AAPLOG Response to ACOG Executive Board Statement of Policy Re: “Partial Birth Abortion,” dated 12 Jan 97. The American Association of ProLife Obstetricians and Gynecologists Feb 1997 Fredric D. Frigoletto, Jr., M.D., President Executive Board American College of Obstetricians and Gynecologists 409 12th Street, SW P.O. Box 96920 Washington, D.C. 20090-6920 Dear Dr. Frigoletto, We are writing on behalf of more than 900 members of the American Association of Pro-Life Obstetricians and Gynecologists (AAPLOG) in response to the American College of Obstetricians and Gynecologists (ACOG) Executive Board Statement of Policy, dated 12 January 1997, and entitled “Statement on Intact Dilatation and Extraction”. We are disturbed that this policy statement came to our attention in an indirect manner. This is a major policy statement from a national medical organization, regarding an issue which is closely associated with the daily work of many of its members. Why then was it only distributed to District Chairs of the College, with instructions to be distributed as “you see fit”? On this subject of ongoing interest, to both the public and physicians, the organization which presumes to speak for obstetricians and gynecologists did not see fit to directly communicate this relevant policy statement to its dues paying members who financed both the Task Force, which reportedly addressed the medical facts of this procedure, and the Executive Board, which approved and released this statement. This is unconscionable. In this document the Executive Board contends that the terms “partial birth abortion” and “brain sucking abortion,” used commonly by laymen and the popular media, are “vague and do not delineate a procedure recognized in the medical literature.” They therefore suggest that the term “intact dilatation and extraction” (intact D & X) replace these common descriptions. We would simply note that any, or all, of these terms may adequately describe the procedure if properly qualified. “Intact D & X” (partial-birth abortion) is defined in the policy statement as being comprised of all of the following four elements: 1. deliberate dilatation of the cervix, usually over a sequence of days; 2. instrumental conversion of the fetus to a footling breech; 3. breech extraction of the body excepting the head; and 4. partial evacuation of the intracranial contents of a living fetus to effect vaginal delivery of a dead, but otherwise intact fetus. Although this careful description has the advantage of clarity, the procedure itself still suffers from a lack of recognition in the medical literature. If, indeed, 5.6% of the approximately 1.5 million legal abortions performed each year in the U.S. occur after 16 weeks of gestation (according to the CDC’s preliminary 1994 figure) and “it is unknown how many of these were performed using intact D & X,” then the potential exists for up to 84,000 of these procedures occurring each year in the United States. And yet, “a select panel convened by ACOG could identify no circumstances under which this procedure. . . would be the only option to save the life or preserve the health of the woman.” Immediately after establishing this lack of legitimate medical necessity for this procedure, the policy states that “an intact D & X, however, may be the best, or most appropriate, procedure in a particular circumstance to save the life or preserve the health of a woman.” To evaluate the validity of this latter statement it would be profitable to consult the guidelines of the U.S. Preventive Services Task Force regarding the relative strength of evidence available for scientific clinical decision making. These guidelines were recently endorsed in ACOG Practice Patterns (Number 1, August 1995): I. Evidence obtained from at least one properly designed randomized controlled trial. II-1. Evidence obtained from well-designed controlled trials without randomization. II-2. Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. II-3. Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence. III. Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. We are aware of no evidence under I, II-1, II-2, or II-3 demonstrating the safety of this procedure or its efficacy to “save the life or preserve the health of a woman.” Nor are we aware of any evidence showing it to be “the best or most appropriate procedure to save the life or preserve the health of a woman” in even one specific circumstance. Perhaps the “select panel” convened by ACOG could be considered to meet the criteria for level III as a report of an “expert committee”. If this is the case, it is instructive that the panel could not identify any circumstance under which this procedure “would be the only option to save the life or preserve the health of a woman.” Further, the assertion of this policy statement that “an intact D & X, however, may be the best, or most appropriate, procedure in a particular circumstance to save the life or preserve the health of a woman” lacks scientific credibility. ACOG’s application of rigorous standards for evaluating other, more mundane subjects, appears punctilious when contrasted with this policy statement. It is further stated that “The potential exists that legislation prohibiting specific medical practices, such as intact D & X, may outlaw techniques that are critical to the lives and health of American women.” Of course, the potential always exists for the inappropriate use of any law, or that further legislation built upon existing law will go beyond the intent of the original law. However, if fear of the “potential” lurking in a proposed law was routinely invoked as a reason to dispense with it, no legislation would ever be enacted. Has it already escaped the collective memory of ACOG’s leadership that prior to the Roe v. Wade decision the pro-life movement appealed to this same rationale by pointing out the “potential” dangers in the legalization of elective abortion? It was contended that in legalizing elective abortion the potential existed for a devaluing of all life, eventually leading to the easy acceptance, and legislative sanctioning, of activities such as euthanasia. This reasoning was dismissed at that time by pro-choice advocates as slippery slope thinking and hysterical overreaction. Why does ACOG now find it acceptable to use slippery slope thinking regarding legislation to ban the partial-birth abortion procedure? In this document, the Executive Board of ACOG has also approved, and emphasized, the following statement: “The intervention of legislative bodies into medical decision making is inappropriate, ill advised, anddangerous.” In the same month that this policy statement was released, the Executive Director of ACOG praised new legislative intervention into medical decision making (Hale RW. New law on female genital mutilation. ACOG Newsletter 1997;41:3). Exhorting the medical profession to take an active lead in preventing “female genital mutilations” he proclaimed that “This new law, with its specific requirements and penalties, will aid in this effort.” Because we agree with the sentiments of Dr. Hale regarding the propriety of this new legislation, we take exception to the condemnation of legislative intervention which is expressed in the “Statement on Intact Dilatation and Extraction.” ACOG cannot have it both ways. Either, the “intervention of legislative bodies into medical decision making is inappropriate, ill advised, and dangerous,” or, the intervention of legislative bodies into medical decision making serves as an “aid” to the medical profession. It is logically incoherent to maintain both positions. In its haste to promulgate and defend a “pro-choice” position on this issue the Executive Board has released a policy statement containing assertions which lack supporting clinical evidence, while concomitantly applying a double standard regarding the appropriateness of legislative intervention into medical decision making. We are concerned that this statement from the Board will compromise ACOG’s future credibility with regard to medical policy statements. In addition, the covert manner in which this policy statement was released will likely foster distrust of ACOG’s leadership among its rank and file members. We hereby go on public record in stating that ACOG does not speak on the issue of partial birth abortion (“intact D & X”) for its members who also belong to AAPLOG. Matthew J. Bulfin, MD, for the Board of AAPLOG AAPLOG Response to ACOG PBA position-97