墮胎的取得是一個種族正義問題

 

Katy Backes Kozhimannil, Ph.D., M.P.A., Asha Hassan, M.P.H. 和 Rachel R. Hardeman, Ph.D., M.P.H.

 

資料來源：n engl j med 387;17 nejm.org October 27, 2022；財團法人台灣紅絲帶基金會編譯

 

 

 

    對生殖上身體自主權的限制——決定是否、何時以及如何生孩子、與誰以及在什麼情況下生孩子的自由——長期以來一直被種族主義者、階級主義者或能力社會主義者用來壓迫和控制被貶低的個人和社區。 2022 年 6 月 24 日，在具有里程碑意義的多布斯訴傑克遜婦女健康組織 (Dobbs v. Jackson Women’s Health Organization) 的判決中，美國最高法院撤銷了墮胎權。儘管墮胎是美國近 50 年來一直受到保護的綜合生殖保健的重要組成部分，但在已禁止或可能禁止墮胎保健的 26 個州，未來的取得將受到嚴重限製或拒絕。

 

  關於墮胎和其他生殖健康服務的法律地位的決定，反映了任何有懷孕能力的人的公民權利地位，但它們對生活在美國的黑人和原住民產生了特別的共鳴，他們經歷了生殖壓迫世紀。多布斯的決定推翻了許多人的基本權利，這是對改善醫療保健種族平等的努力之直接攻擊。事實上，墮胎從根本上可說是一個種族正義問題。我們認為臨床醫生、醫療保健提供系統和政策制定者應該這樣對待它。

 

    美國部分建立在種族差異的生育政策之上。在奴隸制合法化的 256 年間，該國對黑人的生育能力有著重大的經濟利益。生育率的提高意味著更大的勞動力供應和更高的財產價值。因此，奴隸主寬恕了對被奴役者的強姦，對他們隱瞞了有關節育的知識，允許在沒有麻醉的情況下對他們進行婦科實驗，並提供「激勵」來強迫他們生育。墮胎是被奴役的孕婦用來控制其生育能力並防止未來的孩子經歷動產奴隸制的可怕和不人道條件的重要工具。

 

    解放後和吉姆克勞時代，美國對黑人的經濟興趣發生了變化。一旦黑人不再是免費勞動力的來源，以白人至上主義意識形態為基礎的「優生」人口減少政策開始出現在政府和臨床照護中。 1927 年，最高法院在巴克訴貝爾案 (Buck v. Bell) 中將優生絕育法合法化，該案從未被明確推翻。強制絕育，俗稱「密西西比闌尾切除術」，在 20 世紀司空見慣，據估計，政府資助的計劃生育計畫導致多達 70,000 人非自願絕育。

 

    美國的其他種族群體也經歷過生育不公；例如，在 1930 年代和 1970 年代之間，多達三分之一的波多黎各婦女接受了強制絕育手術，通常被稱為「手術」。諸如此類的暴行不僅限於過去：2020 年，移民和海關執法部門對在美國南部邊境尋求庇護的聯邦拘留設施中的女性移民進行了強制絕育。此外，在 20 世紀中葉，波多黎各婦女在不知情的情況下參加了激素避孕的臨床試驗，並被用作尚未獲得食品和藥物管理局批准的避孕藥具的試驗對象。

 

    美國對土著人民（原住民族）的政策透過種族滅絕、強姦、家庭分離、寄宿學校、語言根除、文化同化和生殖剝削來促進消除。在 1900 年代，許多州通過了允許對「弱智者」進行絕育的法律，這種做法在保留地和政府開辦的寄宿學校中廣泛實施，在這些學校中，被強行與家人分離的土著兒童在與部落無關的情況下被撫養長大。此外，以優生概念和美國政府政策為依據的部落成員規則可能會侵犯生殖自由：要成為擁有祖先談判條約權利的部落成員，許多原住民必須證明來自特定部落的最低「血統成份」。這些要求迫使土著人民在其潛在子女是否有資格成為部落成員的情況下考慮生育選擇；如果強姦犯或其他父母沒有來自同一部落的必要血統成份，則因被強姦或意外懷孕而出生的孩子則可能被拒絕與其親生父母在同一部落登記。由於每一種生育選擇都被否定，原住民族（土著人民）和部落離被抹殺更近了一步。

 

    影響生殖健康的系統性種族主義今天出現在孕產婦死亡率統計中；疾病控制和預防中心的數據顯示，黑人和原住民在懷孕期間或分娩前後死亡的可能性是白人的兩到四倍。墮胎比懷孕和分娩更安全，尤其是對黑人和原住民而言，但現在在美國許多社區被定為犯罪。最近的估計顯示，全國範圍內的墮胎禁令將使產婦死亡率總體上升 21%，美國黑人的死亡率上升 33%。

 

    生殖健康結果的種族和民族差異源於獲得照護的不公平。由於廣泛的因素（例如，人際種族主義、與醫療機構的距離、健康保險狀況、就業福利、國家政策），黑人和原住民、移民和農村居民獲得墮胎照護和其他生殖保健之健康服務的機會相對有限。在人們不再能夠輕易獲得避孕藥具或終止意外懷孕的社區中，獲得產前服務和產科照護的機會正在下降，其中以黑人、原住民或拉丁裔為主的社區——包括農村和城市——出現的下降幅度最大。當人們無法預防或終止意外或有醫療風險的懷孕，無法輕鬆獲得產前照護，並且住在距設有產科的醫院數百英里的地方時，臨床醫生難以防止悲劇發生，人們的健康也會受到影響。

 

    隨著對墮胎的限制增加，健康方面的種族不公正現象將持續存在並惡化。多布斯決定對健康的不利影響將對孕產婦死亡率最高、孕產婦和生殖健康種族不平等最嚴重的州的患者、臨床醫生、診所、醫療保健系統和社區造成最嚴重的影響。例如，米歇爾·古德溫（Michele Goodwin）指出，在密西西比州，黑人死於足月妊娠的可能性是合法墮胎的 118 倍。事實上，黑人和原住民在懷孕時面臨著不成比例的健康風險，而這些風險最高的地方也是那些幾乎不可能接受或提供患者可能需要的醫療保健以保護他們的生命、安全或他們家庭之健康的地方。。

 

    多布斯的決定提高了臨床醫生、醫療保健管理者和重視健康中種族正義的政策制定者的風險。生殖保健限制加劇了整個生命週期中站不住腳的種族健康不平等，而不僅僅是在懷孕期間。墮胎是一種醫療保健，古特馬赫研究所估計有四分之一的有懷孕能力的人需要或將需要墮胎。一些需要墮胎的患者被一個貶低他們的社會種族化，如果他們沒有得到他們需要的墮胎，他們可能會經歷悲慘的後果。在州法律允許的範圍內，臨床醫生可以透過提供墮胎照護、支持其他如此做的人以及倡導在其醫療保健系統中提供安全、有尊嚴、人道的生殖保健服務來提供幫助。

 

    SisterSong 組織將生殖正義定義為「在安全和可持續的社區中保持個人身體自主權、生孩子、不生孩子以及養育我們所擁有的孩子的人權」。獲得生殖健康服務——包括墮胎——對於保護任何有懷孕能力的人的全部人性至關重要。在美國，黑人和原住民的全部人性長期以來一直被否認。事實上，與健康、教育和貧困相關的統計數據揭示了支撐美國政治和政策的種族主義。幾代人一直在與這些不公正的原則進行鬥爭，以確保和促進公民權利，且鬥爭仍在繼續。我們認為，臨床醫生有職業義務倡導改善患者和潛在患者生活的政策，包括做任何在他們擴大和保護墮胎機會的權力。墮胎是一個種族正義問題，這是當今值得醫學、政策和公共衛生領域等專業人士堅毅地參與的民權鬥爭

 

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作者提供的披露表可在 NEJM.org 上獲取。來自明尼蘇達大學明尼阿波利斯分校公共衛生學院衛生公平反種族主義研究中心和衛生政策與管理系。本文於 2022 年 9 月 7 日在 NEJM.org 上發表。

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Abortion Access as a Racial Justice Issue

 

Katy Backes Kozhimannil, Ph.D., M.P.A., Asha Hassan, M.P.H., and Rachel R. Hardeman, Ph.D., M.P.H.

 

n engl j med 387;17 nejm.org October 27, 2022

 

 

 

  Restrictions on reproductive bodily autonomy — the freedom to decide whether, when, and how to have a child, with whom, and under what circumstances — have long been leveraged to oppress and control persons and communities that are devalued by racist, classist, or ableist societies. On June 24, 2022, in the landmark Dobbs v. Jackson Women’s Health Organization decision, the U.S. Supreme Court revoked the right to abortion. Even though abortion is an essential component of comprehensive reproductive health care that has been protected in the United States for nearly 50 years, future access will be severely limited or denied in the 26 states that have banned or are likely to ban abortion care.

 

  Decisions regarding the legal status of abortion and other reproductive health services reflect the status of civil rights for anyone with the capacity for pregnancy, but they have a particular resonance for Black and Indigenous people living in the United States, who have experienced reproductive oppression for centuries. The Dobbs decision rolls back fundamental rights for many people, and it is a direct assault on efforts to improve racial equity in health care. Indeed, abortion access is fundamentally a racial justice issue. We believe that clinicians, health care delivery systems, and policymakers should approach it as such.

 

  The United States was built, in part, on racially differentiated policies toward reproduction. During the 256 years when slavery was legal, the country had a substantial economic interest in the fertility of Black people; increased fertility meant a larger labor supply and higher property value. Slaveholders therefore condoned rape of enslaved people, withheld from them knowledge about birth control, allowed gynecologic experimentation on them without anesthesia, and provided “incentives” to coerce them into reproducing. Abortion was an important tool leveraged by enslaved pregnant people to control their fertility and prevent future children from experiencing the horrifying and inhumane conditions of chattel slavery.

 

  After emancipation and during the Jim Crow era, U.S. economic interest in Black bodies shifted. Once Black people were no longer a source of free labor, “eugenic” depopulation policies informed by White supremacist ideology began emerging in both government and clinical care. In 1927, the Supreme Court legitimized eugenic sterilization laws in Buck v. Bell, a case that has never been explicitly reversed. Forced sterilization, colloquially known as “Mississippi appendectomy,” was commonplace in the 20th century, with some estimates suggesting that as many as 70,000 people were involuntarily sterilized by government-sponsored family-planning programs.

 

  Other racialized groups in the United States have also experienced reproductive injustice; for instance, between the 1930s and the 1970s, as many as one third of Puerto Rican women underwent forced sterilization, commonly referred to as “la operación.” Atrocities such as this are not confined to the past: in 2020, Immigration and Customs Enforcement forcibly sterilized female migrants in federal detention facilities who were seeking asylum at the southern U.S. border. Also, in the mid-20th century, Puerto Rican women were enrolled in clinical trials of hormonal birth control without their knowledge and used as test subjects for contraceptives that had not yet been approved by the Food and Drug Administration.

 

  U.S. policy toward Indigenous peoples has promoted erasure by means of genocide, rape, family separation, boarding schools, language eradication, cultural assimilation, and reproductive exploitation. In the 1900s, many states passed laws allowing sterilization of the “feeble-minded,” which was practiced extensively on reservations and at government-run boarding schools, where Indigenous children who had been forcibly separated from their families were raised without connection to their tribal communities.3 In addition, tribal membership rules informed by eugenic concepts and U.S. government policy may infringe on reproductive freedom: to be a member of a tribe with treaty rights negotiated by their ancestors, many Indigenous people must demonstrate a minimum “blood quantum” from a particular tribe. Such requirements force Indigenous people to consider reproductive choices in the context of their potential children’s eligibility for tribal membership; children born as a result of rape or unwanted pregnancy may be denied enrollment in the same tribe as their birth parent, if the rapist or other parent does not have the requisite blood quantum from the same tribe. With every reproductive choice denied, Indigenous peoples and tribes move closer to erasure.

 

  Systemic racism affecting reproductive health shows up today in maternal mortality statistics; Centers for Disease Control and Prevention data show that Black and Indigenous people are two to four times as likely as White people to die during pregnancy or around the time of childbirth. Abortion, which is now criminalized in many U.S. communities, is safer than pregnancy and delivery, especially for Black and Indigenous people. Recent estimates suggest that a nationwide abortion ban would increase maternal mortality by 21% overall and by 33% among Black Americans.

 

Racial and ethnic disparities in reproductive health outcomes follow from inequities in access to care. Owing to a wide range of factors (e.g., interpersonal racism, distance from health care institutions, health insurance status, employment benefits, state policies), Black and Indigenous people, immigrants, and rural residents have comparatively limited access to abortion care and other reproductive health services. In communities where people can no longer readily obtain contraceptives or terminate an unwanted pregnancy, access to prenatal services and obstetrical care is declining, with the steepest decreases occurring in communities — both rural and urban — that are predominantly Black, Indigenous, or Latinx.5 When people can’t prevent or terminate an unwanted or medically risky pregnancy, can’t easily access prenatal care, and live hundreds of miles from a hospital with an obstetrical unit, clinicians struggle to prevent tragedies and people’s health suffers.

 

As restrictions on abortion increase, racial injustice in health will persist and worsen. The adverse health effects of the Dobbs decision will fall hardest on patients, clinicians, clinics, health care systems, and communities in states with the highest maternal mortality and the biggest racial inequities in maternal and reproductive health. For example, Michele Goodwin has noted that in Mississippi, a Black person is 118 times more likely to die from carrying a pregnancy to term than from having a legal abortion. Indeed, Black and Indigenous people face disproportionate health risks when they become pregnant, and the places where these risks are highest are also those where it’s nearly impossible to receive or provide the health care patients may need to protect their life, their safety, or their family.

 

The Dobbs decision raises the stakes for clinicians, health care administrators, and policymakers who value racial justice in health. Reproductive health care restrictions exacerbate untenable racial inequities in health across the life span, not just during pregnancy. Abortion is health care, and the Guttmacher Institute estimates that one in four people with the capacity for pregnancy have needed or will need an abortion. Some patients who need abortions, racialized by a society that devalues them, may experience tragic consequences if they do not get the abortion they need. Clinicians can help by providing abortion care, supporting others who do so, and advocating for safe, dignified, humane reproductive health care services to be provided in their health care systems, to the extent allowed by state law.

 

The organization SisterSong defines reproductive justice as “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” Access to reproductive health services — including abortion — is essential for protecting the full humanity of anyone with the capacity for pregnancy. In the United States, the full humanity of Black and Indigenous people has long been denied. Indeed, statistics related to health, education, and poverty reveal the racism that underpins U.S. politics and policies. Generations have fought against these unjust tenets to ensure and advance civil rights, and the fight continues.1-3 We believe that clinicians have a professional obligation to champion policies that improve the lives of their patients and potential patients, including doing whatever is in their power to expand and protect abortion access. Abortion access is a racial justice issue, and it is today’s civil rights battle worthy of tenacious engagement by professionals in medicine, policy, and public health.

 

 

 

Disclosure forms provided by the authors are available at NEJM.org. From the Center for Antiracism Research for Health Equity and the Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis. This article was published on September 7, 2022, at NEJM.org.