Reality Avoidance?

1. Reality Avoidance? The 2008 APA Task Force Report on Abortion and Mental Health

2. State of the debate • (Affirmers) Some clinicians and researchers (almost invariably pro-life) claim a link between abortion and mental illness, including “Post-Abortion Syndrome” (PAS). • (Deniers) All authoritative sources and professional associations (almost invariably pro-choice) deny any such link.

3. An initial question: Why should we think abortion causes mental illness? • Grant that abortion is bad, causes unhappiness and grief, etc. why should we think that additionally it causes mental illness? • Should it matter that it does? • Do we think that other horrific actions must cause mental illness? e.g. enslaving, dropping atomic bombs, concentration camp guards? • But cf. Prof. Pete Kilner’s research at West Point.

4. Individual trauma vs. public policy issue: a tenable distinction? • Grant that abortion leads to mental illness for some women—does this imply that there is a general risk, of the sort that should enter into official policy and advice? • Childbirth can lead to mental illness—should this be raised when a couple contemplates having a child? • Note: we dismiss bad effects of good things as ‘accidental’; we regard bad effects of bad things as ‘significant’.

5. “No different from other stressors” • It’s common for deniers of the link to say that ‘abortion is no more highly correlated with mental illness than any life stressor’. • But is this very satisfying, given today’s common ‘stressors’?—divorce, abandonment, betrayal,etc. • Are our standards too low?

6. An asymmetry of ‘bias’ • Pro-lifers are not ipso facto committed to abortion-mental health link. • We wouldn’t be surprised to find a link. • We are prepared to find the evidence, if it exists (we won’t overlook anything). • Pro-choicers are ipso facto committed to denying a link.

7. Why “abortion and mental health” at all? • Wikipedia has a lengthy article on ‘Abortion and Mental Health”. Periodic studies of the issue. • The need constantly to deny a link  abortion isn’t an ordinary ‘medical procedure’? • No Wikipedia articles on ‘Appendectomy and Mental Health’.

8. Does the APA Task Force Report add anything to the debate? • It appears to be a comprehensive review of all the best studies, but … • The APA since 1969 has advocated abortion-on-demand. • The lead author of the Report, Brenda Major, is a leading author of studies denying a link. • The Report gives short shrift to claims of PAS.

9. On PAS “This perspective argues that abortion is traumatic because it involves a human death experience, specifically, the intentional destruction of one’s unborn child and the witnessing of a violent death, as well as a violation of parental instinct and responsibility, the severing of maternal attachments to the unborn child, and unacknowledged grief (e.g., Coleman, Reardon, Strahan, & Cougle, 2005; MacNair, 2005; Speckhard & Rue, 1992). The view of abortion as inherently traumatic is illustrated by the statement that “once a young woman is pregnant…it is a choice between having a baby or having a traumatic experience” (original italics; Reardon, 2007, p. 3).”

10. So is the Report biased? • Moira Gaul (FRC), “Biased APA Report Ignores Abortion Risks” • Priscilla Coleman, “APA Report on Abortion-Mental Health Problem Link Politically Biased” This may be true. But the charge of ‘bias’ is easily flung back: “You claim it is biased because of your (equal) bias.”

11. The “abortion distortion” factor • Abortion Distortion: Professionals who otherwise act with competence and integrity depart from professional standards (rigor, consistency, cogency) when adherence to those standards would imply a conclusion at odds with abortion-on-demand. • In cases of Abortion Distortion, restrict your criticism to violations of the relevant professional standards. • Analogy: don’t say “the auditor lacked independence” but prove the audit was faulty.

12. Overview of the Report • Sets down criteria for good methodology. • Examines over 50 studies since 1989 in peer-reviewed journals. • Rejects all but 2 studies, as failing to meet criteria for sound methodology: Gilchrist et al. (1995) and Fergusson et al. (2006). • Favors Gilchrist over Fergusson as being methodologically better. • Bases its conclusion on Gilchrist alone.

13. The Conclusion of the Report “Based on our comprehensive review and evaluation of the empirical literature published in peer-reviewed journals since 1989, the Task Force on Mental Health and Abortion concludes that the most methodologically sound research indicates that among women who have a single, legal, first-trimester abortion of an unplanned pregnancy for non-therapeutic reasons, the relative risks of mental health problems are no greater than the risks among women who deliver an unplanned pregnancy (71).”

14. Three big problems in the Conclusion • The yes-or-no, “accept or reject” approach to examining studies. • Basing a conclusion on a single study. • The fallacy of inferring “evidence of absence” from “absence of evidence”.

15. First problem: The “accept or reject” approach • If studies agree in claiming an effect, the effect is usually stronger or weaker depending upon the better or worse design of the study. • If studies conflict about an effect, then one side can be dismissed only if the error can be explained (which is to ‘explain it away’). • This especially true when conflicting studies are basically sound.

16. Fergusson on the APA Conclusion “As I stated to the APA committee in my review [of an earlier draft], the only scientifically defensible position to take is that the evidence in the area is inconsistent and contested. Under these conditions the only scientifically defensible conclusion is to recognize the uncertainty in the evidence and propose better research and greater investments in this area.”

17. Second problem: basing a conclusion on a single study • Even if there was no conflicting evidence, it is not recommended that a conclusion (esp. on a major social problem) be based on a single study. • APATask Force on Statistical Inference (1999): “ The thinking presented in a single study may turn the movement of the literature, but the results in a single study are important primarily as one contribution to a mosaic of study effects.”

18. Fergusson on the second problem: “What I also think the APA committee has failed to recognize is the size of the research investment needed to pin these issues down thoroughly. The tobacco example is a clear one: there have been literally tens of thousands of studies in this area (I have in fact published over 10 papers on tobacco related topics). This amount of research is needed in an area in which there are strongly divided opinions and deeply rooted agendas. The moral of all of this is very simple: In science drawing strong conclusions on the basis of weak evidence is bad practice. The APA report on abortion and mental health falls into this error.”

19. Third problem: a fallacy • Gilchrist reaches a negative conclusion: it fails to find statistically significant correlations between abortion and mental illness. • The Report reaches a positive conclusion: “…the relative risks of mental health problems are no greater than the risks among women who deliver an unplanned pregnancy.” • The fallacy echoed in media headlines: “Abortion does not cause mental illness, panel says” (New York Times).

20. What should the default be?Where does the burden of proof lie? Fergusson (who is ‘pro-choice’) says it lies with the deniers: “What the Committee has, in effect, said is that until there is compelling evidence to the contrary, people should act as though abortion has no harmful effects. This is not a defensible position in a situation in which there is evidence pointing in the direction of harmful effects. In this respect, the response of the APA committee to this situation appears to follow the type of logic used by the Tobacco industry to defend cigarettes: since, in our opinion, there is no conclusive evidence of harm then the product may be treated as safe. A better logic is that used by the critics of the industry: since there is suggestive evidence of harmful effects it behooves us to err on the side of caution and commission more and better research before drawing strong conclusions. History showed which side had the better arguments.” But a denier might say that it lies with the affirmers.

21. Newman’s notion of ‘antecedent probability’ • When examining—or looking for—evidence, we reasonably bring to bear expectations about ‘what one should expect, given background knowledge’. • We then interpret evidence relevant to ‘what should be expected’. • Statisticians refer to this sort of reasoning as ‘Bayesian’.

22. Antecedent probabilities involving what abortion is. One possibility. • Pregnancy is a diseased or abnormal condition of the body. • The fetus is a kind of unwanted growth, like a wart. • The mother is an autonomous, rational being, who is right to conceive of her body as an instrument for advancing her rational purposes.

23. What an abortion is on this view. • Abortion returns the woman to a normal condition. • The procedure, although internal, is no more invasive in reality than the removal of a wart. • The mother’s decision to have an abortion is an unexceptional instance of instrumental reasoning. An abortion is the removal of something that shouldn’t be there in a woman who shouldn’t be in that condition, by someone who reasonably judges that an abortion would advance her interests as an autonomous self.

24. A second set of antecedent probabilities. • Pregnancy is a perfectly normal condition of a mature woman’s body. • The fetus is the woman’s offspring, not an alien growth (it’s equivalent a part of her which is so closely related that it’s just about the same as her). • Everything about the woman, not simply her body but also her thoughts and emotions (her ‘soul’) are mobilized, and designed to be mobilized, to protect and nurture this child within her.

25. What abortion does on this second view. • Abortion destroys the normal and intended condition of the woman—violently, by suddenly reversing something that she and her body are designed to achieve. • It destroys something so closely related to the mother, that it is as if she is destroying herself. • It is an irrational act, since reasonability in this case involves a kind of sensitivity to and cooperation with forces that do not admit of complete rational explication.

26. Also: antecedent probabilities about mental health The following tend to promote good mental health and are protections against mental illness: • Realism (as opposed to the denial of reality) • Internal harmony (as opposed to conflict, strain, and stress) • A stable sense of self-worth (as opposed to an unstable sense)

27. Abortion seems at odds with realism • Two possible views: • The thing in her womb is her ‘baby’. She is a mother. She has an ultrasound taken; she gives this being a name; she starts buying clothes for it; and so on. • The thing in her womb is a ‘clump of cells.’ She does not have a baby. She is not a mother. • Both can’t be realism.

28. Abortion seems at odds with mental harmony • Disharmony exists if a woman has an abortion, adopts the second view above, but also: • Conflictedly also thinks she is killing her baby. • Later she conceives and adopts the view that the thing in her womb is a baby and she is a mother. • She is in circumstances in which she is asked to sympathize with a pregnant mother who is thinking of the thing in her womb as a baby. • She has two friends, one of whom thinks that the thing in her womb is a clump of cells, and the other who thinks it is a baby, and she is asked to sympathize with each.

29. Abortion seems at odds with a stable sense of self-worth • Suppose a woman who gets an abortion tries to avoid or resolve mental conflict by holding that both views are valid. It’s a difference in ‘social construct’ or ‘conceptual system’. • She thinks, ‘There is no fact of the matter as to whether this living being I am carrying is my baby or not. It’s a baby if one thinks it’s a baby, and it’s not a baby if one thinks it is not a baby.’

30. Connect this idea with self-worth… • The thing in the womb has worth only if someone thinks that it does. • We tend to think about ourselves in the way that we think of others. (Mothers do this especially in relation to their child.) • Therefore? … “I have worth only if someone thinks that I do.” • Contrast this with a mother convinced of the intrinsic priceless worth of her baby, who then thinks that she has worth in the same way that her baby does.

31. Problems in Gilchrist itself. • A study of women recruited by GPs in Scotland and England and then observed by these GPs from the years 1976 to1987. • A woman was recruited if she has an “unplanned pregnancy” (defined as “an unintended pregnancy or one in which the woman could not state, to within 3 months, the duration of her attempts to conceive” (243)) and agrees to participate in the study.

32. Based on the GPs diagnosis, these women were sorted into four classes of morbidity: • prior psychiatric illness other than psychosis; • prior psychosis; • no prior psychiatric illness but previous deliberate self-harm (DSH); • no prior psychiatric illness or DSH. These groups were then studied prospectively, after their choice of abortion or delivery, with their GPs continuing to provide information about mental health sequelae.

33. A woman left the study if either she left that GP’s practice; died; or became pregnant again. • Gilchrist found statistically significant results in only two cases: (i) women without prior psychiatric illness were more likely to develop psychosis if they delivered their baby as opposed to aborting; and (ii) women without prior psychiatric illness were more likely to inflict DSH if they aborted as opposed to delivered their baby. • All other correlations lacked statistical significance.

34. Problem 1: Unreliable diagnoses • The GPs diagnosed 106 cases of puerperal psychosis among the 6000 women who delivered, which is approximately 20 times greater than the recognized and established incidence of this illness. • Because of this aberration, Gilchrist ended up disregarding these diagnoses. For evidence of ensuing psychosis, he relied instead on hospital admissions for psychosis. • In the published article, Gilchrist admits that, therefore, the statistically significant finding of greater psychosis in women who deliver as opposed to abort should be disregarded. • Thus, the only statistically significant result of the study is a finding of greater incidence of deliberate self-harm among women who abort rather than not! • Note: given that GPs’ diagnoses were thus inaccurate, it would seem that the sorting of women into four initial classes of morbidity would also be unreliable, since this depended upon a determination of prior psychosis or not.

35. Problem 2: Not double-blind • The study was not double-blind: one might expect that GPs who had moral qualms about abortion would not seek to participate in the study, whereas GPS who had a prior interest in vindicating legal abortion would self-select in participating in the study. • Moreover, the recruitment of women was not random, as GPs were apparently asked to recruit women with a view to balancing sample sizes. This also would allow bias to enter.

36. Problem 3: Attrition issues • High attrition rate: When the study concluded in 1987, only 34% of women who chose abortion were still in the study, and only 42% of the women who delivered. • Attrition would bias results: women are removed from the study if they conceive another child or leave the practice. But this would remove: • Women with PAS who conceive a ‘replacement baby’. • Women who move to another location because of divorce or other problems.

37. Problem 4: The control group This is why the Task Force favors Gilchrist over Fergusson. The Task Force holds that the correct control for women who have abortions is not either (i) women who don’t have abortions, or (ii) women who have a baby instead of an abortion, but rather (iii) women who have an unplanned pregnancy and who don’t have an abortion.

38. Choice of a control group answers a certain kind of question • One way of reformulating their claim is to say that they are presupposing that the question research should aim to answer is: Suppose a woman is facing an unplanned pregnancy, should one counsel against abortion, in such circumstances, on the grounds of greater risk to mental health than giving birth to the child?

39. An imprecise assumption • Some women do not plan their pregnancies precisely because they don’t perceive the circumstances they are in as difficult. • For other women, who do conceive without planning in circumstances that they view as difficult, their perception of their situation changes over time, so that by the time the baby is born, they welcome the child’s birth. • Also, some women who plan pregnancies nonetheless regard their pregnancies as difficult, or later regard come to regard them as so.

40. But the result is not what was wanted • A study which used the control group advocated by the Task Force would show at best only the health risks of abortion in relation to the health risks of having a child in (it is presumed) difficult circumstances. • That’s like: “There’s this risky situation, A, and getting an abortion poses no more serious health risks than being in this other risky situation, A.”

41. But advocates of abortion typically present abortion to women as a kind of cure-all, as something that ‘solves their problem’ and gets them back to a status ex ante, before they became pregnant. It makes their lives as if they were never pregnant to begin with—that’s the problem. • It is hardly impressive to say that women who get abortions have the same histories of mental illness as women whose life and lifestyle a woman is supposed to be trying to avoid by getting an abortion.