January 9, 1989
Mr. Ronald Reagan
The President of the United States
The White House
1600 Pennsylvania Avenue, NW
Washington, DC 20500
Dear Mr. President:
On July 30, 1987, in remarks at a briefing for Right to Life leaders, you directed the Surgeon General to prepare a comprehensive report on the health effects of abortion on women. It was clear from those remarks that such a report was to cover the mental, as well as the physical, effects of abortion. A review of the scientific literature, the expertise of the Public Health Service, and the experience of national organizations with an interest in this issue form the basis for my conclusion.
The health effects of abortion on women are not easily separated from the hotly debated social issues that surround the practice of abortion. Therefore, every effort has been made to eliminate the bias which so easily intrudes even into the accumulation of scientific data. In this study I have purposely avoided any personal value judgement vis-à-vis abortion as a social issue.
I have approached this task as I did in writing the AIDS report which you requested in 1986. Scientific, medical, psychological, and public health experts were consulted. I met privately with 27 different groups which had philosophical, social, medical, or other professional interests in the abortion issue. The process involved groups such as the Right to Life National Committee, Planned Parenthood Federation of America, the U.S. Conference of Catholic Bishops, the American College of Obstetricians and Gynecologists, and women who had had abortions.
In summary of the situation, each year approximately 6 million women become pregnant; of that number 54 percent or 3.3 million of those pregnancies are unplanned. Over 1.5 million women, or 25 percent of those pregnant, elect abortion each year. Since the legalization of abortion in 1973, over 20 million abortions have been performed. Even among groups committed to confirming a woman’s right to legal abortion there was consensus that any abortion represented a failure in some part of society’s support system,—individual, family, church, public health, economic, or social.
At the time the report was requested, there were those advising you and intimately involved with the social issues of abortion who truly believed that such a report could be put together readily. In the minds of some of them, it was a foregone conclusion that the negative health effects of abortion on women were so overwhelming that the evidence would force the reversal of Roe v. Wade.
There were also others who truly believed differently. While they acknowledge that any surgical procedure done 1.5 million times a year may have some negative health effects on women, in their minds the positive effects of abortion—release from the unwanted pregnancy—far outweighed the perceived negative results.
It is difficult to label the opposing groups in the abortion controversy. Those against abortion call themselves pro-life. On the other hand, those who are not pro-life say the are not pro-abortion; rather, they refer to themselves as pro-choice and supporters of a woman's right to choose abortion.
It is also true that some who are pro-choice are personally opposed to abortion. It is not clear to them where the lines should be drawn between the right of the fetus and the right of the mother. So the pro-choice forces are not monolithic.
Nor are the pro-life forces monolithic. Many ardent pro-life individuals who are dedicated to preserving the life of the fetus do not consider contraception to be ethically, morally, or religiously wrong. But others in the pro-life camp do; indeed, some equate contraception with abortion.
I believe that the issue of abortion is so emotionally charged that it is possible that many who might read this letter would not understand it because I have not arrived at conclusions they can accept. But I have concluded in my review of this issue that, at this time, the available scientific evidence about the psychological sequelae of abortion simply cannot support either the preconceived beliefs of those pro-life or of those pro-choice.
Today considerable attention is being paid to possible mental health effects of abortion. For example, there are almost 250 studies reported in the scientific literature which deal with the psychological aspects of abortion. All of these studies were reviewed and the more significant studies were evaluated by staff in several of the Agencies of the Public Health Service against appropriate criteria and were found to be flawed methodologically. In their view and mine, the data do not support the premise that abortion does or does not cause or contribute to psychological problems. Anecdotal reports abound on both sides. However, individual cases cannot be used to reach scientifically sound conclusions. It is to be noted that when pregnancy, whether wanted or unwanted, comes to full term and delivery, there is a well documented, low incidence of adverse mental health effects.
For the physical situation, data have been gathered on some women after abortions. It has been documented that after abortion there can be infertility, a damaged cervix, miscarriage, premature birth, low birth weight babies, etc. But, I further conclude that these events are difficult to quantify and difficult to prove as abortion sequelae for two reasons. First, these events are difficult to quantify because approximately half of abortions are done in free-standing abortion clinics where records which might have been helpful in this regard, have not been kept. Second, when compared with the number of abortions performed annually, 50 percent of women who have had an abortion apparently deny having had one when questioned. Further, these events are difficult to prove, as sequelae of abortion because all of these same problems can and do follow pregnancy carried to term or not carried to term,—indeed can occur in women who have never been pregnant previously. Clearly, however, the incidents of physical injury is greater in instances where abortions are performed or attempted by those not qualified to do them or under less than sterile conditions.
I have consulted with the National Center for Health Statistics and Centers for Disease Control about the design of appropriate studies which could answer the questions dealing with the physical and psychological effects of abortion.
There has never been a prospective study on a cohort of women of child-bearing age in reference to the variable outcomes of mating. Such a study should include the psychological effects of failure to conceive, as well as the physical and mental sequelae of pregnancy,—planned and unplanned, wanted and unwanted—whether carried to delivery, miscarried, or terminated by abortion. To do such a study that would be above criticism would consume a great deal of time. The most desirable prospective study could be conducted for approximately $100 million over the next five years. A less expensive yet satisfactory study could be conducted for approximately $10 million over the same period of time. This $10 million study could start yielding data after the first year.
There is a major design problem which must be solved before undertaking any study. It is imperative that any survey instrument be designed to eliminate the discrepancy between the number of abortions on record and the number of women who admit having an abortion on survey. It is critical that this problem of “denial” be dealt with before proceeding with further investigations.
That is where things stand at this moment. I regret, Mr. President, that in spite of a diligent review on the part of many in the Public Health Service and in the private sector, the scientific studies do not provide conclusive data about the health effects of abortion on women. I recommend that consideration be given to going forward with an appropriate prospective study.
C. Everett Koop, M.D., Sc.D.
Surgeon General, U.S.P.H.S