From my own experience, and what I have learned from colleagues, it seems clear that women who are granted therapeutic abortions are a special group. They are often among the community elite. Not surprisingly, many are relatives of physicians; it requires a certain knowledge of the law and familiarity with psychiatrists even to know how to go about asking for a therapeutic abortion on psychiatric grounds. Hence this type of abortion is largely a privilege granted to upper-middle-class whites, rarely is available to the poor, uneducated, and black.

When the psychiatrist writes a report stating that the patient will endanger her life by carrying a child to term, he is on shaky intellectual grounds. Many women with serious emotional disturbances who are reluctant to have a baby never contemplate suicide; their lives are not in danger. Other emotionally disturbed women threaten suicide, but it is quite difficult to evaluate the seriousness of their threats.

Psychiatrists know that even when a woman sincerely threatens suicide, she generally can be treated by traditional means without resort to abortion. They are also aware that once the patient realizes there are no alternatives, she probably will respond to psychotherapy, drug therapy, or hospitalization. A woman looking for an abortion on psychiatric grounds quickly learns that she must talk suicide if she is to get her way. It is very easy for the female with an unwanted pregnancy, knowing that illness is a way out, to convince herself that she is ill. It makes little difference whether she does this consciously or unconsciously. The psychiatrist accelerates this process when he directly or indirectly lets the patient know that she must present grave signs of illness before he will recommend abortion.

Many psychiatrists recommend therapeutic abortion for humanitarian reasons, even when not convinced the patient will destroy herself. To do this, however, they must affirm she is suicidal. To salve their professional consciences, they subtly teach the patient (and usually she is an apt pupil) to as as sick as possible and say the right words "I'll kill myself if I'm forced to have this baby"-before they write a psychiatric excuse. Only after she has produced a convincing display of "illness" can she have her abortion. A few doctors more honest about their dishonesty are less scrupulous in documenting the need for abortion, simply say the patient is suicidal.

There are many reasons why a woman may not want to have her baby. Children can be an economic or psychological burden; sometimes the birth of an additional child or a child out of wedlock makes a previously adequate life intolerable. Many mothers bring unwanted children into the world. If they were sufficiently aware and determined, many of them probably could have convinced psychiatrists that they were too sick to carry their children to term.

For every woman who receives an abortion on psychiatric grounds, there are probably a dozen others whose plight is more tragic and whose emotional handicaps are more serious. No psychiatrist, if he is honest with himself. will claim to be able to distinguish between selfish, practical, idealistic, and irrational motivation. Nor can he describe any scientific criteria that enable him to know which woman should have her pregnancy terminated, and which should not. When he recommends an abortion, he usually lies. It is a kind lie, a dishonesty intended to make the world a little better, but it still is a lie. Consider the case of the 24-year-old woman who came to see me requesting a therapeutic abortion. She was in her third month of pregnancy and the possibility of legal abortion was brought to her attention by a psychiatrist, who had been treating her in conventional psychotherapy for about six months. One of six children raised in a poverty-stricken, unhappy home, she remembered that she was frightened most of the time. Her father drank heavily, beat the children. Her mother was intensely religious and harangued the children about the virtues of piety and chastity. When the patient was 13 her father left home and she became dominated by her mother.

She did well as a student after high school, worked as a secretary and saved her money. She entered a teachers' college, obtained a teaching certificate and position as a rural elementary school teacher. After a year of teaching she became depressed. She had few friends, rarely went out with members of the opposite sex. When she began to have crying spells, she consulted a psychiatrist.

During the course of her therapy she began to feel more confident, overcame her shyness, and started to date men. One of her dates was an aggressive

male who got her intoxicated and forced her to have intercourse. This was her first and only sexual experience.

The patient knew that if she carried the baby to term she would lose her job. Because of the moralistic attitude of the community, it would be extremely difficult for her to obtain another teaching job, and she had no other means of support. She had no idea what she would do with the baby. It seemed unlikely that her mother would help her; in fact, she feared that her mother would totally reject her.

A DIFFICULT DECISION

During the course of our interview, I was very aware that she was experiencing profound emotional anguish. At the same time, I was impressed with her character and psychological strength. At no time did she threaten suicide; she was only mildly demanding, and certainly not histrionic. There was little or no doubt in my mind that she could carry her baby to term without endangering her life, but I was deeply moved by the tragedy of her situation. The position I found myself in was not too different from the one a psychiatrist usually faces when he evaluates patients for therapeutic abortion. The most humane and decent thing was to recommend abortion. I had the choice of lying outright by saying the patient was suicidal, or training her to talk of suicide *** to salve my conscience. Whatever I did would be morally questionable.

The psychiatrist who recommends therapeutic abortion should be aware of how this affects the patient. Many who request it do not have the personality strength of the above patient. Granting excuses to emotionally disturbed individuals may, in the long run, harm them. Although there probably is little danger of depression following therapeutic abortion, the process of securing a psychiatric excuse from meeting an obligation may be psychologically damaging; the patient may learn to use "illness" as a means of avoiding other obligations, insist that she should not be held responsible for her actions.

The overall impact of therapeutic abortion does not promote humanistic goals. Helping a few women find an easy solution does nothing for the millions who risk their lives by going to criminal abortionists, or bring unwanted children into the world. Furthermore, granting therapeutic abortions to a select few acts as a safety valve, neutralizing forces that otherwise would press for social change.

"A SOCIAL OPIATE"

If society had to witness the tragedy of highly disturbed women bringing unwanted children into the world, it might examine the whole issue of bringing unwanted children into the world. If women of position and power could not easily rid themselves of unwanted pregnancies, they might be more inclined to promote change in the existing abortion laws. If physicians could not salve their consciences by legally aborting some patients and friends, they too might try to change the abortion laws. Therapeutic abortion laws serve as a social opiate; excuse-giving masks the pain, but does not cure the problem.

Many physicians, attorneys, and legislators have reached the obvious conclusion that every woman should have the right to terminate unwanted pregnancy. They insist that the rules governing abortion should not be part of the criminal law, that the decision should simply be up to the patient and a qualified doctor. They recommend legislation (already enacted in some states) permitting abortion upon request, if a doctor believes it will help the patient.

Unfortunately, even the states that have legalized it have not appropriated funds to make quick, inexpensive abortion available to all citizens. No woman should have to bring an unwanted child into the world, or alternatively have to falsely label herself mentally ill and irresponsible.

Senator BAYH. I just wondered whether you felt there was room for reasonable psychiatrists to differ on this matter.

Dr. BERNSTEIN. In Minneapolis, sir, there are many psychiatrists that feel differently about the abortion question than I do. But I

think they would all individually agree there are no psychiatric reasons for doing an abortion, really. That does not mean they may not find some social reasons, sir.

Senator BAYH. You emphasized that if a person has a psychiatric problem, an emotional problem during pregnancy, just removing the pregnancy does not necessarily remove the psychiatric problem. That problem would exist after the abortion or after the birth. Dr. BERNSTEIN. Yes.

Senator BAYH. Is that basically your premise?

Dr. BERNSTEIN. Yes, yes, sir.

Senator BAYH. And I further deduce from what you said, and you said it much better than I, that many of the most pronounced incidents of psychiatric disturbances, brought by pregnant women to psychiatrists at that time of pregnancy, are normal incidents of pregnancy and will pass with the birth.

Dr. BERNSTEIN. Well, I think in the very early part of most women's pregnancies there are some questions in their mind whether they would like to have this pregnancy. Even people that really say they want it, there are some doubts in their mind because it is inconvenient, it is difficult, you do not look the same, and so on.

But as females progress during their pregnancy, all of them in my opinion have a more positive atttitude toward the pregnancy. At the very beginning most women have negative feelings about it some of the time.

Senator BAYH. All right. Suppose a person has a mental disturbance prior to pregnancy, becomes pregnant, desires an abortion, is denied it. Now, you have made a strong case that the presence or the absence of a baby does not go to the basic mental disturbance.

Do you have incidents where the birth of a baby, given that kind of a mental picture in the first place, compounds the disturbance after birth?

Dr. BERNSTEIN. I think we have had some both ways, Senator. We have had some patients that really did not want the pregnancy and because she has been a patient of mine before continued in therapy. In fact, I just saw her yesterday about some other problem. She is now 46 or 47 years old. She had that baby, which is now a couple of years old-and she said if she had another baby she could raise another one.

On the other hand, we do have people who have mental illnesses after delivery, become ill, and we can treat them. There is no question about that. There is such a thing as postpartum psychosis. We do not know when they are going to get them, but they are brought out. In my own experience and Dr. Zilboorg's they usually do not come from the ones that you would expect them from. But we do get some and you treat them during the pregancy or after the pregnancy, if

necessary.

Senator BAYH. As I recall, you said that most of those psychoses came from the mother who very much wanted the child and intended to become overly possessive.

Dr. BERNSTEIN. Yes. We do have some of the others, too. Some psychiatrically ill patients do break down, but there are very few of them.

Senator BAYH. Is there anyway we can break down the percentage in one instance compared to the percentage in the other?

Dr. BERNSTEIN. Well, let me say it this way. In my experience I do see a lot of them because I am at the medical school. Surprisingly enough, there are very few severe illnesses in my experience in Twin Cities now that I know of after delivery. There are not very many. Most people seem to take their pregnancies pretty well. There are not many post-patrum illnesses that are very severe.

Senator BAYH. Is the impact of the disturbance or the development of the disturbance more or less or about the same now that the Supreme Court has ruled and abortions are granted?

Dr. BERNSTEIN. I do not think I really answered that, because most patients that are having abortions-I can only speak of in Minneapolis-are not sent to psychiatrists. Yes, they seem to be getting along. I see a couple of them, but not a lot. They seem to be getting by. I have to say that, but I do not know what is going to happen in the future. I think that is the important factor. The guilts are going to be there. Now, they may not be severe. I think we will see more

of this.

Now, unfortunately we do not have good data because at least up in Minnesota we don't have a law through yet to determine what happens to patients after abortion. We have tried to get a law through, but they have not been successful. Nobody is going to know what happens after abortion unless we have good follow-up. It is called very privileged information, you see, and I can understand that, too.

Senator BAYH. Have you consulted women that have had illegal abortions?

Dr. BERNSTEIN. Yes, I have seen some that had illegal abortions. Senator BAYH. About psychiatric problems?

Dr. BERNSTEIN. They have come to me for psychiatric problems,

yes.

Senator BAYH. Is this a guilt kind of problem?

Dr. BERNSTEIN. The ones I see, yes. Of course, I am only one psychiatrist, and they may be going to other psychiatrists or they may not be going at all.

Senator BAYH. It would seem to me that at least we ought to try to find the answer if we can as to whether this guilt feeling is significantly affected by the legal nature of the operation. If it is illegal in the back room kind of situation, does that present a different kind of mental burden than if it is sanctioned by the Supreme Court? I am asking not from the moral viewpoint, but from the psychiatric viewpoint.

Dr. BERNSTEIN. The problem is, sir, that we are not getting this data. We just cannot seem to get that. I do not know how it is in your State or the rest of the country, but the women are getting aborted, are just gone. I was hearing one of the obstetricians the other day in Minneapolis. He does lots of these abortions. A lot of them never even get paid for. As a matter of fact, people say they make a lot of money, and I think they do. But a lot of people come and have their abortion and then they are gone. There is no follow-up.

Senator BAYH. I understand you cannot give me your opinion of the psychiatric impact on a patient that you never saw.

But what about those that you have seen since the court ruling? Have you sensed any difference in those cases you have seen since the ruling?

Dr. BERNSTEIN. I see your point. The guilty ones are still getting guilty, yes.

I might clarify a point. A certain number of people that have any kind of procedure, are not going to get guilty. They do not have that kind of personality.

Senator BAYH. It would seem that if that were going to have a mental impact, just for me the impact of taking the unborn child would be a great impact, regardless of what the statute book might say at the moment. But I just wondered whether you had been able to differentiate.

Dr. BERNSTEIN. I would think in general the guilt that the individual feels is not going to be related too much to what the Supreme Court decision said. It is going to be related to what happened to that person early in her life. That is when the guilts are engendered in ourselves.

Senator BAYH. I heartily concur in what you just said about what is going to motivate a person to do something or not do something and the impact the action will have on them, being related to early childhood experiences and the basic principles that were inculcated at a very early age. Would you give us your opinion about what is going to happen to these women that have been getting illegal abortions?

Dr. BERNSTEIN. Illegal abortions?

Senator BAYH. Illegal abortions. Now we have made it legal.

If we made it illegal again, does one assume that the same number of women are going to have and continue to have illegal abortions. having gone through all this publicly?

Dr. BERNSTEIN. I am not sure I exactly have the question. But I still think there are some illegal abortions going on.

Senator BAYH. Well, let me rephrase the question a little more succinctly, because it was sort of a round robin question.

There are x number of women getting illegal abortions.

Dr. BERNSTEIN. Legal?

Senator BAYH. Illegal abortions, prior to the Supreme Court decision.

Dr. BERNSTEIN. Right.

Senator BAYH. The Supreme Court ruling basically made abortions legal. Now, if we proceed along the legislative channels of a constitutional amendment to prohibit abortions, what could we reasonably expect to happen to the number of abortions?

In denying these expectant mothers the abortion option, would we be going back to the number before the Court ruling, the number since the ruling, or somewhere in between?

That may be a question you cannot speculate on. But I am trying to get some background.

Dr. BERNSTEIN. You are wondering if we should go back to what it was before?

Senator BAYH. I just wonder what the impact on society is going to be. I think those of us sitting back here, the toughest job we have is not to determine in our own mind what we believe, but to try to determine what the impact on 210 million other Americans is going to be if we put our conduct into the Constitution of the United States, and this is one of the questions that has been brought to the committee rather frequently.