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Are AI Clinical Protocols A Dobb-ist Trojan Horse?

By MIKE MAGEE

For most loyalist Americans at the turn of the 19th century, Justice John Marshall Harlan’s decision in Jacobson v. Massachusetts (1905). was a “slam dunk.” In it, he elected to force a reluctant Methodist minister in Massachusetts to undergo Smallpox vaccination during a regional epidemic or pay a fine.

Justice Harlan wrote at the time: “Real liberty for all could not exist under the operation of a principle which recognizes the right of each individual person to use his own, whether in respect of his person or his property, regardless of the injury that may be done to others.”

What could possibly go wrong here? Of course, citizens had not fully considered the “unintended consequences,” let alone the presence of President Wilson and others focused on “strengthening the American stock.”

This involved a two-prong attack on “the enemy without” and “the enemy within.”

The The Immigration Act of 1924, signed by President Calvin Coolidge, was the culmination of an attack on “the enemy without.” Quotas for immigration were set according to the 1890 Census which had the effect of advantaging the selective influx of Anglo-Saxons over Eastern Europeans and Italians. Asians (except Japanese and Filipinos) were banned.

As for “the enemy within,” rooters for the cause of weeding out “undesirable human traits” from the American populace had the firm support of premier academics from almost every elite university across the nation. This came in the form of new departments focused on advancing the “Eugenics Movement,” an excessively discriminatory, quasi-academic approach based on the work of Francis Galton, cousin of Charles Darwin.

Isolationists and Segregationists picked up the thread and ran with it focused on vulnerable members of the community labeled as paupers, mentally disabled, dwarfs, promiscuous or criminal.

In a strategy eerily reminiscent of that employed by Mississippi Pro-Life advocates in Dobbs v. Jackson Women’s Health Organization in 2021, Dr. Albert Priddy, activist director of the Virginia State Colony for Epileptics and Feebleminded, teamed up with radical Virginia state senator Aubrey Strode to hand pick and literally make a “federal case” out of a young institutionalized teen resident named Carrie Buck.

Their goal was to force the nation’s highest courts to sanction state sponsored mandated sterilization.

In a strange twist of fate, the Dobbs name was central to this case as well.

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We Freeze People, Don’t We?

By KIM BELLARD

Perhaps you’ve heard about the controversial Alabama Supreme Court ruling about in-vitro fertilization (IVF), in which the court declared that frozen embryos were people. The court stated that it has long held that “unborn children are ‘children,’” with Chief Justice Tom Parker – more on him later – opining in a concurring opinion:

Human life cannot be wrongfully destroyed without incurring the wrath of a holy God, who views the destruction of His image as an affront to Himself. Even before birth, all human beings bear the image of God, and their lives cannot be destroyed without effacing his glory.

Seriously.

Many people have already weighed in on this decision and its implications, but I couldn’t resist taking some pleasure in seeing “pro-life” advocates tying themselves in knots trying to explain why, when they legislated that life begins at conception, they didn’t mean this kind of conception and that kind of life.

John Oliver was typically on point, noting that the Alabama ruling was “wrong for a whole bunch of reasons. Mainly, if you freeze an embryo it’s fine. If you freeze a person, you have some explaining to do.”

The case in question wasn’t specifically about IVF, nor did the ruling explicitly outlaw it. It was a case about a patient who removed stored embryos and accidentally dropped them, and the couples whose embryos were destroyed wanted to hold that patient liable under the Wrongful Death of a Minor Act. The court said they could. Note, though, that neither the patient nor the clinic was being charged with murder or manslaughter…yet.

Although the Alabama Attorney General has already indicated he won’t prosecute IVF patients or clinicians, the ruling has had a chilling effect on fertility clinics in the states, with The University of Alabama at Birmingham health system and others indicating they were putting a pause on IVF treatments.

Justice Parker has long been known as something of a theocrat; as The New York Times wrote:

Since he was first elected to the nine-member court in 2004, and in his legal career before it, he has shown no reticence about expressing how his Christian beliefs have profoundly shaped his understanding of the law and his approach to it as a lawyer and judge.

His concurring opinion claimed: the state constitution had adopted a “theologically-based view of the sanctity of life.” Alabama is not alone. Kelly Baden, the vice president for public policy at the Guttmacher Institute, told BBC: “We do see that many elected officials and judges alike are often coming at this debate from a highly religious lens.”

Speaker Johnson has said:

The separation of church and state is a misnomer. People misunderstand it. Of course, it comes from a phrase that was in a letter that Jefferson wrote. It’s not in the Constitution. And what he was explaining is they did not want the government to encroach upon the church — not that they didn’t want principles of faith to have influence on our public life. It’s exactly the opposite.

And here we are.

Many Republicans are backtracking on the ruling.

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The Voice of Democracy is Young and Female

By MIKE MAGEE

“Don’t call me a saint,” said founder of the early 1930’s Catholic Workers Movement, Dorothy Day. “I don’t want to be dismissed that easily.” Oddly enough, says Jesuit writer, James Martin, “That quote is probably the biggest obstacle to her canonization…Given that quote, would Dorothy really want to be canonized?”

This week’s election results were a sliver of bright light in what has been a rather dark period. But it is at times like this that quiet heroes emerge. If courage has a face, this morning, as results across the land show a sweeping victory for Democrats, and specifically those advancing the cause of women’s autonomy in managing their own health decisions with their doctors, it belongs to a young woman from Kentucky named Hadley.

In the final weeks of the Kentucky governor’s race, as Politico reported, Andy Beshear gave voice to the woman who directly addressed his opponent on camera.  “Anyone who believes there should be no exceptions for rape and incest could never understand what it’s like to stand in my shoes. This is to you, Daniel Cameron. To tell a 12-year-old girl she must have the baby of her stepfather who raped her is unthinkable.”

Absorbing the results of the elections with the rest of us are Governor Chris Christie, Governor Ron DeSantis, Ambassador Nikki Haley, Vivek Ramaswamy, and Senator Tim Scott who took the stage last Wednesday evening in Miami at the 3rd Republican Primary Debate. No doubt they are surrounded by consultants trying to figure out how best to spin this issue. As Dobbs has played out in states like Kansas, Ohio, Kentucky, Wisconsin and beyond, political scientists are likely reminding that in politics, “Sometimes when you win, you lose.”

Court packing on a federal level, and even more importantly by Republican leaders on the state level, has tipped the power of our nation toward minority rule, allowing repugnant leaders to seize control of our legal system. That power has been used over the past decade to allow passage of laws that attack existing rights such as women’s power and autonomy over their own bodies, or construct barriers that obstruct the popular will of the people.  Examples include promoting  extreme gerrymandering and voter suppression, dead ending the Dream Act, or allowing citizen access to weapons of war and a permitless gun-carry law in Florida.

Understandably, citizens have wondered, “Will our Democracy die.” Hadley’s courageous decision reflects a stubborn and determined stance, by she and many others throughout this land, to assure the answer is, “No. Not on my watch!”

Her image and words will be lasting for three major reasons. They prove that:

  1. A healthy democracy requires participation and engagement of citizens.
  2. Freedom and autonomy, including access to health professionals, is sacred and personal.
  3. Women will not accept second class citizenship.

Trump no doubt remains unaware that he has lost everything. Many of his most ardent supporters, including Leonard Leo, the mastermind behind the court packing scheme that brought us the Dobbs decision, remain firmly in a state of denial. But even they must admit this morning, as they stare into Hadley’s eyes, and listen to her steady voice, they have met their match. And she is a young woman who’s message is clear, “Enough is enough!”

Likely channeling another woman’s spirit from a century ago, Hadley’s courage (listen here) was more human than super-human. As Dorothy Day quietly proclaimed, “Don’t call me a saint. I don’t want to be dismissed that easily.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.

Republican Misbehavior Promoted Health Professional Activism

By MIKE MAGEE

If you wanted to create a motto for the summer of 2023 – one that would stand the test of time from the medical exam room of Ohio to the gilded bathroom of Mar-a-lago – it would have to be Jack Smith’s “Facts matter!” If that is true on a national scale, it is equally true in states across the nation where doctors increasingly are coming out from behind a self-imposed clinical curtain and going public.

As reported in ProPublica last week, “Doctors who previously never mixed work with politics are jumping into the abortion debate by lobbying state lawmakers, campaigning, forming political action committees and trying to get reproductive rights protected by state law.”

A few examples:

1. One thousand Ohio doctors signed a full-page ad titled “A Message to our Patients on the loss of Reproductive Rights” in the Columbus Dispatch in response to actions of a state legislature highjacked by radicalized Republicans enacting a 6-week abortion ban post the Dobbs decision. This was after their coalition delivered a protest letter with 700,000 signatures earlier to the State House.

2. Dr. Damla Karsan, a Houston obstetrician, faced off Texas legislators  on July 20th, lending truth to power when she said , ““I feel like I’m being handicapped. I’m looking for clarity, a promise that I will not be persecuted for providing care with informed consent from patients that someone interprets is not worthy of the medical exception.”

3. In Nebraska, the doctor-led “Campaign for a Healthy Nebraska” raised $400,000 to hire political consultants to launch a women’s health rights campaign which helped the Nebraska Medical Society “find its inner voice” and openly oppose abortion restrictions in that state. State Senator Danielle Conrad was impressed. She said, “It’s really just incredible from my vantage point to see how these doctors have been able to not be hobbled by those decades of political baggage, to step forward with this fresh, clear medical perspective and be able to engage more people.”

4. A month earlier, Dr’s Katie McHugh, Gabriel Bosslet, Caroline Rouse and Tracey Wilkinson penned an Op-Ed in STAT in support of their colleague, Dr. Caitland Bernard, who had come to the rescue of a 10 year old Ohio rape victim who had fled to Indiana to gain access to an abortion. Caitlin was shamefully fined $3,000 by the Indiana State Licensing Board. Her colleagues wrote, “While a relatively minor punishment, this finding should send a chill through the medical community and beyond. But that chill shouldn’t be silencing.”

5. In Michigan, a doctor-led group, the Committee to Protect Health Care, teamed up with the ACLU, and successfully passed “Proposal 3”,  a “constitutional amendment to enshrine reproductive rights into the state constitution.” Dr. Rob Davidson declared, “This is a historic victory for reproductive rights in Michigan, and the Committee to Protect Health Care was proud to help get Proposal 3 across the finish line.”

Yesterday’s indictment of  Donald Trump, the citizen, squarely places him and his legislative enablers in Washington and Republican led state houses across our nation, on the wrong side of the truth. As reported, he is accused of “three conspiracies: one to defraud the United States; a second to obstruct an official government proceeding, the certification of the Electoral College vote; and a third to deprive people of a civil right, the right to have their votes counted.”

But what he and his Republican supporters in Washington and state houses across the nation are primarily guilty of, is not simply lying and deceit, but attempting to destroy our democracy and disenfranchise our voters. That is why prosecution under Civil Rights statutes employed in the past to address the savagery of the KKK, are totally appropriate here. Jack Smith’s “stand tall” leadership is a model for us all, and that includes our doctors and nurses.

As I have repeatedly argued, the health of our democracy is inseparably interwoven with the health of our system of caring for each other. At the helm of this system, our health professionals have survived the hurricane force winds of a pandemic, an inequitable and inefficient health delivery system, and a medical-industrial complex that is more focused on seizing patents than serving patients.

And yet, today we take heart. Our physicians, in growing numbers, are rediscovering their strength and their voices. Like Jack Smith, they are speaking up, in opposition to a small group of bitter and evil leaders, who have earned our active condemnation, and now must face the weight of the law.

Mike Magee MD is a Medical Historian, regular THCB contributor, and the author of CODE BLUE: Inside the Medical-Industrial Complex.

Burden of Pain

BY JAY JOSHI

We’re seeing a trend of late, where matters in healthcare once deemed to be civil in nature are turning criminal. We see it for nearly every polarizing health issue, from abortion to opioids. And it’s affecting vulnerable patients the most.

We have two separate systems in place, civil and criminal, because we have different standards of behavior. Civil laws determine whether undue harm was caused by one party to another. Criminal laws determine whether someone committed a crime. The threshold is distinctly different. If someone is caught driving ten miles over the designated speed limit, that person committed a civil infraction of traffic laws. But if someone is caught speeding well in excess, say thirty or forty miles over the speed limit, while driving recklessly, that person committed a crime. The extent of the violation determines the applicable law. That’s why traffic laws have distinct civil and criminal laws.

The same logic applies to healthcare. We have civil penalties for undue harm or malpractice and we have criminal penalties for crimes that transpire in the clinical context. The difference between the two, for something to go from civil to criminal, is mens rea, or a requirement of criminal intent.

Criminal intent implies certain violations were committed deliberately – literally as an act of crime. Normal civil violations, such as malpractice claims, offer physicians protection against liability. That protection doesn’t apply for criminal violations. And that’s the point. It explains why the sudden push by regulators, prosecutor offices, and federal agents to investigate otherwise civil matters as criminal is so pernicious.

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Matthew’s health care tidbits: Texas is the present future of abortion care

Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

In this edition’s tidbits, I have to return to the stunning impact of the Dobbs ruling. We know will happen because it is already happening in Texas where the 6 week law was already being enforced in contravention of Roe v Wade.

Taxpayer money is going to “pregnancy crisis centers” that flat out lie to vulnerable patients about the impact of abortions on their health. Doctors are questioning women who have miscarried–at a moment that is already terrible for them, and women who have miscarried are being denied basic D&Cs–which can kill them.

Don’t get me started on the absolute nonsense being talked–and passed into law –about ectopic pregnancies, of which there are over 130,000 each year in the US, being carried to term. How unlikely is it that an ectopic pregnancy makes it to term with no ill effects? Let me tell you a story. My dad was an OBGYN. He and his anesthetist saved the life of a woman and her baby who somehow had made it to term while being ectopic. During the surgery she needed 12 pints of blood (a normal woman has 7-8 pints in her body) and he considered it the greatest piece of surgery he did in his entire career. He thought that he and the patients were very lucky. So I demand that crazy legislation saying ectopic pregnancies have to be carried to term also mandates that my dad is around to do every single C-Section. Unlikely, as he’s dead, but no crazier than the legislation in Indiana.

Then there’s the impact on telehealth. Most abortions are done using drugs but more and more of the pandemic-era exemptions to prescribing drugs and seeing patients over telehealth across state lines are being withdrawn. Clearly the state-based licensing of doctors is itself ridiculous in an age of online commerce, but despite the DOJ statements the legality of prescribing abortifacients across state lines is very unclear and, as Deven McGraw explained in this harrowing piece on THCB Gang, HIPAA doesn’t protect patient privacy from local law enforcement. So what happens to someone in a state where abortion is banned if they have to go to hospital because of a complication from taking an abortifacient? Trump thinks they should go to jail.

What is clear is that bans on abortion don’t stop abortions. But they do endanger women. And if the pregnancy crisis center stops a woman from getting an abortion, do they help afterwards? Why yes, if you mean by “helping”, they have a celebratory dinner and light a fricking candle.

Mike Magee’s Advice to the AMA on Reversal of Roe vs. Wade

BY MIKE MAGEE

Stable, civic societies are built upon human trust and confidence. If you were forced to rebuild a society, leveled by warfare and devastation, where would you begin? This is the question the U.S. Army faced at the close of WW II, specifically when it came to rebuilding Germany and Japan, hopefully into stable democracies. The Marshall Plan answered the question above, and its success in choosing health services as a starting point was well documented by many in the years to come, including the RAND Corporation. Their summary in 2007 said in part, “Nation-building efforts cannot be successful unless adequate attention is paid to the health of the population.” 

They began with services for women and children, the very location that a splinter of politicians and Supreme Court Justices has targeted, replacing entrusted doctors with partisan bureaucrats in an approach so obviously flawed that it forced a course correction a half-century ago in the form of Roe v. Wade.

The practice of Medicine is complex. Ideally it requires knowledge, skills, supportive infrastructure, proximity and presence. But most of all, it requires trust, especially in moments of urgency, with lives at stake, when an individual, and family, and community are all on high alert. When time is of the essence, and especially if one or more people are trying to make the right decision for two, rather than one life, decisions are impossibly personal and complex.

This was widely recognized by most physicians, including those most devout and conservative nationwide in the troubling years leading up to Roe v. Wade. As recently as 1968, the membership of the Christian Medical Society refused to endorse a proclamation that labeled abortion as sinful. In 1971, America’s leading conservative religious organization, the Southern Baptist Convention, went on record as encouraging its members “to work for legislation that would allow the possibility of abortion under such conditions as rape, incest, clear evidence of severe fetal deformity, and carefully ascertained evidence of the likelihood of damage to the emotional, mental, and physical health of the mother.” In 1973, both the Southern Baptist Convention and the Christian Medical Society chose not to actively oppose the Supreme Court ruling against a Texas law prohibiting abortion known as Roe v. Wade, and reaffirmed that position in 1974 and 1976.

What they recognized was that the nation’s social capital, its political stability and security, relied heavily on the compassion, understanding and partnership engendered in the patient-physician relationship. As most doctors saw it, what possible good could come from putting politicians in the middle of such complicated, emotion-ridden, and highly personal decisions?

The American Medical Association’s prepared reaction to the June 24, 2022, reversal to Roe v. Wade was direct and immediate. They labeled the decision “an egregious allowance of government intrusion into the medical examination room, a direct attack on the practice of medicine and the patient-physician relationship…” Their president, Jack Resneck Jr. M.D. went further to say, “…the AMA condemns the high court’s interpretation in this case. We will always have physicians’ backs and defend the practice of medicine, we will fight to protect the patient-physician relationship..” But what exactly does that mean?

Approaching 75, and a lifelong member of the American Medical Association, I expect I know the AMA, its history as well as its strengths and weaknesses, as well as anyone. Aside from having deep personal relationships with many of the Board of Trustees over the years (some of whom quietly continue to contact me for advice), I have studied the evolution of the patient-physician relationship in six countries over a span of forty years.

Those who know me well, and who have pushed back against my critique of the organization, know that my intentions are honorable and that the alarms that I sound reflect my belief that, for our profession to survive as noble, self-governing, and committed above all to the patients who allow us to care for them, we must have a national organization with reach into every American town and city, and official representation in every state, and every specialty.

My concern today, despite the strong messaging from Chicago, is that the AMA and its members have not fully absorbed that this is a “mission-critical” moment in the organization’s history. It is also an opportunity to purposefully flex its muscles, expand its membership, and reinforce its priorities. The strong words, without actions to back them up, I believe, will permanently seal the AMA’s fate, and challenge Medicine’s status as a “profession.”

Here are five actions that I believe the AMA should take immediately to make it clear that physicians stand united with our patients, in partnership with nurses and other health professionals, and that the actions of last week can not and will not stand.

  1. The AMA should pull all financial support for all Republican candidates through the 2022 elections.
  2. The AMA should actively encourage physician “civil disobedience” where appropriate to protect the health and well being of all women, regardless of age, race, sexual identity, religion, or economic status.
  3. The AMA should convene, under the auspices of its’ General Counsel, Andra K. Heller, a formal strategy meeting with the legal counsels of all state and specialty medical societies to formulate an aggressive legal approach to minimize the damage of the recent Supreme Court action.
  4. The AMA should actively promote AMA volunteers to help provide a full range of women’s health care services at federal institutions and on federal land, and stand up information sites that coordinate travel and expenses should inter-state travel be required for care access.
  5. The AMA should immediately make clear that any restriction of prescribing authority of medications in support of women’s health care, including contraceptive medications and devices, and Plan B treatments will result in a coordinated nationwide disruption of health services.

Mike Magee MD is a Medical Historian and the author of “CODE BLUE: Inside the Medical-Industrial Complex.”

We Have a Right to Privacy…Right?

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BY KIM BELLARD

Well, they did it.  We had a warning they were going to do it, from the leaked opinion in May, but it still was a blow to well over half the country when the Supreme Court struck down Roe v. Wade in its ruling on Dobbs v. Jackson Women’s Health Organization. It didn’t rule that abortion was unconstitutional – as Justice Kavanaugh wrote. “On the question of abortion, the Constitution is therefore neither pro-life nor pro-choice” – but, rather, left it to the “voters,” i.e., the states, to decide.  And, boy, the “pro-life” states have been deciding and are ready to do a lot more deciding.  

There has been lots of outrage, many protests, and calls for the Senate to pass a federal law explicitly granting a right to abortion (although that would require changing the filibuster rules).  Aside from the fact that the Democrats probably don’t have the votes to do that, even if they did, as soon as the Republicans retook Congress and the White House, they’d just repeal it and perhaps pass a law outlawing abortion everywhere.  So it goes.

There are going to be many fights about abortion in Congress and in the states, but I think it’s time for a new strategy.  It’s time to amend the Constitution.  

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American health care leaders are not blameless today

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By MATTHEW HOLT

It is a very sad day for America. Roughly 30% of our country is part of a quasi-religious cult. In general these people reject science and the enlightenment. This week the Jan 6th committee has shown they are prepared to use and support any tools or tactics–up to and including the overthrow of the government, in order to get what they want. 

The overturning of Roe vs Wade is the most visible artifact of a 40-year campaign. The campaign was funded by business leaders like the Koch brothers who want to revoke all environmental, labor and rational restrictions on their activities. Using dark money and the passion of religious zealots who want to control women’s bodies and discriminate against anybody who doesn’t believe what they believe, they have turned this nation back to the 18th century, using the Supreme Court as their vehicle.

The biggest of those dominos has now fallen and women’s right to control their own bodies has been taken away in most states. We can assume a nationwide ban (such as happened in Poland) will be coming here soon, maybe as soon as 2025 if the Republicans win the 2024 elections. And note that the rolling coup described by the witnesses at the Jan 6 hearings show that the Republicans are already blatantly taking over the supposedly neutral election process.

But the American health-care system is not blameless. Abortion and other reproductive health services are clearly part of health care. Yet uniquely in this country the provision of the services has not been from mainstream health care institutions. The leaders of our health care organizations, in particular our major hospital systems, have completely avoided delivering these services. They have been more than happy to allow Planned Parenthood and other specialist organizations to provide reproductive care, and have just looked the other way in the debate. 

Worse, many of our religiously affiliated institutions,  particularly those with a Catholic heritage which represent an enormous amount of hospitals in this country, have banned not only abortion but many other forms of reproductive health care such as female sterilization. The Hyde Amendment, ironically named after a religious bigot who was an appalling adulterer and hypocrite to boot, bans Federal funding for abortions. That means that private Medicaid plans which now cover most births in this country have never offered a full suite of reproductive health care.

Even in recent weeks when the fate of Roe became clear I have heard nothing from major leaders of hospital systems or health plans about this. Some of the newer provider organizations focusing on women, such as Maven and Tia, have been outspoken, as have many non health care-related employers. But the general silence from all major health care organizations in America on this topic has been deafening.

Today there is plenty of shame and blame to go around.

How About This Opportunity, Health Tech Investors? Promoting Contraception vs. Banning Abortion

By MIKE MAGEE

Dr. Linda Rosenstock has an M.D. and M.P.H. from Johns Hopkins, and was a Robert Wood Johnson Clinical Scholar. She is currently Dean Emeritus and Professor of Health Policy and Management at UCLA’s Fielding School of Public Health, but also spent years in government, and was on President Obama’s Advisory Group on Prevention, Health Promotion and Integrative and Public Health.

In the wake of the release of Justice Alito’s memo trashing Roe v. Wade, she was asked to comment about the status of abortion in America. Here is what she said:

“The broader the access to proven family planning methods, the lower the unintended pregnancy rate and the lower the abortion rate. We can’t underestimate the role of educating and empowering women – and men – about these issues.”

These are not simply the opinions or insights of a single health expert. They are backed up by the following facts:

  1. Since 1981, abortion rates in U.S. women, age 15 to 44, have declined by nearly two thirds from 29.3 per 1000 to 11.4 per 1000.

2. Approximately half of all pregnancies in the U.S. are unintended.  Of those unintended, approximately 40% of the women chose to terminate the pregnancy by abortion – either procedural or chemically induced.

3.  The decline in the number of abortions has coincided with increased access to long-acting reversible contraception, including IUD’s and contraceptive implants. These options are now safe, increasingly covered by insurers, and more accessible to at-risk populations.

4. The increasing inclusion of sex education in middle school and high school curricula has been accompanied by a decline in high school sexual activity by 17% between 2009 and 2019.

5. There were 629,898 abortions recorded by the CDC in 2019. For every 1000 live births that year, there were 195 other women who chose to terminate their pregnancies. Almost half of the 1st trimester abortions are now chemically induced through Plan B-type pills.

What is clear from these figures is that knowledge and access to contraception is the best way to decrease the number of abortions in America.

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