey: Prentice'Hallj'Inc.. Gebhard, Paul H., et. al, Pregnancy, Birth and Abortion, New York: Paul B. Hoeber, Inc., T958. Glaser, 8., and A. Strauss, The Discgygry of Grounded Theogy, Chicago: Aldine Publishing Company, l967. Group for the Advancement of Psychiatry, Committee on Psychiatry and Law, The Right to Abortion: A PsychiatricView, New York: Scribner, l970. Hall, Robert E., M.D., A Doctor's Guide to_Having an Abortion, New York: The New American Library, Inc.,—197T} Hammond, Philip E., The Campus Clergyman, New York: Basic Books, Inc., l966. Hanson, N., Patterns of Discovery, London: Cambridge, l958. Henslin, James M. (ed.), Studies in the Sociology of Sex, New York: Appleton-Century-Crofts,‘1971. Hughes, Everett 0., The Sociological Eye: Selected Papers, Chicago: Aldine-Atherton, l972} Knight, Frank H., Risk, Uncertainty and Profit, Boston: Houghton Mifflin Company, 1921. Lader, Lawrence, Abortion, Indianapolis: Bobbs-Merrill, l966. Lee, A. M. (ed.), Principles of Sociology, New York: Barnes and Nobles, l95l. Lee, Nancy Howell, The Search for an Abortionist, Chicago: University of Chicago Press, l969. 457 Leibenstein, Harvey, Economic Theor and Organizational Analysis, New York: Harper & Brothers, 1 60. ' Lemert, Edwin M., Social Pathology, New York: McGraw-Hill Book Company, l951. . Human Deviance, Social Problems and Social Control, Englewood—Cliffs, New Jersey: Prentice-Hall, Inc., 1967. Mayer, Philip, Townsmen or Tribesmen: Conservatism and the Process of Urbanization in a South African City, Cape Town: Oxford University Press. McCall, G. J. and J. L. Sinmons (eds.), Issues in Participant Observation, Reading, Mass.: AddisonzWesley Publishing Company,l969. Mitchell, J. Clyde, (ed.), Social Networks in Urban Situations, New York: Humanities Press, Inc., Distributors, l969. Mueller, Willard F.. Monopoly and Competition, New York: Random House, l970. Packer, Herbert L., The Limits of the Criminal Sanction, Stanford, California: Stanford University Press, T968. Peel, John and Malcolm Potts, Textbook of Contraceptive Practice, Cambridge: At the University Press, 1969. Schur, Edwin M., Crimes Without Victims, Englewood Cliffs, New Jersey: Prentice-Hall, Inc., l965. Sjoberg, G., and R. Nett, A Methodology for Social Research, New York: Harper & Row, l968. Skolnick, J. H., Justice Without Trial, New York: John Wiley & Sons, Inc., l966. Sutherland, Edwin H., and Donald R. Cressey, Princi les of Criminology, 6th ed., New York: J. B. Lippincott Co., 691 Titmuss, Richard M., The Gift Relationship, New York: Pantheon Books, l97l. Turk, A. T., Criminality and Legal Order, Chicago: Rand McNally & Company, 1969. Turner, Victor W., Schism and Continuity in an African Society, Manchester: Manchester University Press for the Rhodes- Livingstone Inst., 1957. Tyler, Stephen A. (ed)., Cognitive Anthropology, New York: Holt, Reinhart and Winston, Inc., l969. 458 Vincent, Clark E., Unmarried Mothers, New York: Free Press, l96l. Whyte, William F., Street Corner Society, Chicago: University of Chicago Press, 1955. Zald, Mayer N., Organizational Change: The Political Economy of the YMCA, Chicago: The university of Chicago Press, T970. Articles and Book Chapters Barth, Fredrick, "The Role of the Entrepreneur in Social Change in Northern Norway," Acta UniversitasBerggnsis. Series Humaniorum Litterarum No. 3. Tergin; 1953; 1‘Rdels of SobTaT OrgahTzationP' _Royal Anthropological Institute, Occasional Papers, l966; "EconomiE'Spheres in Darfur," Association of Social Anthropolo- gjsts Monogrgph, R. Firth (ed.) forthEoming. Black, Mary and Duane Metzger, "Ethnographic Description and the Study of Law," American Anthropologist, V. 6, Part 2 (Special Publications), l4l-l65'(December, l965). Blumer, H., "Collective Behavior," in A. M. Lee (ed.), Princi les of Sociology, New York: Barnes and Nobles, 1951, l67-225. Bucher, Rue, "Pathology: A Study of Social Movements Within a Profession," in Eliot Friedson and Judity Lorber, (eds.), Medical Men and Their Work, Chicago: Aldine-Atherton, Inc., 1972. Dunbar, F., "Psychosomatic Approach to Abortion," in M. Deutsch, Psychology of Women, Vol. II, Motherhood, New York: Grune and Stratton, 1945. Ekblad, Martin, "Induced Abortion on Psychiatric Grounds: A Follow Up Study of 479 Women," Acta Psychiatrica EtNeurologica, Scandinavia, supple., Vol. 99,—l955, (Donald’Burton, translator). Geertz, Clifford, "Ideology as a Cultural System," in David E. Apter (ed.) Ideology and Discontent, New York: The Free Press, 1964, 46-76. Gerlack, L. P. and V. H. Hine, "Decentralized, Segmentary and Reticulate Organizations in Movements of Change . . .," Journal of the Scientific Study of Religion 7. (Spring l968), 23-40. Habenstein, Robert W., "Critique of 'Profession' as a Sociological Category," The Sociological Quarterly, (November, 1963), 29l-300. Hodgson, Jane E., M.D., "Therapeutic Abortion in Medical Perspective." In Minnesota Medicine 53, July, l970: 755-757. 459 Jansson, B., "Mental Disorders After Abortion," Acta Psychologica Scandinavia 41 (1965): 87-110. Kitsuse, John I., "Societal Reaction to Deviant Behavior: Problems of Theory and Method," Social Problems 9 (Winter, 1962): 247a257. Manning, Peter K., "Fixing What You Feared: Notes on the Campus Abortion Search," in J. M. Henslin (ed.), Studies in the Sociology of Spy, New York: Appleton-Century-Crofts,1971. Martin, John 8., "Abortion," Saturday Evenipg Post, (May 20, 1961). Matza and Skyes, "Techniques of Neutralization: A Theory of Delinquency," American Sociological Review 22 (December): 664-670, 1951. Mayer, Philip, "Migrancy and the Study of Africans in Towns," American Anthropologist 64 (1962): 576-592. Morrison, Denton E., Kenneth E. Hornback, W. Keith Warner, "The Environmental Movement: Some Preliminary Observations and Predictions," from William Burch, Neil Cheek and Lee Taylor (eds.), Social Behavior, Natural Resources and the Environment, New York: Harper and Row, T972. Nathanson, Bernard N., M.D., "Ambulatory Abortion: Experience with 26,000 Cases (July, 1969, to August 1, 1971). New England Journal of Medicine 281 (Feb. 24, 1972); 403-4072 Nicholas, R., "Rules, Resources, and Political Activity,“ in Marc J. Swartz, (ed.) Local-Level Politics, Chicago: QAdline PubliShing Company, 1968. Packer, Herbert L., and Ralph J. Gambell, "Therapeutic Abortion: A Problem in Law and Medicine," Stanford Law Review ll (May, 1959 . Pakter, Jean and Frieda Nelson, "Abortion in New York City," Family Planning Perspectives 3 (July 1971): 5-12. Potts, Malcolm, "Legal Abortion in the U.S.A.: A Preliminary Assessment," The Lancet (September 18, 1971): 651-653. Rains, Prudence Mors, Becoming an Unwed Mother: A Sociological Account, Chicago and New York: Aldine-Atherton Inc., 1971. Rosenhan, D. B., "On Being Sane in Insane Places," Science 179 (Jan. 19, 1973): 250-258. Schur, Edwin M., "Abortion and the Social System," Social Problems 3 (October, 1955): 94-99. 460 'Smith, Harvey L., "Crisis in an Institutional Network: Community Health Care," in H. S. Becker, B. Geer, D. Riesman, R. S. Weiss (eds.), Institutions and the Person, Chicago: Aldine Publishing Company, 1968, 1574164. Seidman, R. B., and W. J. Chambliss, "The Criminal Courts," in P. K. Manning (ed.), Social Control and the Agencies of Control, New York: The Free Press, forthcoming. Simon, N. M. and A. Senturia, "Psychiatric Sequelae of Abortion: Review of the Literature," Archives of General ngchiatry_15 (October, 1966): 378-389. Tietze, Christopher, M.D., "Mortality with Contraception and Induced Abortion," Studies in Family Planning 45 (September 1969): 6-8. Ward, Barbara, "Varieties of the Conscious Model," in M. Banton (ed.), The Relevance of Models for Social Anthropology, New York: Barnes & Noble, Inc., 1965, 113-137. Public Documents Petition of Vickers, (1963) 123 N.W. 2d, 253, V. 371 Michigan Compiled Laws, p. 114. People v. Marra, (1970), V. 27, Michigan Appellate I., p. 1. People v. Sessions, (1886), 26 N.W. 291, V. 58, Michigan Compiled Laws, p. 594. People v. Smith, (1941), V. 296, Michigan Compiled Laws, p. 176-180. People v. Wellman, (1967), V. 6, Michigan Appellate, p. 573. S.P.S. Consultants, Inc. versus Louis J. Lefkowitz, Attorney general and Martin S. Mitchell versus Louis J. Lefkowitz, United States District Court, Southern District of New York, 71 Div. 2931, 71 Div. 2990, October 5, 1971). Unpublished Materials Bailey, F. G., "Conceptual Systems in the Study of Politics," Paper presented at the Conference on Middle Eastern Politics, Bloomington, December 1969. Crockett, Ethelene, M.D., "Consumer, Consumer Education, and Protection." Paper presented to the Conference on Planning Abortion Facilities in Michigan (Wayne County Medical Society, Detroit, Michigan, April 23-24, 1971). 461 Downs, Lawrence A., M.D., David Clayson, "Unwanted Pregnancy: A Clinical Syndrome Defined by the Similarities of Preceding Stressful Events in the Lives of Women with Particular Personality Characteristics." Presented at the Twentieth Annual Meeting of the American College of Obstetricians and Gynecologists, Chicago, Illinois, May 3, 1972. Osofsky, J. D. and H. J. Osofsky, "The Psychological Reactions of Patients to Legalized Abortion," Paper presented at American Orthopsychiatric Association Meeting, March, 1971. Wassertheil, S. M., C. B. Arnold, M.D., and R. C. Lerner, "New York State Obstetricians and the New Abortion Law: Physician Experience with Abortion Techniques," Department of Community Health, Albert Einstein College of Medicine, Bronx, New York. 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