Why Knowing How Many Patients You Have Matters

When we overlook the obvious, we can do real evil

Stephen Doran’s new book, To Die Well: A Catholic Neurosurgeon’s Guide to the End of Life, is a gem that pulls off several achievements simultaneously. It’s readable while tackling the major issues of bioethics around death and dying while situating the whole discussion in a spiritual context, recognizing that death is not just a phenomenon but the defining moment of a person’s existence. The book’s breadth matches Doran’s: physician, neurosurgeon, bioethics writer, Catholic deacon. It deserves a read. (A link to the book, published by Ignatius Press, is here.)

I want to focus specifically on one chapter, chapter six, “Perinatal Death.” Doran admits it’s not his expertise and that the daunting issues raised in that field can be intimidating: “Even for someone like myself who is comfortable dealing with challenging medical situations, maternal-fetal medicine seems next level, emotionally and spiritually exhausting. Death is always lurking.” And what makes it challenging is “[u]nlike most other specialties, … [one] is simultaneously caring for two patients, whose welfare is linked together. If you treat the mom, you are treating the baby and vice versa.”

The chapter gets into many details about this field, but the last quotation really struck me as central to the whole discussion, for two reasons. It’s true. It’s also hotly contested today.

Consider the current controversy over Texas’s limits on abortion. The Lone Star State has simply become the poster child for a trope abortionists are pushing all across America: that limits on abortion are inherently life-threatening to women while chilling and deterring good active medical care.

Pro-life people are naïve when they think political debate is conducted on the model of a high school civics class or “Mr. Smith Goes to Washington,” where the truth prevails after rational debate where all parties seriously ponder the arguments. The truth is that the abortion issue is being decided not by rational argument but by stories, narratives that the abortionists are pushing to frame the issue emotionally one way to the marginalization and ultimate exclusion of other views. To that end, hard cases are pushed to frame the whole abortion debate that way. Never mind the adage that “hard cases make bad law.” They make good storylines leading to the kind of law their pushers want.

Back in the 1960s, it was rape and “back-alley abortions.” If you took the arguments seriously, America was in the throes of massive back-alley bloodletting, much of which was driven by women who were raped or otherwise sexually abused. Never mind that the statistics didn’t bear that out. Never mind that the vast majority of abortions — usually around 96% — have no medical or criminal nexus but are procured for socio-economic reasons or pure wish. Never mind that even Bernard Nathanson, one of the purveyors of the “rape and back-alley abortion” figures admitted subsequently the numbers were pulled out of thin air. Did they frame the story successfully for abortionists? Yes.

In the wake of Dobbs, the new scare tactic is that “anti-abortion extremists” will prevent women from accessing medical care necessary to save their lives while doctors will be hounded across America for providing “medical care.” That line worked in Ireland, getting Eire’s pro-life constitutional protections repealed. It almost worked in Malta, but for strong pro-life and Catholic pushback. And now it’s being rolled out in Texas.

I mention this because it’s all happened in the few short months since Doran’s book appeared, but it makes his quotation all the more salient. In speaking of perinatal medicine, Doran states the obvious fact: those specialists treat two patients whose medical situation is interdependent. What the abortionists want you to believe is there’s only one patient. They might not say that out loud. The sneaky snake also didn’t say out loud, “Listen, Eve baby, you ain’t gonna die, God’s just jerking you around.” He simply framed a doubt: “Did God really say…?” Saying out loud “there’s no second patient, or at least none that matters” could prove alienating. As much as people feel sympathy for mothers in medical distress, they also feel some solidarity with babies in those circumstances. So, they’re left aside.

If there are two patients, that fact shapes how one deals with the situation. Doran, for example, discusses ways of handling preeclampsia that involve the principle of double effect. (The same could be said, for example, when addressing a cancerous uterus or ectopic pregnancy). He also shows how those procedures differ from a direct abortion as “treatment” of the problem.

In the process, he demonstrates how a true perinatal specialist strives to save two lives, which is a lot more complicated than simplifying cases because you have no obligation to reckon with that second life.  

The abortionists want nothing of those distinctions, precisely because they do not believe there is a second patient present, or at least one that matters. For them, there is only the mother, and if her extreme situation allows them to smuggle in the principle that her choice is the only thing that matters ever, well you’ve just smuggled in justification for any abortion anytime, which is what the whole thing is about. One might borrow Dickens’s apt description about the width of Scrooge’s staircase to apply it to this smuggling feat: “you might have got a hearse up that staircase, and taken it broadwise, with the splinter-bar towards the wall and the door towards the balustrades, and done it easily. There was plenty of width for that, and room to spare.”

At the same time, the argument provides added benefits. It cements the lie that abortion is “health care.” Pro-lifers deride that claim, insisting that something which kills a patient is hardly “health care.” But if, instead of eliminating the killing, you eliminate the “patient,” well, a non-patient can’t be “killed,” can he? It’s an ideological two-fer!

No one should think this essay is simply a kind of self-evident “gotcha.” It is not. It has real world implications. David Hackney, a Cleveland OB-GYN, penned an op-ed in The New York Times the weekend before Ohio voters adopted an abortion-on-demand state constitutional amendment last November. It was clear this practitioner practically considered one patient: the woman. He objected to the way Ohio framed Issue 1 in speaking about the “unborn child.” Asked whether he ever referred to the unborn child as a “child” (as in “you’re having a baby”) he admitted he did, “informally, all the time, in concert with our patients.”

In other words, whether that clump of cells is a “child” or not is simply a polite verbal convention. If the woman wants the baby in a high-risk pregnancy, it’s a child; if not, maybe/probably not, I don’t know, or it doesn’t matter. Hackney describes himself as a “maternal fetal” practitioner. Well, if the woman has not magically made the fetus a “child,” is she a “mother?” If you ask me to follow that kind of “science,” I pass.

Abortion has so inured us to these contradictions that we take them at face value, even if the so-called “specialists” in a field cannot scientifically admit they have two patients to whose care they are morally obliged to attend. It’s the same problem with secular bioethics; a field that etymologically is the “ethics of life” often fails normatively to admit when that “life” begins and often busily formulates rationales to take it.

So, while I appreciate the masterful detail Doran provides about issues of life and death in the delivery ward and nursery, sometimes one simply needs to be reminded of elementary truths contemporary people seem blind to. Like 2 + 2 is and can only be 4. Like there are men and there are women. And that perinatal medicine involves two patients. Because when we overlook the obvious, we can do some really evil things.


John M. Grondelski (Ph.D., Fordham) was former associate dean of the School of Theology, Seton Hall University, South Orange, New Jersey. All views expressed herein are exclusively his.

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