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The First Pass Effect

The views expressed are those of the author and are not necessarily those of Scientific American.


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When I was a third year at Harvard Medical School, I spent 6 weeks at one of our affiliated hospitals rotating through the Obstetrics and Gynecology department. During this time, I devoted a few afternoons in the family planning clinic, where I was able to learn from diverse women seeking contraceptive options or pregnancy terminations. This experience was transformative.

I should tell my readers right off the bat that I am pro-choice, and that I believe strongly in female autonomy and control over her own body. But I’ll be the first to agree that it’s difficult to argue with those who believe that life begins at conception, for even if those fused cells represent potential and nothing more, potential is all-important, all we often ever have. When I stood in my sterile gown, watching the resident dilate the cervix and then introduce a little plastic tube through the opening to suction to the contents of the uterus out, I was a little on edge. And when we then took the jar of liquid and tissue to the sink and rinsed it out with a sieve, to count the little dismembered fetal parts with a forceps, I have to admit that I was shaken. Here was a little arm. And here was a little thigh. And here we were, putting them together like little puzzle pieces to make sure we hadn’t left anything behind. Never in my life did I think I would bear witness to this. I put a finger to my own pulse.

Just a few nights prior, I had been part of a long argument with friends at a local bar about this very subject.

“If you don’t like it, don’t perform abortions! Don’t get one yourself!” I had said, impassioned. “But quit judging something that you will never know yourself.”

I spoke as if I was in the know, and the others weren’t. But now, standing in the clinic, I had to confront myself with the fact that I really had had no idea what I’d been talking about either. Before this day, I too had not a clue about what a termination really entailed. And I never thought I’d ever find myself looking at a sieve full of miniature body parts.

My resident must have seen the ashen look on my face.

“Are you okay?” she asked. “It’s okay if you need to step away, or go back to the workroom.”

It took me just a second to take stock of myself. “I’m okay,” I said, and I continued to watch.

Over the next few days, a classmate, someone who I respect very much, told me that her time in the family planning clinic had changed her views on abortion.

“I used to be pro-choice,” she said. “But now that I have seen what that means, I don’t think I could ever go through that myself, ever.”

I stayed silent. Amazed, she pressed on, trying to convince me. “I mean, weren’t you disturbed by it? Weren’t you challenged?”

Yes, of course I was disturbed. Of course I was challenged. For starters, I was shaken by how the clinic was hidden away in the deep recesses of the hospital. To get there, we had to walk down a lengthy set of corridors that falsely advertised a different department, go down a stairwell, through unmarked doors that opened with a tap of my employee badge, and into a modest clinic, that made me feel, even as a student, like I was harboring a dark and shame-ridden secret. All of this reaction – to avoid and deter picketers who might impede patient care.

But once in this secret annex, those feelings of unease were quickly replaced by a feeling of solidarity and community. The women who walked through the clinic doors came from all walks of life… some were in their teens and in unsafe relationships, others were women who already had children and felt that they did not have the kind of financial and social support they needed to raise another baby in their homes, and still others were there because they had discovered that their fetus carried such genetic abnormalities that going through the pregnancy to term would result in nothing but swift mortality for the baby and unbearable grief for their family. It didn’t matter what the reason. Social workers, residents and attending physicians, most of them women, grouped together to offer their peers generous levels of support and empathy.

I liked seeing women help other women like this, free of judgment. I liked being a part of that fabric, even just for a day or two.

“But the procedure itself? Didn’t you think it was vile?” my friend asked.

It was gruesome. It was infused with a great deal of emotional significance – most of it, at first pass, horrific. But what else had we seen this year? We had seen necks splayed and muscles parted to the very last tendons in radical lymph node dissections, searching for cancer. We had held on to umbilical cords and tugged at the afterbirth, spinning the placentas in our hands as blood dripped to the floor to make sure there weren’t any rents indicating left over tissue in the womb. We smelled the cold stench of cadavers in autopsy rooms. We learned to fight our own feelings of sympathetic nausea when inserting a nasogastric tube over the sounds of our patient retching in reflex. We smelled AIDS on a patient with medication non-compliance and sky-high viral loads admitted for delirium and sepsis.

Getting caught up in the emotion of what we see may be a natural first inclination for any human being, but what differentiates those in medicine from the rest of society is our determination to plough through those initial feelings of distaste in our mission to help. We fight our bodies’ impulses to flee. We don’t abandon our patients when they need us just because the body’s realities are too overwhelming.

And now I know what a pregnancy termination truly entails. I can own it: I can know that I didn’t just support a woman’s right to end her pregnancy while refusing to look at the nature of the act. The personhood arguments are a slippery thing, and I’m still formulating my own perspectives. But I know that I will never again speak just theoretically about the issue. It’s never so simple as mother versus baby, but if what I value about life are the social and intellectual components and the potential for a self-determined future that accompany a living thing, then I will always remember the fear in those women’s eyes before they let the anesthesia close their lids. I will always remember that teenager who asked me to hold her hand before she went under, asking me not to judge her, not to abandon her.

“I won’t,” I’d said to her then. And I never will.

Image: Michael Lane

Samyukta Mullangi About the Author: Samyukta Mullangi is a fourth year student at Harvard Medical School. She is interested in narrative medicine, and has previously blogged for Medscape's The Differential. Follow on Twitter @samyuktaMD.

The views expressed are those of the author and are not necessarily those of Scientific American.






Comments 7 Comments

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  1. 1. Silenus7 10:33 am 07/31/2013

    Thank you for writing this. I am pro choice, a sex positive activist, and have a PhD from a large medical school. Several woman close to me have had abortions. I always supported them, never tried to dissuade them, but I never felt completely comfortable with abortion. I’ve never really spoken out about my conflicting feelings, but maybe now I will.

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  2. 2. RDH 11:02 am 07/31/2013

    I wonder what the men operating the death chambers at Auschwitz felt. Did they feel they were on a higher mission to help society? Were they really so different? What about Dr. Mengele? Was his belief in a higher cause sufficient to absolve himself of any remorse and or guilt?

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  3. 3. zadie9 11:26 am 07/31/2013

    It bothers me when people reduce something as complex as abortion to the irrefutable and inaccurate analogy of Nazism.

    Either way, this essay is about healthcare providers steeling themselves to do things to patients’ bodies, that may have been hitherto unimaginable. I’m not truly addressing the morality of abortion in this essay, am I? Saving that for another day.

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  4. 4. michael_j_x 11:51 am 07/31/2013

    Really exceptional article. Your message is clear and indisputable, patient care should come before a doctor’s personal feelings, fears and anxieties. However, unlike most of the gruesome procedures you describe, abortion involves more than one patient. This is not a placenta you are removing, nor a collection of dysfunctional body parts. This is a living organism on the way to becoming a fully functional human being. The gruesomeness of the abortion procedure is not due to the “body’s realities”, its because it provides physical evidence of the choice you’ve made between two patients. Those small body parts you are washing away, that’s the patient you chose to abandon. And when the abortion is not medically necessary, you have effectively chosen the social and emotional well being of one patient over the life of another. Fortunately, its not your place to decide when a foetus becomes a human and thus a patient you ought to care for. Your place, as you rightly acknowledge, is to be there for the human in front of you, the human who by law can determine the fate of the life inside her. And no matter where you stand on the matter, its your duty as her doctor to offer her your full expertise and support without prejudice or judgement, even if that means coming face to face with the victim of her decision. Now, I am just happy I am not in your shoes.

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  5. 5. RDH 11:58 am 07/31/2013

    My question was not about morality. Whether the abortionist is doing harm to the baby, especially in the case where the birth of the child is not a threat to the mother’s medical condition (as opposed to say, her economical and/or social position) and whether that is wrong or right was not my point.

    Those that are deeply involved in genocide or mass murder are human beings too. Do you really think they are that much different when it comes to steeling themselves to do what they did or do? Could their first kill not affect them much in the same way the author indicates she was affected?

    Not all involved in genocide are psychopaths. Surely some have emotional responses on their first pass with which they have to come to terms. Some might even think what they did was horrific. At least at the beginning if not always for many.

    One thing we know. The genocides of the 20th and 21st centuries is far surpassed by the number of abortions just in the U.S. since 1973. There must be a lot of “steeling” going on.

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  6. 6. zadie9 12:15 pm 07/31/2013

    So I suppose I can only respond by getting down to basics and refuting the comparison of abortion to murder, and multiple abortions to genocide at all. I think we have very different definitions of life, where it starts, where it’s import lies, and to whom we owe our support.

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  7. 7. michael_j_x 12:19 pm 07/31/2013

    @RDH
    Interesting proposition and I see your point. A soldier carrying a genocide is performing the duties assigned to him/her by society, in the same manner as a doctor performing an abortion, your argument being that both had to, at some point of another, put aside their personal beliefs and carry out society’s dirty work. The difference however lies in the motivation. Maybe a soldier truly believed that his fellow humans will benefit from the extermination of a specific group in the same manner as an abortionist believes that a troubled mother will benefit from the abortion. However, a soldier would had to rationalise his decision in a different way from the abortionist simply because
    a) the benefits of his actions are not immediately observable or verifiable
    b) there is no ambiguity whether the group he is exterminating is human or just flesh.
    Any person not motivated by hatred will have a hard time overcoming these gaps, especially a doctor whose desire is to help his fellow humans no matter their differences.

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