The Wandering Uterus: Politics and the Reproductive Rights of Women 9780814763209

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The Wanderin g Uterus

The Wandering Uterus Politics and th e Reproductive Rights of Wome n

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Cheryl L. Meyer

NEW YOR K U N I V E R S I T Y PRES New Yor k an d Londo n

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NEW YOR K UNIVERSIT Y PRES S New Yor k an d Londo n Copyright © 199 7 b y New Yor k Universit y All rights reserve d Library o f Congres s Cataloging-in-Publicatio n Dat a Meyer, Chery l L. , 1959 The wandering uteru s : politics an d th e reproductive right s of women / Cheryl L . Meyer , p. cm . Includes bibliographica l reference s (p . ) and index . ISBN 0-8147-5563-1 (clot h : acid-free paper).—ISB N 0-8147-5562-3 (pbk . : acid-free paper ) 1. Human reproductiv e technology—Socia l aspects . 2 . Huma n reproductive technology—Politica l aspects . 3 . Human reproduction — Social aspects. 4 . Human reproduction—Politica l aspects . 5. Birth control—Political aspects . 6 . Sex discrimination agains t women. 7 . Women's rights . I . Title. RG133.5.M48 199 7 176—dc20 96-3569 4 CIP New Yor k Universit y Pres s books ar e printed o n acid-fre e paper , and thei r bindin g materials ar e chosen fo r strengt h an d durability . Manufactured i n the United State s o f Americ a 10 9 8 7 6 5 4 3 2

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To my parents, Charles Louis and Camilla Kathryn Meyer, a constant source of support, acceptance, and inspiration

Contents

Acknowledgments i

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Introduction: Th e Wandering Uteru s 1 1. Politic s an d Reproductiv e Technologie s I : Gamete Donatio n 7 2. Politic s an d Reproductiv e Technologie s II : The Legac y o f IV F 4

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3. Politic s an d th e Contro l o f Women's Bodie s 8

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4. Politic s an d Reproductiv e Issue s in the Workplace 10

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5. Politic s an d Reproductiv e Choic e 13

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6. Reproductiv e Intervention s 16

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7. Bac k to the Future ? 19

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Notes 19

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Index 22

1 [vii]

Acknowledgments

Writing thi s boo k ha s bee n a n adventure . A s thi s adventur e came t o a close , anothe r began : I learne d I was pregnant . Thi s news trul y move d th e researc h an d wor k I ha d complete d fo r this boo k t o anothe r leve l o f meanin g an d relevance . I n th e few shor t month s sinc e he r birth , m y daughter , Rachel , ha s transformed m y lif e i n a way I only dreame d wa s possible . Every skil l necessar y t o complet e thi s boo k wa s cultivate d through th e guidanc e o f m y parents . The y continu e t o teac h their childre n t o respect themselve s an d others , to appreciat e th e value o f a n education , an d t o demonstrat e tenacit y i n pursuin g goals in life. You've don e a great job , Mom an d Dad . This boo k woul d no t hav e bee n possibl e withou t th e hel p o f Debra A . Zendlovitz , M.S.W . De b painstakingl y rea d ever y word o f thi s tex t numerou s time s an d provide d a grea t dea l o f editorial assistance . Mor e importantly , however , sh e gav e m e moral suppor t durin g neurotic crises and helpe d celebrat e trium phant moments . Deb has provided m e with a focus bot h person ally and professionally , fosterin g m y growth i n bot h areas . Two mentor s no t onl y influence d bu t inspire d thi s book . Professor Morriso n Torre y o f DePau l Universit y awakene d m e to the importanc e o f women's issue s and , throug h he r cours e o n feminist jurisprudenc e an d he r personal convictions , enlightene d me an d encourage d m e t o find m y ow n voice . Professo r Jan e [ix]

[x] Acknowledgment

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Rutherford, als o o f DePaul , throug h he r cours e an d he r view s on famil y law , challenged m e to thin k mor e deepl y an d analyti cally. I am indebte d t o bot h o f thes e instructor s fo r thei r indeli ble impact o n m y life . The suggestions , direction , an d feedbac k o f Katherin e A . Hermes, Ph.D. , J.D. , als o enhance d th e depth , accuracy , an d scope of the book . Niko Pfun d contribute d everythin g a goo d edito r should : knowledge, editoria l suggestions , marketin g strategies , atten tiveness, and a quick turnaroun d o n everything . However , wha t has mad e Nik o a great edito r ha s bee n hi s humor , flexibility , and support , particularl y durin g wha t I perceive d a s difficul t moments. The researc h assistanc e o f Laur a Markway , Laure l Bloom , and T. J. Williams was invaluable; they offered technica l suppor t when th e ligh t wa s exceedingl y di m a t th e en d o f th e tunnel . I am als o grateful t o the LEXIS research corporation , particularl y Katie Nye, for he r understanding , patience , and help . I also want t o than k Northwes t Missour i Stat e University fo r providing financial an d persona l suppor t fo r m y research . I n particular, Jo n Hixon , Ph.D. , has bee n enthusiasti c an d accom modating a s bot h m y departmen t chai r an d friend . Caro l J . Claflin, Ph.D. , ha s adde d valuabl e editoria l tips , researc h guid ance, and pregnanc y advice . Finally, I wan t t o than k al l o f m y readers . I hop e thi s boo k inspires i n yo u a renewe d interes t in , an d commitmen t to , th e reproductive right s o f women .

Introduction: Th e Wanderin g Uterus

^ - h e issue s surroundin g wom en's reproduction an d reproductiv e right s hav e historicall y bee n tinged wit h th e devaluatio n o f women . Th e theor y o f th e wan dering uterus i s a perfect example . The Greek physicia n Hippoc rates i s generally credite d wit h first suggestin g tha t hysteri a wa s the resul t o f a wanderin g uterus : th e uterus , h e thought , coul d detach itsel f an d wander abou t th e body , causing dysfunction b y adhering t o othe r organs . Fo r example , th e uteru s migh t attac h to th e heart , causin g ches t pains , o r t o th e stomach , causin g gastrointestinal problems . I n turn , thi s woul d caus e wome n t o become hysterica l (evidentl y me n wer e incapabl e o f becomin g hysterical). N o on e kne w fo r certai n ho w t o preven t thi s fro m happening, bu t on e cur e wa s t o ancho r th e uterus . Thi s coul d easily b e accomplishe d throug h eithe r impregnatin g th e woma n or keepin g th e uteru s mois t throug h intercours e s o it would no t seek out th e moisture o f othe r organs . [1]

[2] Introductio

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In th e secon d centur y Aretaeu s suggeste d tha t th e uteru s was attracte d t o o r repulse d b y certai n smells , causin g eithe r a prolapse o r "hysterica l suffocation, " respectively . I f th e uteru s was attracte d t o a smell , i t woul d disten d ou t o f th e vagin a toward it ; i f i t wa s repulsed , i t woul d ascen d towar d othe r organs. Thus , smell s coul d b e use d t o realig n th e uterus . I f th e uterus ha d prolapsed , th e cur e wa s t o plac e a repulsiv e odo r near th e vagina ; i f "hysterica l suffocation " ha d occurred , a pleasant odo r shoul d b e place d nea r th e vagina . Thes e treat ments coul d b e enhance d b y placin g odor s nea r th e vagin a an d nose simultaneously . S o i f th e uteru s ha d prolapsed , plac e a pleasant smel l nea r th e nos e an d a n unpleasan t on e nea r th e vagina an d th e uteru s coul d b e cleverly deceive d int o ascending . Such tricker y reste d o n th e assumptio n tha t th e uteru s was , i n Aretaeus's words , "a n anima l withi n a n animal. " Gale n revise d Aretaeus' theory , suggestin g tha t th e uteru s di d no t mov e pe r se; rather , "abnormal " sexua l functionin g le d t o "hysterica l suffocation." Whe n th e uteru s coul d no t functio n "normally " (for example , i n th e cas e o f a widow) , i t poisone d th e bod y through retentio n o f menstrua l fluid o r ol d semen . On e cur e fo r this malad y wa s t o provid e a wa y fo r th e patien t t o retur n t o a "normal" se x life . Such theories , directl y linkin g hysteri a an d emotiona l stabil ity to uterin e functioning an d heterosexuality , survive d i n ortho dox medical circles up to the late 1800 s an d clearly demonstrat e the influenc e o f sexis m o n reproductiv e rights . No on e venture d a paralle l theor y suggestin g that whe n me n becom e aggressiv e i t is because their testicle s brea k fre e an d relocat e to othe r part s o f the body . Men's response s wer e define d a s "normal, " an d wom en's response s wer e pathologize d becaus e the y wer e no t lik e men's. Toda y thes e notion s stil l exis t althoug h the y hav e bee n reassigned t o th e hormona l influence s relate d t o gynecologica l

[3] Introductio

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functioning: th e uteru s itsel f n o longe r cause s menta l illnes s bu t premenstrual o r postpartu m hormon e fluctuations do . Moreover, th e lega l syste m i s fraugh t wit h paternalisti c no tions towar d women . Women' s reproductiv e system s an d right s have becom e ensnare d i n th e politica l agenda s o f th e America n Medical Association , th e America n Psychologica l Association , insurance companies , pharmaceutica l companies , othe r busi nesses, legislature s and , o f course , politician s a t ever y level . Since abortio n i s th e issu e tha t surface s mos t frequently , som e people naivel y believ e tha t societ y doe s no t meddl e wit h th e reproductive freedo m o f wome n unles s th e lif e o f a fetu s i s a t stake. This is far fro m th e case . In thi s boo k a collectio n o f ostensibl y unrelate d issue s ar e woven int o a tal e reflectin g patriarcha l interventio n int o wom en's reproductiv e right s fro m preconceptio n t o postpartum . When eac h o f these issues is examined separately , subtl e dispari ties between the treatment o f men and women becom e apparent . But b y viewin g the m collectivel y an d throug h a n interdisciplin ary focus tha t encompasse s law , medicine, and psychology, I will show tha t thes e disparitie s moun t u p t o a broa d patter n o f social injustice , namely , the contro l o f women b y men . The firs t tw o chapter s presen t technique s whic h ar e designe d to provid e wome n (an d couples ) mor e contro l ove r thei r ow n reproductive choices . Ultimately , thes e practice s hav e als o re sulted i n healt h risk s t o women , discrimination , an d man y un fulfilled promises . Th e medica l professio n an d th e legislature s have refuse d t o regulat e reproductiv e technologie s i n an y sub stantial way . A s a result , a multibillion-dollar-a-yea r industr y continues t o spira l ou t o f control . Seme n donor s ar e no t rou tinely screene d an d limit s ar e no t place d o n numbe r o f dona tions, thu s creatin g safet y concern s an d th e possibilit y o f satia tion o f th e gen e pool . Eg g donation , whic h ha s bee n portraye d

[4] Introductio

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as a paralle l proces s fo r women , i s a risky , invasiv e procedur e that require s tremendou s investmen t o n th e par t o f th e eg g donor an d overal l has a relatively low rate o f success . Egg donatio n woul d no t b e worthwhil e withou t th e adven t of i n vitr o fertilizatio n an d it s derivatives . I n 197 8 th e first successful birt h fro m i n vitr o fertilizatio n showe d tha t i t wa s possible t o fertiliz e egg s outsid e th e fallopia n tube s an d reim plant th e embry o i n th e uterus . Sinc e then reproductiv e techno logies suc h a s i n vitr o fertilizatio n an d eg g donatio n hav e be come s o commonplac e tha t the y hav e becom e fodde r fo r television sitcoms . Roseanne , a sitco m sta r wh o gav e birt h t o a child conceive d throug h i n vitr o fertilization , facetiousl y de scribed th e proces s o n he r televisio n show . "Grac e Unde r Fire, " another sitcom , aire d a n episod e i n whic h Grace' s bes t frien d asks he r t o b e a n eg g donor . I n vitr o fertilizatio n ha s becom e old news and has paved the way for numerou s othe r procedures , most o f which ar e notoriously unsuccessfu l an d expensive . Surrogacy wa s possibl e befor e i n vitr o fertilizatio n i f th e surrogate agree d t o b e inseminate d wit h th e seme n o f a ma n who woul d late r hav e custod y o f th e child . I n vitr o fertilizatio n made i t possibl e t o implan t a n embry o i n a surrogat e whe n n o genetic tie t o th e surrogat e existe d an d ha s als o provide d physi cians with a n opportunit y t o experimen t wit h freezin g embryos . The issue s o f surrogac y an d froze n embryo s hav e create d un precedented ethical , legal, and medica l dilemmas . The legal profession ha s no t begu n t o catc h u p t o th e medica l advance s an d has bee n draw n int o debate s bette r lef t t o ethicists , suc h a s th e question o f whe n lif e begins . Thi s ha s create d numerou s lega l situations wher e n o on e wins, especially no t women . Moreover , although th e long-ter m healt h consequence s o f th e ne w repro ductive technologie s remai n unknown , th e experimenta l natur e of the procedures an d th e safet y issue s are not a s well publicize d as th e purportedl y risin g rate s o f infertility . A s a result , wome n

[5] Introductio

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(and couples ) floc k t o utiliz e reproductiv e technologies , surmis ing that the y ar e victims o f the infertilit y "epidemic. " While th e medica l professio n ha s bee n give n virtuall y a fre e hand t o emplo y thes e technologies , wome n themselve s hav e been increasingl y regulated . Thi s seem s counterintuitive , give n that i t i s muc h easie r t o regulat e a professio n tha n individuals . Still, law s whic h allo w wome n t o b e punishe d fo r behavin g in certai n way s while they are pregnant hav e bee n proposed , approved, an d implemented . Th e most notabl e o f these relate t o substance abus e durin g pregnanc y an d ar e discusse d i n chapte r 3. I n short , th e medica l professio n ca n creat e lives , eve n i f that mean s riskin g th e lif e and/o r healt h o f women , fetuses , o r children, bu t a woma n carryin g a fetu s ca n b e punishe d fo r making choice s which ma y affec t th e health o f he r fetus . If women' s live s ar e regulate d s o tha t the y wil l no t pu t th e fetus a t risk , the n othe r potentia l hazard s t o th e fetu s shoul d also b e monitored an d regulated . Yet , as we shal l se e in chapte r 4, many industries beside s the medical professio n als o go unreg ulated, even though the y may represent threats to the fetus. Wh y should w e regulate ' women's reproductiv e live s bu t neglec t t o insure overal l reproductiv e health ? Another exampl e o f thi s disparit y i s abortion . Restriction s over a woman' s righ t t o choos e limi t wh o ca n obtai n a n abor tion, whe n the y ca n obtai n it , an d wher e i t ca n b e obtained . Abortion method s hav e als o bee n restricted . RU-486 , which ha s been availabl e i n Europ e fo r mor e tha n a decad e ha s bee n kep t off th e America n marke t b y politica l maneuvering . Wome n ar e being denie d a well-teste d option , onl y t o hav e i t replace d b y procedures tha t ar e les s saf e an d i n som e case s eve n experimen tal. The politics o f abortio n an d RU-48 6 ar e outline d i n chapte r 5. Finally, i f reproductiv e right s o r reproductiv e healt h wer e really a n importan t issu e t o polic y makers , th e appallin g statis -

[6] Introductio

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tics presente d i n chapte r 6 woul d no t exist . Cesarea n section s and hysterectomie s woul d no t b e th e to p tw o surgerie s per formed i n the United States . In many cases , the procedures plac e women a t great ris k fo r littl e benefit . Overall, ther e i s littl e concer n i n ou r societ y fo r th e healt h and welfar e o f th e mothe r o r th e fetu s afte r conceptio n bu t much concer n ove r regulatin g pregnan t women . Onc e gene s ar e safely e n rout e t o th e nex t generation , al l concer n seem s t o dissipate fo r th e mother o r the fetus. Al l of these issues reinforc e the notio n tha t th e social , political, an d lega l focu s o n women' s reproductive right s is driven les s by concern fo r th e health o f th e mother an d the fetus tha n b y a societal desir e to control women , regardless o f th e consequences . This boo k i s intende d t o b e a wide-rangin g introductio n t o issues relate d t o women' s reproductiv e right s an d welfare . I t i s meant t o enhanc e th e awarenes s o f thos e wh o ar e beginnin g t o explore thes e issues , fo r withou t awarenes s ther e ca n b e n o change. Mos t o f th e topic s touche d o n her e ar e explore d exten sively an d i n greate r dept h elsewhere , i n insightfu l publication s offering sophisticate d analyse s o f subtl e nuance s an d debate s that ar e beyond th e scop e of this book . This book i s not primar ily directe d a t th e feminis t schola r o r a t thos e alread y immerse d in th e field o f reproductiv e rights . I t is , rather , fo r al l wome n and me n wh o fight o n a dail y basi s t o mak e informe d decision s about thei r lives .

[1] Politics an d Reproductiv e Technologies I : Gamet e Donatio n

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osanna an d Maur o dell a Corte wer e devastate d whe n thei r onl y child , Riccardo , wa s killed i n a traffi c acciden t a t seventeen . Rosann a said , "I f yo u only knew what darknes s there is in this house, without a youn g boy who filled it with his joy and smile . I desire so much t o hav e another fac e t o caress , t o b e abl e t o hea r somebod y cal l m e mother." 1 S o th e dell a Corte s decide d t o adop t a child . How ever, the y wer e considere d to o ol d fo r adoption . The n Rosann a read a n articl e abou t Severin o Antinori, a gynecologist i n Rome , Italy, who coul d assis t Rosann a i n becomin g pregnant . Antinor i fertilized a donor' s eg g wit h Mauro' s sper m an d implante d th e embryo i n Rosanna' s uterus . O n 1 8 Jul y 1994 , Rosann a gav e birth t o a seven-pound , four-ounc e son . A t sixty-tw o year s old , she is considered th e oldes t woman i n the world t o giv e birth . Postmenopausal mother s o r "Methusela h moms," 2 a s the y have bee n dubbed , hav e becom e a focu s o f debat e relatin g t o [7]

[8] Reproductiv

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advancing reproductiv e technologies . Thes e technologie s hav e placed th e "miracle " o f birt h unde r th e control o f mere mortals . While man y lau d thi s development , other s soun d th e alarm , prophesying outcome s aki n t o tha t whic h issue d fro m Dr . Fran kenstein's laboratory . Sensationalized account s o f reproductiv e technologie s ar e widely circulated , an d virtuall y everyon e ha s a n opinio n regard ing th e morality , ethics , o r legalit y o f thei r use . Ye t rarel y d o those sam e individuals discus s the impac t o n women o f th e ne w reproductive technologies . Whil e the y hav e definitel y provide d women (an d men ) wit h mor e way s t o acquir e offspring , thi s does no t necessaril y translat e int o greate r reproductiv e choice , rights, or control. The focus o f this chapter wil l be on reproduc tive technologie s relatin g t o gamet e (eg g o r sperm ) donation , while th e focu s o f th e nex t chapte r wil l b e o n i n vitr o fertiliza tion, including surrogate motherin g an d cryopreservatio n (freez ing) o f embryos .

Alternative Inseminatio n Alternative inseminatio n (o r AI , formerl y know n a s artificia l insemination) i s the most widely practiced, successful , an d noto rious o f th e reproductive technologies . It has even bee n satirize d (generally withou t muc h success ) b y Hollywood, a s in Whoopi e Goldberg's Made in America. However , lumpin g A I i n wit h th e new reproductiv e technologie s i s somewhat misleading . First, AI does no t involv e muc h technology . I t didn' t tak e th e wonders o f moder n scienc e t o figure ou t th e process . Secondly , although medicall y assiste d A I has recentl y becom e mor e popu lar, probabl y du e t o purportedl y increasin g rate s o f infertilit y and th e adven t o f cryopreservatio n o f semen , th e possibilit y o f alternative inseminatio n wa s mentione d i n th e Talmud, 3 an d

[9] Reproductiv

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animal inseminatio n ha s bee n practice d fo r centuries . Th e firs t recorded gestatio n an d deliver y o f a chil d conceive d throug h alternative inseminatio n occurre d i n 1790. 4 I n fact , legen d ha s it tha t i n 1884 , on e Dr . Willia m Pancoas t anesthetize d th e wif e of a n infertil e ma n and , withou t th e permissio n o f th e ma n o r his wife, inseminate d he r wit h seme n fro m th e "mos t handsom e man i n his class o f medica l students." 5 Th e husban d apparentl y "received th e new s wit h grea t enthusiasm." 6 I n short , "b y th e early 1900's , th e practic e o f D I [dono r insemination ] wa s wel l under way . Twenty-four article s ha d bee n written o n th e subjec t of DI in the United State s b y 1938 , and a 194 1 survey estimate d that almos t 3,70 0 insemination s ha d occurre d i n th e Unite d States." 7 By 1938, the survival of sperm after freezin g (cryopres ervation) wa s note d an d a successfu l huma n pregnanc y fro m frozen sper m wa s recorde d i n 1953. 8 Wha t is new i s the $164 million-a-year "industry " tha t ha s develope d fro m th e increas ing demand fo r seme n and/o r seme n storage. 9 It is impossible t o calculat e th e exac t numbe r o f sper m bank s or physician s wh o perfor m insemination s o r th e numbe r o f inseminations whic h occu r annually , becaus e ther e i s no federa l registry o f providers o r recipients . Record keepin g is often poor , haphazard, o r nonexistent , an d physician s continu e t o d o im proper follow-up . I n Canadia n fertilit y clinics , th e succes s rat e cannot b e established fo r i n vitro fertilizatio n o r A I due t o poo r record keeping. 10 Anecdota l evidenc e o f poo r recor d keepin g made nationa l headline s whe n a New Yor k woma n wa s insemi nated wit h an d impregnate d b y sperm sh e thought wa s from he r dying husband . I n fact , th e seme n wa s fro m a n anonymou s donor whos e rac e wa s obviousl y differen t fro m tha t o f th e woman an d he r husband . Th e woma n sued , maintainin g tha t her daughte r wa s subjecte d t o racia l prejudic e a s a result . Th e case wa s settle d ou t o f cour t fo r $400,000. n A s o f 1987 , onl y about hal f o f th e physician s regularl y performin g insemination s

[10] Reproductiv

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in the United State s indicated tha t they had records which woul d permit the m t o identif y th e specifi c dono r fo r an y specifi c preg nancy.12 The bes t recen t estimate s regardin g inseminatio n practice s are fro m a n Offic e o f Technolog y Assessmen t (OTA ) report , which indicate d tha t approximatel y 172,00 0 wome n underwen t medically supervise d A I i n 1987 , resultin g i n 65,00 0 births . Most majo r hospital s clai m t o hav e a n infertilit y progra m in volving som e aspec t o f alternativ e insemination , an d a n esti mated 11,00 0 physician s perfor m A I occasionally . Ther e ar e approximately 15 0 sper m bank s i n th e Unite d States, 13 supply ing seme n t o physicians , hospitals , o r i n som e cases , privat e individuals. Sometime s seme n fro m husband s o r partner s i s used. Fo r example , i f a ma n ha s a lo w sper m count , seme n specimens ma y b e accumulate d an d frozen , the n use d durin g a woman's fertil e period . I n othe r case s donor seme n i s provided . Donors ar e pai d a n averag e o f fifty dollar s pe r ejaculate . I f the seme n i s t o b e frozen , th e ejaculat e i s generall y combine d with a preservativ e (an d perhap s othe r product s t o preven t th e formation o f ic e crystals ) an d divide d int o thre e o r fou r vials . The vial s ar e cooled , the n place d i n a liqui d nitroge n tan k fo r storage. Sper m ca n b e store d u p t o te n years , perhap s longer , and stil l retain effectiveness . Vial s sel l for a n averag e o f $10 0 t o $140 pe r vial . Women (an d thei r partners , i f the y ar e par t o f a couple ) seeking pregnanc y throug h alternativ e inseminatio n ordinaril y select donor s fro m profile s provide d b y th e sper m bank , hospi tal, o r physician . Thes e profile s ma y b e ver y cryptic , wit h littl e background informatio n abou t th e donor, o r may include exten sive information , includin g physica l characteristic s an d famil y medical history . A t leas t on e ban k provide s a n optio n wherei n the patien t ca n selec t eithe r a n anonymou s dono r o r a dono r who ha s signe d a n "identity-releas e policy." 14 Donor s signin g

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this release polic y agre e to allo w an y chil d conceive d b y insemi nation t o lear n th e identit y o f th e dono r whe n th e chil d turn s eighteen. Thi s latte r optio n i s appealin g t o man y prospectiv e donors a s well a s recipients. In a typica l program , patient s ar e encourage d t o kee p trac k of thei r menstrua l cycle s in orde r t o anticipat e ovulation . Whe n ovulation doe s occur , physician s recommen d tw o t o thre e in seminations pe r cycle , generall y twelv e t o twenty-fou r hour s apart. Th e seme n i s thawe d (i f frozen) , draw n int o a syringe , and place d nea r th e cervi x (o r i n th e uteru s i f th e inseminatio n is intrauterine). Fresh sper m i s mor e motil e an d therefor e provide s a highe r rate o f conceptio n tha n froze n sperm . Additionally , usin g fres h semen ca n virtuall y eliminat e medica l intervention . Quit e sim ply, afte r th e dono r ejaculates , th e seme n i s immediatel y use d for insemination . However , choosin g froze n seme n ove r fres h has numerou s benefits . On e i s a lowe r incidenc e o f birt h de fects.15 Evidently , health y sper m hav e a greate r likelihoo d o f surviving the freezing process . In addition, dono r seme n is sometimes teste d an d rejecte d fo r geneti c defects . Anothe r benefi t cryopreservation provide s i s greater flexibilit y i n the A I process. Previously, donor s ha d t o b e available whe n ovulatio n occurre d in orde r t o donate . Now , th e dono r doesn' t eve n hav e t o b e present. No r doe s a physician. 16 I f th e healt h car e provide r i s amenable, an d th e woma n ha s learne d th e inseminatio n proce dure, th e seme n specime n ca n b e place d i n a portabl e liqui d nitrogen tan k o r in a cooler o f dr y ice and inseminatio n ca n tak e place at home . But th e mos t importan t benefi t o f cryopreservatio n i s safety . A donor ca n now be tested fo r th e presence of infectious disease s such a s HI V upo n donating , an d hi s seme n ca n b e quarantine d until h e i s reteste d si x month s later . Unfortunately , thi s i s no t necessarily standar d operatin g procedure . Physician s stil l con -

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tinue t o us e fres h seme n sample s an d unteste d donors , disre garding healt h an d safet y concerns . In Februar y 1992 , th e infamou s "lov e doctor, " Ceci l Jacob son, wa s brough t t o tria l fo r frau d an d perjury. 17 Apparently , Jacobson ha d use d hi s own sper m t o inseminate an d impregnat e female patient s whil e tellin g the m tha t th e seme n wa s obtaine d from anonymou s donors . H e reportedl y "fathered " seventy-fiv e children throug h suc h deception . Jacobso n wa s abl e t o perpe trate suc h frau d becaus e semen , seme n donors , an d seme n pro viders are not regulated b y any federal agency . Therefore, seme n providers, suc h a s sper m bank s o r privat e physicians , ar e no t required, under federal law, t o follo w an y standard s fo r recor d keeping. No r ar e the y require d unde r federa l la w t o scree n semen donor s i n an y way , eve n fo r infectiou s disease s lik e hu man immunodeficienc y viru s (HIV ) o r geneti c condition s lik e Huntington's disease . Eve n thoug h screenin g bloo d donor s fo r the presence o f HIV has been federally mandate d sinc e 1985, no such regulations exist for semen donors. Th e risk of transmittin g infectious diseas e shoul d hav e alway s bee n a concer n whe n inseminating. Eve n veterinarian s wer e warned , i n 1985 , o f th e risks o f disease s transmissibl e b y seme n transfe r i n animals . AIDS has made inseminatio n potentiall y deadly . The transmissio n o f HI V throug h dono r seme n ha s bee n documented i n research 18 an d anecdotally . Th e first lawsui t i n the worl d filed b y a woma n wh o becam e HIV-infecte d throug h donor seme n cam e t o tria l i n 1991 , in Britis h Columbia , Can ada. 19 Kob e te r Neuze n wa s i n he r thirties , ha d a caree r a s a psychiatric nurse, and wanted t o have a baby. However, sh e ha d not me t th e righ t partner , an d sinc e he r proverbia l biologica l clock wa s ticking, she decided t o try insemination. He r attempt s began i n 198 1 an d continue d throug h 2 1 Januar y 1985 . Sh e had decide d this , he r thirty-fifth , woul d b e he r final attempt . Unfortunately, o n thi s final attempt , sh e wa s inseminate d wit h

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and infecte d b y HIV-positiv e semen . Th e dono r ha d bee n use d to inseminat e thirty-fiv e othe r wome n ove r a fourteen-mont h period. On e o f thos e patients , who di d no t joi n i n th e suit , als o tested HIV-positive . Th e physicia n ha d bee n usin g onl y fres h semen an d ha d no t warne d hi s patient s o f an y risk s associate d with insemination . Kobe te r Neuze n sue d th e physician , Dr . Geral d Korn , an d the donor , Eri c Kyle , wh o coul d no t b e foun d fo r trial . Dr . Korn's screenin g procedure s ha d consiste d o f a n intervie w only . He sometime s teste d seme n fo r th e presenc e o f venerea l diseas e but neve r screene d fo r HIV . Kor n claime d h e wa s unawar e a t the tim e (1985 , th e sam e yea r th e Re d Cros s mandate d testin g of th e bloo d supply ) tha t HI V coul d b e transmitte d throug h donor seme n use d i n insemination . A t trial , expert s presente d conflicting testimon y wit h regar d t o whethe r Kor n coul d hav e been unawar e o f a link , bu t th e jur y foun d Kor n negligen t an d guilty o f breachin g warrant y o f qualit y goods , awardin g te r Neuzen $883,80 0 i n damages . Kor n appeale d th e finding o f negligence an d th e amoun t o f damage s awarded , an d th e ap peals court ordere d a new tria l o n thes e issues. At leas t five wome n i n th e Unite d States , fou r wome n i n Australia, an d tw o wome n i n Canad a hav e reported contractin g HIV throug h inseminations . Tw o o f th e five America n women , Mary Orsa k an d Cynthi a Hallvik , wer e infecte d throug h seme n obtained fro m th e sam e donor. 20 Th e donor' s seme n ha d bee n used t o inseminat e fifty-three women , si x o f who m hav e no t been teste d fo r HIV . Orsak an d Hallvi k hav e bot h brough t suit s against th e physicia n an d clini c involved , th e first lawsuit s filed in the United State s by women infecte d wit h HIV through dono r semen. It is difficult t o determin e ho w man y wome n hav e contracte d HIV throug h insemination . Som e ma y no t b e abl e t o isolat e th e cause o f th e infection . Other s ma y no t repor t th e caus e t o th e

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Center fo r Diseas e Contro l (CDC) . I t i s als o difficul t t o deter mine ho w man y wome n hav e bee n expose d t o HI V throug h inseminations becaus e recor d keepin g fo r donor s an d recipient s is ofte n inadequate . A t leas t on e woma n wh o wa s expose d t o HIV (bu t di d no t contrac t th e virus ) file d a lawsuit. 21 Dian e Brown wa s inseminate d twic e eac h mont h fro m Augus t 198 6 through Apri l 1987 . Th e physician , Dr . Sande r Shapiro , alter nated eac h mont h betwee n fres h an d froze n semen , usin g fres h for th e las t tw o inseminations . Afte r th e las t insemination , th e donor teste d positiv e fo r HIV . Althoug h Dian e Brow n teste d negative fo r HIV , sh e an d he r husban d sue d Dr . Shapir o fo r negligence, medical malpractice , an d inflictio n o f emotiona l dis tress. Th e jur y foun d Dr . Shapir o wa s no t negligent , an d th e verdict wa s uphel d o n appeal . I t i s possibl e tha t othe r wome n who hav e bee n expose d o r infecte d hav e filed lawsuit s bu t tha t these suits have not com e to the attention o f the media an d wer e settled ou t o f cour t o r hav e no t bee n appealed , whic h make s them difficul t t o track . Many wome n hav e riske d exposur e t o HI V fro m seme n tha t has undergon e a controversia l "sperm-cleansing " procedur e (also referred t o a s the "swim-up " method) . In sper m cleansing , the seme n o f a n HIV-positiv e ma n i s centrifuged, an d th e motil e sperm whic h swi m t o th e to p ar e incubated , washed , an d col lected fo r insemination. 22 Usin g thi s method , man y HlV-discor dant couples , wher e th e ma n i s HIV-positiv e an d th e woma n i s not, coul d theoreticall y hav e a healthy child . Some wome n hav e reportedl y conceive d an d give n birt h t o healthy babie s usin g thi s method , withou t becomin g HIV-posi tive. I n 1989 , th e Universit y o f Milan , reporte d tha t fifteen ou t of twenty-nin e wome n becam e pregnan t throug h "processed " semen. 23 Te n health y babie s wer e born , an d al l continu e t o tes t HIV-negative. Conversely, that sam e year a woman i n the United States becam e HIV-positiv e afte r bein g inseminate d wit h

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"cleansed" sperm . She did not report engaging in any other high risk activities . Her physicia n wa s fined five thousand dollar s an d reprimanded b y the Virginia Stat e Board o f Medicine. The CD C cautions against this technique, but it is not regulated. 24 In additio n t o HIV , othe r sexuall y transmitte d disease s hav e been transmitte d throug h dono r semen . Wome n hav e bee n in fected wit h herpes , hepatiti s B , gonorrhea , trichomona s vagi nalis, cytomegaloviru s (CMV) , grou p B streptococc i an d chla mydia trachomatis. 25

State Regulation s Recently, som e state s hav e begu n t o regulat e seme n providers . Of course , stat e regulations , b y thei r ver y nature , ar e no t uni form. Mos t stat e statute s contai n som e provision s regardin g donor screening . Som e requir e tha t th e dono r b e initiall y teste d for HI V infection; 26 other s requir e bot h thi s an d othe r tests. 27 However, thes e statute s d o no t stipulat e restriction s regardin g the us e o f fres h semen , whic h mean s tha t HI V coul d stil l b e transmitted i f th e donor' s bloo d ha d no t seroconverted 28 fro m HIV- t o HIV + a t th e tim e o f donation . Som e state s requir e freezing an d quarantinin g o f seme n fo r si x month s unti l th e donor ca n b e reteste d fo r HIV. 29 A fe w state s allo w variou s exemptions fro m thes e provision s fo r spouse s o r mutuall y mo nogamous partners. 30 A t leas t tw o state s requir e physician s t o warn recipient s abou t th e risk s inheren t i n th e inseminatio n process. 31 Some states require sper m bank s operatin g withi n th e state t o b e registere d wit h th e departmen t o f publi c health . Illinois an d Delawar e fine bank s whic h ar e no t s o registered. 32 Unfortunately, th e statute s d o no t requir e th e registratio n o f private facilitie s o r privat e practitioners , wh o ca n b e th e wors t offenders whe n i t comes to th e careles s screenin g o f donors .

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Violators o f stat e statute s ma y incu r a fine, 33 civi l liability, 34 or eve n criminal liability . For example , in Tennessee i t is considered a crim e i f a perso n wh o know s sh e o r h e i s infecte d wit h HIV "transfers , donates , o r provide s hi s o r he r blood , tissue , semen, organs , o r othe r potentiall y infectiou s bod y fluid s fo r transfusion, transplantation , insemination , o r othe r administra tion to another. " 35 These criminal penaltie s can extend t o medical personnel an d facilitie s whic h fai l t o test fo r HIV. 36 Unfortunately, eve n wher e stat e regulation s exist , the y ar e often violated . I n 1992 , "tw o staf f member s a t Moun t Sina i Medical Cente r allegedl y ra n thei r ow n unlicense d sper m ban k in whic h the y wer e th e onl y donors , misleadin g doctor s an d patients an d ignorin g goo d safet y practices." 37 On e o f th e staf f members involve d wa s a medica l residen t a t th e hospital ; th e other directe d th e medica l school' s teachin g laboratory . Th e staff member s sol d their fresh seme n to physicians from Octobe r 1989 unti l Januar y 1992 , althoug h usin g fres h seme n violate d both medical guidelines and New York state law. Approximatel y twelve wome n ha d bee n inseminate d wit h th e semen . Civi l charges, rangin g fro m sellin g fres h seme n t o failin g t o kee p proper records , wer e filed agains t th e staf f members , th e physi cians wh o use d th e semen , an d th e medica l center . Moun t Sina i claimed th e physician s wer e operatin g withou t thei r knowledg e or approval . A healt h departmen t spokesperson , Pete r Slocum , said, "Luckil y enough , w e don' t hav e an y evidenc e o f diseas e i n these cases." 38 Thi s wa s no t a n isolate d incident , bu t rathe r th e eighth tim e Ne w Yor k ha d shu t dow n a seme n ban k fo r dis obeying stat e regulations . Although som e state s make valian t effort s t o contro l th e haz ards o f A I throug h legislation , th e existin g statute s ar e inade quate. First , seme n i s often shippe d acros s stat e lines . Second, i t is virtually impossibl e t o monito r th e activitie s o f al l the privat e

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physicians wh o migh t b e performin g inseminatio n procedures . Third, man y wome n ar e not informe d b y their physician s o f th e risks relate d t o insemination , receiv e littl e informatio n abou t where the semen was obtained, and are unaware of the applicabl e state regulations . I n general , th e statute s d o no t thoroughl y ad dress all of the dangers associated with AI, particularly the transmission of HIV. Medical guidelines are more comprehensive .

Medical Guideline s In the 198 7 OT A investigation regardin g inseminatio n practice s in th e Unite d States , 37 2 physicians ' survey s wer e reported . O f these, onl y 4 4 percen t teste d fo r th e presenc e o f HI V i n seme n donors, an d betwee n 2 0 percen t an d 3 0 percen t indicate d tha t they teste d fo r th e presenc e o f gonorrhea , syphilis , chlamydia , or hepatitis . All sperm bank s surveye d teste d fo r th e presence o f HIV, bu t onl y twelv e ou t o f fiftee n teste d fo r othe r sexuall y transmitted diseases . The physicians demonstrate d a similar lac k of concer n and/o r knowledg e abou t geneti c defects : 3 7 percen t of the m sai d the y woul d accep t a health y dono r wit h a famil y history o f Huntington' s disease , which i s transmitted geneticall y but remain s asymptomati c unti l late r i n life , whil e 4 9 percen t said the y woul d rejec t a health y dono r wit h a famil y histor y o f hemophilia eve n thoug h th e dono r coul d no t carr y th e gen e fo r hemophilia. 39 Onl y thirteen ou t o f fifteen sper m bank s tested fo r genetic defects . Perhap s i t wa s th e reportin g o f thes e appallin g statistics tha t le d th e medica l professio n t o attemp t t o regulat e themselves b y providing voluntar y guidelines . The first se t of formal guideline s were published b y the Amer ican Fertilit y Societ y (AFS ) i n 1986 , althoug h th e Publi c Healt h Service (PHS ) had already , in 1985 , recommended testin g seme n

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donors' bloo d fo r th e presence o f HIV. 40 By 1988, the Food an d Drug Administration (FDA ) and th e Centers for Diseas e Contro l (CDC) ha d prepare d ne w guidelines , whic h wer e endorse d b y the AFS , th e America n Associatio n o f Tissu e Banks , an d th e American Colleg e o f Obstetrician s an d Gynecologists. 41 Collec tively, these associations recommended tha t physicians no longe r use fres h seme n fo r insemination s unles s th e dono r wa s i n a mutually monogamou s relationshi p wit h th e recipient . Instead , semen specimen s shoul d b e frozen fo r 18 0 day s and onl y use d if the dono r teste d negativ e fo r HI V antibodie s a t th e en d o f tha t period. Additionally , physician s wer e encourage d t o tak e suc h precautions a s assessin g ris k factor s fo r HI V an d conductin g physical examination s o f donors . Thes e guideline s remai n rela tively unchanged , althoug h th e AF S has adde d som e provisions , such a s thos e relatin g t o informe d consen t an d limit s o n dono r paternity. 42 While it is encouraging tha t th e medical profession ha s finall y acknowledged th e hazard s o f dono r insemination , th e estab lished guideline s ar e no t mandatory , an d th e penaltie s o r sanc tions ar e minimal . License s ar e seldo m revoke d no r ar e stif f fines imposed , s o th e guideline s continu e t o b e ignore d an d violated. I n the sam e yea r tha t th e Moun t Sina i employee s wer e charged wit h operatin g a n unlicense d inseminatio n site , a repor t prepared b y th e Canadia n Roya l Commissio n o n Reproductiv e Technology wa s release d tha t reviewe d internationa l insemina tion practices , with a focus o n the American scene . It was foun d that mos t sper m bank s an d fertilit y expert s wer e followin g guidelines bu t tha t som e physician s ignore d them , continuing , for example , t o us e fres h seme n becaus e the y "kno w an d trus t their donors." 4 3 Dr. Geral d Korn, the physician who is being sued b y Kobe te r Neuzen als o "knew " hi s donors. In fact, whe n h e "interviewed " donors, h e woul d no t accep t seme n fro m wha t he determine d

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were "at risk" populations for sexually transmitted diseases, suc h as homosexual men . O f course , since he did no t tes t for sexuall y transmitted diseases, he could not actually determine who was infected an d apparentl y labore d unde r th e assumption tha t hi s donors woul d no t li e t o him . Suc h naiv e thinkin g resulte d i n th e transmission o f HIV to ter Neuzen an d another patient . A simila r exampl e o f naivet e occurre d a t a Ne w Yor k sper m bank. I n 1993 , Idant, on e o f th e mos t establishe d sper m bank s in the United States , violated bot h stat e law s an d medica l guide lines. Idant di d not completely scree n forty activ e donors, thirty one o f who m (th e "directe d donors" ) ha d contracte d wit h women slate d t o b e surrogat e mothers . Th e healt h departmen t determined tha t o f th e fort y donors , ten ha d no t bee n teste d fo r HIV, thirty-two wer e no t teste d fo r hepatiti s a t all , twenty-eigh t were no t completel y teste d fo r hepatiti s B , twenty-eigh t wer e not tested fo r gonorrhea , an d fourtee n wer e not tested fo r syphi lis. To m Favreau , directo r o f Idan t foun d tha t "a s man y a s 23 surrogat e mother s wer e inseminate d wit h sper m fro m th e incompletely teste d donors." 4 4 Nevertheles s Favrea u suggeste d that th e charge s levele d agains t th e sper m ban k wer e vindictive , because the problem wa s bein g corrected. Th e reason som e test s were no t performed , h e said , wa s becaus e h e di d no t thin k the state' s regulation s applie d t o directe d donor s wh o wer e inseminating surrogate s t o bea r thei r ow n biologica l child . Doe s this impl y tha t directe d donor s woul d no t knowingl y expos e a woman t o diseas e bu t othe r donor s would ? Perhap s Favrea u believed tha t a ma n wh o woul d hir e a surrogat e i s suc h a "nice guy " tha t h e coul d neve r carr y HIV . Littl e concer n i s demonstrated her e fo r th e "surrogate " mothe r o r th e fetus . Th e "surrogate" mothe r i s treate d les s a s a patien t an d mor e a s a n incubator. Th e whol e inciden t i s best summe d u p b y Dr. Jeann e Linden, th e healt h department' s directo r o f bloo d an d tissu e resources: "I f nobod y caugh t anything , i t is just goo d luck." 45

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Although th e medica l professio n sincerel y hope s t o regulat e itself throug h establishin g guidelines , i t stil l protect s physician s who violat e them. 46 Fo r example , whe n th e Canadia n Roya l Commission o n Ne w Reproductiv e Technologie s learne d tha t three physician s wer e usin g unteste d fres h semen , i t woul d no t release their name s bu t di d agre e to identify th e provinces wher e they practiced . Patient s an d thei r familie s wer e lef t t o wonde r whether thei r ow n physicia n ha d provide d "safe " seme n speci mens, an d man y undoubtedl y suffere d emotiona l distres s a s they wer e teste d an d reteste d fo r infectiou s diseases , especiall y HIV. The guideline s no t onl y fai l t o ensur e healt h an d safet y bu t leave to o muc h t o th e discretio n o f physicians , especiall y th e selection of would-be parents. No guidelines address discrimina tion in the provision o f services or assert the rights of all patients to treatment . Thi s enable s physician s t o selec t wh o shoul d an d should no t b e "allowed " t o becom e parents , an d choice s ma y be base d o n sexua l orientation , income , o r eve n race . Dr. Korn , who wa s alread y sue d fo r malpractice , mad e headline s onc e again i n 199 3 whe n h e tol d a lesbia n coupl e tha t h e woul d not inseminat e lesbians . Th e coupl e ( a docto r an d a lawyer) , complained t o th e Colleg e o f Physician s an d Surgeon s i n Britis h Columbia, wh o supporte d Korn' s decision . I n fact , i n 1991 , the Royal Commissio n o n Ne w Reproductiv e Technologie s foun d that bein g a lesbia n wa s ground s fo r refusa l o f inseminatio n services a t twenty-eigh t ou t o f forty-nin e Canadia n fertilit y pro grams. 47 Allowin g physician s t o determin e wh o i s fit t o procre ate coul d se t a dangerou s precedent. 48 However , i n 1995 , th e women wo n a Britis h Columbi a Huma n Right s Counci l cas e against Korn, on the grounds that his actions violated the Britis h Columbia Huma n Right s Act , whic h prohibit s discriminatio n based o n sexua l orientation . The y wer e awarde d twenty-fiv e hundred dollar s fo r los s o f dignit y an d nin e hundre d dollar s a s

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reimbursement fo r th e expens e o f havin g t o see k inseminatio n in anothe r province . Finally, eve n thoug h som e guideline s attemp t t o limi t th e number o f children a donor ca n father , i t is impossible t o moni tor thi s withou t som e centralize d syste m o f recor d keeping . Fo r example, a dono r coul d reac h th e paternit y limi t a t on e sper m bank (i f they hav e one ) and , drive n b y financial incentive s o r b y narcissistic thought s o f immortality , simpl y begi n donatin g a t another. Thi s no t onl y raise s th e possibilit y o f satiatio n o f th e gene poo l bu t o f intermarriag e betwee n offsprin g o f th e sam e donor, especiall y i f th e recipient s o f hi s seme n live d relativel y close to on e another. If this scenario seem s unlikely, consider th e seventy-five offsprin g o f Ceci l Jacobson , al l livin g i n th e sam e general regio n an d clos e enoug h i n ag e t o b e potentia l partner s for eac h other .

Solutions On th e surface , A I appears t o offe r wome n greate r reproductiv e choice an d control . Wome n wh o previousl y coul d no t hav e children, becaus e the y wer e singl e o r thei r partne r wa s infertil e or the y wer e lesbians , no w can . However , th e contro l an d th e choices are partly illusory , as they really belon g in large measur e to the physicians who provid e th e services . These physicians ca n choose wh o become s a dono r an d a recipient . The y ca n als o determine wha t test s th e dono r wil l receive , wha t informatio n will b e obtaine d fro m socia l an d medica l interviews , an d ho w those records wil l b e maintained. Additionally , physician s deter mine wha t informatio n th e recipien t receive s regardin g th e re sults of dono r screening . Finally , they ma y eve n selec t the dono r for th e recipient . Barbara Raboy , th e founde r an d executiv e directo r o f th e

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Sperm Ban k o f California , whic h offer s a dono r identit y releas e option, suggest s tha t suc h a n optio n i s on e wa y t o diminis h physician contro l ove r th e A I process . When a coupl e undergoe s counselin g an d i s advise d no t t o in form th e child , th e coupl e i s simultaneousl y discourage d fro m asking question s abou t th e donor . A s a result o f thi s discourage ment, th e couple doesn' t reques t dono r information . Withou t th e request fo r dono r information , th e physicia n an d sper m ban k have n o incentiv e t o releas e dono r information . Withou t thi s incentive, th e sper m ban k free s itsel f fro m th e responsibilit y o f long-term dono r record s maintenanc e an d donor-trackin g (mos t sperm bank s stil l d o no t conduc t follow-u p studie s o f th e us e o f donor semen) . Sinc e th e physicia n and/o r sper m ban k selecte d the donor fo r th e couple, control over the donor selectio n proces s rests wit h th e medica l professio n an d sper m bank . Th e offerin g of a n identity-releas e optio n fo r sper m donor s pierce s th e reig n of contro l an d promote s greate r accountabilit y i n th e practic e o f DI (dono r insemination ) an d sper m banking. 49 The curren t practic e o f A I ma y actuall y curtai l choice s a s wel l as control . Physician s assum e ther e i s n o widesprea d proble m and minimiz e th e risk s associate d wit h AI . B y keepin g silen t about th e hazard s the y tak e upo n themselve s a decisio n tha t should res t wit h th e patient : whethe r th e potentia l benefit s o f a procedure outweig h it s potentia l risks . A thoroug h informe d consent coul d allo w th e patien t t o mak e thi s decision . Clearly, th e bes t wa y fo r patient s t o gai n contro l an d enhanc e options i s t o regulate . M a n d a t o r y federa l regulations , wit h stif f penalties fo r violators , ma y eradicat e healt h risk s a s wel l a s discriminatory practices . Moreover , th e federa l governmen t could provid e a seale d registr y o f donors , includin g suc h crucia l information a s medica l histor y an d previou s paternity . Thi s could virtuall y eliminat e concern s abou t satiatio n o f th e gen e pool an d intermarriage .

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In 1988 , then-Senator A l Gore was purportedly writin g a bil l attempting t o establis h suc h a nationa l dat a bank , bu t today , eight year s later , w e stil l d o no t hav e one . In 1991 , Representative Ro n Wyde n o f Orego n cam e close r t o regulatio n whe n h e "introduced a bil l tha t woul d hav e force d th e embry o labora tories withi n thes e fertilit y clinic s t o b e federall y certified . Bu t the Bus h administratio n sai d i t woul d oppos e effort s t o requir e federal interventio n int o matter s tha t hav e historicall y bee n lef t to th e states." 50 Wyde n the n wrot e a ne w versio n o f th e bil l which woul d hav e require d th e Healt h an d Huma n Service s Secretary t o desig n a saf e certificatio n progra m fo r state s t o adopt. Wyden als o considered "amendin g the bil l so that Ameri can Fertilit y Societ y (AFS ) guideline s o n artificia l inseminatio n will b e considere d th e 'standar d o f care ' i n lawsuit s relate d t o the practice." 51 Th e AF S medica l directo r supporte d Wyden' s initial proposa l t o certif y embry o laboratories , bu t stated , "W e would hav e seriou s reservation s abou t supportin g an y amend ments tha t woul d appea r t o regulat e th e clinica l practic e o f medicine." 52

Egg Donatio n Egg donation i s a relatively newe r an d mor e complicate d proce dure tha n sper m donation . Health y egg s ar e remove d fro m a donor's ovaries , fertilized wit h sper m an d place d i n a recipient' s uterus. Th e first reporte d birt h fro m a donate d eg g occurre d i n Australia i n 1984, 53 whil e th e first reporte d birt h i n th e Unite d States wa s i n 1988. 54 I t i s impossibl e t o determin e ho w man y egg donatio n clinic s exis t i n th e Unite d States , because , lik e sperm bank s an d seme n providers , eg g donatio n clinic s ar e no t federally regulated . I n 1994 , Newsweek estimate d ther e wer e three hundre d assisted-fertilit y clinics , generatin g $ 2 billio n i n

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business a year. 55 Similarly , i t i s impossibl e t o determin e ho w many childre n hav e bee n bor n usin g dono r eggs , bu t a Lo s Angeles physician an d researcher wh o is considered a n authorit y on th e subjec t estimate d tha t th e tota l wa s betwee n 75 0 an d 1000. 56 This may well b e an underestimate , given the possibilit y of poo r recor d keeping , especiall y whe n egg s ar e fertilize d an d cryopreserved a s frozen embryos . Like seme n donors , eg g donor s generall y complet e a screen ing process . However , eg g donatio n clinic s see m t o b e mor e rigorous i n their testin g o f donors . Th e mos t rigorou s screenin g of sper m donor s generall y involve s a physica l examination , urine analysis , and extensiv e bloo d testin g for sexuall y transmit ted disease s an d geneti c defects . Eg g donor s ar e no t onl y rou tinely give n thes e test s bu t ma y complet e a numbe r o f othe r procedures, includin g stres s treadmil l electrocardiography , mammography, ches t radiology , ora l glucos e toleranc e tests , fasting seru m insuli n tests , cervical smea r tests , and ultrasound s of th e pelvis . Additionally , eg g donor s ar e routinel y evaluate d psychologically throug h interview s an d sometime s testing . Oc casionally, eve n th e eg g donor' s partne r receive s psychologica l testing an d medica l test s fo r transmittabl e diseases . I f a candi date is deemed acceptable , the medical regime n begins . The actua l medica l procedur e involve d i n eg g donatio n usu ally begin s tw o t o fou r week s prio r t o extractin g th e eggs. 57 First, th e donor' s natura l ovulator y cycl e i s suppresse d throug h approximately tw o week s o f dail y hormon e injections . The n the dono r receive s dail y hormon e injection s tha t stimulat e th e ripening o f multipl e eggs , otherwis e know n a s "superovula tion." 5 8 Finally , whe n th e egg s hav e mature d enough , a thir d hormone i s injected. Throughou t th e entire process, donors usu ally receiv e numerou s ultrasound s o f th e pelvi s t o monito r th e size o f th e ovarie s an d numerou s bloo d test s t o monito r hor -

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mone levels . These procedure s ar e conducte d i n orde r t o deter mine if and whe n ovulatio n i s about t o occur . Once hormon e manipulatio n i s completed, eg g retrieval ma y be accomplishe d throug h variou s potentiall y dangerou s modal ities. Initiall y eg g retrieva l involve d surgica l interventio n through laparoscope 59 A t leas t thre e wome n undergoin g thi s procedure hav e die d fro m genera l anesthesi a complications . Hemorrhage o r th e rupture o f othe r organ s ma y als o occur . Although surgica l interventio n i s stil l occasionall y used , a more commo n metho d o f eg g retrieva l i s transabdomina l (o r transvaginal) ultrasonicall y directe d oocyt e recovery , o r TU DOR. Fo r thi s procedure , a genera l anestheti c i s occasionall y used, but more often a local will suffice. A needle is then inserte d through th e vagin a o r bladde r an d int o th e ovary , an d th e egg s are extracted . A n ultrasoun d i s used , primaril y t o ensur e tha t the bladde r i s full , a necessar y prerequisit e t o retrieval . Th e donor mus t remai n relativel y immobil e durin g th e proces s t o avoid a rupture o f th e ovarie s o r othe r bod y parts. She may als o endure numerou s puncture s befor e al l th e egg s ar e collected . Although th e donor s typicall y retur n hom e withi n a fe w hours , they usually remain o n supplementar y hormone s an d sometime s painkillers unti l th e bod y return s t o norma l hormona l func tioning. While th e eg g dono r prepare s fo r eg g retrieval , th e dono r recipient prepares for implantation . Lik e the donor, the recipien t also receive s numerou s hormones , i n orde r t o thicke n th e endo metrium an d synchroniz e he r menstrua l cycl e wit h tha t o f th e donor. It coul d b e th e complexit y an d invasivenes s o f th e procedur e that ha s le d t o limite d publi c suppor t an d ethica l controversies . On th e othe r hand , thes e controversie s ma y simpl y represen t a double standar d regardin g reproductiv e technologies .

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Double Standard s Sperm donation create s relatively little controversy anymor e an d has actuall y becom e commonplace . Conversely , eg g donatio n has generate d tremendou s debat e i n a shor t perio d o f time . Numerous book s o n eg g donatio n hav e bee n published , a s wel l as article s i n newspapers , journals , an d la w reviews , while rela tively littl e ha s bee n publishe d o n sper m donation . Question s and objection s aris e tha t hav e neve r bee n broache d wit h regar d to sper m donors , suggesting that publi c attitude s o n thes e issue s may b e influenced b y a double standard . One controversy focuse s o n whether wome n receiv e paymen t for donatin g thei r eggs . I n England , i t i s agains t th e la w t o compensate eg g donors. In fact, eve n the AFS has suggested tha t egg donor s shoul d no t b e compensate d excep t fo r expenses , time, risk , an d inconvenienc e relate d t o donation . N o suc h qualms abou t compensator y sper m donor s i s expressed . Many facilitie s maintai n tha t the y don' t reall y pa y thei r eg g donors pe r s e bu t merel y compensat e the m fo r thei r trave l an d time. 60 However , eve n whe n eg g donor s ar e compensate d fo r "time an d travel, " the y ar e no t compensate d well . Th e averag e compensation i s approximatel y tw o thousan d dollars— a tri fling amount , give n th e tim e commitment , th e invasivenes s o f the process , an d th e risk s involved . I n th e selectio n proces s alone, eg g donor s mak e a muc h greate r tim e commitmen t tha n sperm donors . Th e selectio n proces s fo r sper m donor s ma y entail a screenin g tha t last s severa l hour s an d ma y requir e tw o appointments. Eg g donor s endur e a rigorou s screenin g tha t in volves close r t o sixt y hour s o f testing , spannin g numerou s ap pointments. I f eg g donor s wer e pai d th e minimu m rat e sper m donors ar e paid , twenty-fiv e dollar s pe r hour , the y woul d al ready b e earnin g fiftee n hundre d dollar s fro m th e screenin g alone. This does not include time involved in the procedure itsel f

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or preparatio n fo r th e procedure . Moreover , sper m donor s ar e not expose d t o an y risks , whil e eg g donor s ris k permanen t damage fro m infectio n o r hemorrhaging , whic h coul d resul t i n sterility o r eve n death . I n addition , hormon e injection s hav e been linke d t o a greate r incidenc e o f breas t cance r an d ovaria n cysts, and clomiphene , a commonly prescribed fertilit y drug , ha s been linke d t o ovaria n cancer . Hormon e manipulatio n ha s als o produced sid e effect s suc h a s moo d swings , weigh t gain , ho t flashes, nausea , breas t tenderness , wate r retention , an d ovaria n hyperstimulation syndrom e ( a swellin g o f th e ovarie s tha t call s for immediat e medical attention) . Finally, sperm donor s can an d often d o continu e t o donat e an d mak e additiona l money , whil e egg donors generall y onl y donate once , although i t is possible t o donate ever y si x months . Give n thes e factors , i t i s difficul t t o comprehend wh y eg g donor s shoul d no t b e better compensate d than sper m donors . A ke y issu e underlyin g debat e ove r compensatio n fo r eg g donors seem s t o b e a concer n tha t paymen t ma y mak e eg g donation a bab y brokerag e business . Onc e again , thi s concer n never arise s wit h sper m donors , althoug h the y hav e a muc h greater opportunit y t o make a profit fro m gamet e donatio n tha n women do . Moreover , thi s concer n seem s a bi t misdirected . After all , it is more likel y to b e the clinic s who exploi t th e profi t potential o f th e baby-makin g busines s an d marke t gamete s a s a commodity. For example, one Virginia clini c currently advertise s in England , offerin g a larg e selectio n o f eg g donor s an d n o waiting list . Thi s i s a direc t attemp t t o tak e advantag e o f th e market "shortage " o f dono r egg s i n England. 61 Similarly , a n English clini c offer s fre e i n vitr o fertilizatio n (IVF ) service s t o women wh o agre e to donat e hal f thei r egg s and thereb y circum vents English restriction s o n compensation. 62 I f bab y brokerag e is trul y th e concern , the n wh y no t insis t tha t eg g donatio n clinics operat e o n a not-for-profi t basis ? O r wh y no t regulat e

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advertising rathe r tha n limi t th e paymen t th e dono r ma y re ceive? Egg donatio n cost s recipient s betwee n te n thousan d an d twenty thousan d dollar s pe r attempt . Th e fac t tha t everyon e involved i n th e eg g donatio n process , excludin g th e donor , i s amply compensated , i s rarely debated . N o wome n hav e mad e a fortune, muc h les s a living , fro m eg g donation . Ye t numerou s critics have argue d tha t wome n shoul d donat e egg s out o f altru ism. This notio n ma y b e derive d fro m th e stereotyp e o f wome n as mor e altruistic , nurturing , an d "life-giving " tha n men . Per haps i t i s reall y jus t a n extensio n o f th e societa l notio n tha t women shoul d no t b e compensate d fo r work , an d i f the y are , they shoul d no t b e compensated mor e tha n men . Another controvers y focuse s o n th e anonymit y o f donors . Traditionally, sper m donor s hav e remaine d anonymous , whil e egg donor s wer e ofte n friend s o r relative s o f th e recipient . I n fact, originall y man y clinic s require d recipient s t o fin d thei r own donors . Now, th e movement towar d identity-releas e sper m donors has grown, while egg donors are increasingly encourage d to remai n anonymous . Advocate s o f anonymou s eg g donatio n hold tha t anonymit y ma y preven t eg g donor s fro m becomin g emotionally investe d i n the subsequent fat e o f the egg and some how attemptin g t o late r gai n custod y o r visitatio n o f a child . Once again , n o suc h concer n i s voice d wit h regar d t o seme n donors, eve n thoug h seme n donor s hav e conteste d custod y an d gained visitatio n right s o f babie s bor n fro m thei r donate d semen. Some critic s debat e whethe r wome n shoul d b e "allowed " t o donate thei r egg s a t all . Rarel y doe s anyon e rais e th e corres ponding questio n wit h regar d t o seme n donors . Clearl y seme n donation i s no t a n analo g t o eg g donation . Still , som e ethica l issues are common t o both ; for example , the wisdom an d legiti macy o f interferin g i n the procreativ e process . But eg g donatio n

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seems t o caus e mor e distres s t o th e genera l publi c an d t o eth icists tha n seme n donation , perhap s becaus e o f th e technolog y involved. This issu e may als o dissuad e potentia l donors .

Donor Shortag e The first recorde d cas e o f a n eg g donatio n tha t resulte d i n a birth cam e abou t rathe r serendipitously . Th e dono r wa s i n th e process o f havin g egg s remove d fo r i n vitr o fertilization . Fiv e eggs wer e remove d an d fertilized , bu t accordin g t o th e regula tions, onl y fou r coul d b e implanted i n he r uterus . Sh e agreed t o donate th e fifth, an d a chil d wa s conceive d fro m it . Initiall y other eg g donor s wer e obtaine d i n simila r fashion . Wome n un dergoing sterilization , a hysterectomy , o r i n vitr o fertilizatio n were aske d t o donate . Unlik e semen , unfertilize d egg s di d no t respond wel l t o cryopreservation, 63 s o whe n wome n wer e un dergoing i n vitro fertilizatio n an d ha d extr a egg s extracted, the y were ofte n amenabl e t o donatin g them . Generall y onl y a limite d amount coul d b e implanted , an d th e res t woul d b e destroyed . However, wit h th e adven t o f cryopreservatio n o f embryo s (fer tilized eggs) , wome n undergoin g i n vitr o fertilizatio n ca n no w preserve thei r gamete s fo r thei r ow n futur e attempt s a t i n vitr o fertilization. Additionally , deman d fo r dono r egg s has continue d to increase , resulting i n a n extrem e shortag e o f eg g donors. Th e shortage coul d als o b e exacerbate d b y an y numbe r o f factors , including th e risk s o f th e procedure , it s invasiveness , th e heav y time commitmen t an d inconvenienc e entailed , an d a lac k o f widespread knowledg e abou t th e nee d fo r eg g donors . Regard less o f th e reason , clinic s an d physician s hav e suggeste d inven tive alternatives t o traditiona l eg g donors . One recentl y propose d alternativ e i s t o provid e eg g dono r cards, similar to dono r card s for vita l organs, to al l women wit h

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viable eggs : women coul d choos e t o hav e thei r egg s o r ovarie s removed an d donate d i n th e cas e o f thei r unforesee n demise . Presumably, parent s coul d als o consen t t o donat e thei r daugh ter's eggs (given that sh e is under th e age of consent) i n the even t of he r sudde n death . Therefore , theoreticall y a chil d coul d b e born whos e geneti c mothe r ha d die d i n a car acciden t whe n sh e was to o youn g t o eve n gras p th e implication s o f childre n o r motherhood. If th e ide a o f donatin g dea d children' s egg s t o childles s cou ples seem s abhorrent , anothe r alternativ e sourc e o f eg g donor s may rat e eve n highe r o n th e "yuc k factor." 64 I t i s possible tha t eggs coul d on e da y b e harveste d fro m th e ovarie s o f aborte d female fetuses. 65 O f course , th e woma n wh o underwen t th e abortion, an d wh o woul d b e th e geneti c grandmothe r o f an y child bor n fro m th e fetus' s eggs , woul d hav e t o consent . How ever, give n th e lac k o f contro l ove r th e seme n donatio n "indus try," i t i s difficul t t o imagin e ho w a n unregulate d eg g donatio n "industry" coul d b e secure d agains t ethicall y dubiou s practices . What woul d sto p a physicia n fro m harvestin g egg s fro m a n aborted fetu s withou t th e patient' s consent ? However , thi s ver y real possibilit y doe s no t appea r t o generat e an y concern . Onc e again, ethicist s see m mor e distresse d ove r th e possibilit y tha t women ma y profi t fro m thi s procedur e b y establishin g "feta l farms," wher e aborte d fetuse s woul d b e sol d t o ovu m harvest ers. 66 Presumabl y wome n woul d ge t pregnan t an d purposel y abort (perhap s repeatedly ) simpl y t o sel l thei r aborte d fetus' s eggs. Th e worr y ove r wome n profitin g fro m thei r reproductiv e capacity extend s to absur d proportions . These option s ma y see m distan t possibilities . However , a t least on e woma n i n Kore a ha s alread y give n birt h t o a chil d who wa s conceive d throug h th e donate d gamete s o f a decease d woman. Th e medica l professio n i s desperatel y seekin g t o in crease the supply of egg donors as demand continues to increase.

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In part , thi s deman d i s du e t o medica l advance s whic h hav e exponentially increase d th e numbe r o f potentia l mothers .

"Methuselah M o m s " As debat e rage s o n regardin g potentia l source s o f eg g donors , new concer n ha s arise n ove r wh o shoul d an d shoul d no t b e donor recipients . Severino Antinori's wor k i n Italy has made th e possibility o f postmenopausa l birt h renowne d an d generate d tremendous controversy . Althoug h Antinor i wa s no t th e firs t physician t o successfull y impregnat e postmenopausa l women , his patient s ar e som e o f th e oldes t know n wome n t o giv e birth . The concep t o f "Methusela h moms " ha s receive d littl e suppor t and muc h criticism . Th e ter m itsel f i s catch y an d memorable , but als o degrading . I t i s no t surprisin g tha t man y clinic s wil l not accep t postmenopausa l wome n a s dono r recipients . Franc e strictly prohibit s assiste d conceptio n i n postmenopausa l women. 67 Afte r th e notoriou s cas e o f Rosann a dell a Corte , discussed a t th e beginnin g o f thi s chapter , Ital y als o passe d regulations regardin g th e ag e o f dono r recipient s an d othe r criteria o f eligibilit y (i.e. , lesbian s an d singl e wome n ar e ex cluded). Objections t o postmenopausa l pregnancie s ofte n reflec t dou ble standard s i n notion s o f parenthood . Whe n a n olde r ma n fathers a child , societ y seem s t o rever e hi m a s a parago n o f masculinity an d virility . Ye t when olde r wome n giv e birth , con cerns abound , rangin g fro m th e possibilit y o f th e chil d bein g orphaned t o th e capacit y o f th e mothe r t o parent . Eve n whe n the fathe r i s a s ol d a s th e mother , i t i s th e mothe r wh o i s criticized fo r becomin g a parent late r i n life. This is ironic, given that me n hav e a shorte r lif e expectanc y tha n wome n an d a n older fathe r wil l therefor e b e mor e likel y t o di e befor e hi s chil d

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grows up than will an older mother. Furthermore , older mother s tend t o secur e extensiv e suppor t system s fo r thei r childre n an d are generall y affluen t enoug h t o insur e tha t the y ar e provide d for i n th e cas e o f materna l illnes s o r death . Moreover , younge r women wh o ar e terminall y il l o r wh o liv e o r wor k i n high-ris k situations ar e not prevented fro m havin g a child, despite the ris k of th e child bein g left motherless . Along thes e sam e lines , critic s hav e argue d tha t wome n o f grandparenting ag e should no t b e raising children. Yet the num ber o f grandparents parentin g grandchildre n i s rising steadily, a s the cos t o f da y car e increase s an d th e availabilit y o f qualit y centers decreases . I n fact , interactio n betwee n childre n an d th e elderly i s ofte n intentionall y arranged , t o th e mutua l benefi t o f both groups . Many opponent s als o claim that olde r wome n ar e simpl y to o frail t o g o throug h th e traum a o f birth. 68 However , embry o recipients ar e alway s screene d fo r il l health , an d ther e i s littl e evidence tha t middle-age d mother s ar e an y mor e "a t risk, " i n general, than youn g ones . Finally, some hol d tha t postmenopausa l wome n wh o becom e pregnant ar e utilizin g valuabl e resource s tha t coul d benefi t a younger mother. 69 Ho w ca n anyone asses s benefit, o r happiness , or qualit y o f life ? I t is just a s easy to argu e that postmenopausa l women benefi t mor e fro m motherhoo d tha n d o younge r women, and make bette r mothers to boot. They can often affor d advantages an d luxurie s fo r thei r childre n tha t younge r mother s cannot. I n addition , thei r live s are ofte n organize d i n a way tha t permits the m t o spen d muc h mor e tim e wit h th e chil d tha n a younger mothe r could . Ultimately , wh o know s wha t make s a good parent ? Apparently , member s o f th e medica l professio n believe they know .

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Discriminatory Practice s As eg g donatio n become s mor e prevalent , catalog s wit h eg g donor profile s ar e ofte n availabl e t o prospectiv e recipients . Lik e information i n sper m dono r catalogs , thes e profile s ma y cove r health, age, race, interests, hobbies, occupation, features , educa tional level , an d famil y medica l history . Prospectiv e recipient s can generall y selec t a dono r base d o n whateve r criteri a ar e relevant t o them. Physicians encourag e couples to select a dono r whose feature s wil l b e simila r t o thei r own , particularl y t o th e gestational mother's . I n fact , befor e catalog s wer e available , physicians usuall y attempte d t o "match " donor s an d recipients , provided ther e wer e enoug h donor s t o allo w fo r selection . Pre sumably "matching " facilitate s adaptio n b y the parent s an d th e child to the absence of a genetic link with the gestational mothe r and ma y enabl e th e chil d t o "pass " a s th e gestationa l mother' s genetic offspring . In th e past , adoptio n agencie s regularl y en couraged "matching " o f thi s sort , an d som e still do . "Matching" i s a disconcertin g an d dangerou s concept . I t suggests t o parent s tha t the y ma y b e abl e t o forg o tellin g chil dren abou t thei r geneti c background . Moreove r i t hint s a t no tions o f racia l purity . Recentl y th e actua l racis m inheren t i n th e "matching" polic y wa s highlighte d when , i n separat e incidents , two African-America n wome n chos e Caucasia n eg g donors . Their selection s mad e international headlines . On e woma n wa s married t o a Caucasia n man ; th e othe r woman' s husban d wa s of mixe d race . In a t leas t on e o f thes e instances , African-America n eg g do nors simply were not available. African-American an d Asian egg donors ar e almos t alway s i n shor t supply , du e t o a numbe r o f possible factors , includin g les s intensiv e recruitin g o f minorit y egg donors . "Ideal " Caucasia n donor s ar e activel y recruited : "The blond , blue-eye d forme r colleg e athlete , wh o i s studyin g

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to b e a surgeon , wa s welcome d a s a n answe r t o a praye r b y th e hopeful eg g recipient. . . . Sh e wa s pai d considerabl y mor e fo r her tim e the n th e $35 0 t o $50 0 recommende d b y the America n Infertility [sic] Societ y i n it s guideline s t o clinics." 70 Anothe r clinic's dono r coordinator , wh o als o ha d a n "ideal " blonde haired, green-eye d donor , explained , " I wis h I ha d abou t 2 0 clones o f he r i n differen t hai r colors." 7 1 Sh e di d not , however , say that sh e wanted an y "clones " wit h differen t ski n colors . Some donor s ar e routinel y screene d ou t o f th e proces s be cause of their sexua l orientation . Fo r example , one clinic refuse s to accep t lesbia n donor s becaus e of the possible hereditary com ponent i n homosexuality. 72 Th e logi c here , apparently , i s that i t is better no t t o have a child tha n t o have a gay one . These discriminator y practice s exten d t o recipients . Mos t re cipients ar e Caucasian , upper-incom e couples . Although upper income minority couples may seek egg donors, they may becom e discouraged b y th e lac k o f "matching " donors . Th e screenin g process for recipients , which i s left t o the discretion of the clinics and physicians , ma y als o discourag e member s o f ethnic/racia l minority groups , a s wel l a s singl e women , lesbians , o r anyon e else deeme d "inappropriate " fo r parenthood . Eg g donatio n ha s become a proces s wherei n infertil e Caucasia n couple s procreat e while othe r infertil e couple s o r individual s continu e t o see k alternatives. This i s particularly unfortunat e give n the increase d rates of infertility amon g people from minorit y groups. Minorit y donors ar e no t recruited ; minorit y recipient s canno t find "matching" gametes ; an d whe n minorit y recipient s "choose " Caucasian donors , they are scrutinized an d criticized . For exam ple, whe n on e blac k woma n attempte d t o obtai n egg s fro m a Caucasian donor , th e clini c conferre d first wit h th e Huma n Fertilisation an d Embryolog y Authorit y befor e the y woul d pro ceed. Thi s licensin g burea u di d no t object , mos t likel y becaus e there wer e n o minorit y donor s available . I t i s unclea r wha t th e

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board woul d hav e rule d i f egg s fro m a blac k dono r wer e avail able but the couple simpl y preferred a Caucasian donor . In Italy, such a n instanc e provoke d protes t fro m th e publi c an d th e medical community. 73 Procreation shoul d b e a fundamenta l right , availabl e t o ev eryone. Ye t decision s regardin g recipient s ar e lef t t o physician s and, i n som e countries , legislators . Som e recipient s ar e deeme d unacceptable becaus e o f thei r age . Others ar e indirectly discour aged becaus e o f thei r race . Still others ar e denie d acces s becaus e of thei r income , marita l status , o r sexua l orientation . I n th e past, whe n sper m bank s an d physician s deeme d som e wome n "inappropriate" fo r parenthood , th e women circumvente d suc h discrimination b y establishing their ow n facilities . Bu t egg dona tion raises concerns that migh t make i t difficult t o go this route .

Risks t o Wome n an d Thei r Childre n A numbe r o f women' s issue s com e t o th e for e i n gamet e dona tion. Firs t an d foremos t i s concer n fo r women' s health . I n ga mete donatio n i t is always the woman wh o i s at risk. The seme n donor i s in n o danger , whil e th e seme n recipien t ofte n risk s th e transmission o f sexuall y transmitte d o r othe r infectiou s disease s from seme n no t teste d adequatel y o r no t froze n and/o r quaran tined. I t i s als o th e woma n wh o i s a t ris k i n eg g donation . Most donor s experienc e som e sid e effect s fro m th e procedure , sometimes seriou s ones . Th e recipien t risk s complication s fro m hormone manipulatio n an d implantation . Complication s ca n arise i n an y phas e o f th e proces s an d ca n lea d t o temporar y o r permanent damage . Thes e risk s ar e no t alway s clea r t o eithe r the donor o r th e recipient . The childre n create d b y thes e reproductiv e technologie s als o face certai n hazards . Fo r example , afte r "successful " infertilit y

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treatment, Hele n Puse y becam e pregnan t wit h quadruplets . Sh e was no t cautione d regardin g th e risk s o f a multipl e pregnanc y to eithe r hersel f o r th e fetuses . Tw o o f th e childre n die d shortl y after birth . Bot h o f th e survivin g childre n hav e a multitud e o f physical problems , an d on e ha s sever e cerebra l palsy . "Doctor s do ten d t o thin k the y ar e God, " Puse y remarks . "The y thin k that the y ar e th e expert s an d the y know . Bu t a t th e en d o f th e day they practice their medica l technology bu t we are left t o liv e with the results." 74 Althoug h th e burde n i s shared b y the family , it i s generally th e woma n wh o wil l bea r th e brun t o f reproduc tive mishaps, psychologically an d physically . Most medical innovations begi n with animal experimentatio n and g o o n t o clinica l trial s wit h humans . Eg g donatio n bega n with animals , but unlik e most medica l research , di d no t procee d to a controlle d stud y wit h huma n participant s informe d o f th e experimental natur e o f th e treatment . Virtuall y o n th e spu r o f the moment , th e techniqu e wa s attempte d o n a woman , suc ceeded, an d becam e widel y availabl e a s a ne w reproductiv e technology withou t extensiv e trial s o r testing . I n essence , women wh o ar e currentl y undergoin g eg g donatio n an d othe r reproductive interventions , suc h a s sper m cleansing , are th e ex perimental phas e o f th e project . The y ar e "livin g labora tories," 75 a s the y hav e ofte n bee n throughou t th e histor y o f obstetrics an d gynecology . Mario n Sims , renowne d a s th e "fa ther o f gynecology, " becam e obsesse d wit h finding a cur e fo r vesicovaginal fistulas, rupture s o f th e vagina ofte n cause d b y a n instrument use d durin g labo r (i.e. , forceps). 76 Sim s obtaine d slave wome n an d performe d repeated , painfu l operation s o n them, withou t anesthesia , i n orde r t o find a wa y t o clos e th e fistula. On e woman wa s operate d o n ove r thirt y times . Yet Sims believed "tha t i t wa s hi s dut y a s a physicia n . . . t o enabl e hi s patients to hav e a s many childre n a s possible." 77 Given th e rigorou s regulator y contro l maintaine d ove r th e

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testing an d developmen t o f othe r medica l innovations , suc h as pharmaceuticals , th e laissez-fair e approac h t o reproductiv e technologies i s incongruous . Typically , befor e a prescriptio n drug i s approve d b y th e Foo d an d Dru g Administratio n an d goes o n th e market , i t mus t underg o extensiv e testin g fo r safet y (albeit ofte n b y the manufacturer). Ye t egg donation, a n invasiv e and hazardou s procedure , encounter s few , i f any , governmenta l roadblocks o r safeguards . Thi s certainl y canno t b e attributed t o a genera l reluctanc e o n th e par t o f th e governmen t t o meddl e with th e fundamenta l righ t t o procreate . Governmenta l inter vention int o abortio n an d contraceptio n choice s clearl y refute s this notion . I t i s unclea r wh y th e governmen t intervene s i n reproductive freedo m whe n th e consequence s o f interventio n can b e detrimenta l t o wome n bu t refuse s t o interven e whe n th e consequences ca n benefi t them . Despite health concerns, reproductive technologies ar e laude d for enhancin g women' s reproductiv e control . In th e nex t fe w year s th e rapi d developmen t o f ne w fertilit y techniques coul d giv e wome n a n unprecedente d contro l ove r their bodies. . . . Imagine your recently married daughter has just been kille d i n a ca r accident . Yo u discove r tha t sh e carrie d a donor card allowing her ovarian tissue to be transplanted into an infertile woman . Althoug h sh e wa s dead , th e resultin g chil d would b e genetically hers, but you would neve r se e your grand child.78 How doe s th e decease d woma n hav e mor e reproductiv e contro l over he r body ? I f anything , sh e ha s los t control . A t best , repro ductive technologie s increas e th e option s availabl e t o some in fertile women . Th e contro l ove r wh o ca n an d canno t becom e mothers wit h th e ai d o f reproductiv e technolog y lie s wit h th e medical profession , a patriarchal system . Arguably, reproductiv e technologie s hav e diminished worn -

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en's contro l ove r mothering , particularl y wit h th e adven t o f egg donation . First , th e invasivenes s o f th e procedur e an d it s dependence o n medica l personne l mak e man y wome n feel tha t they hav e los t contro l ove r thei r bodies . Certainl y hormon e manipulation does resul t i n a lac k o f contro l ove r thei r bodies . In addition , physician s contro l wh o ca n b e mother s throug h selective dissemination o f information abou t th e process an d th e selection o f "appropriate " eg g donor s an d recipients . Finally , if egg donatio n follow s th e sam e patter n a s surrogac y an d othe r reproductive technologies , som e wome n woul d argu e tha t i t will becom e jus t anothe r wa y t o preemp t women' s reproductiv e choices: "Me n hav e alway s bee n concerne d wit h controllin g women's fertility an d the 'products ' of that fertility. That contro l has range d fro m law s whic h circumscrib e women' s acces s t o contraception an d abortio n t o religiou s an d politica l control s which se t the appropriat e rate s o f reproduction fo r women. " 7 9 The whol e issu e o f reproductiv e technologie s present s a con flict fo r man y women . Som e women , fo r example , wh o favo r reproductive technolog y i n on e contex t (suc h a s abortion) , op pose i t i n another , eve n though , offhand , i t woul d appea r tha t reproductive technologie s are , i n thei r genera l tendency , "pro choice." Prochoic e wome n ofte n perceiv e th e technologie s a s a way t o stra p wome n int o compulsor y motherhood . No w ther e is n o excus e fo r childlessness : wome n withou t mal e partners , women wit h fertilit y problems , wome n pas t childbearin g age — all ca n becom e mother s (o r ca n a t leas t mak e a mor e intensiv e effort t o becom e mothers) . Th e ne w technologies , fro m thi s point o f view , represen t a threa t t o women' s psychologica l an d physical healt h a s well a s a means to undermin e thei r contro l o f their bodies . O n th e othe r hand , prolif e (antichoice ) women , who ofte n emphasiz e th e importanc e o f th e family , frequentl y oppose th e technologies a s artificial an d insultin g t o th e sanctit y

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of marriage . Regardles s o f one' s stance , reproductive technolog ies do no t necessaril y represen t progress .

Regulation If the regulation o f seme n donatio n i n the United State s is weak, the regulation o f egg donation i s virtually nonexistent. I n Franc e medically assiste d procreatio n i s onl y permitte d fo r couple s o f childbearing ag e wh o ar e infertil e o r ma y pas s o n a n incurabl e disease. Additionally , eg g donor s mus t hav e ha d a chil d pre viously an d mus t b e i n a heterosexua l relationship . Recipient s can onl y b e couples wh o hav e live d togethe r a t leas t tw o years . All partie s mus t agre e i n writin g t o th e procedure . Finally , em bryo donations mus t b e authorized i n writing b y both biologica l parents an d hav e judicial approva l a s well. 80 In England, the Human Fertilisatio n an d Embry o Act of 199 0 requires dono r identitie s t o b e kep t confidential , wit h crimina l penalties fo r disclosure . Th e ac t als o establishe d th e Huma n Fertilisation an d Embryolog y Authority , whic h register s sper m and eg g donor s s o tha t potentia l offsprin g d o no t intermarry . The authorit y ca n als o provide basi c details o f th e donor' s char acteristics to offspring . I n addition , th e ac t stipulate s tha t sper m donors ca n b e pai d bu t tha t eg g donor s ca n onl y b e compen sated minimally , to cover expenses , although sterilizatio n ca n b e offered fo r fre e i f women undergoin g th e procedure agre e to eg g donation. I n general , the maximu m numbe r o f childre n allotte d per dono r i s ten , an d donor s ar e no t permitte d t o lear n th e outcome o f their donations . In th e Unite d States , asid e fro m th e la w i n Louisian a whic h bans compensatio n an d a fe w statute s relate d t o custody , no laws regulate any aspec t o f th e eg g donation process .

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Beyond Gamet e Donatio n Gamete donatio n i s onl y on e componen t o f th e ne w reproduc tive technologies . Prio r t o IVF , egg donatio n wa s pointless , an d it i s IVF that ha s create d th e possibilit y o f ful l surrogat e moth ering, wherein th e surrogat e ha s n o biologica l connectio n t o th e child. Finally , IV F has afforde d infertil e couple s a n opportunit y to fertiliz e a n eg g an d cryopreserv e th e embry o fo r futur e im plantation. A s w e shal l se e i n th e followin g chapter , societ y i s still strugglin g t o comprehen d th e complexitie s an d conse quences o f these developments .

[2] Poitics an d Reproductive Technologie s II : The Legac y o f IV F

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unrelentingly th e medi a re port spiralin g rate s o f infertility . Illusion s o f risin g infertilit y rates represen t par t o f th e backlas h agains t America n wome n for choosin g career s ove r famil y o r career s i n additio n t o fam ily: * infertilit y i s their penance . Perhaps now , women wil l learn , once and fo r all , that thei r plac e is in the home . Divine interven tion ha s dole d ou t consequence s fo r wome n venturin g ou t o n careers o f their own . These purportedl y risin g rate s o f infertilit y hav e me t wit h almost freneti c respons e fro m prospectiv e parents . I n par t thi s may be due to increased social and political emphasis on the fam ily, an d i n par t t o erroneou s propagand a suggestin g tha t adop tion i s virtually impossibl e sinc e the legalizatio n o f abortion . [41]

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The Infertilit y "Epidemic " Media estimate s o f th e numbe r o f America n couple s wh o suffe r from infertilit y vary , bu t generall y averag e betwee n 1 0 an d 2 0 percent. Estimate s var y becaus e ther e i s n o se t definitio n o f infertility. I n actualit y th e rat e ha s probabl y hel d stead y o r declined ove r th e las t thre e decades , bu t th e definitio n ha s changed, makin g i t appear tha t infertilit y rate s ar e o n th e in crease.2 I n general , th e variabl e componen t i n thes e definition s is the length o f tim e that mus t pas s without conceptio n befor e a couple i s considered infertile . Prio r t o 1975 , a couple would no t be considere d infertil e unles s the y ha d faile d t o conceiv e afte r five year s o f unprotecte d intercourse. 3 I n 1975 , th e Worl d Health Organizatio n (WHO ) shortene d thi s tim e perio d t o twenty-four months , whil e i n 1988 , th e Offic e o f Technolog y Assessment (OTA ) in the United State s suggeste d twelv e month s was sufficient. 4 Bu t som e seriou s objection s hav e bee n lodge d against thes e new an d les s stringent criteria . When th e definitio n o f 1 2 months o f unprotecte d intercours e is used, only 16 % to 21% of couples meeting this definition actu ally remain infertile throughout their lives. Indeed, several studies suggest tha t abou t 30 % o f couple s tak e mor e tha n a yea r t o conceive at some time during their reproductive lives. A reassessment o f dat a fro m th e Worl d Fertilit y Surve y an d other studie s doe s no t substantiat e a cor e rat e o f infertilit y o f 10% t o 20%. A survey in the United State s reported tha t 8.5 % of married couples with the wife aged 15 to 44 years (n = 8,450 ) were infertile , a n estimat e tha t i s undoubtedl y to o hig h a s a n indicator o f actua l lifetim e infertility , a s th e OT A definitio n o f infertility wa s used . Onl y 3.8 % o f tha t sampl e had never given birth, whereas 4.7% ha d on e or more births before th e onset of infertility. Thes e figures obtained i n 198 8 were unchanged fro m a previous survey conducted in 1982. 5

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Moreover, frequenc y o f intercours e i s rarel y assessed . Whe n i t is, w e se e tha t th e actua l rat e o f infertilit y drop s eve n lowe r a s frequency o f intercours e increases. 6 I n short, althoug h 8 percent of couple s may experienc e difficult y conceiving , most eventuall y conceive.7 But a s report s o f a burgeonin g infertilit y epidemi c escalated , the medica l professio n investigate d solutions . Overall , th e tech niques develope d di d no t focu s o n preventio n o r treatmen t o f infertility bu t rathe r o n way s t o circumven t th e natura l rout e to conception . Th e mos t consequentia l an d pivota l o f thes e techniques wa s i n vitro fertilization .

In Vitr o Fertilizatio n Louise Brown , th e first "test-tube " baby , ha s reache d child bearing age . He r birt h mesmerize d th e worl d i n 1978 : a chil d could no w b e conceived outsid e a woman' s bod y (i.e. , in vitro) . From 197 8 t o 199 1 approximatel y sixty-fiv e thousan d babie s were bor n fro m IV F worldwide , fifteen thousan d i n th e Unite d States.8 Toda y ther e ar e mor e tha n thre e hundre d i n vitr o cen ters, an d th e procedur e i s performe d ove r twenty-seve n thou sand time s per year, i n the United State s alone . The techniqu e whic h le d t o th e conceptio n o f Louis e Brow n has becom e standar d IV F process. First , egg s ar e remove d fro m the biologica l mothe r an d place d i n a "tes t tube " o r mor e accurately, in a culture medium suc h a s a petri dish . Semen fro m the biologica l mother' s partne r (o r a donor ) i s also placed i n th e culture medium i n an attempt t o fertilize th e eggs. If fertilizatio n occurs, som e o r al l o f th e fertilize d egg s (zygotes ) ar e place d i n the biologica l mother' s uterus , usuall y withi n twenty-fou r t o forty-eight hours. 9

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In a n adaptatio n o f th e IV F procedur e calle d co-culturing, 10 eggs fertilized i n vitr o ar e place d i n a n "artificia l womb. " Tech nically th e "womb " i s a tub e containin g endometria l tissu e tha t purportedly simulate s th e fallopia n tubes . Afte r tw o days , an y fertilized egg s are transferred t o the woman's uterus . This procedure i s particularl y usefu l fo r wome n wit h blocke d fallopia n tubes, since the tubes ar e bypassed. In a variant calle d introvagi nal culturing, 11 th e fertilize d egg s are deposite d i n a tube tha t i s hermetically seale d an d place d i n th e prospectiv e mother' s va gina fo r approximatel y forty-eigh t hours . After tha t "incubatio n period" th e tub e i s removed , an d selecte d embryo s ar e place d into th e mother' s uterus . Again , thi s techniqu e i s primaril y de signed t o assis t infertil e females . Ofte n a thir d party , suc h a s a "surrogate mother " o r eg g donor , i s involve d i n th e proces s when th e femal e i s the sourc e o f th e couple's infertility .

IVF Technique s t o Overcom e Mal e Infertilit y In approximatel y hal f o f infertil e couples , male s contribut e t o or ar e th e sourc e o f a couple' s infertility. 12 Severa l procedure s have bee n designe d tha t assis t i n overcomin g mal e infertility . These techniques ar e particularly usefu l fo r me n with lo w sper m counts o r immotil e sperm . On e o f th e best-know n derivative s o f IVF is a process called ZIFT (zygot e intrafallopian transfer) . Th e only differenc e betwee n IV F an d ZIF T i s th e placemen t o f th e zygote. In ZIFT, the zygote is placed in the fallopian tub e instea d of the uterus. In a similar procedure calle d gamete intrafallopia n transfer (GIFT) , eggs ar e extracte d fro m th e biologica l mother' s ovaries, mixed wit h seme n in a culture medium, an d the n place d in th e fallopia n tube s t o allo w fertilizatio n t o tak e plac e "natu rally." Generally , th e sam e instrumen t use d t o "harvest " th e eggs, a laparoscope, i s used t o plac e th e fertilize d eg g (ZIFT ) o r

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the sper m an d eg g (GIFT ) int o th e fallopia n tubes . A surgica l incision i s usuall y mad e i n th e abdome n (o r sometime s th e vaginal wall ) t o enabl e th e laparoscop e t o reac h th e ovarie s o r fallopian tubes . One of the newest techniques fo r surmountin g mal e infertilit y is calle d intracytoplasmi c sper m injectio n (ICSI) . I n ICSI , IV F procedures ar e followed , excep t that , instea d o f combinin g th e sperm an d egg s i n a cultur e mediu m an d allowin g fertilizatio n to occur , singl e sperm ar e directl y injecte d int o the cytoplasm o f individual eggs . Th e sper m i s injecte d throug h a tin y needl e while th e eg g i s hel d i n plac e b y suction . Th e first birt h fro m ICSI i n th e Unite d State s occurre d i n 1993 . ICS I i s a modifica tion o f subzona l inseminatio n (SUZI) , a techniqu e develope d i n the 1980s . I n SUZI , thre e t o five sper m ar e injecte d int o th e space betwee n th e eg g and it s protective barrier , th e zon a pellu cida. (Th e zon a pellucid a form s naturall y aroun d th e eg g whe n ovulation occurs , an d th e sper m mus t penetrat e i t i n orde r t o fertilize th e egg. ) I n a variation o f thi s procedur e terme d partia l zona dissection , aci d i s used t o "drill " a hol e i n th e zon a pellu cida; the n th e eg g i s combined wit h thousand s o f sperm , i n th e hope tha t on e will succee d i n entering it . It i s significant tha t thes e new method s compensat e fo r men' s infertility throug h invasiv e procedure s performe d o n women. High-intervention technique s lik e ZIFT, GIFT, SUZI, or ICSI , all of whic h involv e hormon e manipulation , eg g extraction , an d surgery, carr y eve n mor e risk s fo r wome n tha n th e relativel y low-intervention technique s o f AI .

Recent Innovation s i n th e IV F Procedur e Originally, IV F di d no t involv e direc t manipulatio n o f th e eg g and sperm . Althoug h egg s an d sper m wer e "harvested, " pene -

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tration o f th e sper m b y th e eg g occurre d "naturally. " However , with ICS I an d SUZI , physician s ca n interven e i n th e actua l process o f fertilization . Suc h direc t actio n o n th e sper m o r th e egg i s termed micromanipulation . I n essence , ICS I i s "assisted " penetration. I n a ne w procedur e know n a s "assiste d hatching, " the zygot e is micromanipulated . Once a sper m ha s penetrate d th e zon a pellucida , i t harden s to preven t anothe r sper m fro m penetratin g an d attemptin g t o fertilize th e alread y fertilize d egg . Th e zygot e begin s t o divide , and whe n i t ha s divide d int o sixty-fou r cells , the zon a pellucid a or "shell " begin s t o "crack. " Thi s allow s th e zygot e t o mak e a "connection " wit h an d attac h t o th e linin g o f th e uteru s (endometrium). I f th e shel l doe s no t "crack " and/o r thi s attach ment canno t b e made, the fertilized eg g is expelled . In "assiste d hatching, " develope d b y researcher s a t Cornel l in 1992, 13 aci d i s drippe d o n th e zon a pellucid a unti l a hol e develops, thereb y "cracking " th e "shell, " presumabl y withou t harming th e fertilize d egg . Thi s procedur e mus t b e conducte d with precisio n t o ensur e tha t th e fertilize d eg g is not destroyed . "Assisted hatching " i s performe d afte r th e fertilize d eg g ha s divided int o eigh t cells . Afte r completio n o f th e procedure , th e fertilized egg s are placed i n the uterus . In 1993 , another researche r develope d a natura l cycl e varia tion o f IVF. 14 In thi s method , hormon e manipulatio n i s omitte d from th e IV F process . Instead , th e woman' s natura l menstrua l cycle i s monitored . A t ovulatio n th e matur e eg g o r egg s ar e retrieved. Althoug h fewe r egg s ar e harveste d b y thi s method , their qualit y i s though t t o b e enhanced . Afte r all , the y ar e produced "naturally. "

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H o w Successful ? As wit h infertilit y estimates , estimate s regardin g th e succes s o f IVF vary , largel y du e t o definitiona l differences . Succes s coul d be measured b y th e rat e o f impregnation , th e numbe r o f births , or th e "take-home " bab y rate . Lackin g federa l standard s t o serve a s guidelines , clinic s wer e initiall y fre e t o choos e ho w t o represent thei r success , wit h predictabl e results . I n 1990 , th e AFS discussed th e need to centralize standard s for th e accumula tion an d publicatio n o f succes s rates. If th e actua l health y "take-home " bab y rat e i s the standard , the result s o f IV F ar e no t promising . Worldwid e succes s aver ages betwee n 8 an d 1 6 percent ; mor e depressing , failure rate s are 8 4 t o 9 2 percen t pe r attempt . Failur e rate s increas e wit h each subsequen t attemp t a t IVF . The succes s rates fo r variation s of IVF , suc h a s GIF T an d ZIFT , ar e slightl y higher , wit h ICS I providers boastin g pregnanc y rate s o f 2 0 t o 2 5 percent. 15 How ever, i t i s impossibl e t o determin e i f babie s bor n fro m an y o f these technique s ha d o r develope d congenita l o r developmenta l defects o r abnormalities . Moreover , thes e rate s ma y b e decep tive, a s the y ar e base d o n relativel y health y parents ; i f parent s with healt h risk s (particularl y mothers ) wer e no t screene d ou t of th e process , th e succes s rat e migh t declin e significantly. I t i s also possibl e t o manipulat e succes s rate s i n othe r ways . Fo r example, b y implantin g a greate r numbe r o f embryo s int o th e woman, th e likelihoo d o f "success " increases , albei t a t th e ex pense o f healt h risk s to the mother an d potentia l children .

Costs The actua l monetar y cost s o f IV F var y accordin g t o th e clinic , the procedure s used , an d th e numbe r o f attempts . A singl e

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cycle o f treatmen t cost s a n averag e o f eigh t thousan d dollars. 16 However, mos t couple s ar e no t successfu l o n thei r firs t attempt . Researchers estimat e th e averag e cos t o f a "take-home " bab y from IV F a t a whoppin g seventy-tw o thousan d dollars. 17 I f th e couple choose s t o us e th e ICS I procedure, th e cos t wil l increas e by a n averag e o f on e thousan d t o thre e thousan d dollars . Othe r "extras," suc h a s th e nee d fo r a n eg g dono r o r "assiste d hatch ing," ca n ad d thousand s t o th e overal l cos t o f th e process . Prior t o treatmen t man y couple s spen d thousand s o n fertilit y assessment, testing , an d drugs . One facto r tha t inflate s th e overal l cos t o f IV F i s actuall y a byproduct o f th e process : multiple pregnancies . Generally , mul tiple eggs are extracted durin g IVF procedures (a s well as durin g egg donation). Onc e those eggs are fertilized, physician s attemp t to implan t man y o f the m bac k int o th e uterus , s o tha t a t leas t one successfu l pregnanc y wil l result . Th e numbe r implante d usually increase s wit h th e ag e o f th e woman , presumabl y be cause physician s believ e i t wil l improv e th e possibilit y o f preg nancy, althoug h researc h doe s no t entirel y suppor t thi s assump tion. Multiple birth s ma y resul t i n a numbe r o f complications , including miscarriages , low birt h weights, premature births , an d cesarean sections : Of triplet s an d quadruplet s bor n afte r IVF , 64.1 % an d 75%, respectively, require d admissio n t o intensiv e care , ofte n fo r weeks. Multipl e pregnanc y als o ha s considerabl e social , eco nomic an d psychologica l impac t o n parents . Prematurit y afte r assisted conception was associated with a perinatal mortality rate of 27. 2 pe r 1000 , three time s th e Unite d Kingdo m averag e fo r births afte r natura l conception . Th e increased mortalit y wa s almost entirely due to multiple pregnancy. 18 Comparable statistic s ar e difficul t t o obtai n i n th e Unite d State s because o f lac k o f research , lac k o f regulation , an d lac k o f

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follow-up. Som e obstetrician s an d pediatrician s d o no t eve n learn o f th e circumstance s o f conception , a s patient s ar e some times reluctant t o disclos e this information . Some clinic s voluntarily limi t th e numbe r o f egg s that ca n b e returned t o th e uteru s t o thre e i n orde r t o reduc e multipl e pregnancies. The Britis h Voluntary Licensin g Association (VLA ) has limite d t o thre e th e numbe r o f fertilize d egg s tha t ca n b e returned t o the uterus o n an y one occasion. However, Ia n Craft , a prominen t fertilit y specialis t i n England , di d no t compl y wit h these guidelines, and th e only penalty was a one-year suspensio n of hi s license. 19 Craf t continue d t o practice , withou t furthe r sanction, durin g the year h e was no t licensed . Since practitioner s i n th e Unite d State s ar e lef t t o se t thei r own limit s o n th e numbe r o f fertilize d egg s tha t ca n b e im planted, i t i s no t uncommo n fo r th e patien t t o en d u p carryin g four o r mor e pregnancies . Fo r example , i n a Chicag o clini c i n 1992, Linda Osborn , then thirty-seven, was implanted wit h nin e embryos, which resulte d i n five pregnancies. 20 A s the number o f fetuses increase , s o d o th e risk s t o bot h the m an d th e mothers . Consequently, physician s an d prospectiv e parents ar e faced wit h two choices : either continu e th e pregnancie s an d ris k th e healt h of th e mothe r an d th e potentia l childre n o r selectivel y abor t some o f th e fetuses . Som e couple s ma y b e philosophically , reli giously, o r morall y oppose d t o abortio n o f an y sort . T o thos e who hav e jus t investe d a n incredibl e amoun t o f time , resources , emotions, an d mone y t o achiev e thes e pregnancies , th e ide a o f aborting thei r "investment " i s seldo m appealing . Eve n i f th e couple ca n b e convince d tha t selectiv e abortio n i s i n th e bes t interest o f al l concerned , wh o select s whic h pregnancie s ar e t o be terminated ? Physician s sometime s sugges t abortin g th e leas t healthy an d mos t accessibl e fetuses , bu t thi s invest s physician s with tremendou s discretio n an d control : i t i s the y wh o decid e which fetuses ar e leas t health y an d mos t accessible . Ho w d o

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they decid e thi s whe n dealin g wit h microscopi c beings ? Size ? Gender? On the advice of their physician (th e same one who implante d the nin e embryos) , Lind a an d Ji m Osbor n agree d t o selectivel y abort thre e o f th e fiv e fetuse s sh e wa s carrying . Th e physicia n inserted a needl e int o th e heart s o f thre e o f th e fetuses , thu s terminating thei r existence . Th e aborte d fetuse s wer e the n ab sorbed int o Linda' s body . Late r sh e gave birt h t o health y twins . One oft-overlooke d aspec t o f suc h a decisio n i s the psychologi cal impac t i t wil l hav e o n th e survivin g children , i f an d whe n they ar e informe d o f th e unusua l circumstance s o f thei r gesta tion an d th e sacrificia l eliminatio n o f their siblings . In additio n t o th e monetar y cost s an d ethica l dilemma s re lated t o multipl e births , bot h mothe r an d childre n fac e othe r risks. I n general , non e o f th e reproductiv e technologie s presen t any seriou s risks to the father .

Risks t o th e Bab y In Januar y 1994 , a n Englis h researche r foun d tha t childre n conceived throug h IV F weighe d les s a t birt h an d wer e mor e likely to b e born prematurel y tha n babie s conceive d naturally. 21 One mont h later , researcher s i n Australi a reporte d tha t the y found littl e differenc e betwee n babie s conceive d throug h IV F and babie s conceive d naturally. 22 I n fact , the y indicate d tha t children o f IV F had somewha t bette r socia l skills . Then, i n June 1994, Frenc h researcher s reporte d a "highe r tha n averag e rat e of serious deformities" amon g children o f IVF. 23 Other research ers to o hav e reporte d a greate r incidenc e o f anomalie s amon g children conceive d throug h th e ne w reproductiv e technologies . However, i t i s no t clea r whethe r thes e anomalie s resul t fro m

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the procedure s themselves , fro m th e fac t tha t the y ar e ofte n performed o n wome n wh o (becaus e o f ag e o r gynecologica l problems) offe r les s tha n idea l uterin e environments , o r fro m multiple pregnancies . Alarmingl y fe w studie s hav e bee n con ducted i n th e Unite d States . Th e curren t patient s (an d thei r offspring) ar e truly "livin g laboratories. " One thin g is certain: to dat e there i s no conclusiv e research — in fact, ther e i s little research a t all—o n th e long-ter m effect s o f IVF (an d IV F derivatives ) o n children . Th e potentia l physical , social, an d psychologica l effect s ar e impossibl e t o fatho m a t this point . Th e pathogeni c consequence s o f pas t reproductiv e interventions, suc h a s th e us e o f diethylstilbestro l (DES ) i n th e 1950s to preven t miscarriage , did no t clearl y emerge for a t leas t a generation. 24 Perhaps most alarming i s the fact tha t the newer reproductiv e technologies (particularl y those that involve micromanipulation ) circumvent th e proces s o f natura l selection . Natura l selectio n tends t o preven t defectiv e sper m fro m reachin g o r penetratin g the eg g an d t o destro y defectiv e egg s befor e the y ca n b e fertil ized. Reproductiv e technologie s interfer e wit h thi s process . Fo r example, in ICSI, sperm unabl e t o penetrate th e eg g are injecte d directly int o it . Bu t i f sper m canno t penetrat e th e eg g o n thei r own, perhap s they , o r th e egg , o r both , ar e defective . I f so , enabling sper m t o penetrat e th e eg g ma y resul t i n a n embry o with geneti c defect s o r weaknesses . Micromanipulation als o circumvent s a secon d natura l selection process . I f a fertilize d eg g i s defective , i t ofte n spontane ously aborts. However, with "assiste d hatching, " a fertilized eg g that would onc e have been cast off a s not viable may now attac h to th e wal l o f th e uteru s an d develop . I n addition , th e effec t o f weakening th e zon a pellucid a o n th e fertilize d eg g i s unknown . While IV F facilitates conceptio n (i n cases, for example , where i t

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has bee n blocke d b y anatomica l problem s i n th e mothe r o r father), micromanipulatio n forces it , providin g littl e o r n o op portunity fo r natura l selectio n t o occur . The potentia l consequence s o f thes e intervention s ar e dis turbing, an d t o counte r them , researcher s hav e develope d thei r own method s o f natura l selection . Now, with embry o screening , also know n a s preimplantatio n diagnosis , i t i s possibl e t o tes t an embry o fo r geneti c defect s prio r t o implantin g i t i n th e mother. Fo r year s amniocentesi s an d chorioni c vill i samplin g have been use d to scree n fetuses o f potentially high-ris k mother s for geneti c defects . I f thes e test s reveale d geneti c defects , th e patient(s) wer e give n th e optio n o f terminatin g th e pregnancy . With IVF , patients ca n mak e thi s decisio n befor e implantation . Theoretically, embryo s coul d eventuall y b e screene d fo r geneti c diseases o r deformitie s an d othe r "undesirabl e characteristics. " For example , on e would n o longe r hav e to resor t t o abortio n o r infanticide t o ge t ri d o f unwante d femal e offspring : the y coul d simply b e "screened " ou t i n vitro . Imagin e th e possibilitie s i f genes fo r homosexualit y an d heterosexualit y coul d b e pin pointed—a rea l an d frightenin g prospec t give n th e recen t dis covery o f what ma y b e a "ga y gene. "

Other Risk s t o th e Potentia l Mothe r The same risks inherent i n egg donation ar e present i n IVF, since the sam e proces s i s involved . Hormon e manipulatio n an d th e extraction o f egg s ca n resul t i n numerou s complication s fo r women. Bot h procedure s ar e mor e likel y t o resul t i n a n ectopi c (tubal) pregnancy , a medica l emergenc y usuall y requirin g surgi cal intervention . The y als o increas e th e likelihoo d tha t othe r surgeries wil l b e require d durin g pregnancy , suc h a s cesarea n

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section. Th e medica l intervention s o f thes e processe s als o heighten th e chances o f infection, miscarriage , sterility, and eve n death. However , IV F endanger s onl y on e woman , no t tw o (i f the biologica l mothe r provide s he r ow n egg) . In th e Unite d State s th e federa l governmen t neithe r register s nor license s IV F clinics an d physicians . Thi s allow s a physicia n to se t u p a practice specializin g i n "infertility " treatmen t eve n if he or sh e has had littl e o r no training i n reproductive technolog ies. Othe r countries , suc h a s Britai n an d Australia , hav e regula tions regardin g IV F an d embry o researc h an d requir e licensur e of clinics . For example , in England, i n orde r t o acquir e a licens e to perfor m ICSI , "eac h clini c mus t firs t appl y fo r a researc h license an d perfec t th e techniqu e o n eggs , whic h mus t b e dis carded an d no t transferre d t o a woman' s uterus . I t mus t d o some genuin e researc h i n th e process , althoug h th e result s nee d not b e published . Onc e th e clini c ca n prov e th e competenc e o f its embryologists, i t can appl y fo r a treatmen t licens e an d begi n transferring th e injected egg s to th e woman." 2 5 No suc h standard s exis t in the United State s or Canada . Wit h little o r n o training , mistake s ar e mor e likel y t o occur , an d patients suffe r th e consequences . Conside r th e recen t cas e i n New Yor k wher e a woma n wa s told , whil e i n th e operatin g room awaitin g transplantatio n o f th e fertilize d ovum , tha t he r physician ha d implante d i t previousl y i n anothe r woman . Even tually sh e sue d th e physicia n fo r malpractic e and lost. 26 Give n the impact reproductiv e technologie s ca n hav e o n futur e genera tions an d th e experimenta l natur e o f th e process , standard s fo r licensure, accreditation , an d trainin g shoul d b e o f th e utmos t stringency. Instead , the y ar e nonexistent . In Canada , wher e ther e ar e voluntary guideline s bu t n o regu lations o r licensur e requirements , th e Roya l Commissio n o n New Reproductiv e Technologie s recentl y conducte d a n investi -

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gation int o clinic s offerin g IV F an d inseminatio n services. 27 Striking variation s wer e noted , particularl y i n th e amoun t o f record keeping . While som e clinics were meticulous , others kep t only sketch y records . Poo r recor d keepin g make s i t difficul t t o research the effects o f IVF on mothers, children, and eg g donors. Although parent s ar e no t alway s receptiv e t o follow-u p re search, i t woul d b e eas y enoug h t o requir e the m t o sig n thei r consent t o i t a t th e sam e tim e tha t the y sig n th e consen t fo r treatment. O f course , withou t regulation s i t i s impossibl e t o standardize an y consent o r treatment protocols . Currently, som e clinics provid e ver y specifi c consen t forms ; others , ver y genera l ones. Som e clinic s suppl y informatio n abou t risk s i n languag e so technical a layperson canno t easil y decipher it . The Canadia n commission rate d th e informatio n regardin g risk s tha t clinic s supplied t o patient s an d foun d i t fair t o poor i n overal l quality . Although consen t form s ma y no t infor m couple s o f th e risk s and th e relative experimenta l natur e o f IVF and IV F derivatives, they ofte n limi t liabilit y throug h a variet y o f clauses . For exam ple, th e Virgini a clini c tha t advertise d i n England , boastin g o f the availabilit y o f eg g donors , ha s couple s sig n consen t form s that state , i n part , "I f you , o r an y o f you r offspring , shoul d require an y medica l treatmen t a s a resul t o f physica l injur y arising fro m embry o cryopreservatio n an d th e dono r oocyt e program, financial responsibilit y fo r suc h car e will b e yours." 2 8 In addition , apparentl y "Befor e embryo s ge t anywher e nea r th e deep freeze , th e custome r i s require d t o sig n a lega l documen t specifying wh o will own them i f the couple divorces , the woma n becomes incapabl e o f bearin g a chil d (through , fo r example , hysterectomy), o r an y untowar d even t occurs." 29 I f th e coupl e cannot assum e ownership , it falls b y default t o the clinic. At Johns Hopkins University, the client must sig n a documen t that sound s lik e a consent t o participation i n research :

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I understand that my participation may contribute to the general advancement of scientific knowledge that may benefit som e individuals in the future. I understand that any information obtaine d by my use of th e fertility drug s may be used in medical studies, however, m y name wil l b e kept confidential . I understand tha t my diagnostic studies will be supervised b y one of the investigators and that the Program Director will oversee my care. I am advised that if physical injury shoul d result from participation in this program, the Johns Hopkins University and Hospital provid e n o insuranc e coverage , compensatio n pla n o r fre e medical care plan to compensate me for such injuries. I understan d tha t photograph s o f m y abdomen , o r pelvi c organs, ma y b e taken . I understan d tha t th e purpos e o f thes e photographs i s to teac h othe r physicians . I understand tha t m y confidentiality wil l be protected.30 If these procedures are standard, then why do they sound experi mental? Moreover , ca n prospectiv e parent s reall y provid e informed consen t whe n th e possibl e sid e effect s an d ramification s of th e procedur e remai n unknown ? Finally , althoug h consen t forms can be quite detailed, they rarely address the most commo n side effects couple s experience from IVF : the psychological ones .

The Tumultuou s Psychologica l Experienc e o f IV F Infertility an d infertilit y treatmen t ha s ofte n bee n describe d a s an emotiona l "roller-coaster " ride. 31 Imagin e a heterosexua l couple, with n o know n fertilit y problems , beginnin g thei r initia l attempts a t pregnancy . The y ma y begi n t o not e physiologica l changes i n th e woman , perhap s tak e he r basa l bod y tempera ture, check cervica l mucus , an d eve n bu y a n ovulatio n predicto r kit to determin e pea k fertility . Throug h th e first hal f o f her cycl e they eagerl y wai t fo r th e appropriat e time , an d throug h th e

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latter hal f the y eagerl y awai t th e results . Th e first cycl e i s filled with anticipatio n an d excitement . This patter n the n continue s fo r severa l months . Th e proces s is n o longe r ne w o r exciting . Lookin g fo r sign s o f ovulatio n o r pregnancy ha s simpl y becom e monotonous , an d th e coupl e i s becoming desperate . The y begi n t o inves t mor e emotio n an d perhaps money i n the process an d anxiousl y loo k fo r mor e sign s of fertility . Intercours e become s a chore , no t a pleasure . Th e emotional "rolle r coaster " i s jus t beginning . Th e "ups " com e with eac h ne w attempt , th e "downs " wit h th e star t o f eac h ne w menstrual cycle . Financia l an d emotiona l cost s ofte n begi n t o strain th e relationship . The y begi n t o worr y i f the y ar e victim s of th e "infertilit y epidemic. " Finally , eve n i f conceptio n doe s occur, th e ride may no t b e over. The pregnanc y ma y b e plague d with complications , o r th e woma n ma y miscarry . Fo r patient s using reproductiv e technologies , risk s ar e intensified . Thi s i s particularly tru e wit h IV F an d derivative s o f IVF , whic h hav e increased rate s o f miscarriag e an d multipl e pregnancie s ar e common. For a n infertil e couple , IV F i s a gamble . A s thei r investmen t increases, s o doe s thei r desperatio n an d desire . I t i s difficul t t o give up . Unwittingly , th e coupl e ha s becom e enmeshe d i n th e hopes an d promise s o f IVF ; the y ar e prayin g a t th e alta r o f science. An d the y ar e probably , fo r th e mos t part , unawar e o f the exten t t o whic h decision s mad e b y others , an d fo r politica l reasons, wil l affec t thei r persona l an d seemingl y privat e repro ductive pursuits .

The Politic s o f IV F In 1993 , Congress an d Presiden t Clinto n approve d th e Nationa l Institutes o f Healt h Revitalizatio n Ac t o f 199 3 tha t affect s th e

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cost, effectiveness, an d safet y o f IV F procedures. The bil l allow s the federa l governmen t t o fun d researc h o n IV F (althoug h i n 1994 Clinto n ordere d tha t n o federa l fund s wer e t o b e use d o n human embry o research) . Why , on e wonders , di d th e govern ment wai t s o lon g befor e fundin g researc h o n a n importan t procedure tha t affect s th e live s of millions ? When th e possibility o f "test-tube " babie s becam e a reality i n the mid-1970s , th e Carte r administratio n establishe d a typ e o f institutional revie w boar d (IRB ) calle d th e Ethic s Advisor y Board (EAB) . The EAB was to review research proposal s o n IV F and consequentl y ensur e th e safet y o f IV F researc h partici pants. 32 Withou t th e approva l o f th e EAB , no researc h projec t on IV F coul d obtai n federa l funds . Unfortunately , th e charte r for th e EA B lapsed. Th e subsequen t Reaga n an d Bus h adminis trations neve r renewe d it , thereb y effectivel y stonewallin g an y federally funde d researc h o n IV F an d dismantlin g th e boar d charged wit h th e ethical analysi s o f thi s an d relate d procedures . The la w Presiden t Clinto n signe d i s a mixe d blessing . I n essence, it eliminates th e nee d fo r EA B approval befor e researc h on IV F ca n b e funded . Therefore , mor e federall y funde d re search can , an d probabl y will , ge t unde r way . However , unles s the researche r o r institutio n sponsorin g th e researc h ha s a n IR B itself, th e welfar e o f potentia l researc h participant s wil l no t b e the specifi c focu s o f anyone' s supervision . Thi s coul d b e disas trous. Fortunately , ther e ar e plan s t o creat e a federa l a d ho c advisory panel. 33 No federa l fundin g wa s availabl e i n the early, critical years of IVF development, s o researchers turned t o private grantors, such as pharmaceutical companies , that ofte n ha d a vested interes t i n the outcom e o f th e research . I n th e Unite d State s alone , infertil ity treatmen t i s a n industr y tha t bring s i n a t leas t a billio n dollars a year . A majo r portio n o f th e proceed s com e fro m fertility drug s tha t induc e "superovulation " fo r eg g harvesting .

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These drug s ar e als o use d t o synchroniz e th e cycle s o f th e eg g donor an d th e eg g recipien t an d ar e routin e treatmen t fo r al l types o f infertility . One researche r i n Australia, Ala n Trounson , ha s develope d a technique tha t allow s physicians t o remove immatur e egg s fro m the ovary , virtuall y eliminatin g th e nee d fo r extensiv e us e o f fertility drugs . Afte r th e egg s mature , the y ar e fertilize d an d implanted i n th e uterus . A t leas t on e chil d ha s bee n bor n usin g this method . Economist s predict , "I f th e Trounso n procedur e becomes routine , i t coul d fundamentall y chang e th e IV F busi ness, whic h derive s muc h o f it s profi t fro m th e prescriptio n o f fertility drug s an d th e monitorin g o f patient s fo r advers e side effects. D r Trounso n claim s tha t hi s techniqu e coul d sav e 80 90% o f the current cost s of IVF in America—up t o $10,00 0 pe r cycle." 34 Clearly , pharmaceutica l companie s hav e a conflic t o f interest in funding researc h o n prevention o r cures for infertility , especially i f it involves reducing the use of fertility drugs . The insurance industry also has a vested interest in IVF procedures. Initially , mos t healt h insurer s di d no t provid e coverag e for IVF, 35 but the state s ar e one b y one beginning to mandate it . Insurance companie s fough t th e trend , claiming , amon g othe r things, that th e procedures ar e electiv e an d experimental . How ever, a s overal l healt h car e cost s ros e an d insurer s bega n losin g battles lik e th e on e ove r IVF , the y shifte d t o a ne w strategy : managed care . Now , wher e coverag e i s mandated , insuranc e companies hav e begu n settin g u p preferre d provide r organiza tions (PPOs) , contracting wit h a selected grou p o f healt h profes sionals wh o agre e t o provid e service s fo r a se t (generall y re duced) fee . Insurer s the n offe r bette r coverag e fo r service s rendered b y their preferre d provider s than fo r thos e rendered b y other providers . Clinic s an d physician s wh o choos e no t t o be come a preferre d provide r ma y suffe r fro m a lac k o f referrals . Providers no w compet e t o offe r th e lowes t cos t t o insuranc e

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contractors. Thi s drive s dow n th e expens e o f IV F an d othe r infertility treatments . The casualtie s o f suc h politica l battle s ar e almos t alway s women. I t i s wome n wh o hav e suffere d th e consequence s o f inadequate o r biase d research ove r the last sixteen years. Instead of isolatin g an d identifyin g th e cause s o f an d treatment s fo r infertility, physician s hav e attempte d t o develo p new technolog ies to create life. Ironically, these technologies ofte n cause femal e infertility. Bu t couple s ar e lured , b y thei r ow n hope s an d b y medical hype, to try, try, and tr y again .

Frozen Embryo s The mainstream newspape r headline s soun d lik e those o f super market tabloids : "Timewar p Triplet s Born. " Gu y Hudson , a triplet, wa s bor n i n Jul y 1994 . Hi s sister s ha d bee n bor n thre e years earlier . I n 1991 , when th e Hudson s underwen t IVF , fertilized egg s wer e implante d i n Ms . Hudson' s uterus . Guy' s sister s were th e result . Th e embry o tha t woul d eventuall y becom e Gu y was cryopreserve d and , thre e year s later , wa s implante d i n hi s mother's uterus . Technicall y th e thre e sibling s ar e triplets , con ceived a t the sam e time bu t delivere d thre e years apart. 36 IVF was th e firs t ste p towar d developin g th e technolog y nec essary fo r cryopreservatio n o f embryos . Onc e egg s coul d b e fertilized outsid e th e uterus , i t becam e possibl e t o experimen t with freezing fertilize d egg s or embryos, thereby preserving the m for futur e implantation . Theoretically , i f embryo s coul d b e fro zen, wome n migh t no t hav e t o underg o repeate d hormon e ma nipulation an d eg g extraction . Rather , egg s coul d b e removed , fertilized, an d store d a s embryos , the n implante d durin g subse quent cycle s when th e woma n wa s undergoin g th e natura l hor monal change s tha t favo r pregnancy .

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The first successfu l pregnanc y fro m a cryopreserve d embry o occurred i n Australi a i n 1984 . B y 1992 , ther e wer e 19,89 3 frozen embryo s i n storag e in Australia alone. 37 Th e cryopreser vation o f embryos is relatively simple. The embryo can b e froze n at th e pronuclea r stag e (whe n i t ha s on e cell ) o r afte r i t ha s divided two , four , six , o r mor e times. 38 I t i s dehydrate d t o prevent th e formatio n o f ic e crystals tha t ma y ruptur e th e mem brane an d the n infuse d wit h preservatives , seale d i n a tube , an d slowly frozen . Approximatel y 4 0 t o 5 0 percen t o f embryo s d o not surviv e th e freezin g process . Thos e tha t d o ar e store d i n liquid nitrogen , wher e the y ca n remai n fo r years , perhap s eve n decades o r centuries . As the embry o i s thawed fo r implantation , it is rehydrated . The pregnanc y rat e afte r froze n embry o implantatio n i s about 8 t o 1 2 percent , th e actua l birt h rat e onl y abou t 6 t o 9 percent. Overall , embryo s froze n a t earlie r stage s o f develop ment hav e a greater chance of thriving after implantation . Twin s and triplet s hav e ofte n bee n bor n fro m froze n embryos . Addi tionally, othe r IV F technique s hav e bee n successfull y combine d with cryopreservation . Fo r example , a successfu l birt h resulte d from a froze n embry o create d wit h a dono r egg . Anothe r chil d was bor n fro m a froze n embry o tha t ha d originall y bee n fertil ized throug h th e ICS I technique (th e injectio n o f a singl e sper m into the egg). Embryo cryopreservation ha s also created remark able, often bizarr e scenario s tha t generat e comple x legal , moral , and medica l dilemmas .

The Lega l Statu s o f Froze n Embryo s Even befor e th e first successfu l birt h fro m a froze n embryo , th e courts were debating the legal status of frozen embryo s i n a very

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unusual an d highly publicized case . Elsa and Mari o Rio s wante d to hav e a child. Mari o ha d a so n fro m a previous marriage , bu t Elsa wa s childless . In 1981 , the Riose s travele d fro m Californi a to Australi a t o underg o IVF . The procedur e wa s no t successful , but tw o o f thei r embryo s wer e frozen . I n 1983 , both Mari o an d Elsa wer e kille d i n a plan e crash , leavin g a multimillion-dolla r estate an d tw o froze n embryos . Mario's so n stoo d t o inheri t th e estate, but his claim would hav e been jeopardized i f any childre n were produce d fro m th e froze n embryos . Th e cour t sough t t o determine th e inheritance rights of the embryos, but when i t was learned tha t Mario' s vasectom y ha d rendere d hi m infertil e an d the seme n tha t fertilize d th e egg s had com e from a n anonymou s donor, th e inheritanc e issu e wa s rendere d moot . Th e embryo s were reportedly donate d t o a n infertil e couple . When a cas e involvin g a froze n embry o come s t o th e atten tion o f th e lega l system , i t usually revolves aroun d "ownership " of th e embryo . Thi s become s a ver y complicate d issue . Initiall y the court s mus t decid e i f the embry o i s a human lif e o r not. 39 I f the court s decid e tha t th e embry o i s a huma n "life, " the y nex t must decid e whethe r i t ha s right s tha t mus t b e protected . I f i t does, th e court s ma y decid e t o exercis e thei r paren s patria e power, tha t is , t o mak e decision s i n th e "bes t interest s o f th e child." However , i f th e embry o i s no t a huma n "life, " the n "ownership" o f i t should b e guided b y the laws of property. Th e debate was illustrate d i n the cas e of Davis v. Davis, 40 Mary Su e and Junior Davi s attempte d t o hav e a bab y "natu rally" fo r severa l years . After severa l ectopi c pregnancies , Mar y Sue wa s advise d t o hav e he r fallopia n tube s removed , thu s preventing "natural " conception . Th e Davise s the n underwen t several unsuccessfu l IV F treatments . I n Decembe r 1988 , two o f the Davises ' embryo s wer e unsuccessfull y implante d i n Mar y Sue Davis, and th e remaining seve n were cryopreserved . I n Feb -

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ruary 1989 , the Davise s separated , an d Junio r sue d fo r divorce . The onl y dispute d item s i n th e marita l dissolutio n wer e th e frozen embryos . Mary Su e wanted t o implant th e embryos in herself o r donat e them t o anothe r infertil e coupl e (sh e late r change d he r min d regarding donation) . Junior wante d th e embryo s t o remai n fro zen o r b e destroyed . H e maintaine d tha t h e di d no t wan t an y children o f hi s t o issu e fro m a "broken " home , a s hi s ow n upbringing i n a n institutiona l hom e fo r boy s ha d bee n unpleas ant. Furthermore, Junior argued , to allo w an y of the embryos t o become a full-fledge d chil d woul d b e t o forc e hi m int o parent hood agains t hi s will an d mak e hi m financially responsibl e fo r a child h e di d no t want . I n othe r words , h e argue d tha t h e ha d a fundamental righ t not t o procreate . Apparently, Junio r wa s attemptin g t o us e a variatio n o f th e arguments presente d befor e th e Unite d State s Suprem e Cour t i n Roe v. Wade (1973) . I n Roe v. Wade, th e Suprem e Cour t hel d that wome n ha d th e righ t t o abor t a fetu s i n th e first trimeste r of pregnancy . I n tha t case , th e Cour t ha d t o determin e i f th e interests o f th e stat e i n a prospective , potentiall y productiv e member o f societ y (th e fetus ) wer e compellin g enoug h t o over ride th e fundamenta l righ t o f th e pregnan t woman , derive d from th e Fourteenth Amendment , whic h ha s bee n interpreted a s providing a right to privacy. In Roe v. Wade, th e Suprem e Cour t ruled tha t th e righ t t o privac y include d th e righ t t o bodil y autonomy an d tha t forcin g a woman t o carry a fetus agains t he r will infringed o n her right to bodil y autonom y an d therefor e he r right t o privacy . The y di d no t determin e tha t wome n ha d a fundamental righ t not to procreate . Rather , i n th e cas e o f abor tion, th e woman' s righ t t o privac y an d bodil y autonom y superseded th e rights o f th e fetu s an d th e state' s interes t i n the fetus . In orde r t o conced e Junior' s argument , tha t h e ha d a funda mental righ t not to procreate , implantatio n o f th e embryo s

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would hav e t o infring e o n hi s bodil y autonomy , hi s righ t t o privacy. But the embryo s existe d outsid e o f Junior Davis' s body . Unless h e coul d argu e tha t th e embryo s wer e extension s o f his body—a dubiou s contention—Junio r woul d no t necessaril y have a righ t t o destro y them . I f h e couldn' t argu e this , hi s right t o destro y the m depende d o n whethe r th e embryo s wer e considered "persons " o r property . I f th e embryo s wer e deeme d to b e a for m o f huma n life , th e cour t coul d appl y it s paren s patriae standard t o protect them, and the case would b e resolved under famil y la w principles . I f th e embryo s represen t property , the case should b e resolved unde r th e principles o f property law . Mary Su e argued tha t i f the embryos di d represent property , sh e had a greate r interes t i n th e "property " becaus e sh e ha d a greater investmen t i n thei r creation . Afte r all , sh e underwen t hormone manipulation, surgery , and eg g aspiration (harvesting) , while Junior simpl y supplie d th e semen . Initially, th e cour t rule d i n favo r o f Mar y Sue , declaring tha t life begin s a t conception . Therefore , th e cour t coul d us e th e parens patria e standar d t o "protect " th e embryos . Th e appeal s court overturne d thi s decision , usin g a mor e property-base d analysis. The Tennessee Supreme Cour t uphel d th e appeals cour t decision i n favo r o f Junior . However , th e Tennesse e Suprem e Court di d no t us e a propert y analysis . Th e Tennesse e Suprem e Court hel d tha t dispute s shoul d b e settle d accordin g t o th e preferences o f th e gamet e providers . I f th e preference s ar e i n dispute, the court indicated , prior existin g agreements shoul d b e upheld. If , a s i n th e Davi s case , n o prio r agreemen t exists , the n the cour t rule d tha t th e "relativ e interests " o f th e parties shoul d be balanced . Th e Tennesse e Suprem e Cour t indicate d tha t thei r decision migh t hav e bee n differen t i f i t ha d determine d tha t the part y objectin g t o destructio n (Mar y Sue ) ha d n o othe r "reasonable alternatives " fo r conceptio n an d pregnanc y i n th e future (i.e. , that sh e wa s infertile) . The n destructio n o f th e em -

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bryos woul d interfer e wit h he r fundamenta l righ t t o procreate . The Unite d State s Suprem e Cour t refuse d t o hea r th e case . Junior the n destroye d th e embryos . If th e embry o represent s a huma n life , thi s coul d becom e an insurmountabl e obstacl e t o medica l researc h on , o r eve n performance of , th e IV F procedure . Theoretically , physician s could n o longer conduc t researc h usin g embryos o r discar d fres h or froze n embryos , becaus e t o d o s o coul d b e considere d mur der. In fact, wit h a n 8 5 to 9 0 percent failur e rate , IVF itself ma y be considered involuntar y manslaughter . Interestingly, antichoic e force s hav e bee n relativel y silen t o n the frozen-embry o issue . Eve n thoug h th e Davi s cas e turne d o n the issu e o f whe n lif e begins—th e centra l issu e fo r antichoic e groups—the pligh t o f froze n embryo s ha s no t an d probabl y never wil l creat e controvers y proportionat e t o th e abortio n de bate. It's unlikel y tha t infertilit y clinic s will b e picketed o r infer tility doctor s murdere d becaus e embryo s ar e destroye d a t th e facility. Perhap s thi s i s du e t o genera l ignoranc e abou t th e pro cess. Or perhaps a gender distinctio n i s at work: abortion relate s to women' s fundamenta l righ t t o procreat e o r no t t o procreate , whereas destructio n o f embryos , sinc e i t i s generall y requeste d by men, involves men's fundamenta l righ t t o procreate o r no t t o procreate. Generally, whe n "ownership " o f embryo s i s contested , th e dispute occur s betwee n th e biologica l parents . Usuall y th e bio logical "mother " want s t o implan t o r donat e th e embryo s an d the biologica l "father " want s t o destro y the m (fo r fea r o f bein g asked t o tak e responsibilit y fo r th e childre n tha t coul d resul t from them) . However , i n York v. Jones, th e clini c fough t bot h biological parent s fo r custod y o f th e embryos . Steven an d Riz a Yor k underwen t IV F a t th e Howar d an d Georgeanna Jone s Institut e fo r Reproductiv e Medicin e i n Vir ginia fro m 198 6 t o 1987 . In 1987 , six egg s were remove d fro m

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Riza Yor k an d fertilize d b y Steven' s semen . Five were implante d in Riza' s uterus ; on e wa s cryopreserved . Non e o f th e initia l implantations was successful. Whe n the Yorks moved to Califor nia, they wanted t o transfer th e on e remaining froze n embry o t o a clini c i n California . Th e Virgini a clini c refused , arguin g tha t the York s ha d signe d a consen t stipulatin g tha t th e embry o b e implanted a t th e Virgini a clinic . Th e clini c indicate d tha t th e Yorks coul d donat e th e embry o fo r researc h o r t o anothe r cou ple o r hav e i t destroye d bu t coul d no t transpor t it . They voice d a numbe r o f concern s ove r releasin g embryo s t o clients , includ ing th e possibilit y tha t a n embry o coul d b e damaged , lost , o r stolen. Th e York s maintaine d tha t th e clini c wa s holdin g th e embryo "hostage. " O n th e ev e o f trial , th e clini c agree d t o release th e embry o t o th e York s an d t o compensat e them , t o some extent , fo r thei r lega l expenses . Th e York s agree d no t t o hold th e clini c liabl e fo r anythin g tha t migh t happe n t o th e embryo an d t o take full responsibilit y fo r it . Steven York bough t a sea t o n a fligh t t o Californi a fo r th e liqui d nitroge n tan k containing th e embry o an d transporte d i t t o th e Californi a clinic. Late r attempt s t o implan t th e embry o prove d unsuc cessful. Many clinic s ar e beginnin g t o requir e biologica l parent s t o make provision s fo r an y froze n embryo s prio r t o undergoin g IVF. However , severa l problem s remain . First , th e legalit y o f such provision s ha s neve r bee n contested , s o i t i s still uncertai n how bindin g the y reall y are . Whe n custod y provision s mad e i n a wil l (fo r existin g children ) hav e bee n challenged , the y hav e been disregarded b y the court. Custod y contracts betwee n sper m donors an d sper m recipient s an d betwee n "surrogate " mother s and contractin g partie s hav e als o bee n invalidate d o r disre garded. Second , suc h contract s canno t full y encompas s al l th e possible scenario s tha t ca n unfol d aroun d a froze n embryo . Finally, couple s ca n alway s maintai n tha t circumstance s hav e

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changed s o drasticall y tha t th e contrac t the y signe d ha s bee n invalidated. 41 Controversial, precedent-settin g case s continue t o b e filed. I n 1994, a Long Island coupl e were in the process o f a divorce an d disputed "ownership " o f froze n embryo s create d i n Ma y 1993 . Maureen Kass , a Catholic , argue d tha t th e destructio n o f th e embryos woul d violat e he r religiou s belief s and , moreover , tha t she ha d n o othe r "reasonabl e alternatives " fo r procreation , be cause sh e i s sterile . This ha d bee n a n importan t facto r i n Davis v. Davis, wher e th e cour t rule d tha t froze n embryo s migh t b e used ove r th e objection s o f a potential paren t i f n o "reasonabl e alternatives" fo r pregnanc y remaine d fo r th e paren t attemptin g to retai n th e embryos . I n thei r divorc e agreement , th e Kasse s agreed, regardin g th e embryos , t o abid e b y th e decisio n o f a justice o f th e Suprem e Cour t o f Ne w York . I n contras t t o th e ruling i n Davis, a Nassa u Count y judg e rule d i n favo r o f Mau reen Kas s i n Januar y 1995 . Mauree n sai d tha t sh e woul d hav e the embryos implante d withi n a month. Steven , her ex-husband , said h e would appeal .

The Medica l an d Ethica l Statu s o f Froze n Embryo s Medical an d ethica l issue s becom e particularl y intertwine d when on e i s dealin g wit h froze n embryos . Th e medica l proce dures an d technolog y involve d i n freezin g embryo s creat e ne w ethical dilemmas . Fo r example , i f IV F o r subsequen t implanta tion wit h a froze n embry o i s successful , numerou s othe r em bryos, harvested a t the same time, may remain i n liquid nitroge n indefinitely. Som e prospectiv e parent s wan t t o kee p thes e em bryos i n frozen storag e a s insurance, i n case something happen s to thei r child(ren). 42 Som e clinic s asses s couple s monthl y o r yearly "storage " fees . I t i s unclea r wha t happen s whe n couple s

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want t o retai n thei r embryo s bu t canno t affor d th e storag e costs. Since embryo s ca n remai n froze n indefinitely , i t i s theoreti cally possible fo r biologica l parent s t o hav e a chil d (gestate d b y someone else) decades after the y are deceased. Sinc e the technol ogy tha t make s i t possibl e t o produc e liv e birth s fro m cryopre served embryo s i s barel y a decad e old , a situatio n o f thi s sor t has no t ye t actuall y occurred , bu t i t could . Th e AF S ca n onl y recommend, no t mandate , tha t embryo s b e store d fo r n o mor e than fiv e year s (certainl y no t beyon d th e reproductiv e lif e spa n of the couple) . A relate d issu e i s th e statu s o f embryo s afte r prospectiv e parents decid e t o cance l thei r "insuranc e policy. " Th e embryo s could b e donated t o anothe r infertil e couple , destroyed, o r use d for experimentation . I f the y ar e donate d t o anothe r infertil e couple, th e "adoptive " coupl e wil l obviousl y hav e n o geneti c link t o th e embryos , an d i t coul d b e argue d tha t the y migh t a s well hav e adopte d a n infan t o r chil d alread y born . Th e onl y additional benefi t t o "adopting " a n embry o an d attemptin g IV F would b e th e gestationa l lin k betwee n th e "adoptive " parent s and th e embryo . Thi s hardl y seem s wort h th e cost . Also , sinc e the parents o f donate d embryos , like egg and sper m donors , ar e not registere d o n an y centra l list , th e possibilit y o f a marriag e between sibling s ca n neve r b e precluded . On e coul d limi t th e number o f a give n couple' s embryo s tha t ca n b e froze n o r pro hibit th e furthe r us e o f a couple' s embryo s afte r a se t numbe r of successfu l births . However , th e proble m o f surplu s woul d remain. For parent s wh o hav e gone t o extreme measures , such a s try ing IV F i n orde r t o hav e children , i t mus t b e difficul t indee d t o decide whether t o have their froze n embryo s destroyed . I n som e states an d countrie s th e coupl e woul d no t b e give n thi s choice : legislation protects the embryo from destruction . Similarly, some

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states an d countrie s legislat e agains t th e us e o f nontherapeuti c procedures (i.e. , experimentation ) o n fetuse s o r embryos . Bu t such legislativ e protectio n i s relatively rare , an d withi n th e nex t few years, as IVF and cryopreservation become more popular an d storage spac e increasingl y scarce , man y individual s ma y b e forced t o decide the fate of their could-be children . A Las t Loo k a t Regulation s During late May 1995 , a scandal bega n t o unfol d a t the Univer sity of Californi a a t Irvine's Cente r fo r Reproductiv e Health . O n 2 June , th e universit y accuse d thre e o f th e center' s physicians , each a world-renowne d fertilit y exper t (on e wa s th e physicia n who perfecte d GIFT) , o f breac h o f ethic s an d contract . Th e physicians wer e accuse d o f prescribin g a n unapprove d fertilit y drug an d performin g researc h o n client s withou t thei r consent . The universit y als o allege d tha t i n approximatel y thirt y cases , the physician s remove d froze n embryo s fro m storag e withou t the biologica l parents ' consen t an d implante d the m i n othe r patients. I t i s estimate d tha t u p t o seve n childre n wer e bor n from thes e implantations . Thes e childre n ma y neve r kno w thei r biological parent s an d th e biologica l parent s ma y neve r kno w their children . Th e physician s maintai n tha t i t wa s othe r staf f who bungle d the embryo transfers. Though they violated profes sional guidelines , these physician s hav e no t violate d an y regula tions o r Californi a laws . I n a separat e incident , tw o lawsuit s were filed agains t a Rhod e Islan d clini c i n Jul y an d Augus t o f 1995. Tha t clini c i s accuse d o f "losing " nin e embryos , si x be longing t o on e coupl e an d thre e t o anothe r couple . O f course , these embryo s coul d als o hav e bee n "mistakenly " give n t o th e wrong patients , although th e clinic denies that thi s happened . A fe w state s hav e law s regardin g th e dispositio n o f embryo s or experimentatio n wit h the m o r eve n regardin g th e require d

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record keeping . However , thes e law s ar e spars e an d fa r fro m comprehensive. 43 Ver y littl e movemen t ha s bee n mad e towar d licensure o r th e regulation o f standards . Few politicians wan t t o become entangle d i n a n issu e tha t contain s component s o f th e abortion controvers y an d might thus arouse vehement response s from man y Americans . Furthermore , an y proposa l t o regulat e the medical profession invariabl y ignite s the wrath o f the American Medica l Association , a powerful lobb y an d a generous cam paign contributor . Proposals t o regulat e IV F an d relate d technologie s rais e an other issue , highlighte d b y th e Davi s case . Doe s regulatio n o f reproductive technologie s infring e o n a person' s fundamenta l rights? Th e government s o f Australi a an d Englan d apparentl y do no t thin k so , o r d o no t fee l tha t th e infringemen t i s s o serious that i t should tak e precedence ove r othe r considerations . However, th e politica l climat e o f eac h o f thes e countrie s i s very different fro m tha t o f th e United States . Let u s assum e fo r a momen t tha t regulatin g reproductiv e technologies does interfer e wit h fundamenta l rights . Doe s not , however, a lac k o f regulatio n als o interfer e wit h a n individual' s fundamental rights ? For the infertile, these rights remain illusor y in th e absenc e o f regulation , sinc e hig h cost s and/o r discrimina tory method s o f selectin g "appropriate " client s rul e ou t a grea t many potentia l parents . Furthermore , majo r decisions , suc h a s which fetuse s wil l b e selectivel y aborted , ar e lef t t o physicians . In th e Unite d States , th e medica l professio n enjoy s relativel y free rei n regardin g reproductiv e technologies . Regulatio n woul d bring a wider an d mor e representativ e grou p o f individual s int o the picture , who , wit h thei r mor e varie d interest s an d area s o f expertise, migh t b e bette r abl e t o asses s withou t bia s th e bes t interests of all parties. It is ironic that the country that i s perhaps the larges t provide r o f IV F service s shoul d la g th e furthes t be hind i n research an d regulation .

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"Wombs fo r Rent " When infertilit y stem s fro m a malfunctio n o f th e woman' s re productive system , th e woma n o r coupl e sometime s resor t t o surrogacy.44 "Partia l surrogacy " ha s bee n practice d fo r centu ries. Whe n a woma n coul d no t bea r a child , anothe r woma n agreed (o r wa s forced ) t o becom e impregnate d wit h th e sper m of th e woman' s partne r an d carr y th e chil d t o term . I n fact , i n the Bible , handmaid s gav e birt h fo r Sarah , Rachel , an d Lea h when the y coul d no t conceive. 45 I n thi s case , the "surrogate " i s termed a partia l surrogate : becaus e sh e supplie s th e egg , s o sh e is "partially " th e "mother. " With th e adven t o f i n vitr o fertilization , "ful l surrogacy, " i n which th e "surrogate " simpl y gestate s th e fetu s bu t ha s n o genetic connectio n t o it , becam e possible . Th e gamete s o f a woman an d a ma n ar e combine d i n vitro , an d an y resultin g embryos ar e the n implante d i n th e uteru s o f a thir d person , th e "surrogate." Women who have ovaries and ova bu t are rendere d infertile b y hysterectomy o r uterin e malfunctio n ca n no w hav e a biological child , althoug h the y d o no t actuall y underg o th e pregnancy. I n a variatio n o f thi s process , terme d surrogat e em bryo transfer , th e embry o i s conceive d b y th e geneti c mother , then "flushed " fro m he r uteru s an d implante d withi n a ful l "surrogate's" uterus . This procedure ca n b e used when a biolog ical mother i s able to conceive bu t no t t o gestat e a fetus. Finally , in embry o transfer , th e embry o i s conceived withi n th e "surro gate" (usin g he r egg) , the n "flushed " fro m th e "surrogate's " body an d implante d i n th e uteru s o f a gestationa l mother . Therefore, th e "surrogate's " rol e i s similar t o a n eg g donor. Fo r the remainde r o f th e chapter , th e ter m "surrogacy " wil l b e use d to refer bot h t o ful l an d partia l surrogacy . In surrogac y situations , an y resultin g childre n ar e suppose d to b e surrendere d t o th e contractin g parent s afte r th e birth .

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Generally, "surrogates " receiv e betwee n te n an d fiftee n thou sand dollar s a s payment fo r thei r "services, " which ma y includ e extensive screening , inseminations , pregnancy , an d childbirth . The contractin g coupl e ma y pa y a s muc h a s fifty thousan d dollars whe n agency , medical , insurance , an d surrogac y cost s are totaled, tw o t o thre e time s the cos t o f a typical adoption . While al l reproductiv e technologie s hav e create d som e con troversy, surrogac y ha s ignite d a virtua l firestorm. Mor e laws , lawsuits, an d la w revie w article s hav e bee n touche d of f b y surrogacy tha n b y any othe r reproductiv e technology . Addition ally, ther e ar e mor e book s o n surrogac y tha n o n insemination , IVF, an d froze n embryo s combined . Debate s continu e ove r nu merous issues , includin g whethe r surrogate s shoul d b e paid , whether th e whole concept amount s t o slavery, whether childre n are bein g sold , whethe r th e proces s itsel f shoul d b e prohibited , and whethe r prohibitin g i t violate s constitutiona l rights . Surro gacy arouse s th e wrat h o f som e feminists , th e curiosit y o f th e general public , an d th e concer n o f lega l scholars , ethicists , an d religious groups .

The Lega l Syste m an d Surrogac y It i s estimate d tha t ove r five thousan d childre n hav e bee n bor n through surrogac y contractin g i n th e Unite d State s alone . Th e most celebrate d an d misunderstoo d cas e involvin g surrogac y was th e cas e o f Bab y M (se e below). However, Bab y M wa s no t the first chil d bor n o f a surrogat e mother . "Attorne y Noe l Keane, th e self-proclaime d 'fathe r o f surrogat e motherhood, ' first go t the ide a whe n Jane an d he r husban d To m visite d hi m i n September 1976 . To m ha d 'thi s harebraine d ide a o f finding another woma n t o carr y a chil d fo r them ' (Jan e wa s infertile ) but didn' t kno w ho w t o g o about it." 4 6

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Nor wa s Bab y M th e first surrogac y cas e t o com e t o th e attention o f th e lega l system. 47 I n 1980 , Denis e Thran e wa s inseminated wit h sper m fro m Jame s Noyes , whos e wif e coul d not becom e pregnant. 48 Eventuall y Thran e change d he r min d about surrenderin g th e bab y an d th e Noyese s sue d fo r custody . The Noyese s relente d whe n the y learne d tha t Thran e ha d dis covered tha t Mrs . Noye s wa s a transsexual , a facto r tha t the y believed migh t jeopardiz e thei r bi d fo r custody . In 1982 , whe n a "surrogate " gav e birt h t o a chil d wit h microcephaly, whic h resulte d i n menta l retardation , hearin g loss, an d neuromuscula r disorders , al l parents/prospectiv e par ents renounced custody. 49 Th e microcephal y resulte d fro m cyto megalovirus (CMV) , a sexuall y transmitte d disease . Although i t was determine d tha t th e surrogate' s husban d wa s actuall y th e genetic fathe r o f th e child , th e surrogat e maintaine d tha t th e contracting husban d provide d th e seme n tha t cause d th e CM V infection. Th e surrogat e an d he r husban d late r sue d th e physi cians an d attorney s involve d i n th e cas e (includin g Noe l Keane ) for no t testin g th e seme n use d i n insemination s fo r sexuall y transmitted diseases , thereby no t fulfillin g thei r dut y t o protect . Most surrogacy contracting arrangement s ar e completed wit h little fanfar e an d ofte n wit h positiv e results . However , whe n there i s controversy, i t i s always wel l publicized . I n 1984 , Mar y Beth Whitehea d applie d t o Noe l Keane' s Infertilit y Cente r t o become a "surrogat e mother. " He r motivatio n wa s partiall y altruistic. Sh e intende d t o us e th e ten-thousand-dolla r fe e t o finance he r children's college education. As a part o f the applica tion process , Whitehead wa s "screened " b y a psychiatrist , wh o came t o th e conclusio n tha t Whitehea d migh t hav e difficult y relinquishing a child an d recommende d furthe r counseling . Th e center chos e t o disregar d thi s informatio n an d proceede d wit h inseminations. Eventually , Whitehea d wa s impregnate d wit h

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sperm fro m Willia m Stern . Neithe r Whitehea d no r th e Stern s were informe d o f th e cautions fro m th e "screening. " William an d Elizabet h Ster n ha d postpone d havin g children . They bot h ha d doctora l degrees , an d Elizabet h ha d a medica l degree a s well. When Elizabet h learne d tha t sh e had a mild cas e of multipl e sclerosi s an d tha t pregnanc y woul d exacerbat e th e condition, the Sterns sought the services of a surrogate. Facilitie s providing ful l surrogac y wer e difficul t t o find, s o th e Stern s agreed t o partia l surrogacy . The Stern s met the Whiteheads, an d the contrac t wa s draw n up . Th e Whitehead s agree d t o nam e William a s th e fathe r o n th e birt h certificate , no t t o abor t th e baby unles s th e amniocentesi s reveale d abnormalities , an d t o surrender custod y t o th e Sterns . Th e Stern s agree d t o pa y th e Whiteheads te n thousan d dollar s fo r a liv e birth , on e thousan d dollars i f Ms. Whitehead miscarrie d afte r th e fourt h month . In th e earl y stage s o f pregnancy , th e Stern s an d th e Whiteheads becam e quit e clos e bu t th e relationshi p becam e strained whe n th e Stern s insiste d tha t Mar y Bet h underg o am niocentesis an d ge t mor e be d rest . O n 2 7 Marc h 1986 , Whitehead gav e birt h t o Meliss a Stern/Sar a Whitehead . Sh e di d not nam e Willia m Ster n a s the fathe r o n th e birt h certificat e bu t rather he r ow n husband . No r di d sh e immediately surrende r th e child. Whitehead allegedl y calle d Noel Kean e an d indicate d tha t she could no t follo w throug h o n the agreement. 50 H e reportedl y told he r t o tak e he r bab y home , tha t a t mos t th e Stern s woul d seek visitatio n rights . However , Willia m Stern , wh o ha d los t most o f hi s famil y i n th e Holocaust , wa s no t abou t t o giv e u p his chil d withou t a fight. Thre e day s late r Whitehea d surrend ered th e bab y t o th e Sterns . Th e nex t da y sh e returne d an d pleaded t o kee p th e bab y fo r a wee k longer . Th e Stern s reluc tantly agreed . What followe d wa s perfec t fodde r fo r a made-for-T V movie .

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The Whitehead s lef t wit h th e child , hi d ou t i n hotels , an d wer e eventually arreste d an d brough t bac k t o Ne w Jersey. The Stern s were grante d temporar y custod y o f th e child , bu t Mar y Bet h Whitehead wa s allowe d t o visi t her . At the tria l court , th e judg e held tha t th e contrac t betwee n th e Stern s an d th e Whitehead s was enforceabl e an d awarde d custod y t o th e Sterns . Th e Ne w Jersey appeal s cour t foun d th e contrac t unenforceable , becaus e it amounte d t o "bab y selling, " whic h violate d adoptio n statute s and publi c policy . However, custod y wa s awarde d t o th e Stern s anyway, an d Mar y Bet h Whitehead retaine d visitatio n rights . In Californi a i n 1993 , a cas e addressin g th e right s o f a "ful l (or gestational ) surrogate " wa s decided . Crispin a Calver t wa s unable t o gestat e a fetus , sinc e sh e ha d undergon e a hysterec tomy i n 1984 . However , Crispin a stil l had he r ovaries . Sh e an d her husband , Mark , decide d t o find a surrogat e t o gestat e a n embryo produce d fro m Crispina' s eg g an d Mark' s sperm . Ann a Johnson agree d t o serv e a s a surrogat e fo r th e couple , an d o n 15 Januar y 1990 , al l partie s signe d a contrac t wherei n Ann a agreed to relinquish he r rights to the child in return fo r $10,000 . The Calvert s wer e als o t o suppl y a $200,00 0 lif e insuranc e policy for Ms . Johnson. Eventually , the relationship betwee n th e parties bega n t o deteriorate . Th e Calvert s learne d tha t Johnso n had deceive d the m regardin g he r obstetri c history . Johnson fel t that th e Calverts had abandone d he r during a bout o f prematur e labor an d tha t the y ha d no t pu t enoug h effor t int o securin g insurance. Whe n Johnso n intimate d tha t sh e would no t giv e u p the child, the Calverts countered wit h a lawsuit to establish thei r parental rights. 51 After th e chil d wa s born , temporar y custod y wa s awarde d t o the Calvert s (afte r geneti c test s determine d tha t the y wer e th e biological parents) . Ms. Johnson wa s temporaril y awarde d visi tation rights . Th e tria l cour t foun d tha t th e contrac t wa s en -

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forceable, determine d tha t the Calverts were the child's "genetic , biological an d natura l parents, " an d terminate d Ms . Johnson' s visitation rights . Th e verdic t wa s uphel d b y th e appeal s an d supreme court s o f California . Th e Unite d State s Suprem e Cour t refused t o hea r th e case . Th e Calvert s late r sue d Johnso n an d the surrogac y fir m fo r fraud , breac h o f contract , an d inflictio n of emotiona l distress . Althoug h the y droppe d th e sui t agains t Johnson, the y receive d a n undisclose d amoun t fro m th e surro gacy firm. 52 Just a s th e court s grappl e wit h whic h la w applie s t o froze n embryos, family la w o r propert y law , so must the y grappl e wit h which law applies to surrogacy contracts , family la w or contrac t law. I f surrogac y contract s represen t famil y law , the n th e best interests-of-the-child standar d applies . However , b y th e stan dards o f contrac t law , the first questio n i s enforceability . If th e contrac t amount s t o "bab y selling, " the n i t i s unen forceable, becaus e i t conflict s wit h a numbe r o f adoptio n stat utes and wit h public policy. It is a crime in all states to surrende r a chil d fo r a fee . Som e state s interpre t surrogac y contract s a s baby selling , an d therefor e unenforceable , unles s n o fe e i s in volved. Othe r state s vie w surrogac y contract s simpl y a s servic e contracts. I n a n effor t t o resolv e thes e conflicts , ove r hal f o f the state s hav e propose d surrogac y legislatio n sinc e 1980. 53 However, th e laws that hav e bee n enacte d var y tremendously . Some state s ba n surrogac y contractin g altogether , whil e oth ers ba n commercia l surrogac y contracts—thos e involvin g pay ment—with civi l and/o r crimina l penaltie s fo r violators . Othe r states ba n compensatio n fo r th e surrogat e agenc y o r surrogac y broker, providin g crimina l penaltie s fo r violations . Stil l other s have attempte d t o regulat e custod y o r parentage , tha t is , whether th e gestationa l o r th e biologica l mothe r i s th e lega l mother. A t leas t on e stat e ha s a statutor y provisio n tha t allow s

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surrogates to change their min d abou t surrenderin g the bab y fo r up t o seventy-tw o hour s postpartum . Som e countrie s als o hav e regulations regardin g surrogacy . These statute s rais e question s regardin g sexis m an d gende r equity. Man y stat e statute s addres s and/o r limi t compensatio n to wome n fo r surrogacy . Supposedly , thes e law s ar e designe d t o prevent th e commodificatio n o f babie s an d women' s reproduc tive capacities. However , thi s concer n onl y seem s t o aris e whe n females, no t males , ar e compensate d fo r marketin g thei r repro ductive capacities . Female s ar e expecte d t o becom e surrogate s for strictl y altruisti c motives . Rarel y doe s anyon e questio n whether sper m donor s shoul d b e repeatedly compensate d fo r their "product, " ye t eg g donor s an d surrogate s ar e scrutinized . Clearly th e "product " an d th e proces s ar e differen t fo r sper m donors an d surrogates , bu t th e concep t i s similar . "Women' s work," i t seems , i s no t wort h compensating . Th e iron y i s tha t the compensatio n t o th e surrogat e i s so limite d tha t th e agency / broker generall y end s u p makin g th e windfal l profit . However , most state s are not clamorin g t o limi t agency/broke r profits . State statute s als o ten d t o propos e simplisti c solution s t o complex problems . Fo r example , i n Arizona , Pamel a an d Ron ald Soo s contracte d fo r a ful l surrogacy . Pamel a ha d previousl y had a partia l hysterectom y tha t lef t he r wit h ovarie s bu t n o uterus. Pamel a an d Ronal d underwen t IVF , an d th e embryo s that resulte d wer e implante d i n a surrogate . Unfortunately , th e Sooses divorce d befor e th e birt h o f th e childre n (triplets) , an d when the y wer e born , th e surrogat e gav e temporar y custod y t o Ronald. Unde r a n Arizon a surrogac y law , th e surrogat e i s th e legal mothe r o f th e child . Similarly , othe r state s hav e law s de claring tha t oocyt e donor s (whic h i s wha t Pamel a was , i n es sence) hav e n o right s t o custody . Sinc e he r ex-husban d ha d temporary custod y an d sh e ha d n o lega l rights , Pamel a wa s unable t o see her geneti c offspring fo r thre e months. Apparentl y

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the Arizon a statut e presume s tha t th e husban d o f th e surrogat e is th e fathe r o f th e chil d unles s thi s presumptio n i s challenge d by a paternit y tes t fro m th e geneti c father . N o comparabl e provision permit s geneti c mother s t o challeng e maternity . Pa mela Soo s challenged thi s statute, and i t was struc k dow n b y the appeals cour t a s unconstitutional. Pamel a ca n no w continu e he r fight fo r custody , while Ronal d vow s to appea l th e ruling . Conversely, i n Johnson v. Calvert th e cour t hel d tha t th e genetic mothe r wa s th e lega l mother . Again , thi s represent s a simplistic solutio n t o a comple x problem , settin g a potentiall y disastrous preceden t fo r futur e decisions . I f th e geneti c mothe r is the legal mother, the n eg g donors woul d hav e a legal claim t o children produce d fro m thei r donation s unles s they relinquishe d their parental right s after th e birt h o f the child . As wit h al l statute s tha t var y fro m stat e t o state , suc h a s those tha t concer n gamblin g o r abortion , surrogac y regulation s simply invit e individual s desirin g specifi c surrogac y option s t o travel t o a stat e tha t permit s them . Stric t regulatio n ca n als o drive th e proces s underground , whic h doe s no t serv e anyone' s interest. O n th e other hand, state s without an y legislation i n thi s area onl y ad d t o th e confusion , forcin g eac h judg e t o appl y hi s or he r ow n persona l principle s t o resolv e th e case s tha t com e before th e courts . On a theoretica l level , th e regulatio n o f surrogac y contract s raises constitutiona l issue s a s well . Fo r example , regulatio n o f surrogacy contractin g coul d interfer e wit h a n individual' s righ t to contract . Lega l scholar s debat e whethe r th e fundamenta l right t o procreate , derive d fro m th e righ t t o privacy , include s a fundamental righ t t o privac y i n surrogac y contracting . I f so , the state could no t regulat e surrogac y contract s without demonstra ting a n interes t compellin g enoug h t o overrid e a n individual' s fundamental rights . I n short , th e questio n o f regulatin g surro gacy is enormously complex . Existing regulations hav e not bee n

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challenged o n constitutiona l grounds , an d a constitutional chal lenge coul d prov e quit e successful . Overall , i t i s apparen t that , for surrogac y legislatio n t o b e effective , i t mus t b e more consis tent, les s invasive, and federal .

Ethical Concern s A person' s attitud e towar d surrogac y ofte n depend s o n wha t aspect o f i t has engage d hi s or he r attention . Fo r example , som e individuals expres s suppor t fo r surrogac y becaus e the y believ e that everyon e ha s a constitutiona l righ t t o procreatio n o r t o surrogacy contracting . Conversely , som e individuals oppos e sur rogacy fo r ethica l reasons . A s wit h al l th e reproductiv e techno logies, th e ethica l an d mora l dilemma s surroundin g surrogac y are limitless . Numerous organization s hav e adopte d guideline s regardin g surrogacy.54 Th e America n Colleg e o f Obstetrician s an d Gyne cologists (ACOG ) indicate d tha t i t ha d "significan t reserva tions" regardin g th e procedur e an d offere d recommendation s for physicians . The America n Medica l Associatio n (AMA ) doe s not "endors e [or ] condem n surrogat e parenting " bu t advise s practitioners t o us e "grea t car e an d discretion. " Th e America n Fertility Societ y (AFS ) advise d "intens e scrutiny " o f al l surro gacy situations . They cautione d agains t th e us e o f surrogac y fo r nonmedical reason s an d discourage d widesprea d us e o f surro gacy b y medical practitioners . Furthermore , th e committe e sug gested tha t i f surrogac y wer e undertaken , "i t shoul d b e pursue d as a clinical experiment. " Finally , the AF S advised physician s t o obtain full y informe d consent s an d t o avoi d a conflic t o f inter ests by not acceptin g payment s beyon d thei r customar y fees . The America n Civi l Libertie s Unio n (ACLU ) als o elaborate s their positio n o n surrogac y i n a detaile d document . Th e ACL U

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holds tha t th e stat e doe s no t hav e a righ t t o ba n surrogac y agreements an d tha t compensatio n fo r surrogac y i s acceptabl e as lon g a s paymen t i s no t contingen t o n th e surrogat e relin quishing he r rights . Th e ACL U als o offer s guideline s fo r th e determination o f custody an d parenta l right s i n surrogacy cases . Unfortunately, guideline s hav e not provide d ironcla d answer s to ethica l problems . Wha t if , fo r example , th e circumstance s o f the contractin g coupl e radicall y change , a s i n th e cas e o f a divorce? Th e Moschetta s entere d int o a surrogacy contrac t wit h Elvira Jordan . I n 1990 , whe n Jorda n wa s si x month s pregnant , the Moschetta s bega n discussin g divorc e bu t di d no t infor m Jordan unti l th e da y befor e sh e gav e birth . Jorda n refuse d t o give up th e child , Marissa , unles s th e coupl e agree d t o marriag e counseling. Th e coupl e receive d counselin g an d care d fo r Mar issa fo r si x months . The n Rober t Moschett a too k th e bab y an d left hi s wife . Th e onl y definitive rulin g tha t ha s com e fro m th e California cour t i s that Cynthi a Moschett a canno t b e Marissa' s mother becaus e sh e has n o biologica l relationshi p t o Marissa. 55 The custod y decision s an d inheritanc e right s o f a chil d bor n after contractin g parent s hav e die d ar e similarl y unclear . It i s als o difficul t t o determin e who , i n surrogac y situations , is responsibl e fo r unwante d children . Wha t i f a physicall y o r mentally challenge d chil d o r a n unexpecte d twi n o r triple t re sults fro m a surrogac y arrangemen t an d i s unwante d b y al l parties? Mos t surrogac y contract s hav e clause s tha t attemp t t o assign responsibilit y fo r "less-than-perfect " children . Ofte n these clause s limi t th e contractin g parents ' responsibility . I n 1986, a woma n agree d t o ac t a s a surrogat e fo r he r sister . The surrogat e neglecte d t o infor m he r siste r o f he r histor y o f intravenous dru g use. When th e child was born HIV-positive , all parties refuse d responsibilit y fo r th e child , an d th e chil d wa s placed i n socia l servic e agencies . Who i s responsible fo r a child bor n wit h a physical o r menta l

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defect du e t o fault y prenata l care—th e surrogat e o r th e con tracting parents ? I f th e contractin g parent s attemp t t o dictat e the prenata l regime n o f a surrogat e (fo r example , b y forbiddin g alcohol consumptio n o r smoking) , doe s th e surrogac y contrac t amount t o indenture d servitude ? Finally, i f a surrogate' s healt h i s seriousl y jeopardize d b y th e pregnancy, who , i f anyone , i s liable ? I n 1987 , Denis e Mounc e was i n he r eight h mont h o f a surrogat e pregnanc y whe n sh e died o f a hear t attac k a t th e ag e o f twenty-four . Apparently , Denise require d a hear t monitor , whic h he r physician s tol d he r she would hav e t o purchas e fo r herself . Sh e could no t affor d it , and, allegedly , he r physician s di d no t wan t t o "cu t int o thei r profits" b y purchasin g i t fo r her. 56 Th e physician s an d th e agency were sue d fo r medica l malpractice .

Exploitation vs . Autonom y Feminists ar e divide d ove r th e issu e o f surrogacy . O n th e on e hand, surrogac y i s viewed a s simpl y anothe r wa y t o exploi t an d degrade women, potentially turnin g thos e of low socioeconomi c status int o a class of "breeders. "

The core reality of surrogate motherhood is that it is both classist and sexist : a metho d t o obtai n childre n geneticall y relate d t o white males by exploiting poor women . While it is promoted a s simply supplying babies for those who "desperately" want them, in fact it subverts any principled notion of economic fairness and justice, an d undermine s ou r commitmen t t o equalit y an d th e inherently priceless value of human life. 57 Conversely, som e feminist s argu e tha t wome n shoul d hav e the righ t t o ente r int o contract s an d tha t thos e contract s shoul d

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be enforced . B y no t enforcin g surrogac y contracts , women' s overall capacit y t o contrac t coul d b e diminished . Afte r all , i f a contract a woma n enter s int o regardin g he r ow n bod y canno t be enforced , wh y shoul d an y contrac t sh e enter s int o b e en forced? Proponents o f surrogac y contractin g als o argu e tha t i t i s demeaning t o wome n fo r th e governmen t t o desig n legislatio n that "protects " the m fro m thei r ow n choices . In addition , man y feminists fea r tha t regulating surrogacy ma y undermine th e righ t to bodil y autonom y tha t wome n fough t s o har d t o acquire . Ultimately, "th e rationale s tha t the y [th e feminist s wh o favo r regulation] an d other s ar e usin g t o justif y thi s governmenta l intrusion int o reproductiv e choic e ma y com e bac k t o haun t feminists i n othe r area s o f procreativ e polic y an d famil y law." 58

The Futur e o f Surrogac y The interes t i n surrogac y seem s t o b e wanin g a s w e approac h the en d o f th e century. Interest peake d i n 198 8 with th e Baby M case an d ha s diminishe d since , du e t o a numbe r o f factors . A s reproductive technologie s hav e advanced , fewe r couple s nee d t o resort t o surrogac y i n orde r t o hav e a child . Restrictiv e legisla tion ma y als o hav e curtaile d interest . I t i s als o possibl e tha t the publicit y surroundin g Bab y M ha s discourage d prospectiv e couples fro m attemptin g surrogacy , o r the y ma y b e askin g fam ily member s t o ac t a s surrogate s rathe r tha n contrac t wit h strangers. Perhaps societ y is simply more acceptin g o f surrogac y now, so it receives les s attention fro m th e media . As publi c interes t ha s faded , th e concer n o f legislator s ha s likewise diminished . Thi s i s unfortunate , sinc e alternative s t o simply bannin g surrogac y o r bannin g commercia l surrogac y

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have rarel y bee n explored . Fo r example , state s coul d regulat e the screening/counselin g o f surrogate s an d contractin g parents , and th e result s o f thes e preliminary investigation s coul d b e con sidered b y al l partie s whe n determinin g whethe r t o proceed . Screening i s no t alway s effectiv e an d ma y no t eliminat e disas trous outcomes , bu t i t doe s mak e the m les s likely . I f th e result s of th e screenin g procedure s ha d bee n availabl e t o al l partie s i n the Bab y M case , th e entir e fiasc o migh t hav e bee n avoided . Many issue s coul d b e addresse d i n th e screenin g o f prospectiv e parents, suc h a s parentin g motivation s an d th e stabilit y o f th e relationship. Couple s wh o wis h t o adop t discus s thes e issue s and mor e durin g thei r hom e stud y process . I n fact , Elizabet h Bartholet, a professo r o f la w a t Harvard , believe s tha t partie s involved i n surrogac y contract s shoul d b e regulate d mor e an d adoptive parent s less. 59 She maintains tha t th e la x regulatio n o f IVF an d it s derivative s lure s peopl e int o choosin g thes e proce dures rathe r tha n adoption , sinc e adoptio n criteri a ar e s o rigor ous. I n addition , som e state s hav e healt h car e coverag e fo r IV F while providin g n o financia l incentive s fo r adoption , no t eve n tax breaks . Finally , physician s ofte n advocat e medica l solution s to infertilit y instea d o f encouragin g nonmedica l alternative s lik e adoption. The y see m t o vie w infertilit y a s a medica l challeng e and giv e little thought t o the socia l ramification s o f their recom mendations. Other proposal s fo r regulatio n hav e bee n advance d ove r th e years. Marth a Fiel d suggest s tha t regulation s addres s th e amount o f confidentialit y betwee n th e parties , requirin g eithe r open o r close d agreement s 60 an d tha t minimu m age s fo r surro gates b e set . However , legislator s see m t o approac h surrogac y with a n all-or-nothin g attitud e tha t force s lega l systems (i.e. , the courts) an d individual s int o makin g difficul t choices .

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Misplaced Focu s In th e mids t o f al l th e concer n fo r individua l right s an d regula tions, the bes t interest s o f th e chil d see m to hav e fade d fro m th e agenda. Relativel y littl e researc h ha s bee n conducte d int o th e effects o f reproductiv e technologie s o n children , eithe r physi cally o r psychologically . O n th e par t o f bot h physician s an d parents, this represents th e ultimat e i n narcissistic behavior . Technological effort s t o solv e th e infertilit y "problem " hav e intensified. Th e development o f new, more powerful, mor e inva sive means t o creat e lif e ha s generate d mor e interes t tha n allevi ating o r eliminatin g th e cause s o f infertility . Fo r example , re searchers hav e begu n t o experimen t wit h increasin g th e succes s of IV F through cloning . Onc e a n embry o divide s int o tw o cells , the cell s ca n b e separate d an d allowe d t o develo p int o twins . Other researc h i s being conducte d o n ovaria n grafting . I n ovar ian grafting , th e corte x o f th e ovary , which contain s th e eggs , is removed, frozen , an d late r replaced . Thes e ar e complicate d an d risky procedure s tha t pus h th e limit s o f natur e an d endange r women an d potentia l children . Wouldn' t i t b e simpler , safer , and o f broade r benefi t t o humankind, t o target potential source s of infertility , suc h a s chlamydia ? Chlamydia, a sexuall y transmitte d disease , exists i n epidemi c proportions; i t i s insidiou s an d frequentl y goe s undetected . Of ten th e infectio n result s i n scarrin g o f th e fallopia n tubes , whic h prevents egg s fro m passin g int o th e uteru s an d thu s cause s infertility. Perhap s mor e emphasi s shoul d b e place d o n alleviat ing chlamydi a throug h preventio n an d educatio n tha n o n find ing medica l way s t o bypas s it s results . No t onl y woul d thi s attenuate infertilit y bu t i t woul d als o greatl y diminis h a publi c health hazar d tha t affect s men , women, an d children . Perhaps mor e researc h emphasi s shoul d b e place d o n per fecting existin g medica l interventions , an d avoidin g th e un -

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wanted consequence s o f som e o f them , tha n o n developin g ne w technologies. It should no t b e overlooked tha t infertility i s sometimes iatrogenic , th e resul t o f medica l intervention . O f cours e science mus t progress , bu t no t withou t regar d fo r th e conse quences, to the individua l an d t o society , of it s experiments .

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mericans are becoming more health-conscious. Smokin g i s no w prohibite d o r restricte d i n most publi c facilities . Membershi p i n a health clu b is de rigueu r for th e monie d classes . Shopper s hav e begu n t o rea d th e label s on foo d products , an d th e FD A ha s begu n t o requir e manufac turers to provide more in-depth nutritional informatio n o n thos e labels. No - o r low-fa t an d no - o r low-cholestero l food s ar e in vogue . Extensiv e educationa l an d motivationa l campaign s endorsing "wellness " hav e bee n launche d al l ove r th e country . Some universitie s eve n requir e student s t o complet e course s o n "wellness" a s par t o f thei r genera l education . Man y behavior s that wer e pitche d a s health y twent y year s ago , suc h a s eatin g red meat , ar e no longe r considere d "hear t smart. " This focu s o n healt h an d wellnes s ha s com e t o includ e th e fetus. Man y substance s onc e considere d relativel y harmles s ar e now know n t o affec t th e developin g fetus . Al l container s o f [85]

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alcoholic beverage s no w carr y a labe l starkl y remindin g preg nant wome n tha t th e us e of alcoho l durin g pregnanc y ca n caus e birth defects . Babie s born wit h birt h defect s fro m materna l alco hol us e ma y hav e bee n classifie d simpl y a s mentall y retarde d i n the past , bu t feta l alcoho l syndrom e i s now a distinc t diagnosis . In fact, alcoho l use during pregnancy i s one of the leading cause s of birt h defect s i n the United States . The respons e o f pregnan t wome n t o thes e newfoun d terato gens (substances , processes , o r agent s tha t ca n caus e defect s o r malfunctions i n a developin g fetus ) ha s parallele d th e overal l response o f th e publi c t o healt h warnings : som e hav e chose n t o modify thei r behavior , whil e other s hav e mad e n o lifestyl e changes. However , th e societa l an d legislativ e response s whe n pregnant women ignor e warnings abou t possibl e teratogen s dif fer drasticall y fro m th e correspondin g response s t o othe r indi vidual's choic e o f a potentiall y unhealth y lifestyle . Conside r th e following example : Danita Fitch , 21 , an d G . R . Heryford , 22 , wer e fire d fro m a suburban Red Robin restaurant when they tried to stop a patron Heryford describe d a s "ver y pregnant " fro m havin g a drin k March 13. Jim Roths, Red Robin's director of operations, said Heryfor d and Fitch were fired because they did not treat the customer with "respect and dignity." Heryford sai d Tuesday he first trie d t o stop the woman fro m drinking b y demanding identification . " I was hopin g sh e didn' t have it," he said. "Then I could legally refuse her service." He went to assistant manager Mike Buckley after findin g ou t the woma n wa s 30 . Buckle y ordere d hi m t o serv e th e drink . Instead, Heryfor d tol d Fitc h abou t th e situatio n an d sh e ap proached the woman. "I went u p to he r an d said , 'Ma'am , ar e you sur e you wan t this drink?' " Fitc h said . "An d sh e got reall y ma d an d said , Tt' s past due. It had its chance.'"

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Then, Fitch peeled from a beer bottle the government warning against alcohol consumption b y pregnant women and showe d it to th e patron , wh o complaine d t o Buckley . The tw o wer e the n fired. Heryford sai d Buckle y told the m their job was not to lectur e customers or offer opinion s on prenatal care. Fitch an d Heryfor d sa y the y hop e th e stat e Liquo r Contro l Board will set a policy on serving alcohol to pregnant women. 1 Some peopl e believ e tha t whe n a woma n become s pregnan t she lose s th e righ t t o mak e he r ow n lifestyl e choices . Thes e beliefs ech o th e mai n controvers y regardin g man y reproductiv e rights o f women , particularl y abortion . Th e questio n o f wh o has contro l ove r a pregnan t woman' s bod y remain s th e subjec t of extensiv e debate . Th e us e o f substance s b y pregnan t wome n reflects thi s controversy . O n th e on e hand , i f a woma n ha s reproductive autonomy , thi s decisio n ca n an d shoul d b e her s alone. O n th e othe r hand , fo r som e the us e of substance s durin g pregnancy i s contingent o n th e effect th e substance ma y have o n the developin g fetu s and/o r eventua l child .

Typical Substance s Use d durin g Pregnanc y Each year in the United States , an estimated 1 1 percent o f babie s are bor n afte r exposur e t o illega l an d lega l drug s i n utero . (Thi s is probably a n underestimate , sinc e not al l women ar e tested fo r substance abus e an d man y den y i t eve n whe n dru g test s com e back positive. ) Mos t substance s tha t ar e abuse d fal l int o on e of fou r categories : depressants , stimulants , narcotic s (opioid / morphine derivatives) , an d hallucinogens . Excludin g hallucino gens, whic h ar e largel y illegal , recreationa l drugs , th e othe r categories includ e lega l an d illega l drugs , som e o f whic h ca n b e obtained wit h a prescriptio n o r eve n ove r th e counter . O f

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course, substanc e abus e alway s bring s risk s wit h it , no t jus t during pregnancy . However , i t remain s difficul t t o determin e if a dru g will have an y effect o n the developin g fetus o r how muc h of a n effec t i t wil l have . Thi s ma y depen d o n th e amoun t use d and th e gestational perio d whe n i t was used . Many drug s affec t th e centra l nervou s system . Th e centra l nervous system takes neural messages, triggered b y sensory stim ulation, t o th e brai n t o b e interpreted . Th e brai n the n respond s to the new information. Fo r example, if a child run s ou t in fron t of someone' s car, that visua l stimulus must b e transmitted t o th e brain vi a neurons . Onc e th e brai n ha s deciphere d thi s ne w information, i t send s a messag e t o th e body , agai n vi a neurons , telling it how t o respond . Drugs categorized a s depressants slo w down th e transmissio n of neura l messages . The depressant s includ e lega l drugs , such a s alcohol an d prescriptio n pharmaceutical s lik e libriu m an d Val ium, a s wel l a s illega l ones , suc h a s quaaludes . Th e depressan t most widel y use d durin g pregnanc y i s alcohol, n o doub t i n par t because o f it s legality an d availability . The effect s o f alcoho l us e on th e fetus ca n b e extensive . The most preventable cause of congenital anomalities is maternal alcohol use . Alcoho l i s a poten t teratogen , whic h crosse s th e placental membran e freel y an d can cause irreversible damage to the bod y an d brai n o f th e developin g fetus . Th e Unite d State s Public Healt h Servic e ha s estimate d tha t 8 6 percen t o f wome n drink a t leas t onc e durin g pregnancy , wit h 2 0 t o 2 5 percen t drinking regularly. Further the Centers for Diseas e Control have estimated that more than 8,000 alcohol-damaged babies are born annually. Feta l alcoho l exposur e i s the mos t commonl y know n cause of menta l retardation . Exposur e ca n b e classified a s Fetal Alcohol Effec t (FAE ) o r Feta l Alcoho l Syndrom e (FAS) . FA E involves sligh t t o moderat e damage , whil e FA S entail s sever e damage an d developmenta l problems . The amoun t an d typ e of

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damage depends on the fetus's stage of development during exposure an d th e amoun t an d frequenc y o f alcoho l consumption . Decreased birt h weight, prenatal growth retardation, small head circumference, an d hear t defect s ar e al l characteristic s o f FAS. Alcohol appears to be teratogenic only if used on specific days of gestation.2 Other symptom s o f FA S ar e facia l deformitie s (suc h a s ab normally slante d eyes) , attentio n defici t disorder , learnin g disabilities, lo w intelligence , an d poo r capacit y fo r memoriza tion. 3 I t i s estimate d tha t approximatel y on e ou t o f ever y 75 0 babies bor n eac h yea r ha s FAS ; i n fact , th e figure i s probabl y higher. Lik e alcohol, most o f the othe r depressant s to o can hav e disastrous effect s o n th e fetu s i f ingeste d b y a woma n a t certai n times during he r pregnancy . As opposed t o th e depressants , which inhibi t centra l nervou s system activity , stimulant s excit e centra l nervou s syste m pro cessing. This can caus e a tremendous strai n o n bot h th e nervou s system an d th e body . Stimulant s mimi c th e "figh t o r flight " response th e bod y naturall y ha s whe n confronte d wit h a fearfu l situation. However , wit h stimulant s thi s respons e usuall y ha s a longe r duratio n an d occur s repeatedl y (becaus e th e dru g i s repeatedly used) . Dependin g o n th e drug , th e intensit y o f re sponse coul d var y fro m mil d t o severe . Som e stimulants , suc h as caffeine , ar e considere d relativel y innocuou s b y th e genera l population, whil e others , suc h a s cocaine, ar e perceive d a s dan gerous. In terms of their effec t o n the developing fetus, however , all stimulants shoul d b e viewed wit h caution . Although mor e decaffeinate d product s ar e availabl e no w than twent y year s ago , caffeine i s still consumed i n vas t quanti ties i n coffee , tea , sof t drinks , an d chocolate . Lik e man y drugs , caffeine crosse s th e placenta . Researc h o n th e effect s o f caffein e on a developin g fetu s ha s yielde d mixe d results . However, sinc e

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1980 th e Foo d an d Dru g Administratio n (FDA ) ha s not in cluded caffein e o n th e lis t o f compound s considere d saf e fo r us e during pregnancy . Th e FD A indicate d tha t researc h o n animal s suggests tha t caffein e cause s birt h defects , feta l death , an d re duced birt h weight. 4 Mor e recently , researchers hav e foun d tha t moderate caffein e us e doe s no t increas e th e ris k o f spontaneou s abortion, intrauterin e growt h retardation , o r microencephaly. 5 In an y cas e ther e ma y b e othe r reason s t o giv e u p caffein e during pregnancy. 6 Caffein e ma y sap calcium from th e body an d interfere wit h absorptio n o f iron . I n addition , product s wit h caffeine ofte n contai n othe r product s tha t ca n b e detrimental t o health, suc h a s sugar . Finally , caffein e ca n caus e temporar y abnormal heartbeat , rapi d respiration , an d tremor s i n th e new born. 7 Som e maternit y pack s provide d t o expectan t mother s b y obstetricians eve n include sample s o f decaffeinate d coffee . The verdic t o n caffein e ma y b e somewhat tenuous , but abun dant, unequivoca l researc h demonstrate s th e harmfu l effect s o f smoking o n a developin g fetus . Thes e effect s ar e partiall y du e to nicotine , a stimulant , bu t mainl y du e t o th e carcinogeni c byproducts o f smok e itself , suc h a s carbo n monoxide . I f a woman smoke s prio r t o he r pregnanc y bu t the n give s i t up , th e fetus wil l no t b e affected , bu t i f sh e continue s t o smoke , espe cially afte r th e fourt h month, 8 th e chanc e o f complication s suc h as vagina l bleeding , miscarriage , abnorma l placenta l implanta tion, prematur e placenta l detachment , prematur e rupture d membranes, an d earl y deliver y increases . I t i s possibl e tha t 1 4 percent o f preter m deliverie s i n th e Unite d State s ar e relate d t o cigarette smoking. 9 Smokin g als o appear s t o b e linked wit h lo w birth weight s an d a n increase d ris k o f sudde n infan t deat h syndrome (SIDS) . Long-ter m effect s ma y includ e physica l an d intellectual deficit s i n th e child . Sinc e th e smok e crosse s th e placenta, limitin g oxyge n intak e t o th e fetus , som e o f thes e effects ma y b e relate d t o oxyge n deprivation . No t surprisingly ,

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the risk increase s with th e dose . Secondhand smok e als o poses a risk t o th e fetus . I f a pregnan t woma n doe s no t smok e bu t i s frequently expose d t o a smoke-fille d environmen t a t hom e o r a t work, th e woman an d th e fetus ma y suffe r passiv e damag e fro m inhaling th e sidestrea m smok e produce d b y burnin g cigarettes . In fact , i n som e case s th e fetu s ma y b e a s contaminate d wit h smoke byproduct s a s i f th e pregnan t woma n hersel f ha d bee n smoking. Since the 1980 s th e stimulan t tha t ha s raise d th e mos t alarm , not jus t fo r pregnan t wome n bu t fo r th e genera l population , i s cocaine an d cocain e variant s (crack) . Crac k i s a n affordabl e derivative o f cocaine , whic h make s th e dru g mor e accessibl e t o potential users , includin g pregnan t women . I t i s estimate d tha t one millio n wome n o f childbearin g ag e us e cocaine . A n infan t that i s bor n t o a cocaine-abusing mothe r ha s a n "increase d ris k of growth retardatio n in utero, increase d incidenc e of prematur e rupture o f membrane s an d labor , lo w birt h weigh t an d gesta tional size , poor brai n growth , an d increase d possibilit y o f brai n infarction an d hydrocephaly . Suc h newborn s frequentl y mani fest difficult y keepin g food down ; exhibit spasms , trembling an d muscular rigidity ; and resis t cuddlin g b y arching thei r backs." 1 0 Cocaine-exposed infant s ma y als o hav e difficult y bondin g wit h their mothe r an d hav e a n increase d ris k fo r SIDS , respirator y problems, an d eventua l developmenta l delays . I f th e mothe r injected hersel f wit h cocain e products, the infan t ma y have bee n exposed t o HIV . The third categor y o f drug s ar e painkillers o r narcotics . Pain killers rang e fro m over-the-counte r medication s suc h a s acet aminophen t o prescriptio n medication s suc h a s codeine t o illici t drugs suc h a s heroin . Heroin , a derivativ e o f opium , ha s re ceived th e mos t researc h attention . Pregnan t wome n abusin g heroin ofte n giv e birt h t o infant s wh o ar e bor n addicte d an d must underg o th e ordea l o f withdrawal .

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Classically, withdrawa l affect s th e centra l nervou s system , gastrointestinal tract, and respiratory systems. The babies are highly irritable, wit h tremor s an d hyperflexi a an d a shril l cry . Ofte n seizures accompany withdrawal. Again, these infants ar e hard to console, and maternal bondin g can b e affected. Gastrointestina l symptoms includ e vomitin g an d diarrhea , whic h ca n lea d t o dehydration and electrolyte imbalance.. . . Long-term effects ar e still unknown. 11 Since heroi n i s generall y injected , th e addic t i s expose d t o a number o f healt h risk s tha t ar e i n tur n passe d o n t o th e fetus . These includ e exposur e t o HI V an d hepatitis . Th e fetu s ma y also be affected b y the mother's poo r healt h habits : malnutritio n and anemi a ar e common amon g addicts. 12 Lastly ther e ar e th e hallucinogeni c drugs , includin g mari juana, o r cannabi s sativa . Drug s i n thi s categor y ar e primaril y used fo r recreationa l purpose s an d ar e mostly illegal . Unlike th e previous thre e categories , hallucinogen s hav e a lowe r overal l potential fo r dependenc e o r abuse. 13 Althoug h smokin g mari juana whil e pregnan t doe s no t see m t o caus e birt h defects , "Decreased birt h weigh t an d smal l siz e fo r gestationa l ag e ar e markings o f marijuana exposure . O n th e average the fetus i s 3. 5 ounces lighte r tha n expected . Marijuana-withdrawin g neonate s exhibit markedl y decrease d respons e t o a ligh t directe d a t thei r eyes an d significantl y heightene d tremor s an d startles . Long term effect s ar e unknown." 1 4 Smokin g marijuan a doe s expos e the fetu s t o th e carcinogeni c byproduct s o f smoke . However , since mos t marijuan a user s d o no t smok e ever y da y o r smok e only a small amoun t pe r day , the fetus's exposur e i s significantl y less than tha t o f a fetus whos e mothe r smoke s tobacco . ** * Many substanc e abuser s abus e mor e tha n on e substance . Preg nant wome n ar e n o exception . A crack-addicte d pregnan t

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woman i s ofte n addicte d t o alcohol , nicotine , an d caffein e a s well. Thi s usuall y compound s th e advers e effect s o n th e fetu s and make s treatmen t o f bot h mothe r an d chil d mor e difficult . Furthermore, addict s ma y no t hav e th e bes t healt h statu s prio r to pregnancy , an d thei r fetuse s ma y suffe r fro m th e effect s o f little o r n o prenata l care . I t i s therefor e difficul t t o determin e which complication s ar e directl y du e t o substanc e abus e an d which t o associate d behavior s an d thei r healt h consequences . It i s als o clea r tha t substanc e abus e b y th e fathe r ca n affec t the healt h o f th e fetu s an d ca n hav e long-ter m effect s o n th e eventual child . Cocain e apparentl y bind s wit h th e sper m bu t does no t effec t motility . Ver y littl e researc h focuse s o n th e im pact o f paterna l dru g us e o n feta l health , an d th e results t o dat e are meager an d equivocal .

Legislation In ligh t o f th e potentiall y disastrou s consequences , increase d attention ha s bee n directe d towar d restrictin g pregnan t wome n from usin g or abusin g substances. This movement certainl y con trasts wit h a genera l lac k o f societa l an d legislativ e effort s t o secure saf e an d health y environment s fo r pregnan t wome n an d fetuses. Fe w federa l o r stat e regulation s exis t regardin g VDT s (see chapte r 4) o r questionabl e reproductiv e technologies , an d society i s largely uninforme d a s t o th e potentia l risk s relate d t o these issues . Bu t whe n regulatio n o r censur e i s directe d no t toward corporation s o r th e medica l professio n bu t towar d indi vidual women , legislativ e an d societa l respons e ca n b e alarm ingly swift . Fo r example , i n th e latte r par t o f th e 1980s , th e media bega n t o heighte n publi c awarenes s concernin g th e in crease i n crack-addicte d pregnan t women . B y th e en d o f th e 1980s, substance-abusin g pregnan t wome n wer e bein g trie d fo r

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numerous crimina l an d civi l violations . Althoug h th e nam e o f the offens e ma y diffe r fro m cas e t o case , th e essenc e i s alway s the same : behavio r durin g pregnanc y tha t create s ris k o r har m to th e fetus. 15 Sometimes prosecutor s attemp t t o appl y existin g narcotic s laws t o pregnan t women . I n on e o f th e mos t widel y publicize d cases, a Florid a woma n wa s foun d guilt y o f deliverin g a con trolled substanc e t o a minor . Jennife r Johnso n use d cocain e during tw o pregnancies , an d bot h infant s teste d positiv e fo r cocaine. Ther e wer e n o sign s o f feta l distres s i n eithe r case , bu t when th e Departmen t o f Healt h an d Rehabilitatio n Service s learned o f th e positiv e tes t results , the y decide d t o investigat e and prosecute . In Florida, as in most states , a fetus i s not considered a person under th e law . Therefore , whil e he r childre n wer e stil l i n utero , Johnson coul d no t b e foun d guilt y o f deliverin g a controlle d substance t o a mino r (becaus e the y wer e technicall y no t "peo ple"). However , infant s ar e considere d persons , an d th e prose cutor argue d tha t Johnso n delivere d a controlle d substanc e t o her children , vi a th e umbilica l cord , fro m th e tim e th e infant s left th e birt h cana l unti l th e cor d wa s clampe d sixt y t o ninet y seconds later . Johnso n wa s convicte d an d sentence d t o tw o hundred hour s o f communit y service , on e yea r o f "communit y control," an d fourtee n year s o f probation . Durin g th e first yea r she wa s t o b e subjecte d t o rando m dru g testing . Sh e wa s als o ordered t o complet e a dru g rehabilitatio n progra m an d t o ente r a judiciall y approve d supervisio n progra m i f an y futur e preg nancies occurred. 16 Thre e year s later , i n 1992 , he r convictio n was overturne d b y the Florid a Suprem e Court . Ironically , John son ha d sough t treatmen t durin g he r pregnanc y bu t wa s refuse d because sh e was pregnant . In other crimina l cases , fetal abus e has bee n viewed a s a for m of chil d abuse , an d wome n hav e bee n prosecute d unde r chil d

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protection laws . In a cas e tha t ha s parallel s t o th e Johnso n case, a prosecuto r i n Michiga n charge d Kimberl y Hard y wit h delivering a controlle d substanc e t o a mino r an d second-degre e child abuse . This prosecution wa s als o unsuccessful . Women hav e bee n charge d wit h possessio n o f a controlle d substance, base d o n th e presenc e o f cocain e i n thei r newborn , and wit h manslaughter . Mos t o f th e wome n wh o hav e bee n arrested fo r dru g us e durin g pregnanc y hav e pleade d guilty . However, non e o f th e wome n wh o conteste d hav e bee n con victed. 17 Bu t most wome n canno t affor d t o appea l thei r convic tions. Substance-abusing wome n ar e als o prosecute d unde r ne w laws tha t mak e dru g us e durin g pregnanc y a crim e i n an d o f itself. Thes e wome n ar e no t arreste d fo r sellin g o r possessin g illegal substance s bu t simpl y fo r usin g drug s while pregnant. One propose d Ohi o la w mandate d force d sterilizatio n fo r women wh o coul d no t overcom e thei r addiction . Pet e Wilson , the governo r o f California , propose d legislatio n tha t woul d make i t a crim e t o giv e birt h t o a n infan t wh o wa s harme d b y the mother' s substanc e abus e (includin g alcoho l abuse ) o r wa s addicted a t birth . Consider a possible paralle l t o thi s situation . Wha t i f Jon, a n illegal substanc e abuser , wen t t o a treatment cente r fo r help . H e was not currently usin g drugs bu t clearl y had a tendency towar d physical an d psychologica l addiction . Coul d th e treatmen t cen ter staf f repor t Jo n t o authoritie s fo r previou s illega l substanc e abuse an d hav e him jailed? No, for Jon i s not violatin g an y law s unless h e i s i n possessio n o f th e substance . However , Joan n could b e jailed, if she were pregnant an d sough t treatment . Wh y would th e staf f wan t t o repor t he r an d possibl y dissuad e othe r addicts fro m seekin g help ? Som e state s hav e informan t law s that "deputize " healt h car e worker s an d requir e the m t o repor t instances o f substance-abusin g pregnan t women . I n thi s situa -

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tion healt h car e worker s ar e face d wit h a catch-22 . Repor t the woman , thu s violatin g physician-patien t confidentialit y an d possibly frightenin g othe r substanc e abuser s awa y fro m treat ment, o r fai l t o repor t her , an d ris k bein g hel d i n contemp t o f court o r foun d guilt y o f a crimina l violation . Th e America n Medical Associatio n an d th e America n Publi c Healt h Associa tion hav e alread y voice d thei r oppositio n t o th e effort s o f th e "pregnancy police. " Another metho d use d t o incarcerat e pregnan t substanc e abusers i s t o sentenc e the m t o jai l whe n the y ar e convicte d o f another crim e tha t woul d generall y warran t probation . Thi s type o f convictio n provide s ver y little recourse . The Constitutio n guarantee s al l individuals th e righ t t o equa l protection unde r th e law , whic h means , amon g othe r things , that th e la w applie s equall y t o al l citizens . Fo r example , th e Constitution woul d prohibi t th e enactin g o f a la w tha t crimi nalized a behavio r only if th e acto r wer e o f a certai n race . Similarly, no law may b e enacted tha t onl y males or only female s could conceivabl y violate . Since men cannot gestat e a child, the y could neve r violat e a la w tha t criminalize s a behavio r onl y when th e acto r i s pregnant . An y suc h la w woul d seemingl y b e unconstitutional. Consider a Susa n Doe . Th e da y befor e he r chil d wa s born , she use d cocaine . He r infan t test s positiv e fo r cocain e bu t i s healthy an d show s n o sig n o f addictio n o r impairment . Susa n i s nevertheless convicte d o f chil d abus e an d sentence d t o jail . A t the sam e tim e anothe r woman , Juli e Doe , get s pregnan t an d leads a mode l lifestyl e throughou t he r entir e pregnancy . Sh e receives excellen t prenata l car e an d eliminate s al l potentiall y harmful substance s fro m he r diet . However, th e day befor e Juli e is t o deliver , sh e ha s a fight wit h he r estrange d husband , Tom , and h e batter s her , endangerin g th e fetus . Th e infan t i s un harmed, bu t Tom' s action s coul d hav e resulted i n seriou s conse -

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quences fo r th e child . Becaus e th e fetu s i s no t considere d a person i n mos t states , Tom woul d probabl y no t b e foun d guilt y of an y crime excep t batter y o f Julie, even though h e shoul d als o be convicted o f chil d abuse , a s Susa n was . If the fetu s i s consid ered a perso n i n Susan' s case , i t shoul d als o b e considere d a person i n Tom's . Ye t fe w court s ar e clamorin g t o brin g chil d abuse charge s agains t batterer s an d balanc e this disparity . Mak ing a n actio n illega l onl y whe n th e acto r i s pregnant target s on e group i n a discriminatory way . These law s als o discriminat e agains t wome n o f lo w socioeco nomic statu s an d wome n o f color , wh o ar e disproportionatel y represented i n arrest s an d prosecutions . Thi s disproportio n probably stem s i n par t fro m th e fac t tha t thes e wome n ar e more likel y to com e t o th e attentio n o f state-operate d o r publi c agencies. Reinterpreting law s t o creat e a crim e wher e non e previousl y existed als o raises serious question s o f du e process. Assume tha t a stat e ha s n o la w criminalizin g dru g us e b y pregnan t women . Furthermore, i n tha t stat e th e fetu s i s no t considere d a person . But a prosecutor , seekin g t o convic t a drug-addicte d mothe r who ha s jus t give n birth , attempt s t o appl y t o newborn s th e existing laws against deliverin g controlled substance s to a mino r (using th e umbilica l cor d theory) . Ho w ca n th e woma n b e hel d responsible fo r violatin g a law that , s o far a s she knew o r coul d have known , di d no t exist ? Ho w coul d anyon e possibl y b e required t o kno w o r imagin e al l th e possibl e permutations o f a law tha t migh t expos e the m t o prosecution ? Law s ar e precisel y formulated s o tha t citizen s kno w wha t the y ca n an d canno t d o and prosecutor s kno w wha t the y ca n an d canno t prosecute . Legislative bodie s mak e laws ; prosecutor s ar e no t suppose d t o construct the m a d hoc , inventin g interpretation s tha t wil l serv e their ow n agendas . Criminalizing dru g us e during pregnancy ma y als o violate th e

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right t o privacy , includin g th e righ t t o bodil y integrity , th e righ t to autonom y i n reproductiv e choices , an d th e righ t t o confiden tial patient-physician relationships . I n short , thes e laws threate n procreative choic e altogether . Pregnanc y als o create s a uniqu e situation i n th e applicatio n o f law . Fo r example , ca n a woma n be foun d guilt y o f violatin g a la w agains t abusin g substance s while pregnan t i f sh e di d no t kno w sh e was pregnan t whe n sh e abused th e substances ? Suc h a scenari o highlight s on e o f th e myriad o f problem s wit h legislatin g agains t substanc e abus e while pregnant . In general , lega l standard s fo r crimina l conviction s ar e mor e stringent tha n thos e fo r civi l sanctions . Crimina l conviction s o f pregnant substanc e abuser s ar e usuall y reverse d o n appeal , bu t civil penaltie s ar e mor e likel y t o b e upheld . Fo r example , th e Department o f Famil y Service s ca n b e calle d i n t o institut e civi l proceedings fo r chil d abuse against a pregnant substanc e abuser , and sh e ca n b e penalize d wit h les s chanc e o f reversa l tha n wit h a crimina l conviction . Sh e may not b e incarcerated, bu t sh e ma y well lose custody o f he r child(ren) . Like crimina l statutes , civi l chil d abus e an d neglec t statute s were never meant to apply to prenatal behavior . However, whe n these statute s ar e reinterprete d th e fetu s i s ofte n afforde d th e rights o f a person . Sometime s prenata l substanc e abus e i s pre sumed t o b e evidenc e tha t futur e mistreatmen t o f th e chil d wil l occur, an d temporar y o r permanen t placemen t i n foste r car e i s sought. A well-publicized civi l proceeding took plac e in 199 2 in Con necticut. 18 Th e defendant , Jean , receive d littl e prenatal car e an d abused drug s durin g he r pregnancy . Jea n gav e birt h t o Valerie , who ha d symptom s o f prenata l exposur e t o cocaine . Th e De partment o f Chil d an d Yout h Service s filed petitions fo r tempo rary an d permanen t custod y that , i f approved , woul d hav e ter minated parenta l rights , base d o n Jean' s (an d he r husband's )

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prenatal conduct . Th e tria l an d appellat e court s terminate d al l parental rights . However , th e Suprem e Cour t o f Connecticu t reversed thi s decision , o n th e ground s tha t th e statutor y provis ions permittin g terminatio n o f parenta l right s wer e no t mean t to appl y t o prenata l conduct . Othe r stat e suprem e court s hav e reached th e opposit e conclusio n o n thi s issue. Through civi l proceedings, it also becomes possible to "incar cerate" a pregnan t substanc e abuse r withou t crimina l charges . If th e woma n present s a dange r t o hersel f o r others , sh e ca n b e civilly committed t o an institution unti l she is no longer a threat . Loosely interpreted , thi s mean s tha t he r dru g abus e pose s a threat t o th e fetus , th e statu s o f whic h ha s bee n elevate d t o personhood. I f commitmen t i s shrewdl y timed , th e woma n wil l give birt h befor e sh e i s release d an d th e court s ca n the n tak e custody o f the newborn whil e sh e is institutionalized . Regardless o f whethe r th e proceeding s ar e crimina l o r civil , in orde r fo r the m t o hol d u p o n appeal , the y mus t no t violat e constitutional fundamenta l rights . So far, thi s issue has not bee n debated i n the federa l courts .

Forced Medica l Intervention s Legal protectio n o f "feta l rights " a t th e expens e o f materna l rights has already extended t o forced medica l interventions. On e of th e least intrusiv e o f thes e procedure s involve s mandator y drug testin g o f pregnan t women . Som e physician s wil l onl y provide obstetri c car e i f th e patien t agree s t o rando m dru g an d HIV testing. In fact, th e federal government , which o n the whol e has demonstrate d a tremendou s lac k o f concer n fo r th e healt h of wome n o r fetuses , ha s recentl y urge d physician s t o counse l pregnant wome n t o b e tested fo r HIV . On th e mor e intrusiv e extreme , women hav e bee n compelle d

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to underg o cesarea n section s o r bloo d transfusion s agains t thei r will i n orde r t o sav e the live s o f thei r fetuses . I n these cases , th e court foun d tha t th e state' s interes t i n protectin g th e potentia l life o f th e fetu s outweighe d th e woman' s rights . Th e court' s authority wa s eve n further extende d i n In re Dubreuil. In Dubreuil, a pregnant woma n ha d suffere d complication s fol lowing he r child' s Caesarea n sectio n delivery . Althoug h sh e needed blood transfusions t o remain alive, she refused th e transfusions fo r religiou s reasons. . . . What wa s unusua l abou t th e case was that th e child ha d alread y bee n born. The court note d the woman's four youn g children, including the newborn, would be abandone d i f sh e died , an d i t wa s mostl y fo r th e children' s benefit tha t th e cour t force d th e woma n t o underg o th e life saving procedure.19 Although som e court s hav e decline d t o compe l wome n t o un dergo procedure s agains t thei r will , the majority o f jurisdiction s seem to favor force d intervention. 20 Give n the emergency natur e of thes e decisions , i t i s ofte n moo t fo r th e woma n t o appeal , because th e procedure ha s alread y bee n performed . Advances i n medica l technolog y hav e mad e i t possibl e t o perform surger y o n a fetu s t o correc t deformitie s an d birt h defects. I t i s not onl y possible bu t feasibl e tha t court s coul d on e day compe l pregnan t wome n t o underg o feta l surgery . Thi s precedent coul d b e eve n furthe r extende d t o requir e no t onl y lifesaving feta l surger y bu t therapeuti c feta l surger y a s well . Unlike lifesavin g surgery , therapeuti c surger y i s designe d t o en hance the quality o f the child's life—at th e expense, if necessary , of the mother' s privac y rights . One schola r ha s eve n contemplate d th e possibilit y tha t a biological fathe r ma y a t som e point b e able to compel a biologi cal mothe r t o underg o feta l surgery. 21 Suc h a developmen t ma y seem unrealistic , bu t existin g la w lay s th e foundatio n fo r it .

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Although th e Suprem e Cour t ha s never uphel d law s that requir e a biologica l father' s consen t befor e a woma n ca n obtai n a n abortion, recentl y thes e law s hav e bee n very narrowl y defeated . Second, afte r th e chil d i s born , father s theoreticall y hav e equa l rights wit h mothers . Fo r example , i t i s difficult fo r a woma n t o place he r chil d fo r adoptio n withou t th e biologica l father' s con sent. Finally , afte r a chil d i s bor n th e fathe r ha s ongoin g lega l rights an d responsibilities , suc h a s chil d support . Give n tha t a father ma y hav e a greate r financia l an d emotiona l burde n i f a child i s bor n wit h deficits , a cour t migh t find tha t h e ha d th e right t o forc e th e mother t o hav e feta l surgery . Perhaps the most disturbing aspec t of the recent trend towar d incarcerating o r prosecutin g pregnan t substanc e abuser s i s th e "slippery slope " effect . I t is difficult t o determine , o r eve n imag ine, wha t ma y o r ma y no t b e define d a s substanc e abus e i n th e future. Alread y Pet e Wilso n (a s wel l a s man y others ) ha s pro posed tha t alcoho l b e included . Othe r lega l substance s tha t could represen t threat s t o th e fetus , includin g cigarette s an d caffeine, migh t als o b e subjec t t o legislation . I f th e goa l i s t o control th e amoun t o f exposur e th e fetu s ha s t o potentiall y hazardous conditions , an y numbe r o f behavior s ma y ultimatel y need t o b e regulated , includin g th e amoun t o f prenata l care . However, i t i s unclea r wh o woul d pa y fo r prescribe d increase s in prenata l car e i f th e mother s themselve s wer e no t abl e t o d o so. Exposur e t o wor k stres s an d toxin s ma y als o nee d t o b e controlled, which would b e difficult t o balanc e with the decisio n the Suprem e Cour t reache d i n Johnson Controls (se e chapter 4) , that wome n shoul d no t b e disparatel y treate d i n th e workplac e due t o thei r status . It may on e da y b e possible t o forc e pregnan t women t o underg o amniocentesi s t o detec t geneti c an d birt h "defects." Wh o wil l determin e wha t actio n i s to b e take n whe n there ar e positiv e results—legislature s o r parents ? (An d i f par ents, which one? )

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Laws tha t lea d t o th e incarceratio n o r prosecutio n o f preg nant substanc e abuser s ca n als o hav e unintende d bu t devasta ting practica l consequences . Mos t importantly , pregnan t sub stance abuser s ar e ver y ofte n deterre d fro m obtainin g prenata l care becaus e the y fea r incarceration . I n additio n t o th e fac t tha t incarceration itsel f i s unpleasant, man y of these women fea r tha t they coul d b e force d t o "involuntaril y abandon " thei r othe r children. Fear of losing custody o f children i s the primary reaso n substance-abusing pregnan t wome n d o no t see k treatment . When mother s ar e incarcerated , thei r childre n ar e ofte n place d in foste r care . Onc e foste r placemen t ha s occurre d an d th e mother i s saddle d wit h a crimina l record , i t ma y b e difficul t to regai n custody . O f course , proponent s o f incarceratin g substance-abusing pregnan t wome n argu e tha t foste r car e i s a healthier optio n fo r thes e children . However , ther e ar e alread y a tremendou s numbe r o f childre n i n foste r car e o r waitin g t o b e placed i n foste r care . Recal l tha t th e shortag e o f foste r car e placement le d House Speake r New t Gingric h t o sugges t i n 199 4 the reviva l o f the orphanage . Moreover, incarceratio n o f th e mothe r ma y b e unhealthy fo r the fetus , fo r th e mothe r endure s no t onl y th e stres s o f arres t and prosecutio n bu t th e hazards an d deprivation s o f prison life . There is substantial evidenc e of harassment an d mistreatment of women [prisoners ] explicitly because they are pregnant. . . . One report cite d a patter n o f assignin g pregnan t wome n t o wor k requiring a grea t dea l o f exertio n an d heav y lifting , eve n whe n the women had a history of miscarriage. Sometimes needed medical car e i s delayed , resultin g i n miscarriage s an d babie s bor n dead, o r who di e shortly afte r birth . Inmate s hav e charged tha t such delay is often deliberate . Several class actions have been filed chargin g systematic defi ciencies i n prenata l car e provide d t o incarcerate d pregnan t women. Yeager v. Smith allege d violation s o f th e Eight h an d Fourteenth Amendmen t right s o f pregnan t wome n i n th e Ker n

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county jail and work camp. Of eight plaintiffs, thre e had miscarriages and one gave birth lying on a mat in the jail hallway. The child died shortly thereafter. Th e remaining four plaintiff s were , at th e time o f filing, exposed t o hepatiti s an d measle s and wer e denied vitamins , exercis e an d neede d medica l car e fo r seriou s conditions that threatened their pregnancies. 22 Pregnant inmate s ar e seldo m provide d wit h les s restrictiv e ma ternity clothe s an d ofte n mus t wea r bell y chains , restraint s tha t strap aroun d th e waist , o r chain s tha t exten d t o th e ankle s and/or wrists . Som e priso n program s directe d towar d assistin g pregnant wome n wit h substanc e abus e have bee n successful , bu t most prison s d o not hav e suc h programs . Some state s hav e recognize d tha t incarceratio n o f pregnan t women ma y no t b e in the bes t interest s o f th e fetus , th e mother , or th e state . Law s tha t allo w judge s t o dela y incarceratio n o f pregnant wome n convicte d o f nonviolen t crime s unti l si x week s after th e birt h o f th e chil d o r th e terminatio n o f th e pregnanc y have bee n approve d i n severa l states . Thi s alternativ e provide s the mother a n opportunit y t o bon d wit h the infant an d to secur e living arrangement s fo r th e chil d durin g he r incarceration , thu s saving the stat e healt h car e an d placemen t expenditures . Attempts t o incarcerat e pregnan t substanc e abuser s i n orde r to benefi t th e fetu s ar e ineffectua l fo r a numbe r o f reasons . Fo r example, b y th e tim e mos t wome n ca n b e incarcerated , the y have passe d thei r first trimester , whic h i s usuall y th e perio d during which th e fetus i s most vulnerable t o harmful substances . Moreover, drug s ar e ofte n obtainabl e i n prison . Ultimately thes e law s ar e illogica l an d unproductive . The y don't dete r wome n fro m abusin g substances , onl y fro m seekin g treatment. Fa r fro m ensurin g prope r care , th e law s ofte n ac t a s an obstacl e t o care . It would mak e mor e sens e to offe r pregnan t women wh o see k assistanc e wit h substanc e abus e prosecutoria l immunity than to attempt to sanction them. 23 Moreover, remov -

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ing a child fro m parent s afte r deliver y doe s not preven t prenata l injury.

Prevention Although th e drug s o f choic e a t an y give n moment ma y b e new, the problem o f substanc e abus e i s very old. Substanc e abus e ha s traditionally bee n considere d mor e o f a man' s tha n a woman' s problem. Thi s perceptio n i s partiall y base d i n realit y an d par tially i n gende r stereotypes . Afte r all , abusing substance s i s very "unladylike" behavior . Consequently , women substanc e abuser s have generall y bee n overlooke d b y society , researchers , an d treatment programs . I n compariso n t o mal e substanc e abusers , female substanc e abuser s ge t littl e researc h attentio n an d preg nant substanc e abuser s eve n less. Correspondingly, mos t treatmen t program s wer e designe d with mal e substanc e abuser s (ofte n criminals ) i n mind . Thera pists ar e traine d i n technique s tha t ma y b e nonproductiv e o r counterproductive wit h femal e substanc e abusers . Therap y strategies ar e short-ter m an d confrontationa l i n nature . Thes e strategies woul d no t wor k wit h typica l femal e substanc e abusers. Over 80% have histories of parental substance abuse, child physical abuse, or sexual abuse. Additionally, the women report tha t very few o f the general o r mental healt h car e professionals wh o have treate d the m hav e inquire d abou t thei r childhoo d experi ences. Our staf f ha s found tha t thes e underlyin g issue s can seriously complicate effort s t o help these women becom e drug-free , nurturing parents. Individuals wit h abusiv e background s ten d t o hav e low selfesteem, which , i n turn , negativel y influence s thei r educationa l achievements an d interfere s wit h th e developmen t o f health y social networks.24

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Given thi s profile , wome n substanc e abuser s woul d probabl y benefit fro m long-ter m therap y wit h a more humanisti c an d les s confrontational approach . If i t i s difficul t t o find a treatmen t progra m geare d towar d women, i t i s virtuall y impossibl e t o find on e tha t accept s preg nant substanc e abusers . Dr. Wendy Chavki n (1989 ) surveye d 9 5 percent o f th e dru g treatmen t program s i n Ne w Yor k Cit y an d found tha t 5 4 percen t o f the m exclude d pregnan t women . I n addition, 67 percen t denie d treatmen t t o pregnan t addict s o n Medicaid, an d 8 7 percen t denie d treatmen t t o pregnan t crac k addicts. 25 Pregnant substanc e abuser s represent ne w challenges to treat ment programs . Fo r example , detoxificatio n ma y b e difficul t o r impossible wit h pregnan t women , dependin g o n th e dru g use d and th e stag e o f th e pregnancy . Th e stresse s o f dru g withdrawa l may har m th e fetu s o r terminat e th e pregnancy . Additionally , the staf f mus t b e traine d an d th e facilitie s equippe d t o handl e prenatal issue s an d emergencies . A s i s tru e o f man y women , pregnant wome n ma y hav e othe r childre n who m the y canno t abandon i n orde r t o atten d a n inpatien t dru g rehabilitatio n program, s o chil d car e facilitie s mus t als o b e available . Finally , therapists mus t tak e int o accoun t tha t th e woma n ma y b e i n treatment ove r th e protest s o f a n abusive , ofte n addicted , partner. An effective dru g prevention progra m fo r wome n woul d hav e all o f th e followin g additiona l components : advocate s wh o wil l assist with othe r agencies , educational an d caree r services , after care, assistance with basi c needs such as housing, multiple coun seling modalities , an d multipl e type s o f service s (i.e. , rangin g from inpatien t t o home-based). 26 The numbe r o f treatmen t program s tha t accep t pregnan t women i s unlikel y t o increase . Basically , treatin g pregnan t sub stance abuser s require s treatmen t center s t o inves t mone y t o

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modify thei r program s whil e simultaneousl y increasin g thei r liability, all for littl e profit potential . Pregnant substanc e abuser s are a higher-ris k populatio n tha n substanc e abuser s i n general , due t o pregnancy-induce d healt h issues . Furthermore , propor tionally fe w o f th e client s presentin g t o privat e facilitie s wil l b e pregnant an d substanc e abusing . Federa l o r state-funde d clinic s are more likel y to see pregnant substanc e abusers , because man y of the m ar e either o n Medicai d o r hav e no insuranc e a t all . Moreover societa l an d legislativ e respons e i s presently geare d more toward punishmen t tha n prevention . Althoug h man y indi viduals vie w substanc e abus e a s a disease , i f th e abuse r i s a pregnant woman , a moralisti c ton e creep s i n an d th e woma n i s seen a s a "ba d mother " wh o willfull y indulge d hersel f a t th e expense o f he r child' s health . I n 1992 , o f th e $1 2 billio n allo cated b y the federa l governmen t t o dru g programs , les s than 2 0 percent wa s spen t o n preventio n an d treatment: 27 "Th e federa l budget fo r th e fiscal yea r 199 2 propose d a n allocatio n o f $331,169,000 t o construc t an d fun d 3,60 0 ne w priso n beds , and $99,000,00 0 t o fun d 8,99 7 new dru g treatmen t slots . Not e that priso n bed s ar e muc h mor e expensiv e tha n dru g treatmen t slots: On e priso n be d cost s $91,99 1 a s compare d t o $11,00 4 per dru g treatment slot." 28 This emphasi s o n incarceratio n instea d o f preventio n an d rehabilitation i s extremely shortsighte d give n th e cos t t o societ y from babie s bor n dru g addicted . Althoug h preventio n woul d entail a greate r "front-end " investment , th e long-ter m expendi ture woul d b e greatl y diminished . I n 1992 , th e cos t o f treatin g drug-exposed infant s wa s estimate d a t $ 3 billion. 29 Thi s doe s not includ e th e cost s o f th e longe r postnata l car e require d b y drug-addicted mothers , th e expens e o f foste r car e o r specia l education programs , o r th e eventua l cost s t o societ y fro m los t wages, lifetim e car e (fo r some) , o r crim e (committe d b y th e mother o r th e child) . Thi s figure als o doe s no t includ e th e cos t

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of maintainin g "boarde r babies, " thos e wh o ar e abandone d b y their mothers an d becaus e of addictions o r physical deficit s mus t remain i n th e hospital . Som e o f thes e babie s ar e HIV-positive . When preventio n program s hav e bee n implemented , the y hav e generally save d governmen t monie s an d bee n successful . I n fact , for ever y dolla r investe d i n dru g treatment , societ y save s five dollars i n reduced crim e an d welfar e costs. 30 Although tremendou s societa l ange r i s directe d a t wome n who continu e t o us e substances whil e pregnant, fe w alternative s are available to them. I f they go to a federally funde d clini c the y cannot ge t a federall y funde d abortion . Often , b y th e tim e the y learn the y ar e pregnant , i t ma y b e to o lat e fo r a n abortion . I f they see k prenata l care , th e wor d o n th e stree t i s tha t the y wil l be incarcerate d an d los e custod y o f thei r othe r children . Eve n if al l thes e obstacle s ar e surmounted , ther e ar e probabl y no t appropriate treatmen t facilitie s availabl e an d i f the y are , the y often hav e lon g waiting lists . Legislation agains t substanc e abus e durin g pregnanc y i s clearly no t th e solution . Thi s approac h ha s n o tangibl e benefit s and infringe s o n constitutiona l rights . T o gran t th e fetu s th e same right s a s th e mothe r (o r eve n greate r rights ) i s t o tak e a step bac k towar d paternalisti c protectio n o f wome n an d fetuse s by th e legislatur e an d lega l systems . I f wome n wil l ultimatel y have th e responsibilit y fo r th e childre n the y bear , the y shoul d also b e responsibl e fo r choice s relate d t o thei r ow n prenata l care. It i s a n od d coincidenc e tha t debate s ove r th e statu s o f th e fetus aris e a t a time when th e validit y o f Roe v. Wade i s increasingly unde r attack . I f th e fetu s i s elevate d t o a perso n i n th e context o f substanc e abuse , then th e foundatio n o f Roe v. Wade may b e jeopardize d (se e chapte r 5) . Maybe i t i s n o coincidenc e after all .

[4] Politics an d Reproductiv e Issue s in th e Workplac e

^ t - h e politic s o f reproductio n and the family wer e showcased i n the 199 2 presidential election . Pivotal campaig n issue s focuse d o n th e reproductiv e right s o f women an d suppor t fo r th e family , particularl y i n th e work place. George Bus h was criticized fo r payin g lip service to "fam ily values " whil e stiflin g legislation , suc h a s th e Famil y Leav e Act, that might have assisted familie s i n their attemp t t o balanc e work an d hom e life . This disparit y shoul d no t hav e com e a s a surpris e t o women , who hav e lon g bee n familia r wit h workplac e discriminatio n revolving aroun d famil y an d reproductiv e issues . Many wome n have foun d themselve s inappropriatel y terminate d fro m job s as th e resul t o f a pregnanc y o r denie d promotio n (o r eve n employment) du e t o potentia l futur e pregnancies . A lega l rem edy, albei t burdensome , ha s bee n provide d fo r suc h discrimina tion. However , sometime s eve n the courts hav e difficult y under [108]

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standing an d identifyin g discriminatio n whe n i t i s interwove n with reproductiv e rights . For example , i n 1990 , th e Suprem e Cour t hear d argument s in th e cas e o f International Union, United Automobile, Aerospace and Agricultural Implement Workers of America, UAW, et al. v. Johnson Controls, Inc. 1 (hereinafte r referre d t o as Johnson Controls). Th e plaintiff s appeale d t o th e Suprem e Cour t afte r both lowe r court s ha d rule d i n favo r o f th e defendant , Johnso n Controls, Inc. Johnson Controls , Inc. , use d lea d whe n manufacturin g bat teries. Initially , th e compan y di d no t exclud e pregnan t wome n or wome n capabl e o f childbearin g fro m position s requirin g ex posure t o lea d bu t strongl y discourage d wome n fro m takin g these position s an d ha d the m sig n a form , presumabl y servin g as a liability waiver, indicating that the y had bee n advised o f th e risks. However, i n 1982 , Johnson Controls , Inc . implemented a new policy , known a s a fetal protectio n policy . Now, al l wome n who wer e pregnant , o r merel y capabl e o f childbearing , woul d be exclude d fro m job s tha t coul d expos e the m t o lead . Th e purported goa l o f th e polic y wa s t o protec t unbor n childre n from risk s associate d wit h materna l exposur e t o lead. However , unless a woman coul d medicall y documen t he r inabilit y t o bea r children, she was excluded fro m an y position that entailed expo sure t o lead , whethe r o r no t sh e eve r intende d t o becom e preg nant. Thi s policy not onl y limited women' s exposur e t o lea d bu t also to higher-payin g positions . The plaintiff s i n thi s clas s actio n sui t argue d tha t th e feta l protection polic y a t Johnso n Controls , Inc. , constitute d sexua l discrimination. On e plaintiff ha d chose n to be sterilized to avoi d losing he r job . A secon d plaintif f suffere d a wag e reductio n when sh e was transferre d ou t o f a job tha t expose d he r t o lead . Conversely, a male plaintiff, wh o wa s plannin g t o star t a family , requested a leave o f absenc e i n orde r t o lowe r hi s lead exposur e

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and wa s denied . Th e Suprem e Cour t hel d tha t th e polic y wa s discriminatory an d violate d bot h th e Civi l Right s Ac t o f 1964 2 and Titl e VII as amended b y the Pregnancy Discriminatio n Act. 3 The latter ac t states that decision s about th e welfare o f potentia l children shoul d b e lef t t o th e prospectiv e parents , no t th e pro spective parents' employer . Governmental agencie s suc h a s th e Nationa l Institut e o f Oc cupational Safet y an d Healt h (NIOSH ) wer e designe d t o protec t the healt h o f al l employees . Thei r failur e t o se t specifi c guide lines encouraged Johnson Controls , Inc., and man y othe r corpo rations t o develo p thei r ow n policies , perhap s attemptin g t o limit liability . Employee s coul d no t mak e decision s fo r them selves regardin g exposur e t o reproductiv e hazards , becaus e em ployers mad e thi s decisio n fo r them . As a "bonus, " feta l protec tion policie s coul d als o provid e a wa y t o preven t th e hirin g and promotio n o f wome n whil e bearin g th e appearanc e o f a humanistic concer n fo r th e safet y o f employee s an d thei r poten tial offspring . Two factor s sugges t tha t th e feta l protectio n polic y wa s sim ply a vehicl e fo r discrimination . First , a s th e cour t recognized , the mal e reproductiv e system , lik e th e female , ca n b e adversel y impacted b y exposure t o toxins. If so, why expos e either wome n or me n t o thes e toxins ? Transferrin g wome n fro m thes e posi tions force s me n t o wor k i n a n unhealth y environment . Instea d of transferrin g employees , the risk shoul d b e eliminated . More importantly, in occupations where women workers predominate, suc h a s dr y cleanin g o r hai r styling , wome n ar e no t transferred ou t o f positions tha t expos e them t o potential repro ductive hazards . Concer n fo r wome n and/o r th e fetu s doe s no t appear t o com e int o pla y unti l me n an d wome n ar e competin g for th e same position. When the population expose d to potentia l reproductive hazard s i s almos t exclusivel y female , th e dange r is minimize d o r no t investigated . A glarin g exampl e o f thi s

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minimization i s th e us e o f compute r monitor s o r vide o displa y terminals (VDTs ) i n th e workplace . Th e impac t o f patriarcha l society o n reproductiv e issue s i n th e workplac e i s clearl y re flected i n this issue .

The Compute r Ag e The lin k betwee n electromagneti c emission s (suc h a s those fro m VDTs) an d healt h hazard s ha s recentl y becom e th e subjec t o f increased attention . Powe r line s an d cellula r phone s hav e bee n investigated i n relatio n t o increase d cance r rates . Th e concer n over emission s doe s no t focu s o n periodi c exposure , fo r exam ple, fro m usin g hai r dryers , bu t rathe r o n prolonge d exposur e such a s occur s wit h VD T usage . A connectio n betwee n th e us e of VDT s an d reproductiv e complication s wa s first suspecte d i n the lat e 1970s , whe n cluster s o f wome n VD T operator s bega n reporting highe r tha n averag e rate s o f miscarriage . Th e report s are to o numerou s t o mentio n bu t conside r th e followin g exam ples: In late 1979 and early 1980, six out of 1 0 pregnant women who worked a t Sear s Roebuck's Southwes t Regiona l Offic e i n Dallas "had experienced spontaneou s abortions, and another employe e had delivere d a premature infan t wh o subsequentl y died . Upon investigating, CD C Center s fo r Diseas e Contro l official s deter mined tha t eigh t ou t o f twelv e pregnancie s ove r a fourteen month period of women working in Department 16 8 of the Sears office—a larg e roo m containin g 2 5 VDT s i n on e corner—ha d ended either in miscarriage or neonatal death." 4 In 1979, four ou t of seven pregnant VDT operators who worked in the classified advertisin g department o f the Toronto Star gave birth t o infant s wit h defects : "On e bab y wa s bor n wit h a clubfoot; anothe r with a cleft palate ; a third with an underdevelope d

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eye; an d th e fourt h wit h multipl e hear t abnormalities. " Al l of these babie s wer e bor n withi n a two-mont h perio d t o youn g women wh o ha d neithe r smoke d no r take n drug s durin g thei r pregnancies. Durin g tha t sam e tim e period , thre e employee s a t the Star who didn't work on VDTs gave birth to normal babies. 5 Between 197 9 and 1984 , 24 out of 48 pregnancies amon g VDT operators a t the United Airline s reservation center s in San Francisco "resulte d i n miscarriages , birt h defects , neonata l deaths , premature births, and other abnormal outcomes." 6 More tha n fiftee n year s have elapse d sinc e these reports wer e publicized an d a possible relationship betwee n VDT s and repro duction complication s wa s first theorized . Durin g tha t tim e pe riod, ver y littl e researc h o n thi s issu e ha s bee n conducted , espe cially i n th e Unite d States , an d th e researc h findings tha t hav e been published hav e bee n contradictory .

Just Whe n Yo u Though t I t Wa s Saf e The focu s o f researc h o n VDT s an d reproductiv e complication s is electromagneti c emissions . Electrica l appliance s emi t electro magnetic radiatio n whe n activated . Natura l source s o f electric ity, such a s lightning, also emit electromagnetic radiation . "Elec tromagnetic" implie s tw o fields, a n electri c o r electroni c field and a magneti c field. I n VDTs , a n electroni c bea m passe s through a cathod e ra y tub e (CRT) , activatin g phosphor s tha t coat th e insid e o f th e tube . Thi s activatio n o f phosphor s emit s radiation, an d th e radiatio n create s th e ligh t tha t allow s color s and image s to b e projected o n the computer monitor . Th e radia tion emitte d fall s int o two frequenc y ranges ; very lo w frequenc y radiation (VLF ) an d extremel y lo w frequenc y radiatio n (ELF) . It is unclear which i s more dangerou s t o consumers. Researcher s have generall y focuse d o n th e effect s o f VL F radiation o n spon -

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taneous abortion s o r miscarriages , neglectin g th e effec t o f EL F radiation, whic h som e believe is more dangerous . Early researc h was methodologicall y flawe d an d wa s conducte d o n no w out dated compute r monitors. 7 Mos t recen t researc h i s not substan tially better . One o f th e initia l studie s i n th e Unite d State s wa s conducte d at th e Norther n Californi a Kaiser-Permanent e Medica l Car e Program. 8 Wome n wh o ha d receive d pregnanc y test s a t th e Kaiser-Permanente healt h maintenanc e organizatio n betwee n 1 5 September 198 1 an d 3 0 June 198 2 wer e recruited t o participat e in th e study . Th e origina l purpos e o f th e stud y wa s no t t o investigate th e effec t o f VD T exposur e o n pregnanc y bu t rathe r to stud y th e effec t o n pregnanc y o f a pesticid e spra y use d i n California. Goldhabe r an d he r colleague s the n embedde d expo sure to othe r environmenta l factors , includin g VDTs , within th e design. The pregnancy outcom e o f 1,58 3 wome n wa s examined , largely throug h participan t questionnair e response s an d revie w of medica l records . Th e researcher s foun d a n elevate d ris k o f miscarriage (ofte n considere d a n indicato r o f abnormalit y i n pregnancy), bu t no t birt h defects , fo r wome n wh o reporte d using VDT s mor e tha n twent y hour s pe r wee k durin g thei r firs t trimester o f pregnancy . Unfortunately , lik e mos t o f th e researc h reviewed here , thi s stud y wa s conducte d year s afte r th e fact , when recal l could b e faulty . In th e sam e yea r Goldhabe r an d he r colleague s publishe d their findings , 1988 , Finnis h researcher s publishe d conflictin g findings.9 Nurmine n an d Kurpp a foun d tha t VD T user s demon strated n o increase d ris k o f spontaneou s abortio n an d n o differ ences in length o f gestation o r birt h weight o f infants. However , Nurminen an d Kurpp a di d no t actuall y measur e VD T exposur e but merel y assesse d probabl e exposur e b y askin g wome n thei r job title s an d havin g the m describ e a n ordinar y wor k day . Pur porting t o stud y VD T exposur e withou t askin g an y question s

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about actua l VDT usag e is akin t o studyin g th e effect s o f smok ing o n healt h withou t askin g participant s abou t thei r smokin g habits. Since 1988 , researc h result s hav e continue d t o b e confusin g and contradictory . Bryan t an d Love 10 conducte d interview s o f 334 women wh o had spontaneousl y aborte d an d conclude d tha t VDT usag e wa s no t a factor . I n contrast , Windha m an d he r colleagues 11 foun d tha t th e ris k o f intrauterin e growt h retarda tion was slightly higher wit h greater VDT usage. They suggeste d that th e effect s o f VD T us e ma y var y accordin g t o gestationa l stage a t whic h th e mothe r i s exposed , wit h earlie r exposur e (twelve week s o r less ) resultin g i n a greate r impac t o n preg nancy. (Pregnancie s ar e generall y mor e vulnerabl e i n th e earl y stages.) I f thi s speculatio n i s correct , i t i s possibl e tha t man y women ma y b e unknowingly havin g spontaneou s abortion s du e to VD T exposur e befor e the y ar e eve n awar e tha t the y ar e pregnant. Obviously , it would b e very difficult fo r researcher s t o safely measur e thi s impact . Other researcher s hav e suggeste d tha t VDT s d o no t increas e reproductive complications . I n a pai r o f studies , Brand t an d Nielsen 12 an d Nielse n an d Brandt 13 reporte d n o increase d ris k of congenita l malformation s o r spontaneou s abortion s amon g VDT operators . Anothe r stud y (Roma n e t al. ) confirme d thes e findings a s regards spontaneou s abortions. 14 In this myriad o f research results , two studie s warrant discus sion i n greate r detail , th e first becaus e i t bring s t o th e for e ho w political pressure s influenc e th e investigatio n o f reproductiv e issues i n th e workplace . I n 1991 , NIOS H reporte d th e result s of a long-anticipate d stud y o f th e contributio n o f VDT s t o reproductive complications. 15 NIOS H investigator s originall y proposed a stud y tha t woul d allo w fo r investigatio n int o a number o f factor s affectin g VD T operators , suc h a s stress , i n addition t o electromagneti c emissions . NIOS H als o planne d t o

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examine th e possibl e connectio n betwee n VD T us e an d birt h defects an d infertility . Th e propose d stud y woul d hav e bee n th e most detaile d an d comprehensiv e researc h projec t o n VDTs eve r implemented. Bell Sout h Corporatio n wa s t o provid e th e participants . However, afte r consultant s fo r Bel l Sout h reviewe d th e NIOS H proposal, Bel l South objecte d t o th e proposed inclusio n o f ques tions o n stres s an d fertility , whic h the y sai d wer e "intrusive " and "irrelevant " (an d no doubt posed significant liabilit y issues). Bell Sout h Corporatio n appeale d t o th e Offic e o f Managemen t and Budge t (OMB ) to intercede. The Offic e o f Management an d Budget wa s grante d authorit y t o revie w th e stud y unde r th e infamous Paperwor k Reductio n Act . A t tha t tim e th e OM B operated unde r th e auspice s o f th e Reaga n administratio n an d had bee n accuse d o f obstructin g researc h o n environmenta l an d occupational hazards , especiall y i f th e researc h touche d o n re productive issues . (Late r a n independen t revie w tea m substanti ated thi s claim.) S o it did no t com e a s a surprise whe n th e OM B decreed tha t 9 0 percen t o f th e questions , primaril y thos e o n stress and fertility , b e eliminated fro m th e questionnaire. 16 Addi tionally, th e OM B indicate d tha t i f NIOS H stil l foun d a differ ence betwee n pregnan t wome n expose d t o VDT s an d pregnan t women no t expose d t o VDTs , the y woul d b e require d t o vali date thes e outcome s throug h a revie w o f medica l records. 17 Finally, afte r deletin g th e cor e o f th e study , th e OM B approve d the remainder i n 1986 . Teresa Schnor r an d he r colleague s conducte d th e truncate d NIOSH study . Directory-assistanc e operator s wh o use d VDT s were compare d wit h genera l assistanc e operator s wh o use d a low-radiation, light-emittin g diod e (LED ) scree n rathe r tha n a VDT. Th e researc h tea m interviewe d wome n wh o ha d bee n pregnant, married , betwee n eightee n an d thirty-thre e year s old , and employe d full-tim e fo r as little as one day a s a directory -

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assistance o r genera l operato r betwee n 1 January 198 3 an d 1 August 1986 . To qualif y a s data fo r th e study , their pregnancie s must hav e ende d i n a spontaneou s abortion , liv e birth , o r still birth durin g thi s tim e period . Wome n fitting thes e criteri a wer e interviewed fo r twenty-fiv e minute s sometim e betwee n Jul y 1987 an d Augus t 1988 . Therefore , a t best , wome n wer e inter viewed abou t thei r pregnanc y an d exposur e a t leas t on e yea r after th e fact ; a t worst , fiv e an d a hal f year s after . Moreover , emissions wer e no t measure d unti l 1990 , fou r t o seve n year s after thes e wome n ha d bee n expose d t o th e VDT . Furthermore , only tw o model s o f VDT s ha d bee n used , s o onl y th e effec t o f these tw o model s coul d b e measured . A s a result , sixty-seve n miscarriages wer e no t include d i n th e stud y becaus e th e wome n were n o longe r workin g a t on e o f thes e tw o model s a t th e tim e of th e miscarriage. 18 Finally , i t shoul d b e note d tha t al l wome n had bee n expose d t o som e backgroun d leve l o f EL F radiation , presumably a high level , at the phone company . Not surprisingly , thi s grou p o f researcher s di d no t fin d a n increased rat e o f spontaneou s abortio n amon g VD T operators . Since the effects o f VDT exposure o n fertility, congenital malfor mations, birt h weight , o r prematur e birt h wer e no t examined , no conclusion s coul d b e draw n relate d t o thes e issues . Despit e all of thes e limitations , this stud y was haile d a s a success ; it wa s published i n th e New England Journal of Medicine, an d ever y major newspape r carrie d a n accoun t o f th e finding s (generall y under a headline proclaimin g th e ensure d safet y o f VDTs). Contrast th e NIOS H study , an d th e subsequen t glorificatio n of it s results , with a Finnis h stud y publishe d a yea r later. 19 Th e Finnish stud y was as well designed a s the NIOSH study , perhap s better, ye t the results went virtuall y unnotice d b y the press. The Finnis h researcher s examine d th e pregnanc y outcom e o f women employe d a s ban k clerk s an d clerica l worker s i n Fin land. Informatio n regardin g healt h history , wor k tasks , an d th e

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use o f VDT s durin g th e firs t trimeste r o f pregnanc y wa s ob tained fro m participant s an d thei r employers . Th e researcher s also obtained twelv e emissions measures fro m th e VDTs, including bot h VL F an d EL F emissions . Recal l that , previously , re searchers ha d focuse d primaril y o n VLF emissions. Like NIOSH , th e Finnis h researcher s obtaine d informatio n retrospectively. However, they tested seventee n models o f VDTs. Like NIOSH , th e Finnis h researcher s di d no t find a n increase d risk o f spontaneou s abortio n relatin g t o VL F emissions . How ever, when a hig h leve l o f EL F emissions wa s recorded , th e ris k of spontaneou s abortio n wa s thre e an d a hal f time s greate r fo r VDT operators . Thi s relationshi p wa s stil l significan t afte r th e effects o f ergonomi c factor s an d jo b characteristic s wer e re moved. Unlik e th e NIOS H study , th e Finnis h researc h receive d little acclaim . The on e thin g al l researchers, includin g thos e involve d i n th e NIOSH study , agre e upo n i s tha t mor e researc h need s t o b e conducted. Th e numerou s flaw s i n al l th e previou s researc h designs mak e an y conclusion s questionable . Fo r example , non e of th e studie s wa s designe d wit h a prospectiv e focus , enablin g researchers to examine the outcome o f pregnancies a s they occu r as oppose d t o retrospectively. 20 Researcher s hav e relie d o n th e recall o f sometime s remot e events , providin g participant s wit h an opportunit y t o colo r thei r memories . A prospectiv e stud y would provid e a n opportunit y fo r emission s t o b e measure d during pregnancy , instea d o f havin g t o rel y o n biase d memorie s regarding emissions , wor k stress , o r ergonomics . Informatio n about th e strengt h o f th e emissio n an d th e duratio n o f exposur e could the n b e combine d t o provid e a n exposur e index . How ever, ethica l consideration s woul d probabl y prohibi t a prospec tive study , give n th e detrimenta l effect s stres s coul d hav e o n participants an d thei r fetuses . In additio n t o no t thoroughl y explorin g th e effec t o f VD T

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emissions o n reproduction , researcher s hav e neglecte d numer ous othe r factors . Fo r example , no on e has investigated whethe r VDT exposur e affect s mal e o r femal e fertility . Thi s i s a n im portant consideratio n give n th e purporte d recen t ris e i n unex plained infertility . Th e cumulative effec t o f VDT exposure migh t account fo r som e case s o f temporary , o r eve n permanent , infer tility. Furthermore, th e effect s o f stres s o r ergonomi c factor s i n combination wit h emission s hav e bee n virtuall y ignored . No r has anyon e examine d whethe r stres s o r poo r ergonomic s coul d lead t o o r aggravat e reproductiv e complication s irrespectiv e o f emissions. Th e cause s o f stres s amon g VD T operator s ar e als o unclear, a s i s th e relationshi p betwee n repetitiv e strai n injurie s and reproductiv e complications . At a tim e whe n medica l technolog y i s rapidl y advancing , particularly i n th e are a o f reproduction , wh y ha s i t bee n s o difficult t o desig n o r implemen t a relativel y definitiv e stud y o n VDTs and reproductiv e complications ? Undeniably , i t is difficul t to contro l th e man y factor s tha t migh t sen d dat a askew , fo r example, maternal healt h histories. Clearly it would b e unethica l to selec t a relativel y homogeneou s grou p o f pregnan t wome n and randomly assig n one-fourth o f them to high electromagneti c exposure, one-fourt h t o moderat e exposure , one-fourt h t o lo w exposure, an d one-fourt h t o n o exposur e an d the n measur e the rat e o f reproductiv e complications . However , mos t studie s completed t o dat e lac k eve n th e basic s o f soun d researc h meth odology. I t almos t appear s tha t scientist s ar e avoidin g definitive research i n thi s area . I f a relationshi p betwee n reproductiv e complications an d VDT s wa s discovered , stric t regulation , per haps legislation , woul d b e require d t o ensur e a saf e wor k envi ronment fo r VD T operators . However , partl y du e t o lac k o f research support , severa l progressive attempt s a t legislation hav e already failed .

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Attempts t o Legislate/Regulat e Numerous bill s have been introduced, ordinance s proposed, an d guidelines recommende d ove r th e las t fiftee n year s i n a n effor t to protect VDT operators from variou s associated healt h risks. 21 Most o f thes e endeavor s focu s o n safeguard s agains t th e physi cal effects o f prolonged VD T usage, such a s eye strain o r muscu lar problems. Some include modifications o f workplace practice s or o f workstations . Other s includ e recommendation s fo r preg nant VD T operators . However , despit e a numbe r o f attempts , only one ordinance regulatin g safet y standard s has actually bee n approved, an d the n onl y temporarily . In Decembe r 1990 , Sa n Francisc o approve d a union-backe d ordinance regulatin g mos t workplace s wit h VDTs . Th e ordi nance require d employer s wit h mor e tha n fifteen employee s (including th e cit y government ) t o provid e regula r breaks , ad justable workstations , an d trainin g o n saf e VD T usage . Primar ily, the ordinanc e was designe d t o prevent repetitiv e strai n injur ies, suc h a s carpa l tunne l syndrome . No t surprisingly , th e ordinance me t wit h oppositio n fro m member s o f th e busines s community. Originally, plan s t o limi t electromagneti c radiatio n exposur e were included i n the ordinance . However, i n a compromise wit h the busines s community , thes e plan s wer e scrapped , an d a n advisory committe e wa s established , purportedl y t o monito r research publishe d o n th e effect s o f radiatio n fro m VDT s o n operators. Th e ordinanc e di d includ e recommendation s sug gesting tha t pregnan t wome n b e allowe d t o transfe r t o non VDT wor k shoul d the y desir e t o d o so . Businesse s wer e give n two year s i n whic h t o compl y wit h al l th e provision s o f th e ordinance, an d complianc e wa s t o b e monitore d b y th e Sa n Francisco Healt h Department . I n 1992 , however, a judge struc k down th e ordinance, asserting tha t individua l citie s did no t hav e

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the authorit y t o regulat e safet y i n th e workplace. 22 Th e judg e indicated tha t legislatio n regulatin g th e workplac e wa s unde r federal an d stat e jurisdiction . Interestingly , th e federa l govern ment was joined b y a major compute r manufacture r i n challenging th e ordinanc e i n th e firs t place . Anothe r attemp t a t legisla tion, i n Suffol k County , Ne w York , similarl y failed , becaus e the cour t rule d tha t th e count y di d no t hav e th e authorit y t o legislate. Unfortunately, eve n when bill s regarding VDTs and employe e safety d o come befor e stat e legislatures, they suffe r simila r fates . For example , a bill presented t o the Massachusetts Hous e Com merce an d Labo r Committe e require d employer s t o provid e VDT operator s wit h non-VD T wor k o r radiation-fre e equip ment durin g pregnancy . Actio n o n th e bil l wa s delaye d pendin g the publicatio n o f studie s o n th e healt h effect s o f VDTs . Thi s could b e a lon g wait . Moreover , eve n wit h healt h hazard s suc h as repetitiv e strai n injuries , whic h ar e wel l documente d an d cost employer s a n estimate d $10 0 billio n annuall y i n claims , legislation i s stil l stonewalled , a s i t wa s i n Sa n Francisc o an d Suffolk County . I n fact , i n 1995 , th e Occupationa l Safet y an d Health Administratio n (OSHA ) yielde d t o politica l pressur e from som e member s o f th e Hous e o f Representative s an d re scinded plan s t o issu e regulation s protectin g worker s fro m re petitive strai n injuries . Previous bill s introduce d int o th e Massachusett s legislatur e were als o thwarted. On e legislativ e member indicate d tha t thes e bills simpl y becam e obsolete , becaus e technologica l change s have no w mad e i t possibl e t o desig n a mor e economicall y efficient workstation . Apparentl y thi s membe r di d no t conside r the possibility tha t employer s woul d no t upgrad e thei r worksta tions unles s compelle d t o b y law . Eventually, th e Massachusett s bill died fro m lac k o f interest . Maine an d Rhod e Islan d hav e manage d t o secur e statute s

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that requir e bette r instructio n o f employee s o n th e saf e us e o f VDTs. I n Rhod e Island , th e Departmen t o f Labo r wa s require d to develo p a n "informationa l brochur e relatin g t o th e us e o f video displa y terminal s i n th e workplace." 23 Th e statut e als o required tha t th e Departmen t o f Labor , i n conjunctio n wit h business, industry , an d labo r develo p a pla n fo r disseminatin g the brochur e t o al l "concerne d parties " an d fo r providin g a series of training programs an d seminar s expandin g o n informa tion i n the brochure . In Maine , employer s ar e require d t o provid e a n educatio n and trainin g progra m t o describ e bot h prope r us e o f VDT s and protectiv e measure s operator s ca n tak e t o avoi d injury. 24 Employers must also instruct employees on the use of ergonomi c equipment an d health y posture . Finally , employer s ar e require d to notif y employee s o f thei r right s t o suc h educatio n an d train ing. Al l o f thes e provision s mus t b e carrie d ou t withi n on e month o f employment . Both th e Rhod e Islan d an d Main e statute s ar e relativel y ob scure an d hav e receive d littl e attention . Th e impac t o f th e stat utes or the degree of compliance i s unknown. I n 1994 , Connect icut approve d a statut e tha t require d th e commissioner s o f Labor an d Healt h Service s t o establis h guideline s regardin g safety standard s fo r stat e employee s wh o us e VDT s b y 1 Jul y 1994. 25 Sinc e thes e guideline s d o no t appl y t o privat e industry , they may no t mee t with arden t opposition . Businesses a s wel l a s communitie s hav e presente d stron g op position t o legislatio n regulatin g potentia l workplac e hazards . In fact , businesses , including , o f course , th e compute r industry , have reportedly spen t millions to squelch interes t an d concern. 26 Communities ofte n fea r tha t th e possibl e additiona l expens e of implementin g safet y regulation s wil l dete r businesse s fro m locating i n thei r are a o r eve n provok e som e businesse s int o leaving. Thi s i s a realisti c concern 27 an d support s th e nee d

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for federa l regulation . Unfortunately , th e Hous e Appropriation s Subcommittee slashe d fundin g fo r NIOSH , th e federa l agenc y designed t o advocat e fo r workplac e safety , 24. 9 percen t fo r th e 1996 fisca l year . Simila r proposal s t o reduc e th e OSH A budge t have bee n advanced . Conversely, legislatio n t o protec t worker s fro m th e hazard s of VDT s ha s fe w powerfu l proponents . Politician s generall y avoid thi s issue , undoubtedl y becaus e o f th e potentia l backlas h from busines s an d industry . VD T operator s d o no t hav e thei r own union . However, som e unions tha t includ e clerical worker s have advocate d fo r legislation . Althoug h union s hav e generall y not succeede d i n gettin g legislatio n approved , the y hav e bee n successful a t negotiatin g th e inclusio n o f VD T provision s i n th e contracts o f som e Ne w Yor k Cit y employees 28 a s wel l a s som e employees o f th e Socia l Securit y Administration. 29 Still, neither th e state s no r th e federa l governmen t hav e seri ously attempte d t o utiliz e thei r authority , a s acknowledge d b y the courts, to regulate workplace safety . Federa l standard s coul d be easil y designe d an d implemented . Numerou s othe r countrie s have been regulating VDT emissions and workstations fo r years , and compute r manufacturer s hav e complied .

International Standard s Electromagnetic emission s ar e measure d i n milligaus s (mG) . I n 1986, Sweden' s Nationa l Boar d fo r Measuremen t an d Testin g published a se t o f suggeste d voluntar y guideline s fo r compute r manufacturers, limitin g emission s t o 2. 5 m G (a t approximatel y two fee t fro m th e monitor). 30 Sinc e then , thes e standard s hav e become bot h mandator y an d mor e stringent . Worldwide , Swe den's standard s ar e considere d exemplar y i n use r safety. 31

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(Meanwhile, bac k i n th e Unite d States , on e compute r exper t measured emission s fro m hi s personal compute r a t 10 0 mG.) 3 2 New Zealan d als o enacte d impressiv e regulation s i n 1981 . The Cod e o f Practice 33 provide s guideline s fo r th e workplac e that appl y t o manufacturers , supplier s o f equipment , an d em ployers. Standard s fo r protectio n o f th e eyes , the musculoskele tal system , an d th e ski n wer e established . Employer s ar e als o encouraged t o allo w pregnan t VD T operator s t o transfe r t o non-VDT duties . Becaus e th e standard s appl y t o ne w acquisi tions bu t no t existin g equipment , businesse s an d corporation s could compl y wit h littl e adde d expense . Lik e Sweden , Ne w Zealand i s in th e proces s o f updatin g an d tightenin g thei r stan dards. On th e whole , mos t Europea n standard s ar e mor e stringen t than thos e i n th e Unite d States . Compute r manufacturer s hav e responded t o thi s deman d b y producin g tw o models , on e fo r European market s an d on e for American .

The Cos t o f Regulatin g Ideally, regulations woul d provid e fo r res t breaks , safe worksta tion equipment , limit s o n continuou s usage , and , o f course , the option o f transferrin g t o non-VD T wor k durin g pregnancy . Numerous othe r regulation s coul d b e implemente d easil y an d inexpensively. Severa l simpl e modifications coul d greatl y attenu ate the effec t o f VDTs o n pregnan t women . One commo n misconceptio n i s tha t mos t o f th e electromag netic radiatio n emitte d fro m VDT s come s fro m th e screen . I n fact, mos t o f th e radiatio n i s emitte d fro m th e flybac k trans former i n th e bac k o f th e compute r monitor , followe d b y th e sides an d th e top . Generally , th e dange r regardin g exposur e i s

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not fro m th e VD T operator' s ow n compute r monito r bu t rathe r from computer s behin d th e operator. Man y employer s line computers u p i n rows , wher e th e exhaus t fro m th e bac k o f on e VDT operator' s monito r blow s directl y o n th e bac k o f anothe r operator. T o protec t employee s fro m exposure , th e bac k o f computer monitor s shoul d fac e a n are a awa y fro m othe r em ployees, fo r example , towar d a wall . Anothe r feasibl e solutio n is to pu t greate r distanc e betwee n row s o f operators , a s electro magnetic radiatio n dissipate s beyon d a distanc e o f thre e feet . These solution s ar e relativel y inexpensiv e an d i f federall y man dated, coul d greatl y reduce th e risks o f exposure . It would als o b e simple and inexpensiv e t o require employer s to periodicall y tes t th e leve l o f electromagneti c radiatio n emis sions i n th e workplace . Regulation s coul d specif y acceptabl e emissions levels . Gauge s ar e s o inexpensiv e tha t the y ar e cur rently markete d t o th e genera l publi c t o allo w privat e individu als t o tes t emissio n level s i n thei r ow n homes . Sinc e employer s insist tha t th e curren t level s ar e saf e anyway , periodi c testin g should pos e n o threat , an d th e expens e woul d b e limite d t o th e one-time purchas e o f a gauge . I t i s quit e inconsisten t t o protec t employees fro m th e hazar d o f breathin g secondhan d smok e but d o nothin g t o monito r thei r exposur e t o electromagneti c radiation. Testin g emission s coul d als o protec t a n employe r from unwarrante d suits , since the record woul d sho w that emis sion levels were within th e acceptabl e range . Of course , th e easies t solutio n woul d b e t o requir e tha t em ployees b e full y informe d o n a numbe r o f issues . Firs t an d foremost, employee s should kno w the risks that might b e associated wit h VD T usage , s o tha t the y ca n mak e a n informe d deci sion. I f the y choos e t o tak e th e ris k o f exposur e t o emissions , they shoul d sig n a releas e o f liability . B y not informin g employ ees abou t potentia l risks , employer s hav e i n effec t mad e th e decision o n th e employees ' behalf . This wa y o f proceedin g con -

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flicts with bot h th e Suprem e Court' s rulin g i n Johnson Controls and th e Pregnanc y Discriminatio n Act . I n Johnson Controls th e employer decide d tha t wome n shoul d no t b e expose d t o lea d because i t pose d to o grea t a ris k t o them . I n th e cas e o f VDTs , employers hav e decide d tha t compute r monitor s d o no t pos e a risk, s o everyon e ca n b e safel y exposed . I t i s no t onl y th e em ployees wh o ma y b e harme d b y suc h high-handedness ; th e em ployers ar e settin g themselves u p fo r liabilit y suits . Next, employee s shoul d b e educate d o n ho w t o effectivel y use th e ergonomi c equipmen t employer s spen d s o muc h mone y on. Onl y a smal l percentag e o f employee s kno w ho w t o adjus t their ergonomi c workstation. 34 Sometime s thes e ergonomi c workstations actuall y hav e a n adverse effec t o n employe e healt h when furnitur e i s incorrectl y adjusted . Sinc e ergonomic s ma y factor int o th e reproductiv e complication s suffere d b y VD T operators, teachin g employee s ho w t o adjus t thei r workstation s may alleviat e the problem an d a t a low cost/high benefi t ratio . An alternative o r complement t o workplace regulatio n woul d be the regulation o f computer manufacturers . VD T manufactur ers i n th e Unite d State s alread y hav e th e capabilit y t o tur n ou t low-radiation model s an d VD T screens , o r radiatio n shield s (although th e wort h o f thes e screen s i s debatable , sinc e the y filter emission s fro m th e fron t o f th e monito r wher e emission s are th e weakest) . I n addition , th e deman d fo r low-radiatio n models i s beginnin g t o increas e i n th e Unite d State s a s consum ers hav e becom e mor e concerne d wit h th e potentia l healt h haz ards associate d wit h VD T usage . Compute r manufacturer s could b e require d t o produc e onl y low-emissio n models—th e kind the y alread y produc e fo r th e European market . Thi s woul d not onl y mak e th e workplac e safe r bu t reduc e emission s i n th e overall environmen t a s well . Th e automobil e industr y ha s bee n subject t o comparabl e regulatio n fo r years . If nothing else , manufacturers coul d b e required t o eithe r pu t

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a warnin g labe l o n th e VD T itsel f o r provid e wit h th e purchas e of ever y VD T a pamphle t addressin g safet y issue s (preferabl y both). Th e obviou s benefi t o f a warnin g labe l i s that ever y use r of th e VDT would b e likely to se e it, whereas no t ever y user ha s equal acces s t o packagin g informatio n whe n th e VD T i s i n a work settin g o r publi c facility . Warnin g label s ar e routinel y included o n mos t product s tha t represen t a possibl e safet y risk , from ligh t fixtures t o children' s toy s t o dr y cleanin g bags . I f worded correctly , the y d o no t ope n th e manufacture r u p t o liability bu t simpl y infor m th e consumer . Fo r example , manu facturers o f alcoholic beverage s warn consumer s o f the potentia l hazard o f drinkin g alcoho l whil e pregnant bu t ar e not liabl e if a pregnant woma n choose s t o drink . Similarly , pamphlet s coul d provide informatio n withou t makin g th e VD T manufacture r more vulnerabl e t o liability . Sinc e a lin k wa s suggeste d betwee n cellular phones an d brai n cancer, cellular phone companie s hav e been routinel y includin g safet y informatio n wit h thei r instruc tion booklets . Currently , mos t peopl e d o no t eve n realiz e tha t VDT usag e ha s bee n associate d wit h reproductiv e complica tions, an d th e fe w wh o hav e hear d o f th e risk s ten d t o believ e that i f the y wer e serious , th e governmen t woul d hav e b y no w intervened wit h appropriat e regulation . Man y American s oper ate unde r th e assumptio n tha t th e governmen t i s paternalisti c and place s th e healt h an d welfar e o f th e commo n citize n ove r the interest s o f bi g business .

The Pric e o f No t Regulatin g In no t supportin g regulation , corporation s ar e penny-wis e bu t pound-foolish. Apparentl y th e short-term expens e is a deterrent . However, economica l short-ter m solution s coul d diminis h long term expense . Conversely , a lac k o f interventio n coul d resul t

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in lowe r productivity , highe r healt h car e costs , an d employe e disaffection. VDT-relate d injurie s alread y afflic t a t leas t fiv e million peopl e i n th e Unite d States, 35 costin g corporation s mil lions i n healt h car e claims , los s o f productivity , an d compensa tion premiums . And thi s i s only th e tip o f th e iceberg . Lawsuits ar e croppin g up , an d i t i s onl y a matte r o f tim e before employer s an d manufacturer s wil l routinel y b e sue d fo r health problem s attributabl e t o VD T radiation . Litigant s hav e already claime d tha t electromagneti c emission s fro m cellula r phones, power lines , radar guns , and VDTs are linked t o variou s health hazards , particularl y cancer. 36 Fo r instance , tw o airlin e reservations agent s develope d cervica l cance r an d die d i n 1980 . In a lawsui t file d o n thei r behalf , th e plaintiff s argue d tha t th e cancers wer e cause d b y VDT exposure. 37 Th e cour t hel d fo r th e manufacturer, i n par t becaus e th e plaintiff s di d no t presen t strong enoug h evidenc e fo r a relationshi p betwee n VDT s an d cervical cancer. However, a more compellin g argumen t coul d b e made today . Th e cos t o f litigation , especiall y i f pursue d t o th e appeals level , shoul d provid e employer s wit h a n incentiv e fo r regulation. Product liabilit y suit s hav e als o bee n file d regardin g VDTs. 38 Product liabilit y claim s ca n b e file d agains t anyone , fro m th e manufacturer t o th e distribute r t o th e employer , althoug h th e employer ma y b e immun e fro m liabilit y i n som e case s unde r worker's compensation laws. 39 Product liabilit y claims can focu s on negligenc e (reasonabl e car e wa s no t exercise d t o protec t consumers), o r o n stric t liabilit y (th e produc t wa s defectiv e o r unreasonably dangerous) . I n th e latte r case , a manufacturer' s failure t o war n ca n becom e a pivota l issue . I n an y case , regula tion coul d actuall y protec t manufacturer s an d employer s a s well as employees. If emission standard s wer e set, manufacturers an d employers wh o me t the m coul d insulat e themselve s fro m liabil ity. On th e othe r hand , wit h n o standard s i n place, manufactur -

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ers an d employer s regulat e themselve s an d ma y becom e liabl e for unsaf e conditions . Johnson Controls serve s a s a reminder o f the hazards o f self-regulation . Manufacturers ar e beginnin g t o realiz e th e importanc e o f protecting themselve s an d wardin g of f liability . I n 1992 , Appl e Computer, IB M Corporation , an d Compa q Compute r an nounced plan s t o contribut e $2.2 5 millio n t o creat e th e VD T Health Researc h Foundatio n a t Johns Hopkin s University. 40 Al though thi s sound s like , an d ma y wel l be , a ste p i n th e righ t direction, i t i s importan t t o not e tha t th e fundin g fo r thi s re search come s fro m corporation s wit h a veste d interes t i n th e outcome.

The Waitin g Gam e One influential politicia n has voiced concern ove r the VDT issu e and advocate d increase d researc h an d attention . I n 1989 , then Senator Alber t Gor e underscore d th e nee d fo r mor e researc h o n the relationship betwee n VDT s an d reproductiv e complications : There ar e stil l man y unanswere d question s abou t th e potentia l health effect s o f VDT s an d o f electromagneti c fields generally, but there is no longer an y doubt that thi s form o f radiation can cause som e biochemica l changes . I n m y vie w tha t informatio n alone is sufficient t o warrant a renewed commitment on the part of government and private industry to study this issue and search for solutions to protect people. 41 Obviously tha t renewe d commitmen t ha s yet to b e made. It is estimated tha t ove r twent y millio n America n wome n us e VDTs i n th e workplace. 42 A t thi s poin t th e impac t o f VDT s o n reproduction i s unknown. Eve n i f curren t model s ar e harmless , the potentia l hazard s o f futur e VDT s ar e unknown . A t worst ,

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regulation woul d simpl y b e a superfluou s precaution . However , if VDT s reall y ar e dangerous , regulatio n coul d begi n t o contro l potential healt h hazard s eve n befor e the y emerg e clearl y an d unambiguously. Instea d legislator s wai t fo r researc h results . Bu t without legislatio n researcher s canno t find fundin g sources : businesses d o no t wan t t o fun d researc h tha t ma y resul t i n potential liabilit y issue s fo r them , whil e governmen t grant s ar e often subjec t t o politica l interference , a s demonstrate d b y th e NIOSH study . The poin t o f thi s chapte r i s no t t o convinc e th e America n public tha t VDT s caus e miscarriages . Th e mor e critica l concer n is th e wa y tha t th e politica l agend a behin d thi s issu e ha s hin dered research , s o tha t now , mor e tha n fifteen year s afte r clus ters o f miscarriage s wer e first reporte d i n possibl e associatio n with VD T use , w e stil l hav e n o definitive findings and , mos t importantly, n o constructiv e solution s o r safeguards . If ther e i s a connectio n betwee n VDT s an d miscarriage , th e individuals a t greates t ris k woul d probabl y b e thos e women — for example , telephone operators , mai l orde r clerks , an d airlin e reservations clerks—wh o ar e expose d t o massiv e emission s from numerou s terminal s line d u p i n small , poorl y ventilate d areas. Th e suboptima l workin g condition s combine d wit h rigi d work schedule s make thes e jobs stressful . Ironically , man y blue collar parent s o f baby-boomer s ofte n labore d unde r dangerou s and physicall y debilitatin g condition s i n th e hope s o f givin g their childre n th e superio r educatio n tha t woul d equi p the m t o pursue safe r occupation s i n healthie r environments . However , only th e type s o f hazard s an d physica l stres s hav e changed , no t the levels. It i s curiou s tha t a healt h hazar d tha t potentiall y affect s a vast percentag e o f th e population , mainl y women , ha s bee n largely ignored . I t appear s tha t man y politicians , an d th e gov ernment a s a whole, are quick t o regulate women's reproductiv e

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health an d autonom y i n suc h area s a s abortio n an d substanc e abuse, eve n whe n i t i s clea r tha t wome n d o no t benefi t fro m the attempte d surveillance . However , whe n regulatio n coul d enhance th e healt h an d welfar e o f wome n a t th e expens e o f corporate America , th e governmen t i s extraordinaril y slo w t o act. Eve n i n th e workplace , o r perhap s especiall y i n th e work place, reproductive issue s ar e subjec t t o politica l agendas . In th e 1996 election , th e politic s o f reproductio n an d th e famil y onc e again played a pivotal role .

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ach state or federal election , every nominatio n t o th e Suprem e Court , remind s American s o f the pivotal role that women's reproductive rights play in politics. In elections, some individuals vot e solel y on a candidate's stanc e regarding reproductiv e choice , that is , regarding abortion . Simi larly, th e selectio n an d confirmatio n o f Suprem e Cour t justice s has frequentl y turne d o n th e nominee' s interpretatio n o f an d opinions abou t Roe v. Wade. On e appointmen t coul d disrup t the balanc e o f th e Suprem e Cour t an d affec t th e statu s o f Roe v. Wade an d th e reproductive option s o f generation s o f women . For mos t antichoic e individuals , th e "unborn " ar e huma n beings an d hav e th e sam e right s a s al l othe r citizens . Believin g that there is no one to speak for th e rights of the unborn, the prolifers attemp t t o spea k fo r them . Fo r prochoic e individuals , th e issue is often mor e equivocal. Consider the following example . [131]

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Mary an d John hav e a newbor n infan t wh o wa s bor n wit h a serious live r defect . Th e bab y wil l di e i f sh e doe s no t receiv e a transplant withi n th e nex t fe w days . Mar y i s no t a compatibl e donor bu t Joh n is . N o othe r compatibl e donor s ar e available . Doctors ar e sometime s abl e t o transplan t a portio n o f a liver , but ther e i s n o guarante e o f success , an d th e operatio n als o carries seriou s risk s fo r th e donor , includin g infection , hemor rhage, diminishe d live r capacity , an d complication s (sometime s fatal ones ) fro m anesthesia . Joh n i s conflicted . H e wa s neve r committed t o havin g thi s bab y i n th e firs t place . H e perceive s the risk s t o hi s ow n lif e t o b e significant , an d h e i s philosophi cally oppose d t o surgery . Clearl y John face s a tough choice , bu t it i s his decisio n t o make . Although i t may b e easy to determin e what on e believe s Joh n shoul d d o o r wha t on e woul d onesel f do i n th e sam e situation , th e questio n is , doe s anyon e hav e th e right t o mak e thi s decisio n fo r Joh n an d forc e hi m t o carr y i t out? Prochoice advocate s believ e that , jus t a s n o on e shoul d b e able t o forc e Joh n int o a live r donation , s o n o on e shoul d b e able t o coerc e a woman int o bearin g a child, sinc e i t i s she wh o assumes th e healt h risk s an d ofte n th e economic , social , an d educational burdens . The woman shoul d hav e bodily autonomy , the righ t t o mak e he r ow n decision s regardin g he r ow n body . This doe s no t mea n tha t al l prochoic e advocate s ar e proabor tion, o r woul d choos e t o hav e abortion s themselves . The y sim ply believ e that eac h woman shoul d b e able to make tha t choic e for herself. Sinc e n o on e ca n definitivel y establis h whe n lif e begins, i t i s u p t o eac h woma n t o determin e whethe r he r fetu s represents a huma n lif e o r no t an d whethe r sh e ca n bea r th e responsibility fo r th e decisio n tha t sh e makes .

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Abortion i n th e Unite d State s It is no coincidence that when contraceptiv e research , education , and availabilit y declines , relianc e o n abortio n increases . Fo r example, i n th e 1960 s an d 1970 s ove r twent y pharmaceutica l companies conducte d researc h o n birt h control . Publi c fundin g for contraceptiv e service s significantl y decline d i n th e 1980s, 1 and i n 199 6 onl y on e compan y i s doin g researc h o n birt h con trol. Correspondingly , th e numbe r o f lega l abortion s i n th e United State s rose fro m 744,60 0 i n 197 3 (th e year Roe v. Wade was decided ) t o 1,034,20 0 in 197 5 t o 1,588,60 0 i n 1985. 2 This represents approximatel y one-fourt h o f al l pregnancie s i n th e United States . I t i s estimate d tha t 4 6 percen t o f al l America n women wil l have a n abortio n b y the ag e of forty-five. 3 Birth contro l an d abortio n technique s hav e existe d fo r centu ries. Birt h contro l method s hav e include d ingestin g suc h unap pealing concoction s a s "contraceptiv e fudge, " whic h containe d quinine, borax, salicyli c acid, an d coco a butter , o r usin g woole n tampons. Hippocrate s reportedl y invente d a n earl y versio n o f the intrauterin e devic e (IUD) , consistin g o f a hollo w lea d tub e that wa s filled wit h fa t an d inserte d int o th e uterus . H e appar ently also advised patient s o n ho w t o interrup t a pregnancy. 4 In th e earl y year s o f th e America n republic , commo n la w determined th e lega l statu s o f contraceptio n an d abortion . Un der the common law , termination o f a pregnancy befor e "quick ening," th e firs t apparen t feta l movement , wa s permitted. Abor tion wa s widel y practice d an d les s likel y t o b e perceive d a s morally wron g tha n i t i s today . However , i n th e 1800s , law s against birt h contro l an d abortio n wer e enacted , culminatin g i n the Comstoc k Ac t o f 1873 , a federa l statut e tha t massivel y restricted acces s t o informatio n abou t contraceptio n an d abor tion. Thes e law s wer e a t leas t partiall y influence d b y lobbyin g from th e medical profession. Lobbyin g le d to licensin g laws tha t

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eliminated man y potentia l provider s o f abortio n services , suc h as midwives, and gav e the medical profession contro l ove r abor tion an d othe r obstetric/gynecologica l procedures . Ironically , one hundre d year s later , th e America n Medica l Associatio n (AMA) cam e forwar d a s on e o f th e stronges t advocate s o f safe , legal abortions , afte r viewin g firsthan d th e consequence s o f ille gal ones . Some scholars believe that the Comstock Ac t was the all-mal e legislature's attemp t t o subdu e th e developin g independenc e o f women an d inhibi t change s i n th e famil y structure , includin g declining size. 5 I n an y case , exactl y on e hundre d year s befor e Roe v. Wade, th e Unite d State s first statutoril y restricte d acces s to contraceptio n an d abortion . Many peopl e ar e amaze d t o lear n tha t marrie d couple s wer e not guarantee d th e righ t t o b e fre e fro m crimina l prosecutio n for usin g contraceptive s until 1965. Prio r t o tha t date , som e states ha d law s agains t eithe r usin g contraceptives o r aidin g an d abetting anothe r individua l i n th e us e o f them. 6 I n Connecticut , for example , it was a crime, punishable b y a fine, imprisonment , or both , fo r anyon e t o attemp t t o preven t conception . Anothe r Connecticut statut e mad e i t possibl e t o appl y simila r penaltie s to anyon e wh o assiste d i n contraceptiv e use . When th e directo r of a Planne d Parenthoo d clini c an d a physicia n wer e arreste d for violatin g thes e statutes , they challenge d thei r constitutional ity. Th e Unite d State s Suprem e Cour t rule d tha t suc h law s vio lated a n individual' s constitutiona l right s unles s th e stat e coul d demonstrate tha t a compelling stat e interes t wa s a t stake . Two aspect s o f thi s decisio n wer e extremel y innovative . Th e first wa s th e applicatio n o f th e "stric t scrutiny " criterio n t o state law s o n contraception . I n decidin g whethe r a stat e la w i s constitutional, th e Suprem e Cour t ca n us e on e o f tw o ap proaches o r standards . I f th e "rationa l basis " standar d i s adopted, th e stat e onl y need s t o demonstrat e tha t ther e i s a

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rational basi s o r legitimat e purpos e fo r th e la w tha t i s reason ably relate d t o som e permissibl e governmenta l interest , an d th e law wil l no t b e foun d t o violat e th e individual' s constitutiona l rights. Thi s i s fairl y eas y t o accomplish , an d law s ar e generall y upheld whe n th e Suprem e Cour t use s thi s approach . Wit h th e "strict scrutiny " approach , o n th e othe r hand , th e stat e mus t demonstrate tha t i t ha s a "compellin g interest " i n th e issu e o r the la w wil l b e foun d unconstitutiona l becaus e i t violate s a n individual's constitutiona l rights . It i s much mor e difficul t fo r a state t o demonstrat e a compellin g interest , s o thi s standar d i s the mor e rigorou s o f th e tw o tests . In 1965 , the majorit y o f th e members o f th e Suprem e Cour t chos e t o us e th e strict-scrutin y standard fo r thi s contraception statute . The othe r innovativ e aspec t o f thi s decisio n wa s th e Suprem e Court's findin g tha t contraceptio n law s violate d a n individual' s right t o privacy . Th e Constitutio n doe s no t explicitl y cit e a fundamental righ t t o privacy , bu t th e cour t deduce d i t fro m th e Bill o f Rights , particularl y th e First , Third , Fourth , Fifth , an d Ninth Amendments . These amendment s assur e that citizen s wil l enjoy freedo m o f speec h an d assembly ; tha t the y canno t b e required t o hous e soldier s excep t i n tim e o f war ; tha t the y wil l be protecte d fro m unreasonabl e searche s an d seizures ; an d tha t they wil l no t b e deprive d o f life , liberty , o r propert y withou t due proces s o f law . Furthermore , th e Fourteent h Amendmen t requires th e state s t o uphol d mos t o f th e provision s o f th e Bil l of Rights . Therefore , n o stat e coul d enac t a la w tha t woul d violate thes e provisions, o r th e newly derive d righ t t o privacy . Once th e Suprem e Cour t ha d "fashioned " th e righ t t o pri vacy, severa l quic k decision s expande d thi s right . I n 197 2 th e Court foun d i n Eisenstadt v. Baird tha t th e righ t t o privac y i n contraceptive decision s extende d t o unmarrie d couples. 7 Then , in 1973 , Norm a McCorve y (bette r know n b y th e pseudony m Roe), a woman wh o coul d no t affor d t o trave l t o a stat e wher e

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abortion wa s lega l an d safe , becam e th e primar y plaintif f i n a class actio n sui t challengin g a Texa s statut e tha t criminalize d abortion excep t t o sav e th e lif e o f th e mother . Th e cas e becam e one o f th e mos t controversia l i n th e histor y o f th e Suprem e Court. I n Roe v. Wade th e Suprem e Cour t applie d th e strict scrutiny test and held that the Texas statute violated McCorvey' s right to privacy . In fashionin g it s opinion , th e Cour t attempte d t o balanc e th e woman's righ t t o privacy , th e right s o f th e state , an d th e right s of th e fetus . Th e Cour t rule d tha t th e stat e ha s a compellin g interest i n th e potentia l lif e th e fetu s represent s bu t no t unti l after th e poin t o f viability , th e poin t a t whic h th e fetu s ca n survive o n it s ow n outsid e th e uterus . In short , th e unbor n wer e not elevate d t o personhood . "Stat e regulatio n protectiv e o f feta l life afte r viabilit y thu s ha s bot h logica l an d biologica l justifica tions. If the stat e i s interested i n protecting feta l lif e afte r viabil ity, it ma y g o s o far a s to proscrib e abortio n durin g tha t period , except whe n i t i s necessar y t o preserv e th e lif e o r healt h o f th e mother." 8 A t tha t time , a fetu s wa s no t generall y considere d viable befor e th e thir d trimeste r o f th e pregnancy . Medica l tech nology ha s now extende d th e range o f viability t o the latter par t of th e secon d trimester . In short , prio r t o viability , the state' s interes t i n the fetu s wa s not deeme d compellin g enoug h t o overrid e the woman's right t o privacy. The detrimen t tha t th e stat e woul d impos e upo n th e pregnan t woman by denying the choice altogether is apparent. Specific and direct har m medicall y diagnosabl e eve n in early pregnancy ma y be involved. Maternity, o r additiona l offspring , ma y force upo n the woman a distressful lif e and future. Psychologica l harm may be imminent. Mental an d physical health ma y be taxed b y child care. There is also the distress, for al l concerned, associated with the unwanted child , and there is the problem of bringing a child

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into a family , alread y unable , psychologically an d otherwise , to care for it. In other cases, as in this one, the additional difficultie s and continuin g stigm a o f unwe d motherhoo d ma y b e involved. All thes e ar e factor s th e woma n an d he r responsibl e physicia n necessarily will consider in consultation. 9 The Cour t rule d tha t th e stat e als o ha d a compellin g interes t in the lif e an d healt h o f th e mother . However , sinc e the mortal ity rat e fo r childbirt h i s greate r tha n tha t fo r first-trimeste r abortion, th e Cour t foun d tha t th e state s could no t demonstrat e a compellin g interes t fo r prohibitin g abortio n i n the firs t trimes ter i n order t o preserve an d protec t materna l health . Since 197 3 th e constitutionalit y o f numerou s stat e law s re stricting abortion acces s has been challenged befor e th e Suprem e Court. Thi s ha s place d th e statu s o f Roe v. Wade i n jeopardy . Although Roe v. Wade stil l stand s a s goo d law , som e o f th e decisions hav e whittle d awa y a t th e fundamenta l righ t t o pri vacy in abortion decisions . It is interesting to note that ove r one third o f suc h challenge s hav e originate d i n tw o states , Missour i and Pennsylvania. 10 Althoug h th e challenges have remained sim ilar ove r the last two decades , the Supreme Cour t decision s hav e shifted. Thi s wa s see n mos t dramaticall y i n 1989 , whe n th e impact o f severa l conservativ e justices , appointe d durin g th e Reagan administration , bega n t o b e felt . Thes e appointment s altered th e tempe r o f th e Cour t an d it s position s o n severa l issues. One issu e tha t ha s com e u p severa l time s i s th e requiremen t of informe d consent . Informin g patient s o f treatmen t option s and o f th e possible risk s associate d wit h eac h on e i s good medi cal practice . However , th e informed-consen t statute s tha t hav e been challenge d includ e provision s tha t g o beyon d this , suc h a s a requiremen t tha t wome n seekin g a n abortio n receiv e informa tion o n feta l developmen t o r wai t fo r twenty-fou r hour s befor e undergoing th e procedure . Initiall y th e Cour t foun d thes e pro -

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visions unconstitutional. 11 Nevertheless , i n 1992 , th e Suprem e Court rule d tha t a Pennsylvani a la w requirin g a woman t o sig n an informe d consen t an d the n wai t twenty-fou r hour s befor e receiving a n abortio n wa s constitutional. 12 Thi s waitin g perio d is no minor problem fo r wome n wh o live in rural area s and hav e to trave l hour s t o reac h providers . Abortio n i s no t availabl e i n 83 percen t o f al l countie s i n th e Unite d States , an d i n Sout h Dakota ther e i s only on e abortio n provide r i n th e entir e state. 13 Moreover, given the increasing violence of the antichoice contin gent, requirin g a woma n t o visi t a n abortion-providin g facilit y more tha n onc e may b e putting he r i n considerable peril . The Supreme Court' s ruling s regarding parental consent/noti fication statute s hav e als o bee n contradictory . Man y state s hav e enacted law s requirin g wome n unde r th e ag e o f eightee n t o either notif y o r obtai n th e permissio n o f on e paren t befor e undergoing a n abortion. Initially, the Court found tha t requirin g parental consen t o r notificatio n violate d th e minor' s righ t t o privacy.14 In Planned Parenthood v. Danforth, th e Cour t wrot e Just as with the requirement of consent from th e spouse, so here, the Stat e doe s no t hav e th e constitutiona l authorit y t o giv e a third part y a n absolute , an d possibl y arbitrary , vet o ove r th e decision of the physician and his patient to terminate the patient's pregnancy, regardless of the reason for withholdin g the consent. . . . Constitutiona l right s d o no t matur e an d com e int o bein g magically onl y whe n on e attain s th e state-define d ag e o f ma jority.15 However, i n mor e recen t challenge s t o parenta l consen t stat utes, th e Suprem e Cour t ha s foun d the m t o b e constitutional , particularly i f th e woma n ha s acces s t o a judicia l bypass. 16 A judicial bypas s i s a mean s b y whic h a mino r ca n petitio n th e court to waive the parental-consent requirement . Th e judge ma y or ma y no t agre e t o this , an d obtainin g th e bypas s ca n tak e

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weeks. Often b y the tim e a minor ha s determine d an d acknowl edged tha t sh e i s pregnant , sh e ma y b e quit e advance d i n he r pregnancy. Sh e ma y no t hav e tim e t o attemp t a judicia l bypas s if sh e hope s t o hav e th e abortio n durin g th e first trimester , th e time whe n th e procedur e i s safes t an d leas t traumatic . I n addi tion, th e intimidatio n o f th e judicia l syste m ma y dissuad e man y young women fro m eve n attemptin g a judicial bypass . One youn g woman , Beck y Bell , the subjec t o f a recen t docu mentary, 17 foun d th e judicia l bypas s a n insurmountabl e obsta cle. Whe n Beck y learne d sh e wa s pregnant , sh e confronte d th e father o f th e child . H e wante d n o responsibilit y i n th e matter . Too embarrasse d t o tel l on e o f he r parent s an d obtai n consent , and convince d tha t a judicial bypas s was unlikely , she sought a n illegal abortion . Beck y becam e on e o f man y youn g wome n wh o die each year fro m th e medica l complication s o f a n illega l abor tion. Even if there is a judicial-bypass option , the Court ha s hel d that a statut e requirin g notification/consen t o f both parent s i s unconstitutional. x 8 The Suprem e Cour t ha s als o rendere d mixe d opinion s o n th e constitutionality o f statute s tha t requir e a physicia n t o perfor m viability test s o n wome n seekin g abortion s durin g th e secon d trimester. Initially , th e Cour t foun d suc h statute s vague. 19 Bu t eventually a statut e tha t denie d wome n pas t th e poin t o f viabil ity access to abortio n wa s upheld. 20 The Court' s ruling s have , however , bee n consisten t o n othe r issues. Fo r example , law s tha t requir e wome n t o notif y thei r husbands and/o r obtai n thei r consen t prio r t o obtainin g a n abortion hav e bee n struc k dow n b y th e Suprem e Cour t a s un constitutional. 21 Similarly , th e Suprem e Cour t ha s consistentl y struck dow n statute s requirin g tha t second-trimeste r abortion s be performe d i n hospitals, 22 althoug h i t ha s allowe d a statut e requiring tha t second-trimeste r abortion s b e performe d i n li censed clinics. 23

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Supreme Cour t ruling s o n th e us e o f federa l fund s fo r abor tions hav e als o bee n consistent . Overall , th e Cour t ha s repeat edly hel d tha t statute s limitin g o r denyin g th e us e o f federa l funds fo r abortion s ar e constitutional, 24 eve n thoug h federa l funds ca n b e an d ar e use d fo r pregnanc y an d childbirt h proce dures (an d eve n fo r sterilizations) . I n othe r words , a woma n receiving Medicaid ca n use that coverag e to pay fo r he r prenata l care an d deliver y bu t no t fo r a n abortion . Thi s ca n creat e a serious obstacl e t o abortio n fo r wome n o f lo w income . Th e Court ha s als o hel d tha t publicall y funde d hospital s ar e no t required t o perfor m abortions 25 an d tha t statute s prohibitin g the us e o f federall y funde d employee s o r facilitie s i n abortio n procedures ar e constitutional. 26 I n fact, Presiden t Reaga n imple mented a n administrativ e provisio n whic h mad e i t impossibl e for employee s o f clinic s receivin g federa l fund s t o eve n discus s the option o f abortio n wit h pregnan t wome n withou t jeopardiz ing thei r federa l funding . Thi s infamou s "ga g rule " wa s foun d constitutional b y the Supreme Court 2 7 bu t was voided b y executive order tw o day s afte r Presiden t Clinto n too k office . The Supreme Cour t ha s als o dodged som e potentially contro versial issues . When th e Missour i legislatur e approve d a pream ble to a statute that state d "lif e begin s at conception," th e Cour t deferred rulin g o n th e constitutionalit y o f th e preambl e sinc e i t did no t regulat e abortio n pe r s e bu t simpl y expresse d a valu e judgment o f the state. 28 One o f th e mos t recen t case s t o b e heard befor e th e Suprem e Court bear s noting . I n Bray v. Alexandria Women's Health Clinic,29 th e prochoice plaintiff s attempte d t o use a statute fro m the 1800s , originall y aime d a t th e K u Klu x Klan , t o preven t antiabortion protester s fro m blockadin g clinics . Th e Suprem e Court hel d that suc h an application wa s unconstitutional. (Late r Congress enacte d a la w protectin g acces s t o clinics. ) I n anothe r case, prochoice advocate s successfull y brough t a n action agains t

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a coalition o f antichoice groups, alleging that they were involve d in a nationwid e conspirac y t o clos e abortio n clinic s an d wer e thus i n violatio n o f RIC O (Racketee r Influence d an d Corrup t Organizations Act). 30 Thi s issu e wil l probabl y com e befor e th e Supreme Cour t again , a s violence towar d clinic s increases . The success o r failur e o f thes e challenges i s largely du e t o th e composition o f the Supreme Court . Presidents Reagan and Bush , who openl y voice d thei r antichoic e convictions , wer e abl e t o appoint a numbe r o f justice s t o th e Suprem e Cour t wh o share d their views . Fo r example , Clarenc e Thomas , wh o maintaine d during Senat e confirmatio n hearing s tha t h e ha d n o opinio n o n Roe v. Wade, ha s repeatedl y reveale d hi s antichoice stanc e sinc e his appointmen t t o th e Suprem e Court . Othe r judges , suc h a s Chief Justic e Rehnquis t an d Justic e Scalia , objec t t o th e us e o f the strict-scrutin y tes t t o evaluat e abortio n statute s an d believ e that th e rational-basi s tes t woul d b e mor e appropriate . I f mor e justices ar e appointe d wh o agre e wit h Rehnquis t an d Scalia , i t is likely that Roe v. Wade will be overturned, give n the ease wit h which th e rational-basis requiremen t ca n b e satisfied . Justice Sandr a Da y O'Conno r ha s fashione d he r ow n test , which som e refe r t o a s a middle-groun d approach . O'Conno r applies th e strict-scrutin y tes t onl y whe n th e la w i n questio n creates a n undue burden o n a woman' s righ t t o abortion . A n undue burde n i s a substantia l obstacl e impose d b y th e stat e t o limit access . Otherwise , O'Conno r use s th e rational-basi s test . Justices Kenned y an d Soute r hav e als o com e t o shar e he r ap proach. Thu s th e majorit y o f justice s currentl y o n th e Suprem e Court eithe r d o no t appl y th e strict-scrutin y tes t t o abortio n statutes o r appl y i t only i n selected instances . The justice s wh o vigorousl y defende d a woman' s righ t t o choose, suc h a s Thurgoo d Marshall , Willia m Brennan , an d Harry Blackmu n (th e autho r o f th e Roe v. Wade decision) , hav e all retired . O f th e nin e justice s currentl y o n th e Suprem e Court ,

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three—Rehnquist, Scalia , an d Thomas—hav e repeatedl y vote d against th e tes t se t fort h i n Roe v. Wade. Justic e Whit e (wh o originally oppose d Roe v. Wade i n 1973 ) wa s recentl y replace d by Justic e Ginsberg , bu t i t i s no t ye t clea r ho w Ginsber g o r Justice Breyer , wh o recentl y replace d Blackmun , wil l vot e o n abortion issues . In the meantime, Norma McCorvey , the woman wh o allowe d herself t o b e name d a s plaintif f i n Roe v. Wade, underwen t he r own conversion . I n Augus t 1995 , McCorve y wa s baptize d b y the nationa l directo r o f th e antichoic e grou p Operatio n Rescu e and announce d tha t sh e no longe r supporte d a woman's righ t t o choose abortio n after the first trimester. Whe n Sara h Wed dington, on e o f th e attorney s wh o argue d Roe v. Wade fo r the plaintiff s befor e th e Suprem e Court , learne d o f McCorvey' s attitude chang e sh e stated, "I' m shocked . At a time when we ar e working s o har d t o campaig n fo r peopl e wh o ar e pro-choic e and no t havin g much luck , I didn't nee d thi s one. " 31

A Possibl e Scenari o If Roe v. Wade wer e overturned , eac h stat e woul d the n b e abl e to fram e it s own polic y o n abortion . Man y state s would proba bly rever t bac k t o th e statute s the y ha d o n thei r book s prio r t o the 197 3 decision . Conservativ e state s woul d likel y mak e abor tion illega l o r strictl y limi t access , whil e mor e libera l state s would likel y permi t i t in a relativel y broa d rang e o f circum stances. Therefore , wome n wit h acces s t o mone y wh o wante d to terminat e a pregnanc y bu t wh o live d i n a stat e wher e abor tion wa s illega l coul d trave l t o a n abortion-friendl y state , bu t a poor woma n i n th e sam e situatio n woul d b e confronte d wit h several decisions . She coul d hav e an d kee p th e child , possibl y worsenin g he r

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economic plight. Sh e could giv e the child u p fo r adoption . Note , however, that ther e ar e presently ove r a million children waitin g to b e adopted i n the United State s alone. Contrary t o the pictur e painted b y the popula r media , we suffe r fro m a n extrem e short age o f adoptiv e parents, no t children, a crisi s tha t prompte d Speaker o f th e Hous e New t Gingric h t o sugges t th e reviva l o f the orphanage . Althoug h ther e ca n b e a short waitin g perio d (less than tw o years) fo r health y white infants , there is very littl e demand fo r othe r childre n an d therefor e virtuall y n o dela y i n adopting. Thi s doe s no t includ e th e enormou s number s o f in fants an d childre n wh o ar e literall y starvin g t o deat h an d ar e available fo r adoptio n throug h internationa l agencies . Women coul d als o decid e t o pursu e a n illegal , unsaf e abor tion. Historica l dat a suggest s tha t whe n a woma n desperatel y wants t o terminat e a pregnancy , sh e wil l d o s o eve n a t th e ris k of he r life . Prio r t o Roe v. Wade approximatel y 10,00 0 wome n died ever y yea r i n th e Unite d State s fro m illega l abortions . Today, worldwide, approximately 200,00 0 wome n di e each yea r from botche d abortions . I f Roe v. Wade wer e overturned , haz ardous, illegal abortions woul d agai n becom e on e way out o f a n unwanted pregnanc y fo r thousand s o f women , especiall y thos e of lo w income . If th e fetu s wer e t o b e acknowledge d b y th e Cour t a s a person, wit h constitutionall y protecte d rights , certain postcoita l contraceptives, suc h a s intrauterine device s (IUDs ) an d so-calle d "morning after " pills , coul d b e banned . Postcoita l contracep tives ar e contragestives , meanin g tha t the y prevent , no t th e fer tilization o f th e egg , bu t th e implantatio n o f th e embryo . Fo r example, the IUD irritates the endometriu m an d make s i t inhospitable t o implantation , s o that eve n i f the embry o doe s manag e to attac h itself , it will probably b e spontaneously aborted . I f lif e is deeme d t o begi n a t fertilization , suc h device s coul d becom e illegal.

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IVF practice s coul d als o b e affected . Froze n embryo s coul d have al l th e lega l protectio n afforde d t o persons , an d th e la w might requir e implantation . Othe r law s coul d restric t th e num ber o f embryo s implante d becaus e selectiv e abortion , t o termi nate multipl e pregnancie s tha t threate n th e lif e o r healt h o f th e embryos o r th e mother, migh t ru n int o lega l obstacles . Even th e use of fertility drug s coul d b e drastically affected. 32

The "Abortio n Pill " The struggl e t o obtai n Foo d an d Dru g Administratio n (FDA ) approval fo r on e drug , a virtua l ico n o f reproductiv e freedo m and choice , embodie s th e entir e conflict . Althoug h RU-486 33 has bee n termed th e "abortio n pill, " it can b e used as a precoita l contraceptive, a postcoita l contraceptive , o r a n abortifacien t (an agen t tha t induce s abortion) . Som e researcher s hav e eve n suggested tha t RU-48 6 ma y eventuall y b e availabl e a s a mal e contraceptive. 34 I n addition , i t ma y prov e t o b e a n effectiv e treatment fo r a variety o f illnesses , some o f them terminal . Each ne w menstrua l cycle , a n ovu m begin s t o matur e withi n the ovary . Th e ovu m i s surrounde d b y a follicl e whic h i s com posed o f tissue . Whe n ovulatio n occurs , th e rip e ovu m the n erupts fro m th e follicl e int o th e woman' s abdomina l cavit y an d is usually pulled into the fallopian tube . The follicle, now terme d the corpu s luteum , begin s t o secret e progesterone , whic h pro motes th e thickenin g o f th e endometriu m (th e linin g o f th e uterus) i n preparation fo r possibl e implantation . I f implantatio n occurs, the progesterone sustain s the embryo until the formatio n of th e placenta . I f implantatio n doe s no t occur , th e corpu s luteum wil l graduall y degenerate , an d th e declin e i n progester one (an d othe r hormones ) wil l trigge r th e onse t o f th e nex t menstrual cycle .

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RU-486, o r mifepristone , i s a chemica l compoun d tha t act s as a progesteron e inhibiter . I t prevents progesteron e fro m enter ing th e cell s o f th e endometrium . Th e endometriu m therefor e does no t thicke n i n respons e t o ovulation , an d th e onse t o f th e next menstrua l cycl e is triggered. Sinc e progesterone i s an essen tial componen t i n an y pregnanc y an d ha s a pervasiv e effec t o n the menstrua l cycle , RU-48 6 ca n b e use d a s a contraceptiv e i n two ways . First , lo w dose s ca n b e administere d throughou t th e menstrual cycl e or in the latte r hal f o f it. RU-486 i s thus compa rable t o th e standar d birt h contro l pill , bu t doe s no t expos e th e user t o multipl e hormone s an d ca n b e take n o n a mor e flexibl e schedule. Fo r example , a woma n onl y need s t o us e RU-48 6 during month s whe n sh e i s sexuall y activ e an d ca n discontinu e use a t othe r times . Currently , i n th e countrie s wher e RU-48 6 i s available, it is not frequentl y use d a s a contraceptive . RU-486 ca n als o b e use d a s a postcoital contraceptive , whe n a chose n metho d o f birt h contro l fail s (e.g. , whe n a condo m breaks o r when contraceptive s wer e not used) . IUDs are anothe r example o f postcoita l contraceptives , bu t ca n caus e discomfort , increase th e ris k o f pelvi c inflammator y disease , an d occasion ally perforate th e uterus .

The "Mornin g After " Pil l Sexually assaulte d wome n ar e ofte n offere d a postcoital contra ceptive commonl y calle d th e "mornin g after " pill . Like RU-48 6 the "mornin g after " pil l use s hormona l manipulatio n t o induc e a menstrua l cycle . Som e form s o f th e "mornin g after " pil l con tain DE S (se e not e 24 , chapte r 2) . Th e mos t commo n form , Ovral, i s no t a singula r pil l bu t rathe r a regime n combinin g several o f th e syntheti c estrogen/progesteron e pills. 35 Th e firs t dosage of the "mornin g after " pil l must b e taken within seventy -

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two hour s afte r intercourse , followed b y a second dosag e twelv e hours later . Th e postcoita l effectivenes s rate s fo r th e "mornin g after" pil l an d RU-48 6 ar e similar , althoug h th e rat e fo r RU 486 i s slightl y higher. 36 However , wome n see m t o experienc e more physical side effects fro m th e "mornin g after " pill , such a s nausea an d vomiting . O n th e othe r hand , the y repor t a greate r delay i n the onse t o f their nex t menstrua l cycl e from RU-486. 37 Recent surve y result s indicat e tha t 13 3 ou t o f 17 0 Planne d Parenthood clinic s an d 2 0 ou t o f 2 2 universit y clinic s wil l pre scribe th e "mornin g after " pil l i f a woma n request s i t withi n seventy-two hour s o f unprotecte d intercourse. 38 Mos t o f thes e clinics, particularl y thos e i n universit y settings , hav e ha d a "morning after " pil l available for ove r twenty years. Still, on th e whole, neithe r physician s no r th e genera l publi c kno w muc h about th e "mornin g after " pill . Thi s lac k o f awarenes s ma y b e due i n par t t o th e absenc e o f FD A approva l fo r a "mornin g after" pill , althoug h th e drug s hav e bee n approve d fo r othe r purposes (e.g. , birt h control) . Onc e a dru g i s approve d b y th e FDA, it is possible for physicians to prescribe it for nonapprove d purposes. Wyeth-Ayerst, th e pharmaceutica l compan y tha t manufac tures Ovral , ha s n o incentiv e t o see k FD A approva l fo r it s us e as a postcoita l contraceptive . First , th e expens e involve d i n demonstrating it s safety an d efficac y fo r thi s purpose woul d no t be balance d b y an y comparabl e gai n i n sales , sinc e th e dru g would no t b e consistentl y prescribe d t o an y patient . Second , approval o f Ovra l a s a postcoita l contraceptiv e woul d ope n th e company u p t o liabilit y suit s an d boycotts . A s i t stands , i f a physician prescribe s i t fo r nonapprove d uses , h e o r sh e bear s most o f th e liability , unles s a n inheren t defec t i n th e dru g i s discovered. However , th e lac k o f FD A approval make s th e dru g unavailable a s a postcoita l contraceptiv e t o a tremendou s num ber o f women i f their physicians are unaware o f alternativ e uses.

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Moreover, federall y funde d clinic s canno t dispens e a dru g fo r nonapproved purpose s unles s federa l fund s (Titl e X ) ar e no t used i n th e process . Ther e ar e relativel y fe w clinic s tha t d o not use federa l funds . Th e othe r postcoita l contraceptive , RU-486 , has no t bee n approve d b y th e FD A becaus e o f it s abortifacien t properties.

RU-486 a s a n Abortifacien t Many peopl e believ e tha t RU-486 , shoul d th e FD A approv e it , will make abortio n a s simpl e a s getting a prescription fille d a t a pharmacy. Purportedl y wome n wil l no w b e abl e t o terminat e pregnancies i n th e privac y o f thei r ow n homes . A s a conse quence, i t i s feare d tha t attitude s towar d abortio n wil l becom e nonchalant. Thi s misconceptio n spring s fro m ignoranc e o f ho w RU-486 work s a s an abortifacient . RU-486 i s administere d orall y withi n th e first fe w week s o f pregnancy. Th e earlie r i t i s taken, th e mor e effectiv e i t is. 39 Th e entire proces s require s thre e o r fou r visit s wit h a physician . During th e first visit , a n ultrasoun d i s often conducte d t o deter mine th e woman' s gestationa l stag e an d i f sh e i s a suitabl e candidate (wit h regar d t o he r health ) fo r treatment . Th e dru g may o r may no t b e administered durin g th e first visit. In France , there i s a one-wee k waitin g perio d betwee n th e first visi t an d administration o f th e drug . The drug' s antiprogesteron e proper ties caus e th e endometriu m t o deteriorate , whic h i n tur n cause s the natural secretio n o f prostaglandins, th e hormone s tha t assis t in th e expulsio n o f menstrua l tissu e b y inducing contraction s i n the uterus . Typically, abou t tw o day s afte r th e administratio n o f RU 486, th e woma n typicall y return s t o th e physicia n t o receiv e synthetic prostaglandin s a s well . Originally , syntheti c prosta -

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glandins were administered throug h injections , bu t now they ar e generally administere d orally . Ora l administratio n reduce s th e rate o f absorption , whic h seem s t o enhanc e th e safety , conve nience, and effectiveness o f the product. 40 Misoprosto l (o r Cyto tec), a drug commonl y use d to treat stomac h ulcers , now substi tutes fo r syntheti c prostaglandi n injections—muc h t o th e chagrin o f Cytotec' s manufacturer , th e Searl e Corporatio n ( a subsidiary o f Monsanto) , fo r antiabortionist s hav e threatene d i t with produc t boycott s eve n thoug h Searl e doe s no t marke t th e drug a s a n abortifacient . I n fact , th e produc t informatio n flie r that accompanie s prescription s o f Cytote c clearl y warns agains t the us e of the dru g durin g pregnancy . The embry o i s usuall y expelle d severa l hour s afte r adminis tration o f the prostaglandin, ofte n whil e the woman wait s in th e physician's office . However , sh e mus t retur n i n approximatel y two week s t o determin e i f th e proces s ha s bee n successful . I f used earl y i n th e pregnanc y an d take n i n combinatio n wit h synthetic prostaglandins , RU-48 6 i s approximatel y 9 5 t o 9 9 percent effective. 41 I n France , i f th e treatmen t doe s no t work , the woma n mus t agre e t o hav e a surgica l abortion , sinc e th e drugs may hav e damage d th e fetus . Most known sid e effect s fro m RU-48 6 ar e relativel y short-lived, usually ceasing within forty-eight hour s after admin istration. Thes e includ e nausea , vomiting , diarrhea , breas t ten derness, headache , fatigue , an d abdomina l cramps . Som e ab dominal crampin g i s painfu l enoug h t o requir e analgesics . Severe uterin e bleedin g ca n las t ove r a week , wit h abou t on e i n five hundred wome n requirin g blood transfusions. A few wome n (six i n five hundred ) experienc e a significan t dro p i n bloo d pressure. Som e o f thes e sid e effect s ar e directl y attributabl e t o RU-486, bu t mos t resul t fro m th e combinatio n o f RU-48 6 wit h synthetic prostaglandins . Th e long-ter m effect s o f RU-486 , par -

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ticularly o n futur e fertilit y an d th e immun e system , ar e no t ye t known. Of th e mor e tha n 150,00 0 wome n wh o hav e use d RU-486 , three suffere d hear t attacks , on e o f whic h wa s fatal . Eac h o f these women reportedl y ha d othe r "ris k factors " tha t ma y hav e led t o th e complication s (th e woma n wh o die d wa s a heav y smoker an d wa s undergoin g he r thirteent h abortion. ) A s a re sult, th e dru g i s no t recommende d fo r wome n wh o smok e o r who hav e or have had fibroids, circulatio n problems , high bloo d pressure, diabetes , sever e bronchitis , glaucoma , ulcers , colitis , anemia, bloo d clottin g problems , adrena l glan d problems , hear t disease, hig h cholesterol , a recen t caesarea n section , asthma , heart problems , pelvi c inflammator y disease , o r abnorma l men strual cycles . It is also not recommende d fo r wome n ove r thirty five year s ol d o r thos e mor e tha n seve n week s pregnant . I n addition, onl y speciall y traine d physician s shoul d administe r the dru g an d onl y whe n cardiovascula r monitorin g equipment , resuscitation medication/equipment , an d emergenc y facilitie s ar e available. Contrast abortion s brough t o n b y RU-48 6 wit h th e typica l surgical abortion . I f the pregnanc y i s in it s first trimester, gener ally a procedure know n a s a D & E (dilation an d evacuation ) o r vacuum aspiratio n i s performed : th e cervi x i s dilated , an d th e contents o f th e uteru s ar e remove d throug h suctioning . I f th e abortion i s performe d earl y i n th e pregnancy , th e woma n ma y not nee d a n anestheti c a t al l o r onl y a local one . Occasionally, i f som e product s o f pregnanc y remain , th e woman ma y hav e t o underg o a D & C (dilatio n an d curettage) . The cervi x i s dilate d an d th e wall s o f th e uteru s scraped . Th e D & C use d t o b e th e standar d procedur e fo r abortion , bu t i t has man y mor e risk s tha n a D &c E, includin g th e us e o f a general anesthetic , and i s less frequently use d today .

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There ca n b e man y sid e effect s fro m a surgica l abortion , including hemorrhaging , abdomina l pai n an d cramping , an d nausea. I f th e pregnanc y ha s advance d beyon d sixtee n weeks , saline o r syntheti c prostaglandi n i s often injecte d int o the amni otic sa c t o induc e labor . Labo r compound s th e ris k fro m th e abortion. Th e overal l ris k o f deat h fro m a legal , surgica l abor tion i n th e Unite d State s wa s estimate d i n 198 5 t o b e 0. 4 pe r 100,000. For women i n the United States , RU-486 would no t necessar ily b e a n easie r o r cheape r wa y t o terminat e a pregnanc y an d i s slightly less successfu l tha n surgica l abortion . RU-48 6 ma y re quire mor e visit s an d tak e mor e overal l tim e tha n mos t surgica l abortions. Unless a twenty-four-hou r waitin g perio d i s impose d after th e signin g o f th e informe d consent , surgica l abortio n generally require s tw o visits , on e fo r th e actua l procedur e an d one for a follow-up exam . Give n the greater numbe r o f appoint ments neede d whe n RU-48 6 i s th e abortifacien t o f choice , i t may prove eve n more costl y than surgery . However, RU-48 6 i s probabl y safer . I t i s als o les s invasive : women repor t feelin g mor e i n contro l o f th e proces s an d thei r bodies. Additionally, RU-48 6 ca n b e administere d earlie r i n th e pregnancy, an d unles s th e procedur e i s unsuccessful , surgery , with it s risk s o f infection , injury , an d anesthesi a complications , is eliminated. Som e wome n repor t tha t th e psychologica l tol l i s greater wit h RU-486 ; some report tha t i t is greater with surgica l abortions.

Why RU-48 6 Isn' t Availabl e i n th e Unite d State s RU-486 wa s synthesize d i n 198 0 b y a Frenc h researche r name d Etienne-Emile Baulie u an d wa s late r develope d b y th e dru g company Roussel-Ucla f (henc e th e initial s RU). I n 1988 , th e

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French governmen t approve d th e us e o f RU-48 6 a s a n abortifa cient, bu t Roussel-Ucla f withdre w i t fro m th e Frenc h marke t i n response t o protest s fro m th e Catholi c Churc h an d threatene d boycotts. Additionally, som e o f th e wives an d childre n o f Rous sel-Uclaf executive s wer e receivin g anonymou s threats. 42 More over, 5 5 percen t o f Roussel-Ucla f i s owne d b y Hoechs t A . G. , whose chie f executiv e office r i s a devout Catholic . Eventually, th e Frenc h ministe r o f healt h overrule d Roussel Uclaf's withdrawal , callin g RU-48 6 th e "mora l propert y o f women." Cynic s suggeste d tha t thi s actio n wa s motivate d b y the Frenc h government' s financial interes t i n th e dru g (i t own s 35 percen t o f Roussel-Uclaf ) o r wa s a n effor t t o absolv e Rous sel-Uclaf o f mora l responsibilit y i n th e public' s ey e an d thu s allow it to reap its profits. Th e company denie d the latter allega tion. 43 Similar protests were staged i n the United States , even thoug h the antichoic e administration s o f Reaga n an d Bus h neithe r in vited no r supporte d th e marketin g o f RU-486 . In fact , th e FD A specifically banne d th e importatio n o f RU-486 . Unde r th e Fed eral Food , Dru g an d Cosmeti c Ac t o f 1938, 44 befor e an y dru g can b e introduce d int o interstat e commerc e i t mus t b e foun d safe. I n 196 2 tha t ac t wa s expande d t o ensur e tha t drug s intro duced int o interstat e commerc e wer e no t onl y saf e bu t als o effective. T o obtai n FD A approval , a ne w dru g mus t first b e sponsored b y a dru g manufacturer , wh o submit s a n Investiga tional Ne w Dru g application. 45 Next , th e safet y an d effective ness o f th e dru g mus t b e supporte d b y researc h findings, whic h are submitted , alon g wit h informatio n abou t th e dru g an d it s possible uses , t o th e FDA . Technically , th e FD A mus t rejec t or accep t th e applicatio n withi n 18 0 days , bu t extension s ar e common. In Jul y 198 8 th e FD A introduce d a ne w program , calle d Pilot Guidance , which allowe d unapprove d drug s tha t pose d n o

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safety ris k t o b e importe d i n smal l quantitie s b y individual s fo r personal use . Forty drug s wer e exclude d fro m importation . RU 486 wa s no t excluded , however , i t wa s quickl y adde d t o th e exclusion lis t i n respons e t o politica l pressur e fro m con gressmen. The validit y o f thi s exclusio n wa s teste d i n July 1992 , whe n Abortion Right s Mobilization , a prochoic e group , fle w Leon a Benten, wh o reportedl y feare d a surgica l abortion , t o Englan d to obtai n RU-48 6 t o terminat e he r pregnancy . Whe n Bente n attempted t o brin g th e dru g bac k wit h he r t o th e Unite d States , it wa s confiscate d b y U.S. Custom s a t Kenned y Airpor t i n Ne w York City . Bente n sue d th e FDA , allegin g tha t i t acte d illegall y in confiscatin g th e drug . Whil e th e distric t cour t rule d i n Ben ten's favor, th e appeals court blocke d the district court's decisio n and th e U.S . Suprem e Cour t uphel d th e ban . Bente n subse quently ha d a surgical abortion . In effect th e ba n quashe d al l research o n RU-486 . In part thi s was du e t o th e ba n itsel f an d i n par t t o th e hostil e environmen t it created . Althoug h a n exceptio n t o th e importatio n ba n migh t have bee n mad e fo r researc h purposes , fe w peopl e wer e willin g to conduc t o r fun d researc h o n a dru g s o controversial . More over, Roussel-Uclaf , whic h hel d th e paten t rights , woul d no t sponsor th e dru g fo r FD A approva l whil e powerfu l sector s o f the American publi c were s o hostile t o it . The compan y decide d that, i n order fo r the m t o expor t th e dru g a s an abortifacient , the importing countr y woul d hav e to satisf y five conditions: (1) Abortion must be legal. (2) It must be widely accepted by "public opinion." (3 ) A suitabl e prostaglandi n mus t b e available . (4 ) Distribution must be under tight official control , as with narcotics. (5) Patients must sign a letter agreeing to a surgical abortion if th e pil l failed . I n practice , ther e wa s a sixt h condition : th e company would not sanction exports unless ranking government officials urge d them to do so. 46

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Although th e Unite d State s coul d hav e seize d th e paten t right s from Roussel-Ucla f i f th e publi c interes t wa s a t stake , neithe r the Reaga n no r th e Bus h administratio n interprete d th e unavail ability o f RU-48 6 a s a threa t t o th e publi c interest . A t thi s point th e possibility o f RU-48 6 becomin g availabl e to America n consumers seeme d remote . I n fact , Congressma n Ro n Wyde n referred t o th e ba n an d th e withholdin g o f FD A approva l a s "medical McCarthyism. " Then, i n 1992 , th e politica l climat e fo r RU-48 6 bega n t o change, wit h th e electio n o f Bil l Clinto n a s president . O n 2 2 January 1993 , Clinton's third da y in office, h e signed a presiden tial memorandu m encouragin g th e Departmen t o f Healt h an d Human Service s t o facilitat e testin g an d licensin g o f RU-48 6 i n the Unite d States . I n hi s memorandum , Clinto n suggeste d tha t the FD A ba n ma y hav e bee n prompte d b y consideration s othe r than th e safet y o f th e drug . Next , i n Apri l 1993 , the America n Medical Associatio n (AMA) , whic h ha d supporte d legalizin g RU-486 sinc e 1990 , an d th e America n Colleg e o f Obstetrician s and Gynecologist s (ACOG ) urge d Roussel-Ucla f t o appl y fo r FDA approva l s o tha t th e dru g coul d b e mad e availabl e i n th e United States . Finally, even th e FD A becam e mor e hospitable : i t indicated tha t furthe r clinica l trial s migh t no t eve n b e necessar y in order t o gain approval. 47 Roussel-Uclaf coul d no longer clai m that ther e wa s a n environmen t hostil e t o RU-48 6 i n th e Unite d States. After a yea r o f negotiation s (an d proddin g fro m th e Clinto n administration), i n Ma y 199 4 Roussel-Ucla f agree d t o relin quish th e technology an d paten t right s fo r RU-48 6 t o th e Popu lation Council , a nonprofi t contraceptio n researc h group. 48 Roussel-Uclaf receive d n o remuneratio n i n exchang e bu t di d secure immunity fro m liability . This factor weighe d heavil y wit h the company , give n th e liabilit y issue s relate d t o birt h contro l devices. (Roussel-Ucla f probabl y di d no t perceiv e tha t th e mar -

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ket valu e o f RU-48 6 woul d offse t th e liability. ) Roussel-Ucla f also receive d som e insulatio n fro m boycotts . However , shortl y after th e agreemen t wa s reached , antichoic e contingencie s tar geted severa l Roussel-Ucla f an d Hoechs t product s fo r boycott , attempting t o "persuade " the m t o rescind the licens e agreement . The Populatio n Counci l immediatel y assure d th e genera l publi c that Roussel-Ucla f n o longe r ha d lega l right s t o th e patent , an d the boycot t waned . As of 1996 , the impor t ba n o n RU-48 6 remain s i n effect, bu t the Populatio n Counci l i s attempting t o begi n researc h trial s o n its us e a s a n abortifacient . Th e researc h i s schedule d t o includ e two thousan d wome n enrolle d i n te n t o twelv e differen t clinic s across the United States . Eventually, the Population Counci l wil l probably see k FD A approva l fo r th e dru g an d a n America n manufacturer an d distributor . (Reportedl y dozen s o f manufac turers, most with limited product lines , have declared themselve s willing to ac t a s distributors. ) In 1994 , th e Worl d Healt h Organizatio n (WHO ) launche d an investigatio n int o th e us e o f RU-48 6 a s a postcoita l contra ceptive. Th e onl y America n researc h sit e schedule d wa s Sa n Francisco Genera l Hospital . I n Ma y 1994 , withi n twenty-fou r hours o f th e firs t advertisements , eight y wome n i n tha t cit y volunteered t o participat e i n th e study . I n Sa n Francisc o alone , twenty-one hundre d wome n wer e administere d th e dru g t o as sist i n determinin g th e optima l dos e fo r preventin g pregnancy . In tw o previou s studies , RU-48 6 wa s foun d t o b e 10 0 percen t effective a s a postcoital contraceptive . If the dru g i s approved a s a postcoita l contraceptive , i t ca n als o b e used , thoug h no t mar keted, a s a n abortifacient . However , regardles s o f th e results , i t is unlikel y tha t WHO , whic h woul d overse e th e distributio n o f RU-486 t o nonindustrialize d countries , would ac t i n oppositio n to America n sentiment , becaus e WH O receive s significan t fi nancial backin g fro m th e United States .

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Supporters o f RU-48 6 woul d lik e to se e the approva l proces s expedited, i n cas e futur e presidentia l election s resul t i n a n antichoice administration . I f an d whe n i t i s approve d i t wil l probably b e for ver y limited purposes . Antichoice force s ar e no t alon e i n thei r oppositio n t o RU 486. Som e prochoic e feminist s als o oppos e approval , althoug h for ver y different reasons . Politics makes strang e bedfellows .

Opposition t o RU-48 6 In contras t t o th e ver y voca l an d ver y visibl e antichoic e contin gencies, mos t peopl e i n th e Unite d State s woul d lik e t o kee p abortions lega l an d mos t believ e tha t RU-48 6 shoul d b e mad e available t o th e America n public . O n th e abortio n issue , th e Clinton administratio n appear s t o represen t th e view s o f th e majority. To antiabortionists, RU-48 6 i s a "huma n pesticide, " destroy ing "life, " a s they define it . This is inarguable, sinc e it represent s a personal , ofte n religious , belief . A secon d concer n i s that RU 486 wil l mak e abortio n easier , henc e mor e common , an d tha t attitudes towar d abortio n wil l becom e mor e casual . Th e avail able dat a d o no t suppor t thes e notions . Sinc e RU-48 6 wa s introduced i n Franc e i n 1988 , th e abortio n rat e ha s no t in creased. I n fact , on e coul d argu e tha t RU-48 6 actuall y lower s the abortio n rate : whe n use d a s a postcoita l contraceptive , i t makes th e uteru s unfavorabl e t o pregnancy , bu t technicall y a n abortion i s no t performed . Thi s howeve r provide s littl e solac e for thos e who believ e life begin s at conception . Prolifers als o maintai n tha t the y ar e concerne d ove r healt h risks t o women . Thi s i s als o th e mai n concer n fo r som e pro choice feminists . Fo r example , Janic e Raymond 49 argue s tha t RU-486 i s dangerou s an d tha t it s long-ter m effect s ar e un -

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known. Sh e refer s t o th e dru g a s a "chemica l brew " o r "dru g cocktail." Thi s i s a vali d concern . However , th e lac k o f wide spread, independen t researc h o n th e safet y o f RU-48 6 i s no t atypical, especiall y withi n th e are a o f women' s reproductiv e health. Historically , man y obstetric/gynecologica l procedure s were use d withou t bein g thoroughl y investigated . Additionally , many obstetric/gynecologica l medication s prescribe d fo r wome n were not adequatel y researched . Moreover , many curren t proce dures an d prescription s lac k empirica l support , an d a number o f these threate n women' s genera l health , thei r reproductiv e health, o r their lives . Clearly, there i s no need t o ad d t o the list . Notwithstanding, fo r a pharmaceutical, RU-48 6 ha s amasse d a tremendou s amoun t o f supportiv e data . Sinc e 1988 , 150,00 0 to 200,00 0 wome n hav e take n th e drug . Othe r postcoita l con traceptives an d abortifacient s currentl y i n us e hav e les s o r n o research support . Fo r example , i t i s impossibl e t o kno w th e long-term effect s o f birt h contro l pill s unti l th e firs t generatio n of wome n wh o use d the m fo r prolonge d period s becom e meno pausal and/o r postmenopausal . Ther e i s scan t researc h o n th e effects o f usin g Ovra l a s a postcoita l contraceptive , ye t thou sands o f wome n ar e prescribe d th e dru g eac h year . A dru g containing DES i s stil l prescribe d a s a n emergenc y postcoita l contraceptive. O n th e fac e o f it , a t least , RU-48 6 seem s safe r than an y of these drugs, since it blocks the production o f natura l hormones rathe r tha n introducin g syntheti c one s into the body . Perhaps mor e importantly , a t thi s poin t th e concep t o f a chemical postcoita l contraceptive/abortifacien t i s so well know n (and accepted ) that , i f RU-48 6 i s no t mad e availabl e i n th e United States , physician s an d agencie s wh o hav e concocte d al ternatives—true "chemica l brews"—ma y pu t women' s healt h at a greate r risk . I n Augus t 1995 , the prestigiou s New England Journal of Medicine publishe d a stud y b y Richar d U . Haus -

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knecht, a N e w Yor k gynecologist , w h o combine d t w o readil y available prescriptio n drugs , misoprosto l (Cytotec ) an d metho trexate, t o induc e abortion . Cytote c i s th e syntheti c prostaglan din commonl y use d wit h RU-486 . Methotrexat e i s a treatmen t used fo r arthritis , cancer , an d asthma . Excerpt s fro m on e p o p u lar guid e t o prescriptio n drug s includ e th e followin g caution s regarding methotrexate . Methotrexate ca n b e extremel y toxic , eve n i n th e relativel y lo w doses prescribe d fo r rheumatoi d arthritis . Thi s dru g shoul d b e considered "last-resort " therap y fo r non-cance r therapie s t o b e used onl y fo r sever e case s tha t hav e no t responde d t o othe r treatments. Methotrexat e shoul d b e prescribe d onl y b y doctor s who ar e familia r wit h th e dru g an d it s potentia l fo r producin g toxic effects . . . . Methotrexate ca n trigge r a uniqu e an d danger ous form o f lung disease at an y time during the course of therapy . . . . Methotrexat e ca n caus e sever e reductio n i n red - an d white blood-cell an d bloo d platele t counts . . . . Methotrexate ca n caus e severe diarrhea , stomac h irritation , an d mout h o r gu m sores . Death ca n resul t fro m intestina l perforatio n cause d b y metho trexate. . . . Th e mos t commo n sid e effect s ar e live r irritation , loss o f kidne y function , reductio n i n bloo d cel l counts , nausea , vomiting, diarrhea , stomac h upse t an d irritation , itchin g rash , hair loss , dizziness, and increase d susceptibilit y t o infection . Less common sid e effects includ e . . . slight paralysis. 50 Hausknecht selecte d w o m e n fo r th e stud y w h o wer e i n goo d health, emotionall y stable , an d les s tha n sixty-thre e day s int o their pregnancy . H e administere d a dos e o f methotrexat e intra muscularly, the n fiv e t o seve n day s late r administere d misopros tol intravaginally . O u t o f 17 8 w o m e n , 15 3 aborte d afte r th e first dos e o f misoprostol . A secon d dos e o f misoprosto l wa s administered t o th e remainin g twenty-fiv e w o m e n , an d eightee n then aborted . Seve n w o m e n neede d suctio n curettage . Tw o re searchers a t th e Universit y o f Californi a i n Sa n Francisc o hav e

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also tested Hausknecht's regime n o n more than fifty women an d plan t o tes t a hundre d more . However , on e membe r o f th e research tea m warne d tha t wome n shoul d no t tr y thi s metho d on thei r own , sinc e "w e can' t sa y wit h certaint y tha t thi s i s safe." 51 The questio n o f safet y aside , the ne w abortifacient s an d post coital contraceptive s brin g wit h the m th e prospec t o f commer cial exploitation . Althoug h th e drug s cos t les s tha n $10 , Haus knecht charge s $65 0 pe r patien t fo r th e entir e treatment. 52 London clinic s offe r treatmen t wit h RU-48 6 t o America n women wh o ar e abl e t o remai n i n Englan d fo r a two-wee k follow-up—a conditio n tha t restrict s th e patien t poo l t o thos e with enoug h mone y an d leisur e fo r suc h a prolonge d stay . I f the FD A woul d approv e an d regulat e a n abortifacien t fo r th e American market , i t woul d d o muc h t o righ t th e presen t ine qualities i n acces s to abortion . Abortion Right s Mobilization , th e grou p wh o sponsore d Benten's challenge regarding th e illegality o f the import ban , ha s also bee n frustrate d b y th e dela y i n approvin g RU-486 . The y have replicate d an d synthesize d a duplicat e medicatio n an d ar e ready t o begi n clinica l trials . Thi s "clone " ha s reportedl y bee n used fo r ove r five year s i n China . Althoug h al l th e physician s involved i n this enterprise undoubtedl y hav e women's safet y an d interest a t heart , th e extensiv e trial s throug h whic h RU-48 6 ha s already gon e make i t the safes t abortifacien t no w known . But i s i t safe r tha n a pregnancy ? Thi s i s determined, i n part , by th e ag e an d healt h o f th e woman . I t i s als o influence d b y where sh e lives. For ver y young women , wome n i n poor health , or wome n i n part s o f th e worl d wher e advance d medica l tech nology i s lacking, usin g RU-48 6 a s a n abortifacien t ma y indee d be safer tha n carryin g a child t o term . Not tha t RU-48 6 i s a no-ris k wa y t o terminat e a pregnancy . At leas t on e woma n ha s die d fro m th e procedure . Bu t surgica l

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abortions, eve n th e lega l kind , ar e als o no t entirel y saf e (al though the y ar e a good dea l safe r tha n nonlega l improvisations , such a s coa t hanger s an d knittin g needle s inserte d throug h th e cervix). RU-48 6 i s a t leas t a s safe , an d probabl y safer , tha n th e chemical abortion s tha t ar e currentl y obtainabl e i n th e Ameri can marke t an d tha t ar e no t a s well supervised . Furthermore , i f abortion itsel f i s a matte r o f choice , s o too , t o a certai n extent , should th e metho d be , an d RU-48 6 certainl y rank s amon g th e respectable options . FDA approval o f RU-486 may actually decreas e the availabil ity o f surgica l abortions . Tha t is , man y physician s ma y switc h to RU-48 6 a s thei r metho d o f choic e fo r terminatin g a preg nancy an d discontinu e o r reduc e thei r practic e o f surgica l abor tion. Unfortunately , thi s i s already happenin g i n respons e t o th e increased violenc e of antichoic e activist s a t abortion facilities . I n fact, onl y approximatel y one-fourt h o f physician s ar e eve n trained i n surgica l abortio n procedures . Training i s not require d for boar d certification . Th e AM A ha s recentl y indicate d tha t i t may chang e thi s polic y an d requir e al l physician s t o b e traine d in surgical abortion . It is hoped tha t this move will make i t more difficult fo r antiabortionist s t o targe t certai n physicians . In France , RU-48 6 ha s no t diminishe d th e availabilit y o f surgical abortion . Onl y approximatel y 3 0 percen t o f wome n who hav e abortion s i n France abor t usin g RU-486, althoug h 8 0 percent o f thos e wh o ar e eligibl e t o us e RU-48 6 selec t i t ove r surgical abortion . RU-48 6 ma y o r ma y no t reduc e th e numbe r of physician s wh o offe r surgica l abortion s bu t wil l likel y in crease th e numbe r wh o offe r abortion s i n general . I n a recen t survey, thre e ou t o f fou r obstetricians/gynecologist s sai d the y would includ e RU-48 6 i n thei r repertoir e o f treatment s i f i t were FD A approved. Makin g i t more difficul t t o targe t abortio n providers woul d hopefull y decreas e th e harassmen t client s cur rently endur e fro m antiabortionists .

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Some argue tha t RU-48 6 wil l increase relianc e o n physicians , since i t require s mor e visit s tha n surgica l abortion , an d tha t th e whole abortio n proces s shoul d b e demedicalized . However , a t this point , i t i s th e medicalizatio n o f th e proces s tha t impose s some regulation . Demedicalizatio n coul d b e a slipper y slop e whereby les s credentiale d individual s ca n offe r cut-rate , lower quality services .

Benefits o f Approvin g RU-48 6 Perhaps th e mos t appealin g attribut e o f RU-48 6 i s it s potentia l for treatin g variou s illnesses . Thi s i s als o likel y t o b e th e mos t profitable aspec t o f RU-48 6 fo r manufacturers . Severa l coun tries hav e alread y begu n researchin g th e drug' s possibilitie s a s a treatment fo r prostate , ovarian , an d brai n cancer , Parkinson' s disease, glaucoma , Cushing' s syndrome , depression , premen strual syndrome , an d Alzheimer' s disease . I n th e Unite d States , investigation int o using RU-486 a s a treatment fo r breas t cancer , endometriosis, an d fibroi d tumor s i s currentl y unde r way . Pro gesterone, which i s produced i n bot h male s an d females , exacer bates a numbe r o f thes e illnesses , an d a progesteron e inhibito r such a s RU-486 coul d attenuat e them . Fo r example , in meningi omas (benig n brai n tumors ) symptom s worse n durin g preg nancy, whe n a woma n produce s greate r amount s o f progester one. 53 RU-48 6 reduce s th e amoun t o f progesteron e tha t cell s absorb an d curtail s th e growt h o f th e tumor. Unfortunately , th e FDA ba n ha s impede d America n researc h o n th e therapeuti c uses of RU-48 6 a s well a s on it s contraceptive an d abortifacien t properties. I t i s ironi c tha t "pro-life " forces , b y threatenin g t o boycott product s fro m an y manufacture r o r distributo r o f RU 486, hav e helpe d t o kee p a potentiall y life-saving dru g ou t o f the hands o f American researcher s an d consumers .

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In additio n t o providin g treatmen t fo r numerou s disorder s and ailments , RU-48 6 coul d eas e th e implementatio n o f man y obstetric/gynecological procedures . Whe n use d wit h syntheti c prostaglandins, RU-48 6 seem s t o decreas e pai n durin g surgica l abortions. I n th e cas e o f a miscarriage , RU-48 6 ca n assis t i n expelling the dead fetus . Finally , RU-486 ca n facilitat e th e open ing o f th e cervi x i n obstetric/gynecologica l procedure s suc h a s D&E. If RU-48 6 i s made availabl e i n th e Unite d States , researcher s can a t leas t begi n t o examin e th e drug' s properties , eve n i f no t in the contex t o f women's reproductiv e health . I n addition , RU 486 ma y facilitat e researc h an d treatmen t o f illnesses , suc h a s breast an d ovaria n cancer , tha t ar e life-threatenin g t o women . Moreover, th e dru g ma y provid e ne w lead s i n treatin g som e sources o f infertility , suc h a s fibroid s an d endometriosis . Thi s may rende r othe r potentiall y dangerou s procedures , performe d to cure o r circumven t infertility , unnecessary . Finally, approval o f RU-486 ma y make abortion s mor e acces sible t o rura l population s i n th e Unite d State s an d thir d worl d countries. Worldwide , approximatel y five hundre d wome n di e each day fro m botche d abortions . RU-48 6 coul d greatl y dimin ish thi s number . O f course , RU-48 6 coul d potentiall y increas e this number, i f the drug ha s unknown long-ter m effects . Bu t thi s is a moo t poin t i n countrie s wher e th e averag e lif e spa n fo r women i s alread y short . Regardless , i t i s unlikel y tha t RU-48 6 could tur n ou t t o b e a s deadly , an d o n s o wid e a scale , a s botched surgica l abortion s currentl y are . Although , th e medica l facilities an d supervisio n i n thir d worl d countrie s ma y no t b e adequate fo r administratio n o f RU-486 , neithe r ar e the y ade quate fo r surgica l abortions . If RU-48 6 becam e availabl e i n th e Unite d States , i t woul d have a tremendou s potentia l fo r abuse , rangin g fro m a woma n turning he r prescriptio n ove r t o a frien d i f sh e decide d t o con -

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tinue her pregnancy t o physicians writing unmonitored prescrip tions tha t coul d becom e blac k marke t drugs . I n addition , i f an y physician coul d prescrib e RU-486 , i t woul d b e impossibl e t o follow u p o n o r trac k patients , especially i f they faile d t o retur n for subsequen t treatment . Non e o f thi s ha s happened i n France , where th e dru g i s strictl y regulated . Th e Unite d State s woul d have t o implemen t a simila r polic y immediatel y upo n approva l of th e drug . Othe r medica l procedures , suc h a s alternativ e in semination, illustrat e th e disastrou s consequence s tha t ca n at tend th e failur e t o regulat e a reproduction "industry. " Finally , i t is essentia l tha t wome n b e strongl y encourage d t o retur n fo r follow-up treatment . Clearly, RU-48 6 i s no t a panacea . However , a s wit h othe r reproductive technologies , i t i s her e t o stay . No w th e emphasi s should shif t t o regulatio n over , an d researc h on , th e processe s and product s o f thes e technological developments .

Epilogue On 3 0 Decembe r 1994 , Joh n C . Salv i II I sho t an d kille d th e receptionists a t two abortio n clinic s in Massachusetts. Salv i quietly walke d int o th e first clini c an d aske d "I s thi s Planne d Par enthood?" Whe n Shanno n Lowne y sai d tha t i t was , h e opene d fire with a .22-calibe r rifle . This bring s th e know n deat h tol l amon g abortio n clini c workers t o five. Tw o physician s an d a securit y escor t hav e als o been kille d whil e attemptin g t o d o thei r jobs . Score s o f other s have bee n injured an d threatened. There have been kidnappings , arson, bombings , an d violence . Som e peopl e believ e tha t anti abortion tactic s hav e simpl y becom e anothe r for m o f terrorism . After th e violenc e i n Massachusetts , almos t everyon e con demned Salvi' s actions . Ye t Planne d Parenthoo d receive d on e

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call wit h th e messag e "Yo u go t wha t yo u deserved, " an d Salv i had supporter s marchin g outsid e hi s jai l cell. 54 Abortio n re mains the most emotionall y charge d politica l issu e in the Unite d States sinc e th e civi l right s movement . Almos t everyon e ha s a n opinion, usuall y a vehement an d unequivoca l one . Baulieu, th e dru g researche r wh o synthesize d RU-486 , onc e commented, "I n France, issues of morality ten d t o b e individual, private matters . I n th e Unite d States , they ca n tur n int o genera l political debates." 55 Certainly , whe n issue s o f moralit y concer n women's reproductiv e rights , the y frequentl y tur n int o genera l political debates .

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A

ngela wa s onl y thirtee n years ol d whe n sh e wa s diagnose d wit h leukemia . Fo r nearl y a decade sh e battle d th e cancer , whic h cos t he r he r lef t le g an d hip. Finally , th e cance r wen t int o remission ; Angel a marrie d and becam e pregnant . Unfortunately , th e diseas e returned , an d Angela, twenty-seve n year s ol d an d si x month s pregnant , en tered th e hospital t o die . Aware tha t sh e woul d probabl y no t carr y th e bab y t o term , Angela agree d t o allo w physicians to perform a cesarean sectio n after th e twenty-eight h wee k o f he r pregnancy , whe n th e fetu s might b e viable , eve n thoug h th e surger y wa s likel y t o haste n her ow n death . Angela' s conditio n rapidl y deteriorate d durin g the twenty-fifth an d twenty-sixt h week s o f her pregnancy, an d i t became clea r tha t sh e migh t no t surviv e unti l th e twenty-eight h week. Furthermore , becaus e o f he r condition , he r physician s speculated tha t th e fetu s wa s bein g deprive d o f th e oxyge n [164]

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crucial t o norma l development . The y estimate d tha t th e fetu s would hav e a 5 0 t o 6 0 percen t chanc e o f survival , wit h a 2 0 percent chanc e o f impairment , i f a n emergenc y cesarea n sectio n were performed immediately . Angela was under heavy sedation, and it is unclear whether she was capabl e o f givin g a n informe d an d clear-heade d consen t t o the procedure. Apparently she consented at one point and denie d consent at another. However, Angela's family clearly opposed th e operation. They fel t that sh e had endure d enoug h pain. The hospital sough t judicial interventio n t o determin e thei r lega l (an d t o a certain extent moral) responsibilities. Could they, and more importantly should they, force Angela to undergo a cesarean sectio n to whic h sh e ha d no t explicitl y consented ? Di d th e right s o f th e fetus overrid e Angela's right to bodily integrity, her right to mak e decisions abou t wha t coul d b e done to he r ow n body , an d even , perhaps, her right to life itself ? The cour t ordere d th e cesarea n sectio n b e performe d o n An gela. As she was bein g taken t o surgery , a panel o f thre e appeal s court judge s uphel d th e decision . Th e bab y die d withi n hours , and Angela die d two days later, with the knowledge that the sur gery ha d bee n conducte d withou t he r explici t consen t an d tha t the bab y ha d died . Afte r Angela' s deat h th e decisio n wa s over turned, an d he r parents won a civil suit against the hospital. Th e court held that even when a patient is close to death, medical personnel mus t stil l abid e b y his o r he r wishes , unless a compellin g reason to override them exists. Angela shoul d have been allowe d to make her own decisions about her life and health . Unlike Angela, most women facin g th e possibility o f cesarea n section ar e i n a stat e o f min d wher e the y ar e capabl e o f clearl y giving o r withholdin g consent . However , lik e Angela, the y ma y still find tha t th e choic e i s taken ou t o f thei r hands . Durin g th e 1960s an d eve n int o th e 1970s , th e chanc e tha t a pregnan t woman i n th e Unite d State s woul d hav e a cesarea n sectio n wa s

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approximately 5 percent , o r on e i n twenty . Toda y th e probabil ity i s betwee n 2 0 an d 2 5 percent , on e i n five, o r possibl y eve n one i n four. 1 Hospital s var y i n thei r cesarea n sectio n rate , wit h some toppin g 5 0 percent . Th e rate s als o var y fro m stat e t o state, rangin g fro m 16. 3 percen t (Colorado ) t o 28. 4 percen t (Arkansas).2 I n fact , i t ha s bee n predicte d tha t i f th e tren d continues unabated , th e rate coul d reac h 4 0 percen t b y the yea r 2000. In just two decade s th e rate has quadrupled. 3 In a cesarea n sectio n th e bab y doe s no t emerg e throug h th e vaginal cana l bu t i s remove d fro m th e uteru s throug h surgery . After th e woman ha s been prepped fo r surger y and catheterized , a regiona l o r genera l anestheti c i s administered . I f regional , the woma n ma y fee l som e uncomfortabl e pushin g an d pulling , although a scree n generall y prevent s he r fro m watchin g th e procedure. I f a genera l anestheti c i s used, th e woma n i s uncon scious durin g th e "birth. " Horizonta l incision s ar e mad e i n th e abdominal an d uterin e walls , an d th e placent a i s "delivered. " Then th e uteru s i s lifted throug h th e openin g an d suture d whil e resting o n th e woman' s abdomen . Afte r th e uteru s i s returned , the woma n i s externally suture d wit h clamp s o r "staples. " Gen erally a n intravenou s tub e (IV ) fo r nutritio n an d medicatio n i s used durin g th e surger y an d sometime s afterward . Afte r severa l hours i n the recover y room , th e woma n ma y b e transferred t o a postpartum room . Women ofte n experienc e pain, soreness, fatigue, an d ga s afte r a cesarea n an d ma y remai n catheterize d fo r a da y o r two . Th e hospital sta y i s usuall y thre e t o fou r time s longe r tha n fo r a vaginal delivery . Overal l recover y take s longe r too , and th e pai n and weaknes s ma y continu e fo r fou r t o si x weeks . Th e ris k o f hemorrhage an d infectio n i s enhanced , a s ar e othe r complica tions associate d wit h surgery , suc h a s advers e reaction s t o th e anesthesia, damag e t o th e bowel , bladder , o r othe r organs , chronic pai n fro m sca r tissue , infertility , an d miscarriage . I n

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general, the rat e o f complication s fo r cesarea n section s i s five to ten times higher tha n fo r vagina l births. 4 Cesarean section s ar e suppose d t o b e reserve d fo r high-ris k births. Fo r thes e birth s cesarean s hav e probabl y increase d th e survival rat e and/o r decrease d complication s an d impairment s for bot h th e mothe r an d child . High-ris k situation s includ e cephalopelvic distortio n (th e fetus' s hea d i s to o larg e t o pas s through th e pelvis) , a feta l o r materna l conditio n tha t make s labor an d vagina l deliver y risky, unusual feta l presentatio n (e.g. , breech), placent a previ a (th e placent a i s blockin g th e cervica l opening), o r abrupti o placent a (th e placent a ha s partiall y sepa rated fro m th e uterin e wall). 5 However , thes e maladie s ar e no t increasing a t suc h a n accelerate d rat e a s t o accoun t fo r th e tremendous ris e in cesarean sections . Given a choice , i t i s unlikel y tha t mos t wome n woul d prefe r a cesarea n sectio n ove r a vagina l deliver y (althoug h som e do) . Cesarean section s ar e no t o n th e ris e becaus e wome n ar e clam oring t o underg o a n ofte n unnecessar y surger y tha t result s i n death tw o t o five times a s ofte n a s vagina l deliver y does . Man y women di e ever y yea r fro m unnecessar y cesareans . Ralp h Nad er's Publi c Citizen , a consume r researc h an d advocac y group , estimates th e optima l cesarea n sectio n rat e a t 1 2 percent ; th e United State s Publi c Healt h servic e ha s se t a nationwide goa l o f 15 percent b y the year 2000. 6 Bu t the cesarean rat e continues t o skyrocket, demonstratin g onc e agai n ho w th e failur e t o regulat e a reproductiv e industr y endanger s th e health o f women .

The Ris e i n Cesarea n Rate s Why ha s th e cesarea n sectio n rat e rise n ove r th e las t thre e decades? Althoug h th e ide a ma y see m counterintuitive , medica l technology itsel f migh t b e partiall y t o blame . Electroni c feta l

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monitors (EFMs) , onc e reserve d fo r high-ris k births , ar e no w used routinel y (i n thre e ou t o f fou r birth s i n 1990)7 EFMs , which ca n aler t physician s t o th e first indication s o f feta l dis tress, n o matte r ho w minute , com e i n tw o forms , externa l an d internal. Th e externa l monito r i s strappe d o n a woman' s abdo men an d detect s feta l heartbea t an d contraction s throug h ultra sound. After labo r ha s begun an d th e amniotic sa c has ruptured , a senso r ca n b e attache d t o th e fetus' s scal p t o provid e a mor e accurate measur e o f hear t rat e an d pressur e throug h interna l monitoring. EFM s ar e highl y unreliable , producin g man y fals e positives an d ofte n signalin g distres s when non e exists . Unfortu nately, onc e alerted , man y physician s immediatel y resor t t o a cesarean sectio n o r othe r interventio n withou t investigatin g th e source, o r eve n th e reality , o f th e apparen t distress . Two factor s may contribute t o this knee-jerk reaction . First, obstetrician s an d gynecologist s ar e amon g th e physi cians mos t ofte n sue d fo r malpractic e i n th e Unite d States , an d more suit s ar e won agains t the m tha n agains t an y othe r medica l specialty. In part, this is due to the emotional investmen t o f thei r patients. The y ar e understandabl y cautious . A n obstetricia n i s more likel y t o b e sue d fo r no t performin g a cesarea n sectio n than fo r performin g one . A bab y ma y suffe r sid e effect s fro m the anesthesi a use d durin g a cesarea n o r breathin g problem s from th e lack o f stimulatio n th e lungs normally receiv e during a vaginal birt h bu t run s a greate r ris k o f damag e o r deat h i f th e cesarean i s not performe d tha n i f it is. Statistics suppor t th e theor y tha t man y cesarean s ar e per formed becaus e th e docto r fear s bein g sued . I n on e study , whit e women ha d a highe r cesarea n rat e tha n blac k wome n (23. 6 percent versu s 18. 6 percent ) an d college-educate d wome n a higher rat e tha n hig h schoo l dropout s (24. 9 percen t versu s 18. 5 percent). 8 It is reasonable t o speculat e tha t physician s anticipat e more lawsuit s fro m whit e wome n tha n fro m blac k an d mor e

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from bette r educate d women . Women wit h private insurance ar e also mor e likel y t o fil e a lawsui t tha n Medicai d recipients , an d the forme r hav e a higher cesarea n rat e tha n th e latter . Second, th e EF M ha s partiall y replace d th e personne l wh o supervised th e birt h proces s i n th e past , personne l capabl e o f exercising discretio n tha t a machin e canno t provide . Moreover , the huma n elemen t ma y generat e a leve l of comfor t tha t relaxe s both the woman an d the fetus. In the Netherlands, using person nel rathe r tha n EFM s t o asses s th e conditio n o f th e fetu s ha s proven quit e successfu l i n keepin g cesarea n rate s lo w (7. 9 per cent i n 199 1 ).9 Ther e pregnan t wome n ar e divide d int o high and low-ris k groups , an d thos e i n th e latte r ar e attende d b y midwives an d genera l practitioner s durin g labor . I n th e Unite d States, som e wome n hav e bee n hirin g labo r assistants , o r "dou las," wh o provid e emotiona l suppor t durin g delivery . Othe r labor assistants , know n a s "monitrices, " g o beyon d emotiona l support an d ma y perfor m vagina l exams , tak e bloo d pressure , and monito r th e feta l heartbeat . Wome n wit h labo r assistant s tend t o hav e shorte r labor , fewe r cesarea n section s an d requir e less anesthetic an d fewe r inductions . In one South African study , women wit h doula s wer e foun d t o b e les s anxiou s abou t thei r baby th e da y afte r birt h and , si x week s later , experience d les s postpartum depressio n an d ha d mor e positiv e self-estee m re garding their capacitie s a s mothers. 10 Deliveries assiste d o r performed b y midwives als o have man y of thes e benefits . Midwive s ma y wor k wit h wome n i n hospital s or a t home . O n th e whole , midwive s emplo y noninterventionis t techniques in their practices, attempting natura l solution s befor e resorting t o medica l ones . However , midwives , particularl y those tha t assis t in home births , are bein g increasingly force d b y state regulation s t o hav e a nursin g degre e i n orde r t o becom e licensed. Eve n i f the y d o becom e licensed , the y ma y no t receiv e support fo r thei r practic e from othe r obstetri c professionals. Fo r

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example, i n 1975 , Yale University Hospita l withdre w th e right s of physician s o r nurse-midwive s wh o participate d i n hom e births t o practice i n the hospital . Of course , providin g ever y pregnan t wome n wit h a midwife , labor assistant , o r nurs e would requir e a n increas e i n personnel , and mos t insurer s wil l no t cove r suc h "luxuries. " Insuranc e companies ofte n neglec t prevention a t the expense o f later inter vention, provin g themselve s penny-wis e bu t pound-foolish . Eliminating hal f th e cesarea n section s performe d i n th e Unite d States pe r yea r coul d sav e approximatel y $1. 3 billio n i n healt h care costs. Profit ha s bee n suggeste d a s anothe r reaso n tha t cesarea n rates hav e bee n rising . Th e averag e hospita l an d physicia n cos t for a vagina l deliver y i n 199 1 wa s $4,720 , whil e th e averag e cesarean sectio n cos t $7,826 . In 1993 , 19. 5 percen t o f pregnan t women o n Medicai d underwen t cesareans , while th e figures fo r women covere d throug h privat e insuranc e o r Blu e Cross/Blu e Shield were 25.7 and 26. 7 percent, respectively. This differentia l is surprising, give n tha t i t is the Medicai d recipient s wh o woul d ostensibly b e mos t likel y t o hav e th e kin d o f poo r prenata l care an d pregnanc y complication s tha t mak e cesarea n sectio n necessary. However, Medicaid offer s littl e monetary incentiv e t o perform a cesarean , whil e privat e insuranc e i s mor e generous . Women wh o self-pai d ha d th e lowes t cesarea n rat e o f al l (16. 1 percent). Additionally , governmen t an d teachin g hospitals , which provid e littl e financial incentiv e fo r cesareans , have lowe r cesarean rates . Nonprofit hospital s ha d a rat e o f 2 2 percent , a s opposed t o 29 percent fo r proprietar y hospitals . The influenc e o f th e profi t motiv e i s als o suggeste d b y re search result s o n repea t cesareans . For-profi t hospital s ha d higher rate s o f repea t cesarean s tha n Kaiser-Permanent e healt h maintenance organizations , whose physicians ar e encouraged t o keep cost s down. 11 Contrar y t o popula r wisdom , i t i s possibl e

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for a woman wh o ha s ha d a cesarea n t o hav e a vagina l birt h i n subsequent pregnancie s ( a VBAC—vagina l birt h afte r cesar ean). Th e notio n tha t thi s i s impossibl e le d man y physician s to routinel y schedul e cesarean s fo r pregnan t wome n wh o ha d previously ha d one , a practice tha t contribute d t o th e explodin g cesarean rate . Initially , whe n vertica l incision s wer e use d fo r cesareans, physician s feare d tha t a subsequen t vagina l birt h might ruptur e th e uterus . Today , horizonta l incision s ar e th e norm, an d abou t one-thir d o f th e wome n wh o hav e give n birt h through cesarea n sectio n procee d t o vagina l deliverie s i n subse quent pregnancies . Th e possibilit y o f a ruptur e o f th e uteru s i s less than 1 percent. Eve n s o with moder n obstetri c technolog y a rupture rarel y cause s a problem . I n fact , th e VBA C rat e in creased fro m 12. 6 percen t i n 198 8 t o 25. 4 percen t i n 1993 . Ideally, it could clim b even higher . Insurance companie s see m t o b e attemptin g t o squelc h an y profit motiv e connecte d wit h th e performanc e o f c-sections . Fo r example, i n Illinois , preferred provider s o f Blu e Cros s mak e th e same amoun t regardles s o f whethe r th e deliver y wa s vagina l o r cesarean. 12 Insuranc e companie s hav e als o attempted t o educat e pregnant employee s an d thei r partner s abou t th e benefit s o f vaginal deliver y an d th e drawback s o f cesareans . Som e insur ance companie s ar e eve n willin g t o pa y fo r a secon d opinio n regarding schedule d cesareans , i n orde r t o decreas e unnecessar y surgeries. Cigna Healt h Pla n ha s taken a differen t approach . Instea d o f restricting th e physician' s profit , the y hav e decide d t o restric t the patient' s care . A mem o sen t t o Florid a obstetrician s indi cated tha t wome n wh o giv e birth throug h cesarea n sectio n wer e to b e discharge d withi n forty-eigh t hours , within twenty-fou r i f the deliver y wa s vaginal. 13 Thi s approac h i s no t uniqu e t o Cigna. Whereas the average hospital sta y after a vaginal deliver y was 3. 9 day s i n 1970 , i t i s no w dow n t o tw o days , wit h som e

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women bein g discharge d withi n eigh t hours . Reductio n i n th e amount o f hospita l tim e that insurer s will cover doe s no t penal ize physicians, because their fee is largely for th e delivery. It doe s hurt hospital s somewhat , bu t mainl y i t hurt s wome n an d thei r infants. Althoug h a quic k discharg e ma y reduc e th e possibilit y of babie s bein g expose d t o infection s a t th e hospita l an d ma y actually facilitat e bondin g betwee n mothe r an d child , man y mothers, particularl y first-timers , ar e no t read y fo r discharg e s o quickly. Hospital s ar e no w experiencin g a n upswin g i n admis sions o f jaundice d an d dehydrate d babie s whos e mother s di d not realiz e tha t thei r mil k wa s no t bein g properl y released . However, throug h implementin g suc h managed-car e policies , insurers stan d t o sav e $ 4 billio n pe r year : $100 0 fo r eac h da y that a maternity roo m i s not used . In response t o these "drive-throug h deliveries, " the America n Academy o f Pediatric s ha s issue d a polic y statemen t indicatin g that mos t mother s an d babie s nee d t o sta y i n th e hospita l a t least forty-eigh t hour s afte r delivery . I n addition , severa l state s have implemented law s requiring insurer s to pay for a minimu m of forty-eight hour s o f hospital care for bot h th e mother an d th e baby. (Thi s i s reduced t o twenty-fou r hour s i f insurer s wil l pa y for a follow-up hom e visi t fro m a nurse. ) Tw o othe r state s hav e enacted simila r laws , an d severa l mor e ar e proposin g them . O n 11 Ma y 1996 , th e da y befor e Mother' s Day , Presiden t Clinto n joined i n th e fra y an d appeale d t o Congres s t o enac t a la w tha t would guarante e wome n a forty-eight-hour hospita l sta y afte r a vaginal delivery , ninety-six hour s afte r a cesarean . Some physician s ma y favo r cesarean s fo r anothe r reason : convenience. The physician's investmen t o f time i s generally less for a cesarea n sectio n tha n fo r a vagina l delivery . I n fact , fo r a scheduled cesarean , th e deliver y dat e i s arranged prio r t o labor . The recent trend toward inducin g labor when a woman i s "over due" als o suggest s a convenienc e motive . I t i s impossibl e t o

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determine scientificall y i f convenienc e i s a facto r i n th e risin g cesarean rate , bu t i t i s disheartenin g t o thin k tha t som e physi cians may prescribe cesareans or inductions simpl y to make thei r schedules mor e agreeabl e an d withou t regar d fo r th e patient' s distress. Some medica l professional s hav e suggeste d tha t additiona l reasons underli e th e risin g cesarea n rate . The y conten d tha t women ar e gainin g mor e weigh t durin g pregnancy , makin g i t difficult t o delive r th e large r babie s vaginally . Whil e i t i s tru e that wome n ar e gainin g mor e weigh t durin g pregnanc y no w than the y di d i n th e pas t (whe n physician s encourage d onl y twelve t o fiftee n pound s o f weigh t gai n durin g pregnancy) , thi s factor alon e canno t accoun t fo r th e cesarea n boom . Th e ten dency towar d weigh t gai n durin g pregnanc y i s presumabl y na tionwide, bu t cesarea n rate s var y greatl y amon g state s an d hos pitals. Additionally , i f bigge r babie s necessitat e cesarea n sections, then why aren't physicians forestalling excessiv e weight gain b y educatin g an d monitorin g thei r patient s rathe r tha n intervening surgicall y a t th e las t minute ? Many physician s als o argu e tha t th e cesarea n rat e ha s rise n because technolog y ha s enable d mor e high-ris k wome n t o be come pregnan t an d giv e birth . Thi s i s true, bu t othe r industrial ized countrie s hav e no t see n simila r astronomica l increase s i n cesarean rates. Japan, Slovenia , and the former Czechoslovakia n republic hav e cesarea n rate s o f 6 t o 7 percent; 14 Britain , 1 3 percent. 15 I n addition , th e heav y relianc e o n cesarea n sectio n has no t lowere d th e rat e o f infan t deat h i n th e Unite d States . Perhaps tha t i s why s o man y voices , fro m th e U.S . Departmen t of Publi c Healt h t o th e America n Colleg e o f Obstetrician s an d Gynecologists, ar e callin g fo r a reductio n i n cesareans . Ye t re searchers concentrat e thei r effort s o n creatin g mor e high-ris k technology t o impregnat e wome n rathe r tha n o n investigatin g ways to facilitat e th e birt h process .

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Whose Lif e I s Thi s Anyway ? In a n innovativ e mov e t o bot h increas e th e accountabilit y o f physicians an d protec t the m agains t lawsuits , Florid a ha s en acted legislatio n requirin g tha t the y follo w guideline s regardin g cesareans i f federa l o r stat e mone y i s use d i n an y wa y a s pay ment fo r th e surgery : "Thes e practic e parameter s shal l address , at a minimum, th e following : feasibilit y o f attemptin g a vagina l delivery fo r eac h patien t wit h a prio r caesarea n section ; dys tocia, includin g arreste d dilatio n an d prolonge d deceleratio n phase; feta l distress ; an d feta l malposition." 16 Thi s legislatio n also require s tha t hospital s establis h pee r revie w board s t o as sess whether eac h cesarean conducte d wa s in fact necessary . Th e results o f eac h revie w ar e share d wit h th e physician an d use d a s part o f th e hospital' s qualit y assuranc e monitoring . Th e overal l results ar e the n mad e availabl e t o th e governor , th e Speake r o f the Florid a Hous e o f Representatives , an d th e presiden t o f th e Florida Senate . Thi s legislatio n represent s a ste p i n th e righ t direction. However , i t doe s no t appl y t o cesarean s covere d b y private insurance , whic h ar e th e one s tha t mos t nee d moni toring. The judicial syste m ha s als o becom e involve d i n forced medi cal reproductiv e interventions . Angela' s cas e wa s probabl y th e most famou s instanc e o f a n enforce d cesarean , bu t i t was not a n isolated one . Many othe r wome n hav e bee n coerced int o cesare ans they di d not want . A Nigerian woman , nam e unknown , pregnan t wit h triplets , refused to consent to a cesarean although the doctor recommended that suc h a delivery would b e safer fo r th e multiple births . This woman believed that a natural delivery would be safe for her . In addition, she and her husband planned to return to Africa, to an area wher e cesarea n deliver y migh t no t b e possible shoul d the y have childre n later . . . . The hospita l obtaine d a cour t orde r t o

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perform a cesarean, bu t th e woman wa s not tol d o f i t until she went into labor. When she and her husband resisted, seven security officer s force d th e husban d fro m th e hospital . Th e woma n was tied to the bed while struggling and screaming and a forced cesarean wa s performed. Th e woman an d th e three infant s sur vived the surgery. 17 Prior t o Angela' s case , judicia l respons e t o suc h situation s was mixed . Som e court s woul d orde r th e woma n t o underg o a cesarean while others would not . Now man y courts have chose n to follo w th e preceden t se t b y Angela' s case . I t i s impossibl e to determin e ho w man y wome n hav e bee n force d t o underg o cesareans b y cour t orde r an d hav e no t appeale d th e decisio n or ho w man y wome n hav e concede d t o th e operatio n whe n threatened wit h a court order . Pregnant wome n hav e als o bee n force d t o underg o bloo d transfusions, t o delive r i n a hospital rather tha n a t home, and t o remain i n th e hospita l becaus e the y di d no t follo w medica l advice. Man y state s hav e law s tha t forc e a pregnan t woma n i n a termina l conditio n t o remain o n lif e support , even if she has a living will specifically stipulating that such measures should not he used to keep her alive. I n eac h o f thes e instances , th e health , welfare, an d right s o f th e fetu s supersed e th e health , welfare , and right s o f the pregnant woman .

So N o w What ? As physician s bega n t o tak e ove r th e childbirt h proces s fro m midwives ove r a centur y ago , i t becam e increasingl y subjec t t o technological intervention . N o longe r wer e wome n givin g birt h in the quiet privacy o f their home s bu t rathe r i n sterile examina tion room s with brigh t lights ; anesthesia dulle d pai n bu t eventu ally le d t o th e us e o f forcep s t o compensat e fo r th e inabilit y o f

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the anesthetize d mothe r t o push . I n th e las t fe w decades , wit h the hel p o f women' s healt h advocates , man y physician s hav e begun t o realiz e th e benefit s o f not intervening , an d loo k wit h favor o n birthin g rooms , natural childbirth , an d th e method s o f Lamaze. But , ironically , th e rat e fo r th e mos t invasiv e interven tion, th e cesarean section , continues high . The medica l professio n i s beginnin g t o polic e itsel f wit h re gard t o cesareans , bu t governmen t drag s it s feet . Whil e legisla tures hav e bee n quic k t o regulat e midwive s (thereb y decreasin g the option s availabl e t o pregnan t wome n outsid e o f hospitals ) and hav e no t hesitate d t o reac h fo r contro l ove r th e live s an d choices o f pregnan t women , legislatio n t o protec t pregnan t women fro m th e excesse s o f industrie s lik e th e medica l profes sion i s slo w an d underinclusive . Th e judicia l syste m ha s com pounded thi s problem b y not taking a definitive stan d o n consti tutional right s related t o bodil y integrity . Finally, although childbirth i s one of the most common event s to occu r i n hospitals , i t i s stil l on e o f th e leas t understood . Th e medical profession ha s done very little to furthe r it s understand ing o f childbirt h an d develo p mor e option s fo r proble m preg nancies an d hav e indee d show n littl e interes t i n doin g so . I n some way s i t i s th e "everyday " qualit y o f childbirt h tha t dis courages investigation : i t i s take n fo r grante d an d seem s t o offer fe w enticin g prospect s fo r research . Bu t sinc e physician s themselves hav e mad e th e proces s mor e complicated , the y should fee l obligate d t o find bette r solutions , i f no t t o al l prob lems, at leas t to the problems the y have helpe d t o create .

Other Unnecessar y Reproductiv e Surgerie s Approximately on e hundre d year s ago , physician s bega n per forming "cesarea n hysterectomies. " I t was believe d tha t wome n

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would di e 9 5 percen t o f th e tim e fro m a cesarea n unles s th e uterus wa s als o removed . Removin g th e uteru s presumabl y re duced fatalit y t o 5 percent. 18 Although thes e procedure s ar e rarel y performe d togethe r to day, they stil l keep pace with eac h other . Cesarea n sectio n i s the most frequentl y performe d surger y i n th e Unite d States ; next i n line is hysterectomy. Approximately 600,00 0 hysterectomie s ar e performed i n th e Unite d State s eac h year , a t a cos t o f roughl y $2 billion . O f tha t number , 76. 4 percen t ar e performe d o n women o f childbearin g ag e (betwee n twent y an d forty-nin e years old) . Therefore , a significan t percentag e o f wome n livin g in th e Unite d State s will probabl y fac e a decisio n abou t surger y on thei r reproductiv e organ s a t som e tim e i n thei r life , whethe r it is a cesarean o r a hysterectomy . The similaritie s betwee n cesarean s an d hysterectomie s d o no t end there . Women' s healt h advocates , medica l professionals , insurance companies , consume r groups , an d patient s hav e bee n questioning th e necessity o f hysterectomie s fo r decades . As long ago as 1948, documented evidence indicated that hysterectomy was an over-performed operation . By the late 1960' s the emerging women's movement helpe d to focus nationa l attentio n on the subject, an d i n 1978 , hysterectomy, alon g with tonsillectomy, becam e th e centra l issu e i n a congressiona l hearin g o n unnecessary surgery in the U.S. The hearing brought to light the fact tha t ther e ha d bee n n o well-designe d studie s t o determin e the appropriat e indication s fo r eithe r operation , the n th e tw o most commonly performed surgica l procedures. 19 A large-scal e clinica l stud y wa s conducte d o n tonsillectomies , and th e procedur e wa s determine d t o b e largel y unnecessary . The incidence of the operation subsequentl y decreased . No com parable stud y has ever bee n conducted o n hysterectomies . How ever, a widel y cite d 199 0 Blu e Cross/Blu e Shiel d o f Illinoi s

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survey suggest s tha t a t leas t one-thir d o f hysterectomie s ar e unnecessary. Blu e Cross/Blu e Shiel d would , o f course , benefi t from a reductio n i n th e numbe r o f hysterectomie s an d it s findings migh t b e suspecte d o f bia s o n tha t account . Bu t disinter ested researchers have also estimated th e number o f unnecessar y hysterectomies t o b e ver y high , sometime s a s hig h a s 9 0 per cent. 20 Eve n i f th e figure i s onl y 3 0 percent , a t th e curren t rat e of 600,00 0 hysterectomie s pe r year , wit h on e deat h fo r ever y thousand, unnecessar y hysterectom y woul d accoun t fo r 18 0 deaths per year .

Kinds an d Cause s o f Hysterectom y There ar e four basi c types o f hysterectomy. A partial o r subtotal hysterectomy involve s onl y the remova l o f th e uterus . In a complete o r total abdominal hysterectomy th e cervi x i s als o re moved. A total abdominal hysterectomy with bilateral salpingooophorectomy include s remova l o f th e uterus , cervix , ovaries , and fallopia n tubes . Removin g th e ovarie s alon e i s terme d a n oophorectomy. Finally , i n a radical hysterectomy, th e uterus , cervix, ovaries , fallopia n tubes , uppe r portion s o f th e vagina , and pelvi c lymph node s ar e excised . All of thes e surgerie s ca n b e conducted abdominally , throug h an incision in the abdominal an d uterine walls. It is also possibl e to conduc t som e o f thes e surgerie s vaginally , reducin g recover y time an d expense . However , onl y abou t on e i n five hysterecto mies are vaginal . Most hysterectomie s ar e electiv e surgeries , performe d unde r nonemergency conditions . Ove r time , individual physician s an d the medica l professio n a s a whol e hav e foun d hundred s o f reasons fo r recommendin g a hysterectomy , includin g "overeat -

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ing, painful menstruation , attempte d suicide , and, mos t particu larly, masturbation , eroti c tendencie s o r promiscuity." 21 Cur rently, th e mos t commo n reaso n (3 0 percent ) i s fibroid tumors . Fibroid tumor s ar e benig n growth s presen t i n 3 0 t o 5 0 percen t of wome n betwee n fort y an d fifty year s old . African-America n women ar e particularl y susceptible . I t i s believe d tha t fibroids may b e related t o estroge n levels , since they see m to b e nonexistent prio r t o puberty , shrin k afte r menopause , an d worse n dur ing pregnancy . Fibroid s ar e generall y insid e th e endometriu m (the linin g o f th e uterus ) o r withi n o r outsid e th e uterin e wall . They var y i n siz e an d numbe r an d ma y o r ma y no t induc e symptoms, suc h a s bleeding, pain, pressure, and infertility . The next most common reaso n fo r recommendin g a hysterectomy (2 4 percent) i s endometriosis. Although endometriosi s wa s described ove r a century ago , it still remains a n elusive disorder , in which par t o f th e endometrium , normall y she d a t th e star t o f each menstrua l cycle , ha s migrate d instea d t o othe r area s o f the body . On e theor y suggest s tha t endometriosi s begin s wit h retrograde menstruation , tha t is , when th e menstrua l flui d tha t is usually she d throug h th e cervi x i s forced bac k u p throug h th e uterus an d sometime s ou t th e oviducts . Retrograd e menstrua tion probabl y occur s i n mos t wome n withou t causin g endome triosis. However , i n som e women , th e tissu e implant s itsel f an d begins to grow. Generall y this endometrial tissu e remains withi n the pelvic area, bu t i t has bee n know n t o trave l anywher e i n th e body, includin g th e limb s an d majo r organs . Th e implant s ma y bleed cyclicall y wit h th e menstrua l cycle , o r th e tissu e ma y rupture, causin g interna l bleeding . Th e tissu e ma y eve n develo p into benig n tumors . Th e primar y symptom s o f endometriosi s are crampin g an d pain , althoug h som e wome n experienc e nei ther. Fo r thos e wh o d o experienc e pain , i t ma y occu r durin g menstruation o r intercours e o r both . Durin g menstruation som e

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women ma y als o suffe r fro m nausea , vomiting , heav y bleeding , fainting, headaches , and diarrhea . A few women ma y experienc e abdominal bleedin g or infertility . The thir d mos t commo n reaso n fo r a hysterectom y (2 0 per cent) i s a prolapse. A prolapse occur s when weakene d ligament s enable th e uteru s and/o r cervi x t o descen d int o th e vagina . I n rare cases , the prolaps e ma y eve n protrud e fro m th e body . Pro lapse may cause pelvic pain o r backache , frequent bladde r infec tions, o r a feelin g o f fullnes s o r incontinenc e du e t o pressur e on th e bladde r o r bowel . Interestingl y som e physician s hav e "induced" prolapse s i n a n attemp t t o "help " women . Twenty-five years ago, we often use d mild prolapse of the uterus to justif y a hysterectom y t o a hospita l committe e tha t woul d otherwise have required a woman to have as many as six children before sh e could b e sterilized. We'd plac e a n instrumen t o n he r cervix, an d attemp t t o pul l i t dow n int o th e vagin a s o as to b e able t o sa y tha t sh e had a so-calle d uterin e prolaps e wit h trac tion. Fortunately , thes e tactics ar e considered t o b e unnecessar y and unethica l today , whe n n o woma n shoul d hav e a hysterec tomy suggested to her solely for sterilization purposes. (Although unfortunately, som e o f thes e practice s stil l continue! ) I n actua l fact, ver y few women—even thos e who do have legitimate prolapse—require hysterectomy today. 22 Some state s now hav e legislation agains t performin g hysterecto mies fo r purpose s o f sterilization . Th e physician s wh o "in duced" thes e prolapse s apparentl y ha d altruisti c motives . Bu t the patriarcha l notio n tha t the y kne w wha t wa s bes t fo r th e patient, wit h o r withou t consultin g her , i s objectionable, a s i t i s in medica l practic e generall y an d i n obstetric s an d gynecolog y in particular . Other reason s physician s hav e recommende d a hysterectom y include abnorma l bleedin g and , o f course , cancer. 23 Abnorma l bleeding i n an d o f itsel f doe s no t justif y a hysterectomy . Afte r

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all, mos t wome n d o no t kno w th e actua l rang e o f "normal " menstrual bleeding . "Normal " flow varie s fro m individua l t o individual an d acros s th e lif e span , usuall y increasin g an d de creasing severa l time s i n the cours e o f a woman's life . However , most physicians accep t their patient' s self-repor t o f flow withou t attempting an y objectiv e assessment . Befor e performin g a hys terectomy fo r abnorma l bleeding , i t i s importan t t o asses s whether i n fac t th e bleedin g i s abnorma l an d i f so , wha t i s causing it . Uterin e cancer , hormona l imbalances , fibroids, an d estrogen replacemen t therap y ar e al l associate d wit h abnorma l uterine bleeding. It is not even necessarily a sign of gynecologica l malfunction bu t ma y sprin g fro m othe r problem s altogether . Numerous wome n hav e undergon e a hysterectom y fo r abnor mal bleedin g onl y t o discove r late r tha t the y ha d a completel y benign condition . One ou t o f ten hysterectomies i s performed wit h cance r treat ment o r cance r preventio n i n mind , clearl y th e mos t legitimat e reason. However , th e justificatio n fo r hysterectom y a s preven tion o r treatmen t depend s o n th e typ e o f cance r involved . Th e most commo n gynecologica l malignanc y i s cancer o f th e uterus , followed b y cance r o f th e cervix , followe d b y ovaria n cancer . Other gynecologica l cancer s d o occur , suc h a s vaginal , vulvar , or fallopian , bu t no t nearl y a s often . One ou t o f ever y forty-fiv e girl s bor n toda y wil l eventuall y battle uterin e cancer , usuall y o f th e endometrium . I t is generally detected a t aroun d th e tim e o f menopaus e o r later . However , women wh o ar e a t ris k fo r developin g endometria l cance r ca n be routinel y screene d throug h a n endometria l biopsy . I f th e disease i s detecte d i n it s earl y stages , alternative s t o hysterec tomy, suc h a s hormona l therapy , ar e ofte n successful . I n a n advanced stage , some type o f hysterectom y i s usually required . Women ar e encourage d t o hav e a regula r Pa p smea r ever y year to facilitate earl y detection o f cervica l cancer, a disease tha t

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strikes on e i n ever y sixty-thre e wome n an d particularl y target s women o f lowe r socioeconomi c status . A s wit h uterin e abnor malities, dependin g upo n th e severit y o f th e disease , a hysterec tomy ma y no t b e necessary , fo r cervica l cance r spread s slowly . However, onc e invasiv e cance r o f th e cervi x ha s bee n estab lished, hysterectomy ma y b e unavoidable . Very fe w wome n wil l actuall y hav e ovaria n cance r durin g their lives : abou t twenty-on e thousan d case s ar e diagnose d i n the United State s each year. It is however th e most deadl y o f th e gynecological cancers , due partly t o the fac t tha t i t is so difficul t to detec t an d treat . Th e symptom s ar e vagu e an d ca n b e misin terpreted. A s wit h th e othe r gynecologica l cancers , treatmen t depends o n th e exten t o f the disease . Sometimes physician s wil l remov e health y ovarie s fro m a woman t o preven t th e possibility o f ovaria n cancer . Health y ovaries ar e removed i n 6 0 percent o f women wh o hav e abdomi nal hysterectomies . I n wome n unde r forty-fiv e year s ol d wh o have hysterectomie s becaus e o f fibroids, 3 7 percent los e health y ovaries. Bu t th e incidenc e o f ovaria n cance r i s s o lo w tha t th e ovaries o f fifteen hundre d wome n woul d hav e t o b e removed t o prevent on e cas e o f ovaria n cance r (barrin g a n overwhelmin g hereditary tendenc y i n an y particula r case) . There i s littl e justi fication fo r th e "preventative " remova l o f gynecologica l struc tures. Imagine an often cite d parallel. Prostate cancer strikes five out of ever y hundre d males , but remova l o f th e prostat e ca n signifi cantly impair male sexual function. Woul d an y physician sugges t removing th e prostates o f twent y male s to prevent cance r i n on e of them ? When th e ovarie s ar e removed, th e woma n i s sent int o an earl y menopaus e an d ma y b e plague d wit h a variet y o f sid e effects. In fact, the side effects o f hysterectomy differ radicall y depending upon whether the ovaries remain intact .

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Surgical Complication s an d Sid e Effect s It i s difficul t t o determin e wha t percentag e o f wome n suffe r surgical complication s o r sid e effect s fro m hysterectomy . Man y women ma y no t repor t complication s o r sid e effect s becaus e they ar e embarrasse d o r ar e no t awar e tha t the y ar e experienc ing a side effect o f the surgery. Too often physician s an d patient s dismiss complaint s a s psychologica l disturbance s unrelate d t o surgery. Therefore, an y estimate of the number o f women suffer ing complication s o r sid e effect s o f hysterectom y i s likely t o er r on th e lo w side . Nevertheless, on e ofte n cite d statisti c indicate s that nearl y 5 0 percent o f women suffe r complications. 24 The mos t frequen t complicatio n i s infection , whic h afflict s approximately on e ou t o f ever y thre e women . Othe r complica tions includ e hemorrhage , damag e t o surroundin g organ s (par ticularly the bowel and bladder) , the need for additiona l surgery , transfusion reactions , cardia c arrest , problem s wit h clotting , stroke, difficult y wit h incisio n healing , incisiona l o r instrumen tal hernia , anesthesi a complications , an d death . Som e o f thes e complications ar e rare; some ar e relatively frequent. 25 It i s impossibl e t o lis t al l th e potentia l sid e effect s fro m a hysterectomy. Perhap s th e mos t far-reachin g sid e effect s ar e those tha t touc h o n subjectiv e well-bein g an d qualit y o f life . Ironically, man y wome n experienc e a decreas e i n qualit y o f life afte r hysterectomy , whe n i t wa s th e potentia l increas e tha t convinced the m t o underg o th e surger y i n th e first place . Al though som e wome n repor t increase d anxiet y an d irritabilit y following a hysterectomy, the most widel y reported sid e effect i s depression. In some women th e depression i s transient; i n other s it is long-term an d ma y even be linked to suicide. The depressio n could ste m fro m an y numbe r o f causes , includin g hormona l changes (a s with postpartu m depression) , physica l changes , un -

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successful remediatio n o f symptoms , o r los s o f reproductiv e organs. Some wome n repor t a diminishe d sexua l capacit y afte r hys terectomy. Althoug h th e effec t o f hysterectom y o n sexualit y ha s not bee n wel l researched , i t appear s tha t surger y doe s hav e a n effect o n pleasure an d libido . It isn' t surprisin g tha t sinc e 1944 , onl y fourtee n studie s hav e been published o n the sexual impact o f hysterectomy. However , the result s o f thes e fe w studie s sugges t tha t hysterectom y doe s have a negative impact on women's se x lives. All but one foun d some evidenc e o f diminishe d desir e o r lessene d (o r lac k of ) or gasm. O n the average , more than one-thir d o f al l women questioned reported a change for the worse in sexual feelings. 26 Women wh o hav e ha d thei r ovarie s remove d ar e mor e likel y t o express dissatisfactio n wit h thei r sexua l encounters , especially if hormone replacemen t therap y ha s no t bee n initiated . (I n hor mone replacemen t therapy , wome n ar e provide d wit h syntheti c hormones tha t simulat e natura l hormona l functioning. ) The physica l sid e effects o f hysterectom y ca n includ e fatigue , insomnia, weigh t gain , headaches , dizziness , backaches , vagina l dryness, "ho t flashes," an d a n increas e i n bladde r o r bowe l problems. If the ovaries have been removed, more seriou s consequences ca n result . Th e bod y abruptl y cease s t o produc e hor mones tha t th e ovarie s helpe d t o regulate , the lac k o f whic h ha s been linke d t o a n increase d susceptibilit y t o hear t diseas e an d osteoporosis. Overall , wome n ar e a t a muc h greate r ris k fo r heart diseas e an d osteoporosi s tha n fo r ovaria n cancer , s o re moving health y ovarie s to prevent th e latte r seem s ill judged . Some o f th e mos t devastatin g consequence s o f hysterectom y occur whe n wome n awake n t o find tha t th e surger y ha s bee n more extensiv e tha n the y were le d to expect. Patients sometime s sign blanke t consen t form s tha t allo w physician s t o remov e an y

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organ the y dee m necessar y t o remove . Sometime s thes e form s do allo w patient s t o specif y whic h organ s the y d o no t wan t removed. However , suc h a selection ma y overreac h th e patient' s knowledge. Fo r example , i n Englan d on e physicia n wa s investi gated fo r abortin g a fetu s durin g a hysterectomy . Th e patient , who ha d endometriosi s an d ha d bee n tryin g t o conceive , agree d to a hysterectom y afte r sh e wa s tol d tha t conceptio n woul d b e impossible. He r physicia n assure d he r tha t sh e coul d no t b e pregnant. Durin g surgery , the physician discovere d tha t sh e was, but th e fetu s wa s aborte d wit h th e remova l o f th e uterus . Th e patient woul d no t hav e consente d t o hysterectom y i f sh e ha d known sh e wa s pregnant . Crimina l charge s wer e file d agains t the physician . In another Britis h case , a patient explicitl y state d tha t sh e di d not wan t he r healthy ovar y removed , bu t th e physician remove d it anyway . On e Canadia n woma n receive d fifty-three thousan d dollars i n damage s whe n he r ovar y wa s remove d b y surgica l error. He r attorne y complaine d tha t thi s wa s to o little , give n that, i n anothe r case , a ma n ha d receive d eight y thousan d dol lars whe n hi s testicl e wa s mistakenl y removed . Nor a Coffey , director o f HER S (Hysterectom y Educationa l Resource s an d Services Foundation) , ha s indicate d tha t suc h unauthorize d re movals ar e commonplac e i n th e Unite d State s a s well . T o pre vent suc h incidents , som e state s hav e enacte d legislatio n requir ing tha t patient s b e informe d o f al l risk s an d sig n a detaile d consent prio r t o surgery . In Ne w York , patient s mus t b e provided wit h a standardize d written summar y tha t include s the diagnoses fo r whic h hysterec tomy i s typically a treatment, th e type s o f hysterectomy, th e sid e effects, an d a discussion o f alternativ e treatments . I n California , patients mus t als o receiv e informatio n regardin g th e lengt h an d cost o f th e hospita l stay . Eac h patien t mus t als o sig n a n in formed consen t prio r t o surgery ; i n Californi a i f th e physicia n

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proceeds withou t obtainin g suc h a consent , h e o r sh e i s consid ered guilt y o f unprofessiona l conduct . Suc h legislatio n protect s both patient an d physician, but as yet the other forty-eigh t state s have not followe d suit .

Alternatives The alternative s t o hysterectom y var y accordin g t o th e com plaint. On e curren t treatmen t fo r fibroids involve s usin g anti hormone agents , thereby decreasin g th e woman's estroge n level s and shrinkin g th e tumors . I f a woma n i s in he r lat e forties , thi s may slo w th e growt h o f th e tumor s enoug h s o tha t th e natura l processes o f menopaus e ca n b e relied upo n t o d o th e rest . I f th e woman i s younger , o r th e fibroid s ar e particularl y extensive , antihormone therap y ma y reduc e th e siz e o f th e tumor s enoug h so tha t the y ca n b e remove d throug h a procedur e know n a s a myomectomy. I n a myomectomy , th e tumor s ar e remove d bu t the uteru s remain s intact , thus preserving fertility . Since th e mid-1980 s tw o type s o f endoscope s hav e mad e i t possible t o perfor m myomectomie s les s invasively , resultin g i n lower cost s an d shorte r recoveries . Endoscope s ar e instrument s with thi n fiberoptic tube s that ar e inserted int o the body an d ac t as telescopes , transmittin g interna l image s t o a vide o monitor . Some endoscope s ac t solel y t o assis t visualization , whil e other s also hav e surgica l functions . On e typ e o f endoscope , the hyster oscope, i s inserte d throug h th e cervix . I n a hysteroscopi c myo mectomy, electrica l curren t o r lase r beam s ar e use d t o cu t fibroids fro m th e uterin e wall . I f th e fibroid i s outsid e o f th e uterus, another typ e of endoscope, known a s a laparoscope, ca n be inserte d throug h a n incisio n nea r th e navel . Othe r smal l incisions i n th e abdomina l wal l assis t i n th e myomectomy . La paroscopes ar e als o use d to perform vagina l hysterectomies .

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There ar e alternativ e treatment s fo r endometriosi s a s well , including dru g therapy . Physician s hav e als o bee n performin g a procedure know n a s dilatio n an d curettag e o r D & C (ofte n "jokingly" referre d t o a s "dustin g & cleaning" ) o n wome n fo r years a s a treatment fo r endometriosis . I n a D & C the cervi x i s dilated an d th e linin g o f th e uteru s i s gently scrape d awa y usin g a sharp , spoon-shape d instrumen t ( a curette) . Thi s procedur e was commo n i n th e pas t an d i s still widely practice d today . Th e use o f a hysteroscop e coul d greate r enhanc e it s effectiveness , since i t woul d mak e th e interio r o f th e uteru s visible . I n a variation o f th e D & C , termed endometria l ablation , th e linin g of th e uteru s i s cu t awa y throug h th e us e o f lase r beam s o r electrical current , wit h th e assistanc e o f a hysteroscope . Al though mor e precis e tha n a D & C , thi s procedur e almos t always result s i n infertility . Anothe r therap y fo r endometriosi s is tuba l ligation . B y tyin g th e fallopia n tubes , menstrua l fluid s are blocke d fro m backin g u p int o th e pelvi c cavity , makin g i t difficult fo r endometria l tissu e t o trave l an d implan t there . Needless t o say , th e passag e o f th e eg g t o th e uteru s i s als o blocked, s o pregnancy i s unlikely. Even prolaps e ca n b e treate d throug h procedure s othe r tha n hysterectomy. Th e ligament s supportin g th e uteru s ca n b e strengthened throug h exercise . I n anothe r minimall y invasiv e procedure, a rubbe r o r plasti c pessar y ca n b e use d t o hol d th e uterus i n place . Finally , i t i s possibl e t o surgicall y realig n th e uterus, particularly wit h th e ai d o f a laparoscope . Despite numerou s benefits , thes e alternativ e procedure s ar e still used relatively seldo m an d ofte n incorrectly . Hysterectomie s are easie r t o perfor m an d generall y les s time-consuming. More over, physician s ar e no t routinel y traine d i n th e us e o f alterna tives, particularl y thos e tha t involv e th e us e o f endoscope s fo r gynecological procedures . Thes e precisio n instrument s requir e expert visual-moto r coordinatio n an d a grea t dea l o f practice .

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The procedure s mus t b e performed man y time s (a t least twenty five) before th e physicia n ca n b e considered adequatel y trained . Unfortunately, man y physician s hav e n o forma l trainin g wit h endoscopes o r laparoscope s bu t learn , s o t o speak , o n th e job . Since i t i s so eas y t o perforat e th e uteru s o r surroundin g organ s with thi s technology , i t i s no t surprisin g tha t ther e ar e man y reports o f mor e seriou s complications , includin g death , fro m endoscopically assiste d gynecologica l procedure s tha n fro m tra ditional hysterectomies . Onc e again , lac k o f regulatio n ha s re sulted i n wome n bein g use d a s guine a pigs . Thi s i s a perfec t example o f ho w technolog y coul d benefi t wome n bu t doe s not , due t o a lac k o f contro l ove r bot h th e procedur e an d th e pro vider. As with cesareans , it is impossible t o ignor e th e profit motiv e involved i n hysterectomy . Fewe r hysterectomie s ar e performe d when physicians are not directl y compensated fo r th e procedure , as with prepai d healt h plan s (excep t i n trainin g hospital s wher e unnecessary hysterectomie s hav e bee n performe d t o giv e intern s practice i n th e procedure) . Additionally , alternativ e procedure s provide less financial incentiv e because they are time consuming . Insurance play s a n importan t par t i n th e profi t motive . O n the on e hand , som e insuranc e companie s hav e supporte d th e performance o f hysterectomies , sinc e th e operatio n wil l likel y reduce th e numbe r o f subsequen t gynecologica l claim s fro m the patient . O n th e othe r hand , othe r insuranc e companie s ar e beginning t o realiz e tha t the y ar e payin g fo r a vas t amoun t o f unnecessary surgery . In order t o reduce the number o f unnecessary hysterectomies , insurance companie s hav e implemente d severa l ne w strategies . Some companie s no w requir e a secon d opinion . Other s refus e to cove r electiv e hysterectomies . Som e innovativ e insuranc e companies mee t wit h physician s wh o hav e hig h hysterectom y rates an d discus s ho w his/he r rate s compar e wit h thos e o f othe r

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physicians, thu s applyin g wha t migh t b e considere d pee r pres sure wit h educationa l overtones . I n a n extensio n o f thi s proce dure, on e insuranc e compan y identifie s communitie s wit h hig h rates o f hysterectom y an d implement s revie w procedures . Thi s company als o reward s high-qualit y car e (measure d b y low inci dence of complications ) wit h bonuses . None o f th e alternative s presente d i s a panacea , an d eac h has it s ow n potentia l sid e effect s an d complications . Eve n so , hysterectomy shoul d b e the last , no t th e first, recours e fo r treat ing gynecological disorders . Unfortunately, th e alternative s hav e not inspired , a s on e woul d expect , a significan t an d stead y decline in the number o f hysterectomies . Interestingly, i f anyon e ha s begu n t o regulat e th e medica l profession, i t i s th e insuranc e industry , an d th e medica l profes sion ha s fough t thi s ever y ste p o f th e way . (It s respons e t o managed car e i s just on e exampl e o f thi s resistance. ) Bu t whil e women ma y benefi t fro m som e o f th e insuranc e companies ' provisions an d regulations , th e companie s clearl y ar e no t moti vated b y humanitarian concern s bu t b y efforts t o reduc e expen diture. Why I s Hysterectom y a Firs t Choic e an d No t a Last Resort ? Many medica l personne l persis t i n believin g tha t th e uteru s i s a disposable organ , even a nuisance, in the postchildbearing years . Castration i s define d a s remova l o f th e se x gland s (th e ovarie s or th e testes) . Would 600,00 0 me n a year (76. 4 percen t o f the m still in their childbearin g years ) b e recommended for , o r consen t to, testicula r castration ? Most physician s an d endocrinologist s clearl y d o no t under stand th e repercussions o f hysterectomy , largel y becaus e they d o not understan d th e effect s o f hormone s an d hormon e changes .

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Premenstrual syndrome , postpartum depression , even pregnanc y symptoms—the medica l professio n clearl y doe s no t understan d any o f thes e condition s an d ha s relegate d the m t o th e real m o f psychology. I n fact , althoug h medica l student s ar e i n genera l taught t o loo k fo r a physical , no t a psychological , basi s fo r symptoms, th e revers e i s true whe n i t come s t o women' s issues . Premenstrual syndrom e no w appear s i n the Diagnostic and Statistical Manual of Mental Disorders. Postpartu m depressio n i s not even covered i n the curricula o f most medical schools . When a woma n balk s a t havin g he r uteru s removed , physician s ofte n maintain tha t sh e i s just bein g sentimenta l abou t he r reproduc tive organs o r suffering fro m "empt y nes t syndrome." However , this highlight s a n interestin g disparity . I f al l o f thes e disorder s are simpl y psychological , wh y d o physician s continu e t o trea t them medically ? I f PM S i s jus t a menta l condition , the n wh y prescribe everythin g fro m painkiller s t o hysterectomy fo r it ? The numbe r o f hysterectomie s performe d i s als o influence d by training and communit y norms . In other countrie s the hyster ectomy rate s ar e almos t alway s les s tha n th e rat e i n th e Unite d States, sometime s a s muc h a s 5 0 percen t less , ye t th e rate s o f death fro m gynecologica l diseas e ar e equa l t o tha t o f th e Unite d States. I n othe r words , America n doctor s ar e no t i n fac t savin g lives i n proportio n t o th e numbe r o f hysterectomie s the y per form, fro m whic h it is reasonable to conclude that many of thes e hysterectomies ar e unnecessary . Mor e evidenc e o f communit y influence come s fro m comparin g regiona l rate s withi n th e United States . Lik e th e rat e o f cesarea n section , th e rat e o f hysterectomy (amon g younge r women ) i s higher i n the South. 27 It i s difficul t t o imagin e tha t souther n wome n actuall y hav e more gynecologica l problem s tha t requir e cesarean s an d hyster ectomies tha n d o wome n elsewher e i n th e country . Mor e likely , local norms affec t th e way a physician i s trained an d th e way h e or sh e evaluates an d treat s a patient's condition .

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At present , cesarea n sectio n an d hysterectomy , th e tw o mos t common surgerie s i n th e country , appea r t o protec t physician s from liabilit y mor e tha n the y protec t women' s healt h an d qual ity o f life . The lac k o f understanding , lac k o f contro l o r regula tion ove r th e process , an d lac k o f investigatio n int o alternative s is pervasive an d appalling . Som e physicians hav e begu n t o rais e questions abou t thes e surgeries , t o monito r themselves , an d t o seek alternatives , bu t the y ar e i n th e minority , an d th e curricul a of medica l school s hav e no t show n an y significan t correspond ing change . Give n ho w trainin g an d communit y norm s affec t medical decisions , a significan t downwar d tren d i n th e nea r future i s unlikely . I n th e meantime , onl y th e insuranc e compa nies are insisting o n restraint . Although i t seem s reasonable t o sugges t tha t wome n educat e themselves o n issue s o f reproductiv e healt h an d becom e wise r consumers, no t al l wome n hav e th e time , energy , an d resource s to d o so . Moreover, som e women ar e admitte d fo r treatmen t i n emergency situation s an d hav e n o opportunit y t o stud y th e issues befor e the y ar e asked t o make crucia l decision s (o r befor e others mak e thes e decision s o n thei r behalf) . Th e botto m lin e is that consumers pay professionals t o know their area o f expertis e and t o provid e sound , reliabl e advic e tha t ha s th e consumer' s best interes t a t heart . Physician s i n particula r ar e boun d t o honor th e implici t contract , fo r the y tak e a n oath , whic h pa tients trust, t o d o no harm .

[7] Back t o th e Future ?

^L-he Constitutio n guarantee s certain right s t o al l citizen s o f th e Unite d States , regardles s o f gender. Man y o f thes e right s hav e bee n discusse d i n thi s book . Yet me n an d wome n ar e ofte n treate d quit e differently , b y th e law, th e medica l profession , an d societ y i n general , whe n the y try to exercis e thes e rights, and take n a s a whole, the disparitie s seem formidable . I t i s clear tha t "rights " ar e meaningles s unles s they ar e uphel d b y the lega l system, an d uphel d fo r everyone . All reproductiv e right s ar e inextricabl y linked , an d losse s i n any on e are a ma y represen t losse s acros s th e board . Fo r exam ple, i f th e stat e ca n pas s law s forbiddin g pregnan t wome n fro m using substance s tha t ma y har m th e fetus , wha t wil l happe n t o a woman' s righ t t o choos e a n abortion ? Reproductiv e issue s represent a comple x array ; non e o f the m ca n b e viewe d i n isolation. These issue s ar e onl y likel y t o becom e mor e complicate d i n [192]

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the future . Eac h yea r reproductive technologie s soun d mor e an d more lik e science fiction. I t is already possibl e t o create identica l twins b y clonin g a fertilize d eg g befor e i t begin s t o subdivide . Researchers hav e als o begu n t o successfull y ovaria n graft . Wit h ovarian grafting , i t ma y on e da y b e possibl e t o remov e ovarie s and cryopreserv e the m fo r futur e us e b y the woman o r a donor . Thus, i f a woma n wa s undergoin g chemotherap y o r wante d t o delay childbirth , sh e coul d preserv e he r ovarie s unti l sh e wa s ready t o us e them , thereb y retainin g th e integrit y o f th e eggs . The reproductiv e technolog y "business " i s alread y booming , and advance s suc h a s ovarian graftin g wil l surel y generat e mor e interest and more business . In addition, recent judicial decisions , such a s thos e regardin g Bab y Jessic a an d Bab y Richar d hav e made som e couple s leer y o f adoptin g an d incline d t o tr y fo r biological parenthood , n o matte r wha t th e cost, effort, o r risk . Correspondingly, lega l dilemma s hav e als o becom e mor e complicated. Conside r th e cas e o f Judith Hart . Judith wa s bor n in Jun e 1991 , althoug h he r biologica l fathe r ha d die d i n Jun e 1990. Judith' s father , Edward , ha d seme n specimen s froze n prior t o hi s death. Hi s widow, Nancy, underwen t GIF T afte r hi s death an d conceive d Judith . Afte r Judit h wa s born , Nanc y ap plied t o Socia l Securit y fo r survivo r benefit s fo r he r bu t wa s denied. I t seem s Louisian a ha s a la w statin g tha t a chil d bor n more tha n thre e hundred day s afte r a man's deat h canno t b e his child. Shoul d Judit h b e allocate d survivo r benefits ? Shoul d sperm o r egg s b e allowe d t o surviv e th e individua l fro m who m they came , o r shoul d the y b e destroye d upo n hi s o r he r death ? Reproductive technolog y i s evolving s o rapidly tha t i t i s reshaping society in ways tha t presen t conundrum s o n a daily basis . As for substanc e abus e an d pregnancy , ne w drug s ar e contin ually introduced int o the American market , creating new oppor tunities fo r abus e an d addiction . Th e fundin g fo r th e "wa r o n drugs" i s largel y allocate d towar d enforcemen t o f law s rathe r

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than towar d prevention . A s Democrat s an d Republican s fight over wh o ca n cu t mor e mone y fro m th e federa l budget , th e minuscule amoun t o f mone y availabl e fo r preventio n an d treat ment o f addictio n ha s dwindled . I t i s likely that mos t program s for pregnan t substanc e abuser s wil l b e funde d throug h privat e sources, since pregnant substanc e abuser s represen t onl y a smal l subset o f th e nation' s dru g abuser s an d legislator s an d politi cians d o no t fee l tha t a specia l outla y i s warranted. Suc h short sightedness i s incredible , give n th e mone y tha t i s eventuall y saved b y effectiv e preventativ e treatment . Moreover , a s th e number o f pregnan t wome n brough t t o cour t fo r substanc e abuse during pregnancy mounts, other pregnant substanc e abus ers becom e mor e likel y to avoi d treatmen t center s ou t o f fea r o f incarceration o r o f losin g their children . As for th e workplace, it is not likely to spontaneously becom e safer fo r pregnan t women . We need more intensive research int o potential hazards . Again , thi s simpl y i s no t happenin g o n a large enoug h scal e o r a t a rapi d enoug h pac e t o kee p u p wit h technological advances . Abortion right s continu e t o remai n o n shak y ground . RU 486 trial s have begu n i n the United States , but th e journey fro m trials t o FD A approva l i s a lon g an d treacherou s one . I n th e meantime politic s o r experimenta l setback s coul d stal l th e proj ect, an d changin g presidentia l administration s coul d stifl e ap proval altogether . Eve n i f RU-48 6 i s mad e available , th e abor tion controvers y wil l only shif t t o othe r arenas , not fad e away . Finally, cesarean an d hysterectom y rate s ar e not dramaticall y decreasing, an d n o on e i s systematicall y investigatin g th e situa tion t o determin e ho w ofte n an d whe n thes e surgerie s ar e actu ally necessary . Change s ar e unlikel y withou t regulation , whic h is unlikel y withou t researc h data . I n th e meantime , liabilit y suits ensur e tha t physician s remai n surgery-prone . Ironically , physicians often unnecessaril y remove ovaries during hysterecto-

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mies, causin g infertility . Wome n an d couple s the n see k hel p through reproductiv e technologies . Thi s become s a viciou s cy cle. To o man y peopl e hav e becom e dependen t o n th e medica l system to make thei r dream s a reality . *# #

There i s a bumpe r sticke r whic h read s "I f yo u can' t trus t m e with a choice , ho w ca n yo u trus t m e wit h a child? " I f wome n cannot mak e goo d decision s regardin g prenata l health , the n why ar e they given such enormou s decision-makin g responsibil ity afte r a chil d i s born ? Ho w ca n wome n mak e suc h goo d parents bu t lac k suc h capacities when the y ar e parents-to-be ? Early i n my pregnanc y I was offere d th e opportunit y t o hav e a materna l seru m screening , whic h include s a bloo d tes t t o determine whethe r th e fetu s i s at ris k fo r severa l birt h defects . I am considere d a n "a t risk " patien t becaus e I am ove r thirty-fiv e years old . Th e tes t present s n o ris k t o th e fetu s o r th e mothe r (except from a blood draw ) bu t has a high rate of false positives . If i t i s positive, additiona l test s ar e recommended , includin g a n ultrasound and/o r amniocentesis . Amniocentesi s carrie s it s ow n risks: th e fetu s ma y b e injure d b y it . I chos e no t t o hav e th e maternal seru m screening . Althoug h a negativ e resul t migh t have bee n reassuring , a positiv e on e migh t hav e mad e m e s o nervous that m y bab y could hav e bee n adversely affecte d simpl y by m y anxiety . I coul d hav e trie d t o alla y th e anxiet y throug h further testing , bu t I did no t wan t t o ris k injurin g th e bab y an d was particularly leer y of amniocentesis . I a m gla d tha t th e seru m tes t i s availabl e an d tha t I ha d th e choice t o determin e wha t wa s bes t fo r m y chil d an d myself . I know wha t I a m capabl e o f handlin g an d a m fairl y wel l verse d in reproductive issues . But what i f that test had bee n mandatory , or wha t i f certai n subsequen t action s wer e mandator y i n th e case o f a positiv e result ? Eac h cas e i s s o highl y individualize d

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that n o edic t shoul d depriv e women o f thei r choices . No legisla tion force s wome n t o breast-fee d o r t o bu y saf e cribs ; non e should regulat e importan t reproductiv e decisions . Much o f thi s boo k ha s focuse d o n th e nee d fo r regulatio n t o assure tha t reproductiv e right s ar e upheld . Thi s shoul d no t b e misconstrued. Wome n d o no t nee d an y mor e regulatio n ove r their reproductiv e lives , o r an y furthe r diminutio n o f thei r au tonomy. Rather , th e institution s tha t hav e gaine d contro l ove r women's reproductiv e right s nee d t o b e force d eithe r t o relin quish i t o r t o se t standard s tha t minimiz e hazar d an d prohibi t discrimination. Leavin g industrie s an d businesses , includin g th e business o f medicine , t o regulat e themselve s ha s prove n disas trous fo r women . In a jus t world , devoi d o f sexism , heterosexism , racism , an d capitalist greed , governmen t regulatio n woul d b e unnecessary . In a n imperfec t worl d suc h a s ou r own , regulation s ca n a t leas t restrain abus e an d com e t o th e ai d o f it s victims . Thos e wh o are discriminate d agains t woul d a t leas t hav e a lega l recourse . However, protective regulation i s on a continuum with paternal ism, an d i t is easy to cros s th e fine line. Regulation tha t touche s on reproductiv e issue s an d right s shoul d originat e from , an d b e developed an d supervise d by , individuals wh o ar e committe d t o the autonom y o f women . This boo k i s a cal l t o action . Organize d advocate s fo r wom en's rights , suc h a s th e Nationa l Organizatio n fo r Wome n (NOW), the National Abortio n Right s Action League (NARAL) , the Feminis t Majorit y Foundation , an d th e Nationa l Women' s Health Networ k provid e a focu s fo r wor k towar d tru e gende r equality. Bu t powerfu l force s ar e arraye d agains t them , inten tionally o r unintentionall y opposin g thei r goals . Thes e rang e from antichoic e group s t o certai n sector s o f busines s an d indus try t o th e paternalisti c traditio n i n la w an d government . Al though man y individual s an d organization s see m to believ e tha t

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they hav e a stak e i n controllin g th e reproductiv e right s o f women, n o on e seem s willin g t o tak e responsibilit y fo r an y o f the outcomes . Ho w many , fo r example , o f th e thousand s an d thousands o f American s wh o d o no t believ e a woma n shoul d have th e righ t t o choos e abortio n ar e prepare d t o adop t he r unwanted children ? Th e consequence s o f controllin g a woman' s reproductive choice s fall overwhelmingl y o n th e woman herself . One purpos e o f thi s boo k i s t o provid e reader s wit h a n opportunity t o conside r thes e issues a s well a s the ethical , medi cal, an d lega l rationale s tha t underli e curren t practices . A broader an d deepe r publi c awarenes s o f th e issue s will naturall y bring to the fore advocate s fo r women' s healt h an d reproductiv e rights wh o ar e bette r equippe d t o tak e o n leadershi p roles . T o paraphrase a quot e tha t ha s ofte n bee n attribute d t o Margare t Mead, "Neve r doub t tha t a smal l grou p o f thoughtful , commit ted citizen s ca n chang e th e world . Indeed , i t i s th e onl y thin g that eve r has. "

Notes

NOTES T O CHAPTE R ON E

1. Chri s Mihil l an d Sall y Weale, "Birt h Pangs : Has Fertilit y Treat ment Se t th e Right s o f th e Unbor n Chil d agains t Thos e o f Desperat e Parents?" Guardian, 5 January 1994 . 2. Ther e i s apparentl y n o comparabl e ter m fo r olde r me n wh o become fathers . 3. Elizabet h Noble , Having Your Baby by Donor Insemination (Boston: Houghton Mifflin , 1987) , 87 . 4. Noble , Having Your Baby, 87 . 5. Noble , Having Your Baby, 87-88 . 6. Noble , Having Your Baby, 88 . 7. Noble , Having Your Baby, 89 . 8. Noble , Having Your Baby, 106 . 9. Sall y Squires , "Whe n th e 'Father ' I s a Sper m Donor : Shoppin g for Saf e Sperm, " Washington Post, 1 1 February 1992 , final edition . 10. "Canadia n Artificia l Inseminatio n Stud y Warn s o f HI V Risk, " Reuters, 2 8 Apri l 1993 , British Columbi a cycle . 11. Robi n Schatz , "Risk y Business : Unlicense d Sper m Ban k Face s Charges," Newsday, 26 Apri l 1992 , city edition . 12. Offic e o f Technolog y Assessment , 100t h Cong. , 2d sess. , Artificial Insemination Practice in the United States: Summary of a 1987 Survey. 13. Jef f Stryker , "Artificia l Inseminatio n I s Mor e Widel y Avail able—and Mor e Problematic, " Dallas Morning News, 1 2 Octobe r 1993, final home edition . 14. Barbar a Raboy , "Secrec y an d Opennes s i n Donor Insemination : [199]

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A Ne w Paradigm, " Politics and Life Sciences 1 2 (Augus t 1993) : 1 9 1 92. 15. Cher i Pies , Considering Parenthood (Sa n Francisco : Spinsters / Aunt Lute, 1988) , 187 . 16. Althoug h in some states, to sever the donor's rights to paternity , a physicia n mus t perfor m th e insemination . Nanc y E . Roman , "La w on Artificia l Inseminatio n I s Stil l i n Infancy : Rights , Responsibilitie s Evolving," Washington Times, 1 4 Februar y 1994 , final edition . Se e also Californi a Civil Code, Annotated (Deerin g 1994) , sec. 7005. 17. "Fertilit y Docto r Foun d Guilt y o f Fraud, " Chicago Tribune, 5 March 1992 , sec. 1. 18. Mar y An n Chiasson , Ran d L . Stoneburner , an d Stephe n C . Joseph, "Huma n Immunodeficienc y Viru s Transmissio n throug h Arti ficial Insemination, " Journal of Acquired Immune Deficiency Syndromes 3 (1990) : 69-72 . 19. Lesli e Berkman , "HI V Peri l i n Artificia l Inseminatio n Cited ; Health: Woman, Infecte d b y Carrie r o f Viru s Tha t Cause s AIDS , Urges Others t o Mak e Sur e Tha t Clinic s D o Prope r Tests, " Los Angeles Times, 2 9 April 1994 , Orange Count y edition . 20. ter Neuzen v. Korn, 4 1 ACW S 3d 432 (1993) . 21. Brown v. Shapiro, All N W 2 d 24 7 (1991) . 22. "Sper m Washing Stud y Encouraging bu t U.S. Researchers Leer y of Risks, " AIDS Alert 8 (April 1993) : 53. 23. Tw o women becam e pregnan t an d miscarrie d bu t becam e preg nant again , s o ther e wa s a tota l o f seventee n pregnancies . August o E . Semprini, Paol o Levi-Setti , Maddalen a Bozzo , Marin a Ravizza , Ann a Taglioretti, Patrizia Sulpizio , Elena Albani, Monica Oneta , an d Giorgi o Pardi, "Inseminatio n o f HIV-Negativ e wit h Processe d Seme n o f HIV Positive Partners," Lancet 34 0 (Novembe r 1992) : 1317 . 24. "Virgini a Docto r Reprimande d i n HIV 'Sperm-Washing ' Case, " Aids Weekly, 1 2 Octobe r 1992 . 25. Report s o f th e transmissio n o f sexuall y transmitte d disease s from dono r seme n ca n b e foun d i n an y o f th e following : Willia m R. Berry , Ra y L . Gottesfeld , Harve y J . Alter , an d Joh n M . Vierling , "Transmission o f Hepatitis B Virus b y Artificial Insemination, " Journal of the American Medical Association 257 (Februar y 1987) : 1079 81; Lauren e Mascola , "Seme n Donor s an d th e Sourc e o f Sexuall y Transmitted Disease s i n Artificially Inseminate d Women : The Sag a Un -

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folds," Journal of the American Medical Association 25 7 (Februar y 1987): 1093-94 ; Donal d E . Moore , Rhod a L . Ashley , Pau l W . Zarut skie, Rober t W . Coombs , Michae l R . Soules , an d Lawrenc e Corey , "Transmission o f Genita l Herpe s b y Dono r Insemination, " Journal of the American Medical Association 26 1 (Jun e 1989) : 3441-43 ; B.S . Shanis, J.H. Check , an d A.F . Baker, "Transmissio n o f Sexuall y Trans mitted Disease s b y Dono r Semen, " Archives of Andrology 2 3 (1989) : 249-57. 26. Fo r example, Illinois and Delaware , which have virtually identi cal statutor y provision s regardin g seme n donor s an d sper m banks , require donor s t o b e tested fo r an y causative agen t o f AIDS at th e tim e of th e donation . Se e Illinois Compiled Statutes, Annotated (1994) , sec. 20: 2310/55.46(c ) an d Delawar e Code, Annotated (1993) , sec . 16 : 2801(b). However , ther e i s n o mentio n o f quarantinin g th e seme n fo r six month s o r retestin g o f th e donor . Maryland' s provision s ar e les s broad, requirin g testin g fo r HI V bu t no t possibl e causativ e agent s o f AIDS. Annotated Code of Maryland (1993) , sec. 18-334(b)(l) . 27. Indian a requires testing for syphilis and hepatitis B in addition t o HIV. Se e Indian a Statutes, Annotated (Burn s 1994) , sec . 16-41-14 5(a)(l)(2)(3). In addition to the tests required in Indiana, Californi a als o requires testin g fo r hepatiti s C an d huma n T lymphotrophi c virus- 1 (HTLV-1). Se e Californi a Codes, Annotated (Deerin g 1994) , sec . 1644.5(a). Florida requires testing for HIV and other communicable diseases specified b y the Department o f Health an d Rehabilitative Services . See Florida Statutes (1993) , sec. 381.0041(1). Kentucky requires testin g for HIV and other communicable diseases as specified b y the United Net work for Orga n Sharing, the American Association of Tissue Banks, and the Eye Bank Association of America. Ohio requires a thorough medica l examination o f the donor an d suggests that "th e laboratory studie s ma y include, bu t ar e no t limite d to , venerea l diseas e researc h laboratories , karotyping, G C culture , cytomegalo , hepatitis , kem-zyme , Tay-Sachs , sickle-cell, ureaplasma, HTLV-III, and chlamydia. " 28. HI V i s detecte d whe n a n individual' s bloo d test s positiv e fo r antibodies t o th e disease ; henc e th e ter m "HIV-positive. " I f a perso n becomes infected , i t usuall y take s approximatel y si x month s fo r th e antibodies t o appea r i n the blood . Durin g those si x months, they coul d transmit th e virus, even though thei r bloo d test s negative for antibodie s to HIV .

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29. Fo r example , Indiana, Michigan , an d Louisian a al l require tha t semen b e quarantine d fo r si x month s an d th e dono r teste d a t th e tim e of donatio n an d reteste d i n si x month s fo r evidenc e o f th e HI V virus . Louisiana Statutes (1993) , sec. 40: 1062.1(B) . See also Michiga n Compiled Laws (1992) , sec. 333.20179(1) an d Indian a Statutes, Annotated (Burns 1994) , sec. 16-41-14-7(a)(l)(2) . 30. Fo r example , i n Indiana, i f th e recipien t an d th e dono r ar e i n a mutually monogamou s relationship , th e practitioner i s required t o per form a n HI V tes t annuall y a s lon g a s inseminatio n continues . Se e Indiana Statutes, Annotated (Burn s 1994) , sec . 16-41-14-7(b)(l) . I n Louisiana an d Florida , a husban d ma y donat e seme n t o hi s wife with out bein g subjecte d t o an y testing . Se e Louisian a Revised Statutes (1993), sec . 40 : 1062.1(B)(1 ) an d Florid a Statutes (1993) , sec . 381.0041(3)(b). 31. Fo r example , Kentuck y an d Florid a requir e physician s t o war n recipients o f th e ris k o f contractin g HIV . Se e Kentuck y Revised Statutes, Annotated (Baldwi n 1993) , sec . 311.281(7) ; Florid a Statutes (1993), sec. 381.0041(12). 32. Fo r example , Delawar e an d Illinoi s requir e al l sper m bank s operating withi n th e stat e to registe r with th e Department o f Healt h b y May 1 of eac h year. Those failin g t o register ar e subjec t t o a fine of five thousand dollars . Se e Illinoi s Compiled Statutes, Annotated (1994) , sec. 20 : 2310/55.46(a) ; Delawar e Code, Annotated (1993) , sec . 16 : 2801(a). 33. I n Louisiana , healt h facilities , physicians , o r agencie s tha t vio late an y provision s regardin g seme n specimen s ca n b e fined u p t o two thousan d dollars . Se e Louisian a Revised Statutes (1993) , sec . 40 : 1062.1(E). 34. I n Louisian a an d Michigan , healt h facilities , physicians , o r agencies tha t violat e an y provision s regardin g seme n specimen s ca n b e held liabl e fo r damage s i n civi l actions . Se e Louisiana Revised Statutes (1993), sec . 40 : 1062.1(E) ; Michiga n Compiled Laws (1992) , sec . 333.16273(2). 35. Tennesse e Advance Legislative Service (1994) , pub . chap . 952(2)(a)(2). Suc h crimina l exposur e t o HI V i s a Clas s C felon y i n Tennessee an d Indiana . Se e Indiana Statutes, Annotated (Burn s 1994) , sec. 35-42-l-7(b) . However , th e offens e change s t o a Clas s A felon y i f it result s i n th e transmissio n o f HI V t o an y othe r person . Illinois ,

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Delaware, an d Florid a hav e simila r statutor y provisions . Suc h legisla tion ha s com e unde r attac k fo r bein g overbroad : se e Michae l L . Clos son an d Jeffrey S . Deutschman, " A Proposal t o Repea l th e Illinoi s HI V Transmission Statute, " Illinois Bar Journal 7 8 (Decembe r 1990) : 592 600. 36. Fo r example , i n Illinoi s an d Delaware , negligently , recklessly , intentionally, o r knowingl y usin g seme n fo r inseminatio n whe n th e donor ha s teste d positiv e fo r HI V o r othe r causativ e agent s o f AIDS is a felony , a s i s usin g seme n fo r insemination s withou t meetin g othe r mandatory testin g requirements . Se e Illinois Compiled Statutes, Annotated (1994) , sec . 20 : 2310/55.46(c) ; Delawar e Code, Annotated (1993), sec . 16 : 2801(c). In Florida , an y perso n wh o fail s t o tes t seme n destined fo r us e i n insemination s i s guilty o f a misdemeanor . Se e Flor ida Statutes (1993) , sec. 381.0041(ll)(a) . 37. Schatz , "Risk y Business. " 38. Schatz , "Risk y Business. " 39. Th e gen e for hemophili a i s carried an d transmitte d b y females . 40. "Testin g Donors o f Organs , Tissues, and Seme n for Antibod y t o Human T-Lymphotropi c Viru s Typ e III/Lymphadenopathy-Associate d Virus," Morbidity and Mortality Weekly Report 3 4 (Ma y 1985) : 294 . The America n Medica l Associatio n endorse d th e Publi c Healt h Ser vice's recommendation i n 1987 . 41. "Seme n Banking , Orga n an d Tissu e Transplantation , an d HI V Antibody Testing, " Journal of the American Medical Association 25 9 (March 1988) : 1301. 42. Dian e M . Gianelli , "Benefit s See n i n Regulatin g Fertilit y Medi cine," American Medical News 3 5 (Marc h 1992) : 3. 43. Sharo n Kirkey , "Artificia l Insemination : Som e Doctors Ignorin g Guidelines, Says Technology Report," Ottawa Citizen, 2 0 March 1992 , Valley edition . 44. Robi n Schatz , "4 0 Sper m Donor s No t Tested, " Newsday, 1 5 July 1993 , city edition . 45. Schatz , "4 0 Sper m Donors. " 46. "MD s t o Sa y Monda y i f Unteste d Sper m Use d Here, " Gazette (Montreal), 1 May 1993 , final edition . 47. Rebecc a Wigod , "Lesbia n Coupl e Wh o Wan t Chil d Denie d Sperm," Vancouver Sun, 2 2 July 1993 , 2 star edition . 48. A . Brewaeys , H . Olbrechts , P . Devroey , an d A.C . Va n Steir -

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teghem, "Counsellin g an d Selectio n of Homosexual Couple s in Fertilit y Treatment," Human Reproduction 4 (1989) : 850-53. 49. Raboy , "Secrec y and Openness, " 191 . 50. Gianelli , "Benefit s Seen, " 3 . 51. Gianelli , "Benefit s Seen, " 3 . 52. Gianelli , "Benefit s Seen, " 3 . 53. "Firs t Test-Tub e Birt h Usin g Donate d Egg, " Associated Press, 12 January 1984 , P.M . cycle. Rowland report s a birt h fro m a donate d egg i n 1983 , bu t n o confirmatio n ca n b e located . Roby n Rowland , Living Laboratories (Bloomington : Indiana Universit y Press , 1992), 17. 54. "Firs t 'Tes t Tube ' Bab y Conceive d throug h Eg g Dono r Pro gram," Newswire, 2 1 November 1988 . 55. Melind a Beck , Mary Hager , Pa t Wingert , Patrici a King , Jeanne Gordon, Stanle y Holmes, and Susa n Miller, "Ho w Fa r Shoul d We Push Mother Nature, " Newsweek, 1 7 January 1994 , 54 . 56. Richar d Scheinin , "Wh y Olde r Moms, Fetal Eggs and 'Designe r Babies' Provok e Outrage, " Dallas Morning News, 2 3 Januar y 1994 , final home edition . 57. Ki m Kowsky , "Give r o f Life , Agai n an d Again ; 'Super-Donors ' Repeatedly Undergo a Lengthy, Painful Proces s to Help Fertility Clinic s Meet the High Deman d fo r Eggs. " Los Angeles Times, 3 January 1993 , home edition . Under th e mai n headline , one dono r wa s cite d a s saying , "I'm prou d tha t I can d o this. " 58. Rowland , Living Laboratories, 22 . 59. Fo r a n extensiv e discussio n o f thes e procedure s an d th e risk s involved, se e Rowland, Living Laboratories, 25-30 . 60. However , donor s ar e generall y no t full y compensate d unles s donation i s successful . Fo r example , on e woma n wh o coul d no t com plete th e proces s becaus e sh e develope d ovaria n cyst s durin g th e hor mone manipulatio n wa s terminate d fro m th e eg g donation progra m a t Mount Sina i an d onl y partiall y compensated . A spokesperso n insiste d that th e hospita l wa s no t purchasin g egg s bu t compensatin g onl y fo r time an d inconvenience . Additionally , th e dono r ha d no t signe d a n informed consen t no r bee n apprise d o f th e risks . Whe n th e dono r brought he r case to the attention o f the media, she learned Moun t Sina i was no t eve n license d a s a n eg g donatio n clini c i n th e stat e o f Ne w York, whic h require s licensur e o f gamet e donatio n facilities . Moll y

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Gordy, "Eg g Dono r Rejected : Problem s Plagu e Unlicense d Center, " Newsday, 8 May 1992 , city edition . 61. Davi d Fletcher , "Wome n Urge d t o Ignor e Instan t Fertilit y Of fer," Daily Telegraph (London) , 25 August 1994 . 62. Davi d Fletcher , "Fertilit y Barterin g Rule s Fac e Review, " Daily Telegraph (London) , 1 9 February 1994 . 63. Rowlan d say s tha t egg s ar e larg e cell s an d difficul t t o freeze , because ic e crystal s for m an d ruptur e th e membrane . Sh e als o cite d a successful birt h fro m a froze n eg g i n 1983 , bu t th e eg g ha d onl y bee n frozen a matte r o f hours . Rowland , Living Laboratories, 17 . Recentl y Australian researcher s clai m t o hav e develope d a successfu l metho d o f freezing egg s befor e fertilization . Davi d Williams , "Australi a Claim s World Firs t i n Freezin g Huma n Eggs, " Agence France Presse, 1 9 Jun e 1994, International New s section . Sinc e the eggs cannot, lik e semen, b e frozen an d quarantine d fo r si x months , the y pos e a n increase d ris k o f HIV transmission . 64. Th e "yuck " facto r i s used to refe r t o the distaste an d skepticis m of th e genera l publi c regardin g reproductiv e technologica l advance s b y the medica l profession . Lind a Grant , "Fiftee n Year s Ago , th e World' s First Test-Tub e Bab y Wa s Greete d wit h Wonder . Bu t No w W e Ar e Being Aske d t o Accep t Scientifi c Advance s Tha t See m Repulsive , Eve n Dangerous. Shoul d Ou r Moralit y B e Determine d i n a Laboratory? " Guardian, 2 8 January 1994 . 65. Englan d recentl y vote d t o ba n th e futur e us e o f feta l egg s fo r this procedure . Christin e Doyle , "Whe n Donor s Answe r a Woman' s Dream a s th e Controvers y Ove r 'Designe r Babies ' Continues, " Daily Telegraph (London) , 26 July 1994 . 66. Marily n Elias , "Wh o Control s Reproductiv e Technology? " USA Today, 5 January 1994 . 67. Lind a Grant , "Fiftee n Year s Ago." 68. Abigai l Trafford , "Post-Menopausa l Mom s Caus e a Stir, " Record (Bergen) , 1 7 January 1994 . 69. Trafford , "Post-Menopausa l Moms. " 70. Caro l Stocker , "Th e Eg g Donor : Helpin g Infertil e Couple s Takes Time , Dedicatio n an d Resilience, " Boston Globe, 1 0 Decembe r 1991, city edition . 71. Kowsky , "Give r o f Life. "

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72. Kowsky , "Give r o f Life. " 73. Abbi e Jones , "Fertilit y Doctor s Tr y t o Eg g O n Donors, " Chicago Tribune, 6 March 1994 , sec. 6. 74. Mihil l an d Weale, "Birt h Pangs. " 75. Rowland , Living Laboratories. 76. Dian a Scully , Men Who Control Women's Health: The Miseducation of Obstetrician-Gynecologists (Ne w York : Teacher s Colleg e Press, 1994) , 40. 77. Fo r a more thoroug h discussio n o f Sim s and hi s medical proce dures, see Scully, "Men Who Control Women's Health," 40-48 . 78. Ailee n Ballantyne, "M y Baby' s Brave New World," Times (Lon don), 4 January 1994 . 79. Alexande r Dorozynski , "Franc e Battle s Ou t Bioethic s Bill, " British Medical Journal 30 8 (Januar y 1994) : 291. 80. Dorozynski , "Franc e Battles. " NOTES T O CHAPTE R TW O

1. Susa n Faludi , Backlash: The Undeclared War against American Women (Ne w York : Anchor Books , 1991) , 27-32 . 2. Janic e G . Raymond, Women as Wombs: Reproductive Technology and the Battle over Women's Freedom (Sa n Francisco : Harper , 1993), 3-5 . 3. Faludi , Backlash, 28 . 4. Patrici a Stephenso n an d Marsde n G . Wagner , eds. , Tough Choices: In Vitro Fertilization and the Reproductive Technologies (Philadelphia: Templ e University Press , 1993) , 3. 5. Stephenso n an d Wagner, Tough Choices, 3-4 . 6. Stephenso n an d Wagner , Tough Choices, 6 . 7. Stephenso n an d Wagner , Tough Choices, 6 . 8. Dian e M . Gianelli , "Embry o Researc h Coul d Hel p Many , bu t Is It Ethical?" American Medical News 3 7 (Marc h 1994) : 1 . 9. Gianelli , "Embry o Research. " Th e numbe r o f America n babie s born fro m IV F ha d rise n t o ove r twent y thousan d b y 1994 . "Ne w Fertility Techniqu e fo r Male s Offer s Hope, " Orlando Sentinel, 6 Jul y 1994, 3 star edition . 10. Roby n Rowland , Living Laboratories: Women and Reproductive Technologies (Bloomington : Indian a Universit y Press , 1992) , 40.

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11. Rowland , Living Laboratories, 40 . 12. Niel s E . Skakkebaek , Aleksande r Giwercman , an d Davi d d e Kretser, "Pathogenesi s an d Managemen t o f Mal e Infertility : Revie w Article," Lancet 34 3 (Jun e 1994) : 1473. 13. Josep h B . Verrengia, "Hatchin g Hop e fo r th e Infertile, " Rocky Mountain News (Denver) , 1 0 January 1994 , Local section . 14. Brenda n Pereira , "Cheaper , Les s Stressfu l IY F Metho d Intro duced," Straits Times, 1 5 September 1993 , Home section . 15. Richar d Saltus , "Techniqu e Ma y Trea t Sever e Mal e Infertility, " Boston Globe, 2 0 April 1994 , city edition . 16. Danie l Q . Haney , "Wha t Cos t Test-Tub e Baby ? $72,000, " Associated Press, 28 July 1994 , P.M. cycle. 17. Haney , "Wha t Cost. " 18. Rober t M . L . Winsto n an d Ala n H . Handyside , "Ne w Chal lenges i n Huma n I n Vitr o Fertilization : Scientifi c an d Ethica l Difficul ties," Science 26 0 (Ma y 1993) : 932. 19. Rowland , Living Laboratories, 66. 20. Lorrain e Fraser , "Thes e Littl e Boy s Ar e Happy , Adore d an d Cherished. Bu t Three o f Their Brother s an d Sister s Died s o They Coul d Have Life, " Associated Newspapers, 7 November 1993 . 21. "Danger s t o Test-Tub e Babie s Totall y Ignored, " Guardian Newspapers, 9 January 1994 , News section . 22. "IV F Babie s Develo p Normally , Stud y Finds, " Washington Times, 1 3 February 1994 , final edition . 23. "Frenc h I n Vitro Birth s Stud y Finds High Rat e o f Deformities, " Reuters World Service, 3 0 June 1994 , British Columbi a cycle . 24. DE S i s a dru g tha t wa s widel y prescribe d fo r wome n i n th e 1950s an d 1960 s to prevent miscarriag e unti l i t was discovered tha t th e female offsprin g o f wome n wh o ha d use d th e dru g durin g pregnanc y showed a tendency t o develo p vaginal cancer . 25. Gai l Vines , "Shot s i n th e Dar k fo r Infertility, " New Scientist 140 (2 7 November 1993) : 13. 26. "Medica l Malpractic e I n Vitr o Fertilization, " New York Law Journal (Jul y 1993) : 2 1. 27. "Roya l Commissio n o n Ne w Reproductiv e Technologies, " Canada Newswire, 2 8 Apri l 1993 , Domestic New s section . 28. A s cited i n Sara h Boseley , "G o t o Wor k o n a n Egg, " Guardian, 17 September 1994 .

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29. A s cited i n Boseley, "G o t o Work. " 30. Maria n D . Damewood , The Johns Hopkins Handbook of In Vitro Fertilization and Assisted Reproductive Technologies (Boston : Little, Brown an d Company , 1990) , 54. 31. Stephenso n an d Wagner, Tough Choices, 10 . 32. Josep h Palca , " A Wor d t o th e Wise ; O n th e Approva l o f I n Vitro Fertilizatio n Research, " Hastings Center Report 2 4 (Marc h 1994): 5. 33. Palca , "Wor d t o th e Wise." 34. "The y Ar e the Eg g Men," Economist, 3 Septembe r 1994 , Business, Finance, and Scienc e section . 35. Numerou s individua l an d clas s actio n suit s hav e bee n filed against insuranc e companie s fo r thei r failur e t o provide IV F coverage. 36. Sara h Grady , "Brothe r Bor n Thre e Year s afte r Sisters, " Associated Newspapers, 2 9 July 1994 , evening standard . 37. "Australia : Froze n Embry o Number s Up, " Reuter Textline (Melbourne), 3 February 1994 . 38. Delthi a Ricks , "Froze n Embry o Techniqu e Post s Lo w Preg nancy Rate, " Orlando Sentinel Tribune, 2 5 Ma y 1990 , 3 sta r edi tion. 39. I n som e state s thi s i s no t a n issue . Fo r example , Missour i la w declares tha t lif e begin s a t conception , an d i n Louisian a a froze n em bryo i s considered viable . 40. Davis v. Davis, 84 2 S W 2d 58 8 (1992) . 41. Fo r a n extensiv e discussio n o f th e legalit y o f alternativ e direc tives, se e Joh n A . Robertson , "Prio r Agreement s fo r Dispositio n o f Frozen Embryos, " Ohio State Law Journal 5 1 (1990) : 407-24. 42. Emm a Tom , "Australia : Mother' s Dilemm a ove r Froze n Em bryos," Reuter Textline (Melbourne) , 1 9 June 1993 . 43. Fo r a n extensiv e discussion o f regulations, see Robert J. Muller , "Davis v. Davis: Th e Applicabilit y o f Privac y an d Propert y Right s to Th e Dispositio n o f Froze n Preembryo s i n Intrafamilia l Disputes, " University of Toledo Law Review 2 4 (1993) : 763-804 . 44. "Womb s fo r rent " ha s becom e a derogator y phras e t o refe r t o surrogacy. 45. Marth a A . Field , Surrogate Motherhood (Cambridge : Harvar d University Press , 1988) , 5. 46. Georg e J . Annas , "Fair y Tale s Surrogat e Mother s Tell, " i n

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Larry Gostin , ed. , Surrogate Motherhood: Politics and Privacy (Bloomington: Indian a Universit y Press , 1990) , 44. 47. Fo r a n extensiv e discussio n o f nationa l an d internationa l legis lation an d cas e law , see Diederika Pretorius , Surrogate Motherhood: A Worldwide View of the Issues (Springfield : Charle s C . Thomas, 1994) . 48. Field , Surrogate Motherhood, 1 . 49. Field , Surrogate Motherhood, 1-2 . 50. Phylli s Chester , "Mother s o n Trial : Custod y an d th e 'Bab y M ' Case," i n Dorchen Leidhold t an d Janice G . Raymond, eds. , The Sexual Liberals and the Attack on Feminism (Ne w York : Pergamo n Press , 1990), 95-102 . 51. Johnson v. Calvert, 85 1 P 2d 77 6 (1993) . 52. Dava n Maharaj , "Orang e Count y Focus : Santa Ana ; Surrogat e Mother, Coupl e Dro p Suits, " Los Angeles Times, 2 2 June 1994 , Metr o section. 53. Pretorius , Worldwide View, 57. 54. Complet e copie s o f al l o f thes e guideline s ar e include d i n Larr y Gostin, ed., Surrogate Motherhood: Politics and Privacy (Bloomington : Indiana Universit y Press , 1990) , appendix 4 . 55. Hild e L. Nelson, "Hel d t o a Higher Standard, " Hastings Center Report 2 1 (Ma y 1991) : 2. 56. Dian e Burch , "Surrogac y Spawn s a Ne w Wav e o f Litigation : After Bab y M , Lega l Issue s Ge t Mor e Comple x (an d Perhap s Mor e Costly)," Legal Times, 2 9 January 1990 . 57. Annas , "Fair y Tales," 44. 58. Lor i B . Andrews , "Surrogat e Motherhood : Th e Challeng e fo r Feminists," i n Gostin , Surrogate Motherhood, 167 . 59. Elizabet h Bartholet , Family Bonds: Adoption and the Politics of Parenting (Boston : Houghton Mifflin , 1993) . 60. Field , Surrogate Motherhood, 61-69 . NOTES T O CHAPTE R THRE E

1. "Tw o Cocktai l Server s Fire d fo r Lecturin g Pregnan t Patron, " Chicago Tribune, Apri l 1991. 2. Ke n Pea k an d Franki e Su e De l Papa , "Crimina l Justic e Enter s the Womb : Enforcin g th e 'Right ' t o B e Bor n Drug-Free, " Journal of Criminal Justice 2 1 (1993) : 245.

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3. Pea k an d De l Papa, "Crimina l Justice. " 4. Jame s L . Mills, Lewis B . Holmes, Jerome H . Aarons , Joe Leig h Simpson, Zane A. Brown, Lois G. Jovanovic-Peterson, Mar y R . Conley , Barry I. Graubard, Rober t H . Knopp, and Boyd E. Metzger, "Moderat e Caffeine Us e an d th e Ris k o f Spontaneou s Abortio n an d Intrauterin e Growth Retardation, " Journal of the American Medical Association 269 (1993) : 593. 5. Mill s et al., "Moderat e Caffeine. " 6. Arlen e Eisenberg , Heid i E . Murkoff, an d Sande e E . Hathaway , What to Expect When You're Expecting (Ne w York : Workma n Pub lishing, 1991) . 7. Eisenberg , Murkoff, an d Hathaway , What to Expect, 60 . 8. Eisenberg , Murkoff, an d Hathaway , What to Expect, 60 . 9. Eisenberg , Murkoff, an d Hathaway , What to Expect, 56. 10. Pea k an d De l Papa, "Crimina l Justice," 249 . 11. Pea k an d De l Papa, "Crimina l Justice," 250 . 12. Pea k an d De l Papa, "Crimina l Justice," 249 . 13. Wit h th e exceptio n o f th e amphetamin e derivative s o f halluci nogens. 14. Pea k an d De l Papa, "Crimina l Justice," 248 . 15. Lis a C . Ikemoto, "Th e Cod e o f Perfec t Pregnancy : At the Inter section o f th e Ideolog y o f Motherhood , th e Practic e o f Defaultin g t o Science, an d th e Interventionis t Mindse t o f Law, " Ohio State Law Journal 5 3 (1992) : 1266 . 16. Ther e wer e othe r provision s a s well, suc h a s requirin g Johnso n to complete a high schoo l equivalency test . 17. Ikemoto , "Perfec t Pregnancy, " 1268 . 18. In re Valerie D., 61 3 A 2d 74 8 (Conn . 1992) . 19. Davi d C . Blickenstaff , "Definin g th e Boundarie s o f Persona l Privacy: I s Ther e a Paterna l Interes t i n Compellin g Therapeuti c Feta l Surgery?" Northwestern University Law Review 8 8 (1994) : 1168 . 20. Blickenstaff , "Definin g Boundaries, " 1169 . 21. Blickenstaff , "Definin g Boundaries. " 22. Susa n Stefan , "Whos e Eg g I s I t Anyway? : Reproductiv e Right s of Incarcerated, Institutionalized an d Incompetent Women," Nova Law Review 1 3 (1989) : 442. 23. Margare t P . Spencer , "Prosecutoria l Immunity : Th e Respons e to Prenatal Dru g Use," Connecticut Law Review 2 5 (1993) : 406.

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24. Jud y Howard , "Chroni c Dru g User s a s Parents," Hastings Law Journal 4 3 (Marc h 1992) : 651-52 . 25. Wend y Chavkin , "Dru g Addictio n an d Pregnancy : Polic y Crossroads," American Journal of Public Health 8 0 (1990) : 485. 26. Stephe n R . Kandal l an d Wend y Chavkin , "Illici t Drug s i n America: History, Impac t o n Wome n an d Infants , an d Treatmen t Strat egies for Women, " Hastings Law Journal 4 3 (Marc h 1992) : 642. 27. Jud y Licht , "Pregnan t Addicts : A Call fo r Treatment , No t Pun ishment," Washington Post, 2 9 June 1993 , final edition. 28. Kat e Bagle y an d Alid a V . Merlo , "Controllin g Women' s Bod ies," i n Alid a V . Merl o an d Joycely n M . Polleck , Women, Law and Social Control (Needha m Heights , MA : Ally n an d Bacon , 1995) , 136. 29. Licht , "Pregnan t Addicts. " 30. Spencer , "Prosecutoria l Immunity. " NOTES T O CHAPTE R FOU R

1. International Union, United Automobile, Aerospace and Agricultural Implement Workers of America, UAW, et al. v. Johnson Controls, Inc., I l l Sup . Ct. 119 6 (1991) . 2. Title VII of the Civil Rights Act of 1964, a s amended , U.S. Code, vol . 42, sec. 2000e e t seq (1990) . 3. Pregnancy Discrimination Act of 1978, U.S. Code, vol . 42 , 9 2 Stat. 2076, sec. 2000e(k). 4. "Miscarriage s an d Compute r Terminals, " Doctor's People Newsletter 3 (Marc h 1990) : 1 . 5. "Miscarriage s an d Compute r Terminals, " 1 . 6. "Miscarriage s an d Compute r Terminals, " 1 . 7. However , a thorough revie w can b e found i n Rosalind S . Bramwell and Marilyn J. Davidson, " A Review of Current Evidence concern ing Possibl e Reproductiv e Hazar d fro m VDUs, " Journal of Reproductive and Infant Psychology 1 0 (1992) : 3. 8. Marily n K . Goldhaber , Michae l R . Polen , an d Rober t A . Hiatt , "The Ris k o f Miscarriag e an d Birt h Defect s amon g Wome n Wh o Us e Visual Displa y Terminal s durin g Pregnancy, " American Journal of Industrial Medicine 1 3 (1988) : 695. 9. Tuul a Nurmine n an d Kar i Kurppa , "Offic e Employment , Wor k

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with Vide o Displa y Terminals , an d Cours e o f Pregnancy, " Scandinavian Journal of Work, Environment and Health 1 4 (1988) : 293. 10. Heathe r E . Bryant an d Edga r J. Love , "Vide o Displa y Termina l Use an d Spontaneou s Abortio n Risk, " International Journal of Epidemiology 1 8 (1989) : 132 . 11. Gayl e C . Windham, Laur a Fenster , Shann a H . Swan , an d Ray mond R . Neutra , "Us e o f Vide o Displa y Terminal s durin g Pregnanc y and th e Ris k o f Spontaneou s Abortion , Lo w Birthweight , o r Intrauter ine Growt h Retardation, " American Journal of Industrial Medicine 1 8 (1990): 675. 12. Lar s P. A. Brandt an d Clau s V. Nielsen, "Congenita l Malforma tions amon g Childre n o f Wome n Workin g wit h Vide o Displa y Termi nals," Scandinavian Journal of Work, Environment and Health 1 6 (1990): 329. 13. Clau s V. Nielsen an d Lar s P. A. Brandt, "Spontaneou s Abortio n among Wome n Workin g wit h Vide o Displa y Terminals, " Scandinavian Journal of Work, Environment and Health 1 6 (1990) : 323. 14. Ev e Roman , Valeri e Beral , Marg o Pelerin , an d Caro l Hermon , "Spontaneous Abortio n an d Wor k wit h Visua l Displa y Units, " British Journal of Industrial Medicine 4 9 (1992) : 507. 15. Teres a M . Schnorr , Barbar a A . Grajewski , Richar d W . Hor nung, Michae l J . Thun , Grac e M . Egeland , Willia m E . Murray , Davi d L. Conover , an d Willia m E . Halperin , "Vide o Displa y Terminal s an d the Risk o f Spontaneou s Abortion, " New England Journal of Medicine 324 (Marc h 1991) : 727. 16. Marjori e Sun , "Federa l VD T Stud y Finall y Win s Approval, " Science 232 (Jun e 1986) : 1594 . 17. Burea u o f Nationa l Affairs , Inc. , "OM B Decisio n Allow s VD T Study, bu t NIOS H i s Wary o f Requirements, " Government Employees Relations Report 2 4 (Jun e 1986) : 846 . 18. Lauri e Garrett , "VDTs , Miscarriag e No t Linked : U.S . Stud y Greeted wit h Relief , bu t Critic s Decr y Limite d Scope, " Newsday, March 1991 . 19. Marja-Liis a Lindbohm , Mail a Hietanen , Pentt i Kyyronen , Markku Sallmen , Patric k vo n Nandelstadh , Helen a Taskinen , Matt i Pekkarinen, Matt i Ylikoski , an d Kar i Hemminki , "Magneti c Field s o f Video Displa y Terminal s an d Spontaneou s Abortion, " American Journal of Epidemiology 13 6 (Novembe r 1992) : 1041.

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20. A prospectiv e stud y wa s propose d sometim e i n th e 1980 s b y physicians a t Moun t Sina i Schoo l o f Medicine , a n industria l healt h research facility . Th e results have not bee n published a s of yet. Peter H . Lewis, "Persona l Computers : Question s o n Healt h an d PC's, " New York Times, 5 July 1988 , late city final edition . 21. A s early as 198 4 a safeguard bil l was introduced int o the Hous e Labor an d Commerc e Committee . "VD T Safeguar d Bil l Stalle d i n House Committee, " Proprietary to United Press International, 2 5 Apri l 1984, A.M. cycle. 22. "Judg e Overturn s Sa n Francisc o VD T Law, " Chicago Tribune, 14 February 1992 , sec. 1 . 23. Rhod e Islan d General Laws (1993) , sees. 28-20-2.1. 24. Main e Revised Statutes (1993) , sec. 252. 25. Connecticu t Annotated Law Statutes (1993) , sec. 228. 26. Mar k A . Pinsky, "VD T Radiation, " Nation, Januar y 1989 , 4 1. 27. Eri c Schmitt , "Businesse s Asses s Impac t o f La w o n Vide o Ter minals," New York Times, 1 9 June 1988 , late city final edition . Thi s i s especially tru e wit h th e ne w Nort h Atlanti c Fre e Trad e Agreemen t (NAFTA). 28. Michae l Powell , "VD T Workers Ge t Som e Relief i n City' s Con tract Agreement, " Newsday, 2 6 June 1990 , city edition . 29. Kevi n G . Hall, "SSA , AFGE Sig n Three-Year Pact, " Proprietary to United Press International, 25 Januar y 1990 , Britis h Columbi a cycle. 30. Pau l Saffo , "Th e Threa t o f Electromagneti c Fields : Ar e Ou r Computers Killin g Us?" PC Computing 5 (Decembe r 1992) : 126 . 31. Davi d Kirkpatrick , "D o Cellula r Phone s Caus e Cancer? " Fortune, Marc h 1993 , 82. 32. Saffo , "Th e Threa t o f Magneti c Fields, " 126 . 33. Factories and Commercial Premises Act, New Zealand Code (1981), a s note d i n th e Code of Practice o f th e Industria l Welfar e Division o f the Department o f Labour . 34. See , fo r example , Pete r H . Lewis , "Th e Executiv e Computer : Are Compute r Safet y Law s Taking th e Righ t Tack? " New York Times, 6 January 1991 , late edition . 35. Arthu r Goldgaber , "Busines s Fear s Unwield y Impositio n o f New Municipa l Law s Coverin g Vide o Termina l Use, " Los Angeles Business journal 1 3 (Februar y 1991) : 7.

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36. Marc o Quazzo , "Electromagneti c Field s an d Defec t Claims : Will Manufacturers B e Liable for Persona l Injuries?" Computer Lawyer 11 (Marc h 1994) : 2 1. 37. Hayes v. Raytheon, no . 92-4000 4 7t h (1993 ) a s cite d i n Quazzo, "Electromagneti c Field s and Defec t Claims, " 3 . 38. Lawrenc e Chester , "Repetitiv e Motio n Injur y an d Cumulativ e Trauma Disorder : Ca n th e Wav e o f Product s Liabilit y Litigatio n B e Averted?" Computer Lawyer 9 (Februar y 1992) : 13. 39. Joh n Gliedman , "Magneti c Field s an d Cancer : Shoul d Yo u B e Concerned?" Computer Shopper 1 3 (Januar y 1993) : 862 . 40. Louis e Kehoe, "Th e Friends That Ma y Als o Be Foes," Financial Times Limited, 8 December 1989 , sec. 1 . 41. Alber t Gore , as cited i n Kehoe, "Th e Friends. " 42. Teres a M. Schnor r o f NIOSH, as cited i n Susan Okie , "N o Lin k Found betwee n VDTs , Miscarriages, " Washington Post, 1 4 Marc h 1991, final edition . NOTES T O CHAPTE R FIV E

1. "Tota l publi c dollar s spen t fo r contraceptiv e service s fel l b y one-third betwee n 198 0 an d 1990. " WAC STATS: The Facts about Women (Ne w York: New Press , 1993) , 1 . 2. Mauree n Harriso n an d Stev e Gilbert , eds. , Abortion Decisions of the United States Supreme Court: The 1970 3s (Beverl y Hills : Excel lent Books, 1993) ; Maureen Harriso n an d Stev e Gilbert, eds. , Abortion Decisions of the United States Supreme Court: The 1980's (Beverl y Hills: Excellen t Books , 1993) ; Mauree n Harriso n an d Stev e Gilbert , eds., Abortion Decisions of the United States Supreme Court: The 1990's (Beverl y Hills: Excellent Books , 1993) . 3. Richar d Lacayo , "Abortion : Th e Futur e I s Alread y Here, " Time, 4 May 1992 , 27. 4. Fo r a fascinatin g histor y o f contraceptive s an d abortion , se e Kirtsi A . Dyer , "Curiositie s o f Contraception : A Historica l Perspec tive," journal of the American Medical Association 26 4 (Decembe r 1990): 2818. 5. Mar y Becker , Cynthi a Gran t Bowman , an d Morriso n Torrey , Feminist jurisprudence: Taking Women Seriously (St . Paul : West Pub lishing, 1994) , 368.

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6. Griswold v. Connecticut, 38 1 US 479 (1965) . 7. Eisenstadt v. Baird, 405 U S 438 (1972) . 8. Roe v. Wade, 41 0 U S 113 (1973) . 9. Roev. Wade, 113 . 10. Th e fou r Missour i case s ar e Planned Parenthood v. Danforth, 428 US 52 (1976) ; Poelker v. Doe, 43 2 US 519 (1977) ; Planned Parenthood v. Ashcroft, 46 2 U S 47 6 (1983) ; an d Webster v. Reproductive Health Services, 49 2 U S 490 (1989) . The Pennsylvania case s are Beal v. Doe, 43 2 U S 43 8 (1977) ; Colautti v. Franklin, 43 9 U S 37 9 (1979) ; Thornburgh v. American College, 47 6 U S 74 7 (1986) ; an d Planned Parenthood v. Casey, 505 US 833 (1992) . 11. Akron v. Akron Center, 462 U S 416 (1983) . 12. Planned Parenthood v. Casey, 833. 13. Lacayo , "Th e Future, " 27 . 14. Planned Parenthood v. Danforth, 52 ; Akron v. Akron Center, 416; an d Bellotti v. Baird, 443 US 662 (1979) . 15. Planned Parenthood v. Danforth, 52 . 16. Planned Parenthood v. Ashcroft, 476 ; Planned Parenthood v. Casey; an d Ohio v. Akron Center for Reproductive Health, 49 7 U S 502. 17. Abortion Denied: Shattering Young Women's Lives, Feminis t Majority Foundation , 1990 , videocassette . 18. Hodgson v. Minnesota (1990) , 497 US 417. 19. Colautti v. Franklin, 379 . 20. Webster v. Reproductive Health Services, 49 0 an d Thornburgh v. American College, 747 '. 21. Planned Parenthood v. Danforth, 52 an d Planned Parenthood v. Casey, 833. 22. Akron v. Akron Center, 41 6 an d Planned Parenthood v. Ashcroft, 476 . 23. Simopoulos v. Virginia, 46 2 U S 506 (1983) . 24. Beal v. Doe, 43 2 U S 438 (1977 ) an d Maher v. Roe, 43 2 U S 464 (1977). 25. Poelker v. Doe, 43 2 US 519 (1977) . 26. Webster v. Reproductive Health Services, 490 . 27. Rust v. Sullivan, 50 0 US 173 (1991) . 28. Webster v. Reproductive Health Services, 490 . 29. Bray v. Alexandria Women's Health Clinic, 50 6 US 263 (1993) .

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30. National Organization for Women v. Scheider, 62 USL W 407 3 (1994). 31. " ' J a n e Roe ' Joins Anti-Abortion Group, " New York Times, 1 1 August 1995 . 32. Fo r extensiv e discussio n o f th e repercussions , se e John A . Rob ertson, "I n the Beginning: The Legal Status of Early Embryos," Virginia Law Review 76 (1990) : 487-91 . 33. Als o referre d t o a s RU48 6 an d R U 486 . Sinc e Roussel-Ucla f signed thei r right s ove r t o th e populatio n council , th e dru g wil l b e known a s mifepristone, rathe r tha n RU-486 , in the United States . 34. I t limit s th e mobilit y o f sperm , thereb y makin g fertilizatio n les s likely. 35. Als o known a s the Yuzpe method . 36. I n a recently publishe d study , the pregnancy rat e fo r RU-48 6 a s a "mornin g after" pil l was significantly lower than for Ovral. Anne M.C. Webb, Jean Russell, and Ma x Elstein , "Compariso n o f Yuzpe Regimen , Danazol, an d Mifepriston e RU48 6 i n Ora l Postcoita l Contraception, " British Medical Journal 30 5 (October 1992) : 927. The results of anothe r study comparin g RU-48 6 an d Ovra l a s postcoita l contraceptive s indi cated that RU-486 was more effective, althoug h the differences wer e no t striking. Anna Glasier, K.J. Thong, Maria Dewar, May Mackie, and Da vid T. Baird, "Mifepriston e (R U 486) Compare d wit h High-Dose Estro gen an d Progestoge n fo r Emergenc y Postcoita l Contraception, " New England Journal of Medicine 32 7 (October 1992) : 1041-44 . 37. Webb , Russell , an d Elstein , "Compariso n o f Yuzpe " an d Gla sier e t al., "Mifepriston e (R U 486)." 38. Do n Colburn , " A Morning-Afte r Pill : New Stud y Say s RU-48 6 Works Bette r tha n Curren t Methods, " Washington Post, 1 3 Octobe r 1992, final edition . 39. I n some cases it is used u p unti l the ninth wee k o f pregnancy . 40. I t i s believe d tha t th e on e fatalit y tha t resulte d fro m RU-48 6 may hav e bee n relate d t o th e injectio n o f a concentrate d dosag e o f synthetic prostaglandins . 41. Withou t syntheti c prostaglandin , th e succes s rat e range s fro m 60 t o 8 5 percent . O.M . Avrech , A . Golan , Z . Weinraub , I . Bukovsky , and E . Caspi , "Mifepriston e (RU486 ) Alon e o r i n Combinatio n wit h a Prostaglandin Analogu e fo r Terminatio n o f Earl y Pregnancy : A Re view," Fertility and Sterility 56 (Septembe r 1991) : 385-93.

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42. Etienne-Emil e Baulieu , The "Abortion Fill": RU-486 A Woman's Choice (Ne w York: Simon an d Schuster , 1990) , 109 . 43. Susa n Headden, "Th e 'Abortion-Pil P Wars, " New Woman, Oc tober 1992 , 119 . 44. Federal Food, Drug and Cosmetic Act of 1938, U.S. Code, vol . 21, sec . 301-1509(1988) . 45. Fo r a complet e revie w o f th e FD A approva l process , se e Kar i Hanson, "Approva l o f RU-486 a s a Postcoital Contraceptive, " University ofPuget Sound Law Review 1 7 (1993) : 163-89 . 46. Baulieu , Abortion Pill, 108 . 47. "FD A Clearin g Wa y fo r Frenc h Abortio n Pill, " San Francisco Chronicle, 1 7 December 1992 , final edition . 48. Th e Populatio n Counci l ha s als o sponsore d othe r controversia l contraceptives, suc h a s Norplant an d IUDs . 49. Renat e Klein , Janice G . Raymond , an d Lynett e J. Dumble , RU 486: Misconceptions, Myths and Morals (Nort h Melbourne , Australia : Spinifex Press , 1991) . Of relate d interes t b y the sam e author : Janice G . Raymond, Women as Wombs: Reproductive Technology and the Battle over Women's Freedom (Sa n Francisco: Harper, 1993) . 50. Harol d M . Silverman , ed. , The Pill Book (Ne w York : Banta m Books, 1994) , 566-68. 51. "Low-Cos t Alternativ e t o RU-48 6 Abortio n Pil l Bein g Stud ied," Los Angeles Times, 2 0 Octobe r 1993 , home edition . 52. Caro l Jouzaitis , "Doctor' s Abortion-Dru g Techniqu e Draw s Fire," Chicago Tribune, 1 2 Septembe r 1994 , North , sport s final edi tion. 53. "Abortio n Pil l May Battl e Brai n Tumors ; RU486 Use d t o Figh t Meningioma," Science News 14 3 (1993) : 255. 54. Pa m Lambert , "Th e Killin g Field, " People, 1 6 Januar y 1995 , 40-43. 55. Ron e Tempest , " A Frenc h Optio n o n Abortion, " Los Angeles Times, 1 1 August 1990 , home edition . N O T E S T O C H A P T E R SI X

1. Arlen e Eisenberg , Heid i E . Murkoff, an d Sande e E . Hathaway , What to Expect When You're Expecting (Ne w York : Workma n Pub lishing, 1991) , 243.

[218] Note

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2. Davi d Brown , "20-Yea r Ris e i n Caesarea n Deliverie s Appear s to Hav e Stopped, " Washington Post, 1 9 May 1994 , final edition . 3. Suzann e Arms , Immaculate Deception II: A Fresh Look at Childbirth (Berkeley : Celestia l Arts, 1994) , 91. 4. Arms , Immaculate Deception II, 91 . 5. Eisenberg , Murkoff , an d Hathaway , "What to Expect, 33 2 4 5 46. 6. Brown , "20-Yea r Rise. " 7. Arms , Immaculate Deception II, 93 . 8. Marth a Shirk , "C-Sectio n Rat e Differ s Widel y Accordin g t o Income, Race, " St. Louis Post-Dispatch, 1 0 Septembe r 1993 , 5 sta r edition. 9. Piete r E . Treffers an d Mari a Pel , "Th e Risin g Trend fo r Caesar ean Birth, " British Medical Journal 30 7 (Octobe r 1993) : 1017 . 10. Arms , Immaculate Deception II, 163 . 11. Randal l S . Stafford , "Th e Impac t o f Non-Clinica l Factor s o n Repeat Cesarea n Section, " Journal of the American Medical Association 26 5 (1991) : 59-63 . 12. "Illinoi s Blue s Repor t Di p i n Rat e o f C-Sections, " Modern Healthcare, 1 2 November 1990 , news digest section . 13. Rober t McCabe , "Cign a Pla n Limit s Sta y fo r Delivery, " Port Lauderdale Sun-Sentinel, 2 6 August 1993 , Business section . 14. Aliso n Macfarlan e an d Geoffre y Chamberlaine , "Wha t I s Happening t o Caesarea n Rates? " Lancet 34 1 (Octobe r 1993) : 1005 . 15. Treffer s an d Pel , "Th e Risin g Trend. " 16. Florid a Statutes (1993) , sec. 383.336. 17. Lis a C . Ikemoto, "Th e Cod e o f Perfec t Pregnancy : A t the Inter section o f th e Ideolog y o f Motherhood , th e Practic e o f Defaultin g t o Science, an d th e Interventionis t Mindse t o f Law, " Ohio State Law Journal 5 3 (1992) : 1243. 18. Herber t A . Goldfar b an d Judit h Greif , The No-Hysterectomy Option: Your Body —Your Choice (Ne w York : Joh n Wile y an d Sons , 1990), 134-35 . 19. "Unnecessar y Hysterectomy : Th e Controvers y Tha t Wil l No t Die," HealthPacts 1 8 (Jul y 1993) : 2. 20. Stanle y West an d Paul a Dranov , The Hysterectomy Hoax (Ne w York: Doubleday, 1994) , 1 . 21. Wes t an d Dranov , The Hysterectomy Hoax, 18 .

[219] Note

s t o Chapte r 6

22. Goldfar d an d Greif , The No-Hysterectomy Option, 125 . 23. Othe r curren t reason s fo r recommendin g a hysterectom y in clude pelvi c inflammator y disease , cysts, pelvic pain , an d premenstrua l syndrome. 24. Iva n K . Strausz , You Don't Need a Hysterectomy: New and Effective Ways of Avoiding Major Surgery (Ne w York : Addison-Wes ley, 1993) , 52-56 . 25. Se e Strausz , You Don't Need a Hysterectomy, 52-5 6 fo r mor e details. 26. Wes t an d Dranov , The Hysterectomy Hoax, 48 . 27. Th e West als o has a high rat e o f hysterectomies .

Index

abortion, 3 , 5 , 30 , 4 1, 49, 52 , 62 , 69, 77, 87, 101 , 107 , 129 , 136 , 147, 157-58 , 163 , 185 , 192 , 194 , 197; antiabortion , 140 , 148 , 155 , 159, 162 ; choices, 37; clinics , 141 , 162; illegal , 134 , 139 , 143 ; informed consent , 137-38 ; legal , 133; methods , 5 , 144-63 ; pill, 5 , 144-63; proabortion , 132 ; "pro choice," 38 , 131-32 , 140 , 142 , 155-56; prolif e (antichoice) , 38 , 131, 138 , 140-42 , 151 , 154-55 , 159, 160 , 196 ; second-trimester , 139; selective , 9 ; spontaneous , 90 , 111-14, 116-17 ; surgica l abortion , 149, 150 , 152 , 159-61 . See also dilation an d curettag e (D&C) ; di lation an d evacuatio n (D&E) ; RU 486 Abortion Right s Mobilization , 152 , 158 acetaminophen, 91 . See also sub stance abus e (durin g pregnancy ) adoption, 7 , 33, 4 1 , 74, 82 , 101 , 143, 193 , 197 ; o f embryos , 6 7 AIDS, 12 . See also huma n immuno deficiency viru s (HIV ) alcohol, 88 , 93 , 95 . See also feta l al cohol exposure ; substanc e abus e (during pregnancy ) alternative inseminatio n (AI), 8 , 11 , 16-17, 21-22 , 45 ; first chil d con -

ceived via , 9 ; numbe r undergoin g procedure, 10 ; success rate , 9 American Associatio n o f Tissu e Banks, 1 8 American Civi l Libertie s Unio n (ACLU), 78-79 American Colleg e o f Obstetrician s and Gynecologists , 18 , 78 , 153 , 173 American Fertilit y Societ y (AFS) , 17 18, 23 , 26, 47 , 7 8 American Infertilit y Society , 3 4 American Medica l Association , 3 , 96, 134 , 153 , 15 9 American Psychologica l Association , 3 American Publi c Healt h Association , 96 amniocentesis, 52 , 101 , 19 5 Antinori, Severino , 7 , 3 1 Aretaeus, 2 artificial insemination , 23 . See also alternative inseminatio n (AI ) assisted-fertility clinics , 2 3 Baby M , 71-72 , 81-82 . See also sur rogacy Baulier, Etienne-Emile , 150 , 16 3 Benten, Leona , 152 , 15 8 birth control , 133 , 146 , 153 ; pill, 145. See also contraceptiv e

[221]

[222] birth defects , 86 , 92 , 100-101 , 1 1 1 13, 115 , 19 5 Bray v. Alexandria Women's Health Clinic, 14 0 British Columbi a Huma n Right s Act , 20 British Columbi a Huma n Right s Council, 2 0 British Voluntar y Licensin g Associa tion (VLA) , 4 9 Brown, Louise , 43 . See also "tes t tube" babie s caffeine, 89 , 90 , 93 . See also sub stance abus e (durin g pregnancy ) Canadian Roya l Commissio n o n New Reproductiv e Technologies , 20 cannabis sativa , 92 . See also sub stance abus e (durin g pregnancy ) Caucasian donors , 3 4 Center fo r Diseas e Contro l (CDC) , 14-15, 18 , 11 1 cesarean: hysterectomies , 176 ; sections, 6 , 52-53 , 100 , 164-77 , 188 , 190-91, 194 ; vagina l birt h afte r (VBAC), 17 1 cigarette smoking , 90 . See also sub stance abus e (durin g pregnancy ) "cleansed" sperm , 1 5 cocaine, 89 , 91 . See also substanc e abuse (durin g pregnancy ) co-culturing, 44 . See also i n vitr o fer tilization codeine, 91 . See also substanc e abus e (during pregnancy ) Coffey, Nora , 18 5 Comstock Ac t o f 1873 , 13 3 contraception choices , 3 7 contraceptive, 134 , 145 , 160 ; laws , 135; male , 14 4 controlled substance , 94-95 , 97 . See also substanc e abus e (durin g preg nancy) crack, 91-92 , 105 . See also sub stance abus e (durin g pregnancy )

Index cryopreservation, 8-9 , 11 , 24, 29 , 40, 59-61 , 65, 19 3 c-section. See cesarean , section s Davis vs. Davis, 61 , 66 della Corte , Rosanna , 7 Department o f Chil d an d Yout h Ser vices, 9 8 Department o f Healt h an d Rehabili tation Services , 9 4 depressants, 8S-S9. See also sub stance abus e (durin g pregnancy ) Diagnostic and Statistical Manual of Mental Disorders, 19 0 diethylstilbestrol (DES) , 5 1 dilation an d curettag e (D&C) , 149 , 187 dilation an d evacuatio n (D&E) , 149 , 161 donated gametes , 3 0 donor, 10-16 , 18-20 , 22-25 , 28-29 , 33-34, 39 , 43 , 132 ; anonymous , 9-10, 12 ; directed, 19 ; identity , 22 , 39; inseminatio n (DI) , 9 , 18 , 22; lesbian, 34 ; "matching, " 33-34 ; minority, 34 ; paternity, 18 ; recipient, 25 ; screening, 15 ; semen, 10 13, 15 , 2 2 doulas, 169 . See also labo r assistant s drug abuse . See substanc e abus e (during pregnancy ) egg, 4 , 26 , 43-45 , 48-49 , 51 , 53, 83; assisted hatching , 46 , 48 , 51 ; donation 3-4 , 7-8 , 23-31 , 33-40 , 44, 48 , 52 , 54 , 58 , 60 , 76-77 ; ex traction 45 , 59 ; fertilization, 43 , 46; freezing , 4 ; retrieva l methods , 25; source s of , 30 ; recipient , 28 , 34-35, 38 . See also embryo , zy gote embryo, 4 , 7 , 40 , 44 , 47 , 50-51 , 57 , 68, 70 , 76, 83 , 143-44 , 148 ; cryopreservation of , 29 , 54 , 59-60 , 67 ; donations, 39 ; freezing, 4 , 8 , 24 , 59-62, 64-67 , 7 1 , 75, 144 ; geneti c

[223] defects, 5 2 laboratories , 23 ; legality, 60-66 ; recipients , 32 ; screen ing, 5 2 endometriosis, 179 , 185 , 18 7 Ethics Advisor y Boar d (EAB) , 5 7 Family Leav e Act , 10 8 "father o f gynecology. " See Sims , Marion Federal Food , Dru g an d Cosmeti c Act o f 1938 , 15 1 Feminist Majorit y Foundation , 19 6 fertility, 38 , 55 , 115-16 , 118 , 149 , 186; assessment , 48 ; clinics, 9 , 23; drugs, 55, 57-58 , 6 8 fetal: abuse , 94 ; "farms, " 30 ; protec tion policy , 109-10 ; rights , 99 ; surgery, 100-101 . See also fetal al cohol exposur e fetal alcoho l exposure , 88 ; Fetal Al cohol Effec t (FAE) , 88 ; Fetal Alco hol Syndrom e (FAS) , $6, 88-8 9 fetus, 3 , 5-6, 19 , 30 , 49-50 , 52 , 62 , 69, 85-94 , 96-103 , 107 , 110 , 117 , 136, 143 , 148 , 164-65 , 167-69, 175, 185 , 192 , 19 5 Food an d Dru g Administratio n (FDA), 18 , 89-90 , 144 , 146-47 , 151-54, 158-59 , 194 ; Pilot Guid ance project , 15 1 Galen, 2 . See also Aretaeu s gamete intrafollopia n transfe r (GIFT), 44-45, 47, 68 , 193 . See also i n vitr o fertilizatio n hallucinogens, 92 . See also substanc e abuse (durin g pregnancy ) Hardy, Kimberly , 9 5 Hart, Judith , 19 3 Hausknecht, Richar d U. , 157-5 8 heroin, 91-92 . See also substanc e abuse (durin g pregnancy ) Hippocrates, 1 , 13 3 HIV: -discordan t couples , 14 ; infec tion, 15 ; -negative, 14 ; -positive ,

Index 14, 79 , 107 ; -positive semen , 13 ; -testing, 9 9 hormone manipulation , 38 , 45, 5 2 Human Fertilisatio n an d Embry o Ac t of 1990 , 3 9 Human Fertilisatio n an d Embryolog y Authority, 34 , 3 9 human immunodeficienc y viru s (HIV), 11-20 , 91-92 , 9 9 hysterectomy, 6 , 29 , 70 , 177-78 , 180-91, 194 ; informed consent , 185; partia l 76 , 178 ; radical, 178 ; total abdominal , wit h bilatera l sal pingooophorectomy, 17 8 Hysterectomy Educationa l Resource s and Service s Foundatio n (HERS) , 185 hysteria, 2 hysterica, 1 "hysterical suffocation, " 2 "identity-release policy, " 10 . See also donor, anonymou s identity-release sper m donors , 28 illegal drugs , 88 , 92 . See also sub stance abus e (durin g pregnancy ) infectious disease , 11-12 , 20 , 35 . See also huma n immunodeficienc y vi rus (HIV ) infertility, 4-5 , 8-9 , 2 1 , 44, 53 , 63, 69-71, 82-84 , 115 , 118 , 161 , 166 , 180, 187 , 195 ; clinics, 64 ; i n cou ples, 40 , 61-62 , 67 ; definition , 42 ; epidemic, 56 ; programs, 10 ; rates , 41-43, 47 ; treatment, 35-36 , 55, 57,59 In re Dubreuil, 10 0 insemination, 9 , 11-21 , 54 ; intra uterine; practices , 10 , 1 1 International Union, United Automobile, Aerospace and Agricultural Implement Workers of America, UAW, et. al. v. Johnson Controls, Inc. Se e Johnson Controls, Inc.

[224] intracytoplasmic sper m injectio n (ICSI), 45-48 , 5 1 , 60. See also i n vitro fertilization ; subzona l insemi nation (SUZI ) intrauterine devic e (IUD) , 133 , 143. See also contraceptio n choice s introvaginal culturing , 44 . See also i n vitro fertilizatio n in vitr o fertilization , 4 , 8 , 27 , 29 , 40 , 43-48, 50-51 , 53-55 , 60-61 , 6 4 69, 71 , 76, 82 , 144 ; politics, 5659; risk s t o mother , 52 ; succes s rate, 9 . See also co-culturing ; in trovaginal culturing ; gamet e intra fallopian transfe r (GIFT) ; intracy toplasmic sper m injectio n (ICSI) ; subzonal inseminatio n (SUZI) ; zygote intrafallopia n transfe r (ZIFT ) Jacobson, Cecil , 1 2 Johnson, Jennifer , 94-9 5 Johnson Controls, Inc., 101 , 109-10 , 125, 12 8 Johnson v. Calvert, 77 Keane, Noel , 71-7 3 labor assistants , 169-7 0 laparoscope, 44 , 186-8 8 laparoscopy, 25 . See also egg , re trieval method s librium, 88 . See also substanc e abus e (during pregnancy ) "love doctor. " See Jacobson, Ceci l marijuana, 92 . See also substanc e abuse (durin g pregnancy ) McCorvey, Norma , 135-36 , 14 2 "Methuselah moms, " 7 , 31 . See also postmenopausal mother s micromanipulation, 46 , 51-5 2 midwives, 169-70 , 175-76 . See also labor assistant s "morning after " pills , 143 , 145-46 . See also contraceptiv e

Index multiple births , 48 , 50 ; complica tions, 4 8 multiple pregnancies , 48 , 51 , 56 narcotics 91 , 94. See also substanc e abuse (durin g pregnancy ) National Abortio n Right s Actio n League (NARAL) , 19 6 National Institut e o f Occupationa l Safety an d Healt h (NIOSH) , 110 , 114-17, 122 , 12 9 National Institute s o f Healt h Revital ization Ac t o f 1993 , 5 6 National Organizatio n fo r Wome n (NOW), 19 6 National Women' s Healt h Network , 196 natural selection , 51-5 2 nicotine, 90 , 93 . See also substanc e abuse (durin g pregnancy ) Occupational Safet y an d Healt h Ad ministration (OSHA) , 120 , 12 2 Office o f Technolog y Assessmen t (OTA), 1 0 Operation Rescue , 14 2 opium, 91 . See also substanc e abus e (during pregnancy ) over-the-counter medications , 91 . See also substanc e abus e (durin g preg nancy) painkillers, 91 . See also substanc e abuse (durin g pregnancy ) Planned Parenthood v. Danforth, 13 8 postcoital contraceptives , 143-47 , 154-56, 15 8 postmenopausal birth , 3 1 postmenopausal mothers , 7 . See also "Methuselah moms " postmenopausal pregnancies , 3 1 postmenopausal women , 31-32 ; a s donor recipients , 3 1 postpartum depression , 19 0 precoital contraceptives , 14 4

[225] Pregnancy Discriminatio n Act , 110 , 125 prescription pharmaceuticals , 88. See also codeine ; depressants ; librium ; substance abus e (durin g preg nancy); valiu m Public Healt h Servic e (PHS) , 1 7 quaaludes, 88 . See also substanc e abuse (durin g pregnancy ) Racketeer Influence d an d Corrup t Organizations Ac t (RICO) , 14 1 radiation, 112 , 116 , 119 , 123 , 128 ; extremely lo w frequenc y (ELF) , 112-13, 116-17 ; very lo w fre quency (VLF) , 112 , 11 7 reproductive: choice , 3 , 8 , 2 1 , 98, 197; complications , 112 , 118 , 125-26, 128 ; control, 8; freedom , 37, 144 ; hazards, 110 ; health, 5 , 129, 156 , 161 , 191 ; rights, 1-3 , 5 6, 8 , 87 , 108-9 , 131 , 163, 192 , 196-97; technology , 3-5 , 8 , 3 5 40, 50-51 , 53 , 69, 71 , 78, 81 , 83, 93, 162 , 193 , 19 5 Roe. See McCorvey , Norm a Roe v. Wade, 107 , 131 , 133, 136 37, 141-4 2 Roussel-Uclaf, 150-54 . See also RU 486 Royal Commissio n o n Ne w Repro ductive Technologies , 20 , 53 RU-486, 5 , 144-63 , 194 . See also contraceptive; Roussel-Ucla f Salvi, John C , III , 162-6 3 semen, 4 , 8 , 10-11 , 13-14 , 16 , 18 , 20-21, 29 , 43; donation, 3 , 12 , 17, 24 , 28 , 30, 35 , 39 ; freezing , 150; fresh , 11-16 , 18-19 ; "pro cessed," 14 ; provider, 15 , 23; recipient, 35 ; specimens, 18 ; storage , 9. See also sperm , bank ; sperm , "cleansing"

Index sexually transmitte d disease , 15 , 17 , 19, 24 , 35 , 72 , 83; chlamydia , 17 , 83; chlamydi a trachomatis , 15 ; cytomegalovirus (CMV) , 15 , 72 ; gonorrhea, 15 , 17 , 19 ; group B streptococci, 15 ; hepatitis, 19 , 92 ; hepatitis B , 15 , 17 , 19 ; herpes, 15 ; syphilis, 17 , 19 ; trichomonas vagi nalis, 1 5 Sims, Marion , 3 6 smoking (durin g pregnancy) . See cigarette smoking ; marijuan a sperm, 7 , 45-46, 51 ; bank, 9-10 , 12 , 15-19, 21-23 , 35 ; "cleansing, " 14 , 36; donation , 8 , 22-24 , 26-29 , 33 , 39, 65 , 76 ; fresh , 11 ; frozen, 9-11 , 14, 35 ; genetic conditions , 12 , 17 ; genetic defects , 11 , 17, 24. See also seme n stimulants, 89-9 1 substance abus e (durin g pregnancy) , 5, 81 , 88, 92 , 95-96, 98-99 , 1 0 1 6, 129 , 194 . See also depressants ; hallucinogens; narcotics ; stimulant s subzonal inseminatio n (SUZI) , 45-4 6 Sudden Infan t Deat h Syndrom e (SIDS), 90-9 1 surrogacy, 4 , 38 , 70-71 , 75-82 ; con tracts, 75-77 , 80 ; partial, 7 0 surrogate, 4 , 40 , 72 , 74 , 77 , 79-82 ; embryo transfer , 70 ; mother , 8 , 19, 44 , 65, 70 , 80 ; parenting, 78 ; payment, 7 1 "swim-up." See sperm , "cleansing " teratogen, 86 , 88-8 9 ter Neuzen , Kobe , 12-13 , 1 9 "test-tube" babies , 43, 57. See also Brown, Louis e Trouson, Alan , 5 8 vacuum aspiration . See dilatio n an d evacuation (D8cE ) valium, 88 . See also substanc e abus e (during pregnancy )

[226] Inde video displa y termina l (VDT) , 93 , 111-29; electromagneti c emissions , 112, 119 , 122-24 , 12 7 Whitehead, Mar y Beth , 72-7 4 World Healt h Organizatio n (WHO) , 42, 15 4

x

Yeager v. Smith, 10 2 York v. Jones, 6 4 zygote, 43, 4 6 zygote intrafallopia n transfe r (ZIFT) , 44-45, 47 . See also i n vitr o fertil ization