U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

85–987 PDF 2003

PARTIAL-BIRTH ABORTION BAN ACT OF 2003

HEARING

BEFORE THE

SUBCOMMITTEE ON THE CONSTITUTION

OF THE

COMMITTEE ON THE JUDICIARY

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

ON

H.R. 760

MARCH 25, 2003

Serial No. 14

Printed for the use of the Committee on the Judiciary

(

Available via the World Wide Web: http://www.house.gov/judiciary

(II)

COMMITTEE ON THE JUDICIARY

F. JAMES SENSENBRENNER, JR., Wisconsin, Chairman

HENRY J. HYDE, Illinois

HOWARD COBLE, North Carolina

LAMAR SMITH, Texas

ELTON GALLEGLY, California

BOB GOODLATTE, Virginia

STEVE CHABOT, Ohio

WILLIAM L. JENKINS, Tennessee

CHRIS CANNON, Utah

SPENCER BACHUS, Alabama

JOHN N. HOSTETTLER, Indiana

MARK GREEN, Wisconsin

RIC KELLER, Florida

MELISSA A. HART, Pennsylvania

JEFF FLAKE, Arizona

MIKE PENCE, Indiana

J. RANDY FORBES, Virginia

STEVE KING, Iowa

JOHN R. CARTER, Texas

TOM FEENEY, Florida

MARSHA BLACKBURN, Tennessee

JOHN CONYERS, JR., Michigan

HOWARD L. BERMAN, California

RICK BOUCHER, Virginia

JERROLD NADLER, New York

ROBERT C. SCOTT, Virginia

MELVIN L. WATT, North Carolina

ZOE LOFGREN, California

SHEILA JACKSON LEE, Texas

MAXINE WATERS, California

MARTIN T. MEEHAN, Massachusetts

WILLIAM D. DELAHUNT, Massachusetts

ROBERT WEXLER, Florida

TAMMY BALDWIN, Wisconsin

ANTHONY D. WEINER, New York

ADAM B. SCHIFF, California

LINDA T. SA ́ NCHEZ, California

PHILIP G. KIKO, Chief of Staff-General Counsel

PERRY H. APELBAUM, Minority Chief Counsel

SUBCOMMITTEE ON THE CONSTITUTION

STEVE CHABOT, Ohio, Chairman

STEVE KING, Iowa

WILLIAM L. JENKINS, Tennessee

SPENCER BACHUS, Alabama

JOHN N. HOSTETTLER, Indiana

MELISSA A. HART, Pennsylvania

TOM FEENEY, Florida

J. RANDY FORBES, Virginia

JERROLD NADLER, New York

JOHN CONYERS, JR., Michigan

ROBERT C. SCOTT, Virginia

MELVIN L. WATT, North Carolina

ADAM B. SCHIFF, California

CRYSTAL M. ROBERTS, Chief Counsel

PAUL B. TAYLOR, Counsel

KRISTEN SCHULTZ, Full Committee Counsel

DAVID LACHMANN, Minority Professional Staff Member

(III)

C O N T E N T S

MARCH 25, 2003

OPENING STATEMENT

Page

The Honorable Steve Chabot, a Representative in Congress From the State

of Ohio, and Chairman, Subcommittee on the Constitution ............................ 1

The Honorable Jerrold Nadler, a Representative in Congress From the State

of New York, and Ranking Member, Subcommittee on the Constitution ....... 3

The Honorable Steve King, a Representative in Congress From the State

of Iowa ................................................................................................................... 4

WITNESSES

Dr. Mark G. Neerhof, Associate Professor of Obstetrics and Gynecology,

Northwestern University Medical School, Attending Physician Department

of Obstetrics and Gynecology, Northwestern Health Care

Oral Testimony ..................................................................................................... 6

Prepared Statement ............................................................................................. 8

Mr. Simon Heller, Director, Center for Reproductive Rights

Oral Testimony ..................................................................................................... 10

Prepared Statement ............................................................................................. 12

Mr. Gerard V. Bradley, Professor of Law, University of Notre Dame

Oral Testimony ..................................................................................................... 16

Prepared Statement ............................................................................................. 18

APPENDIX

MATERIAL SUBMITTED FOR THE HEARING RECORD

Prepared Statement by the Honorable Steve Chabot, a Representative in

Congress From the State of Ohio, and Chairman, Subcommittee on the

Constitution .......................................................................................................... 37

Prepared Statement by the Honorable Jerrold Nadler, a Representative in

Congress From the State of New York, and Ranking Member, Subcommittee on the Constitution ............................................................................ 38

Dr. Mark G. Neerhof submitted an article, ‘‘Rationale for Banning Abortions

Late in Pregnancy,’’ written by Dr. Neerhof and M. LeRoy Spange, M.D.

from the journal of the American Medical Association, Volume 280, No.

8, dated August 26, 1998 ..................................................................................... 40

Documents submitted by Chairman Steve Chabot ............................................... 44

Documents submitted by Representative Jerrold Nadler .................................... 186

Documents submitted by Representative John Conyers, Jr. ............................... 212

(1)

PARTIAL-BIRTH ABORTION BAN ACT OF 2003

TUESDAY, MARCH 25, 2003

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON THE CONSTITUTION,

COMMITTEE ON THE JUDICIARY,

Washington, DC.

The Subcommittee met, pursuant to call, at 2:05 p.m., in Room

2237, Rayburn House Office Building, Hon. Steve Chabot [Chairman of the Subcommittee] presiding.

Mr. CHABOT. The Committee will come to order. This is the Subcommittee on the Constitution of the Judiciary Committee.

This afternoon we will have a hearing on the Partial-Birth Abortion Ban Act, followed immediately by a markup.

We have convened this afternoon to receive testimony on H.R.

760, the ‘‘Partial-Birth Abortion Ban Act of 2003.’’

On February 13th, on behalf of over 100 original cosponsors, I introduced H.R. 760, the ‘‘Partial-Birth Abortion Ban Act of 2003’’,

which will ban the dangerous and inhumane procedure during

which a physician delivers an unborn child’s body until only the

head remains inside the womb, punctures the back of the child’s

skull with a sharp instrument, and sucks the child’s brain out before completing delivery of the now dead infant. An abortionist who

violates this ban would be subject to fines or a maximum of 2 years

imprisonment or both. H.R. 760 also establishes a civil cause of action for damages against an abortionist who violates the ban, and

includes an exception for those situations in which a partial birth

abortion is necessary to save the life of the mother. On March 13,

2003 the Senate approved S.3, which is virtually identical to H.R.

760, by a 64 to 33 vote.

A moral, medical and ethical consensus exists that partial birth

abortion is an inhumane procedure that is never medically necessary and should be prohibited. Contrary to the claims of those

who proclaim the medical necessity of this barbaric procedure, partial birth abortion is, in fact, a dangerous medical procedure. It can

pose serious risks to the long-term health of women. As testimony

received by the Subcommittee during the 107th Congress demonstrates, there is never any situation in which the procedure H.R.

760 would ban is medically necessary. In fact, 10 years after Dr.

Martin Haskell presented this procedure to the mainstream abortion community, partial birth abortions have failed to become

standard medical practice for any circumstance under which a

woman might seek an abortion.

As a result, the United States Congress voted to ban partial

birth abortions during the 104th, 105th and 106th Congresses, and

2

at least 27 States enacted bans on the procedure. Unfortunately,

the two Federal bans that reached President Clinton’s desk were

promptly vetoed.

To address the concerns raised by the majority opinion of the

United States Supreme Court in Stenberg v. Carhart, H.R. 760 differs from these previous proposals in two areas.

First, the bill contains a new, more precise definition of the prohibited procedure to address the Court’s concerns that Nebraska’s

definition of the prohibitive procedure might be interpreted to encompass a more commonly performed late second trimester abortion procedure. As previous testimony indicates, H.R. 760 clearly

distinguishes the procedure it would ban from other abortion procedures.

The second difference addresses the majority’s opinion that the

Nebraska ban placed an ‘‘undue burden’’ on women seeking abortions, because it did not include an exception for partial birth abortions deemed necessary to preserve the ‘‘health’’ of the mother. The

Stenberg court, based its conclusion on the trial courts factual findings regarding the relative health and safety benefits of the partial

birth abortions - findings which were highly disputed. The Court

was required to accept these findings because of the highly deferential, ‘‘clearly erroneous’’ standard that is applied to lower court factual findings.

Those factual findings, however, are inconsistent with the overwhelming weight of authority regarding the safety and medical necessity of the partial birth abortion procedure - including evidence

received during extensive legislative hearings during the 104th,

105th and 107th Congresses, which indicates that a partial birth

abortion is never medically necessary to preserve the health of a

women, poses serious risks to a woman’s health, and lies outside

standard medical care.

Under well settled Supreme Court jurisprudence, the United

States Congress is not bound to accept the same factual findings

that the Supreme Court was bound to accept in Stenberg under the

‘‘clearly erroneous’’ standard. Rather, the United States Congress is

entitled to reach its own factual findings - findings that the Supreme Court consistently relies upon and accords great deference

- and to enact legislation based upon these findings so long as it

seeks to pursue a legitimate interest that is within the scope of the

Constitution and draws reasonable inferences based upon substantial evidence. Thus, the first section of H.R. 760 contains

Congress’s extensive factually findings that, based upon extensive

medical evidence compiled during Congressional hearings, a partial

birth abortion is never necessary to preserve the health of a

woman.

H.R. 760’s findings are not ‘‘false’’ as its opponents have charged.

They are based upon the very opinions of doctors, medical associations, and a review of the practices of the medical profession as a

whole. Thus, they are ‘‘legislative facts’’ drawn from reasonable inferences based upon substantial evidence. The fact that the abortion lobby disagrees with these inferences only demonstrates how

out of step they are with public opinion and the mainstream medical community.

3

Despite overwhelming support from the public, past efforts to

ban partial birth abortions were blocked by President Clinton. We

now have a president who has promised to stand with Congress in

its efforts to ban this barbaric and dangerous procedure. It is time

for Congress to end the national tragedy of partial birth abortions

and protect the lives of these helpless defenseless little babies. And

I will, at this time, yield to the gentleman from New York, Mr.

Nadler, for his opening statement.

[The prepared statement of Mr. Chabot follows in the Appendix]

Mr. NADLER. Thank you, Mr. Chairman. Today we have a very

bad combination: Members of Congress who want to play doctor,

and Members of Congress who want to play Supreme Court. When

you put the two together you have a prescription for some very bad

medicine for women and for this country.

We have been through this debate often enough to know by now

that you will not find the term partial birth abortion in any medical textbook. There are procedures that you will find in medical

textbooks, but apparently the authors of this legislation would prefer to use the language of propaganda rather than the language of

science.

This bill, as written, fails every test the Supreme Court has laid

down for what may or may not be a Constitutional regulation of

abortion. It reads almost as if the authors went through the Supreme Court’s recent decision in Stenberg v. Carhart and went out

of their way to thumb their noses at the Supreme Court, and especially at Justice O’Connor, who is generally viewed as the swing

vote on such matters, and who wrote a concurring opinion stating

very specifically what exactly would be needed for her to uphold

the statute.

Unless the authors think that when the Court has made repeated and clear statements over the years of what the Constitution requires in this area, they are just pulling our collective legs,

this bill has to be considered facially unconstitutional.

First and foremost, it does not include a health exception, which

the Court has repeatedly said is necessary, even with respect to

post viability abortions. The exception for a women’s life that is included in the bill is more narrowly drawn than is required by the

Constitution, according to the Supreme Court, and will place doctors in the position of trying to guess just how grave a danger pregnancy is to a woman’s life before they can be confident that protecting her will not result in jail time.

That is a test that doctors should not have to face. I know that

some of my colleagues do not like the Constitutional rule that has

been played down by the Supreme Court for 30 years, but that is

the law of the land, and the supreme law of the land, and no

amount of rhetoric, even if written into a piece of legislation, will

change that. Even the Ashcroft Justice Department, in its brief in

defending an Ohio statute now before the Court, has acknowledged

that a health exception is required by law, which is not in this bill,

of course.

While I may disagree with the Department’s views on whether

the Ohio statute adequately protects women’s health so as to pass

Constitutional muster, there is at least an acknowledgment that

4

the law requires that protection, which, again, I state is not included in the bill we are considering.

This bill is mostly findings. If there is one thing this activist

court has made clear, it is that it is not very deferential to

Congress’s determinations of fact.

While Congress is entitled to declare anything it wants, the

courts are not duty bound to accept anything we say at face value,

simply because it appears in a footnote to the United States Code.

While I realize that many of the proponents of this bill view all

abortion as tantamount to infanticide, that is not a mainstream

view. This bill attempts to foist a marginal view on the general

public by characterizing this bill as having to do only with abortions involving healthy, full-term fetuses.

If the proponents of this bill really want to deal with post-viability abortions in situations in which the woman’s life and health are

not in jeopardy, they should write a bill dealing with that issue. Although such a bill would be of marginal utility, since 41 States already ban post-viability abortions, except where the life or the

health of the mother is in danger.

Very few people would oppose such a bill. As one of the lead

sponsors of the Religious Freedom Restoration Act, which was

struck down by the Supreme Court, I know what comes of Congress ignoring the will of the Supreme Court. Whatever power Congress had under section 4 of the 14th Amendment as a result of

Katzenbach v. Morgan, a decision copiously cited in the bill’s findings, the more recent Boerne decision vastly undercut those powers.

Even if Katzenbach was still fully in force, as I wish it were, that

case only empowered Congress to expand, not to curtail rights

under the 14th Amendment.

This bill, of course, aims to do the exact opposite, to curtail rights

under the 14th Amendment. We now have a President who has expressed a willingness to sign this bill. He may get his chance. Unfortunately there are dire consequences for American women if this

legislation passes. Perhaps here the role of Congress is to help the

women take a back seat to the most extreme views of the antichoice movement. Fortunately, those dire consequences will not be

enforced long, because the Constitution still serves as a bulwark

against such efforts.

But the majority is not interested, the majority in this Committee and this House is clearly not interested in a bill that could

pass into law and actually be enforced as not contrary to the Constitution. What they want is an inflammatory piece of rhetoric,

which even if passed, would be struck down by the Supreme Court.

The real purpose of this bill that we are considering is not to save

babies but elections. Thank you, Mr. Chairman.

Mr. CHABOT. Thank you. If any other Members would like to

make opening statements, they are free to do so. Mr. King.

Mr. KING. Thank you, Mr. Chairman. As I sit here and listen to

this discussion and this issue of when life begins and the intrinsic

value of human life unfolds before this Congress, again, and I reflect upon some of the history that has been brought out on this

bill a bit earlier, I look down through a number of things in these

opening remarks that I think are essential.

5

One of them is a statement that the majority wants inflammatory legislation, and is not really interested in lives so much as

we are politics. I pray for nothing more than this issue would be

resolved, and the deference of innocent human lives, and go away

from the subject matter of the United States of America forever.

That is my number one most profound belief. I will do everything

in my power to save the lives of innocent babies at whatever stage

of development.

So with that, Mr. Chairman, I thank you for the time. I yield

back the balance.

Mr. CHABOT. Thank you very much.

Mr. Scott.

Mr. SCOTT. No, thank you.

Mr. CHABOT. Any Members of the panel? Ms. Hart. No. Mr.

Feeney from Florida? No. Mr. Forbes from Virginia?

Mr. FORBES. No.

Mr. CHABOT. Thank you very much. We will move forward with

the panel then at this time. We have a very distinguished panel

here this afternoon. I will introduce them at this time. Our first

witness will be Dr. Mark G. Neerhof who has been practicing maternal-fetal medicine for 14 years, is an associate professor of obstetrics and gynecology at Northwestern University Medical School,

and an attending physician in the Department of Obstetrics and

Gynecology, division of maternal-fetal medicine at Evanston,

Northwestern Health Care in Evanston, Illinois.

After completing his residency in obstetrics and gynecology at

Chicago Osteopathic Medical Center in 1989, Dr. Neerhof completed a fellowship in Philadelphia in 1991.

Thereafter, Dr. Neerhof joined Northwestern University Medical

School. Dr. Neerhof is board certified in obstetrics and gynecology

by the American College of Osteopathic Obstetricians and Gynecologist, and in maternal-fetal medicine by the American Osteopathic Board of obstetrics and gynecology.

Dr. Neerhof received his BA in Biology and Chemistry from

Dordt College in Sioux Center, Iowa in 1980, and his DO from Chicago College of Osteopathic Medicine in Chicago, Illinois in 1984.

And we welcome you here this afternoon, Doctor.

Our second witness will be Simon Heller. Mr. Heller, who was

most recently Director of the Domestic program of the Center for

Reproductive Law and Policy, now known as the Center for Reproductive Rights. He is a constitutional law expert who has been an

abortion advocate for over 10 years.

Most recently, Mr. Heller argued on behalf of Dr. Leroy Carhart

in Stenberg v. Carhart. In addition, he has litigated a number of

other abortion-related cases throughout the country, including challenges to Medicaid funding restrictions, laws that limit the performance of an abortion to a physician, parental involvement laws

and the partial birth abortion bans of Wisconsin and Virginia.

Prior to helping fund the CRLP, Mr. Heller was a staff attorney

in the Reproductive Freedom Project of the American Civil Liberties Union. He also served as an assistant district attorney in

Manhattan.

Mr. Heller received his juris doctor from Yale Law School in

1986, and his masters and bachelors degrees from the State UniVerDate 11-MAY-2000 23:23 Jun 03, 2003 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6601 G:\WORK\CONST\032503\85987.000 HJUD3 PsN: HJUD3
6

versity of New York at Stony Brook. Mr. Heller currently serves as

of-counsel to the Center for Reproductive Rights. We welcome you

this afternoon. Our third witness will be professor Gerard V. Bradley. Professor Bradley currently teaches constitutional theory, first

amendment, trial advocacy and legal ethics at Notre Dame Law

School, where he has taught since 1992.

Prior to joining the faculty at Notre Dame, Professor Bradley

served as assistant professor, associate professor, and professor at

University of Illinois College of Law, where he taught criminal procedure, constitutional law, religion and law, and trial advocacy.

Prior to joining the faculty at the University of Illinois, Professor

Bradley spent three years as an assistant district attorney, trial division, in the New York County district attorney’s office. Professor

Bradley received his BA in history from Cornell University in 1976,

and his juris doctor from Cornell Law School in 1980, where he

graduated first in his law school class.

Mr. CHABOT. So we welcome all three of the witnesses here this

afternoon, and we will begin with Dr. Neerhof. And, as you may

or may not be familiar, we have a system of lights which are right

there on the desk. The green light will indicate that you have five

minutes to testify, yellow will mean you have a minute to wrap up,

and the red light, we would appreciate if you would conclude your

testimony approximately at that time. We always give a little leeway, if necessary, but we try to keep within the parameters of that,

if possible.

So, Dr. Neerhof.

STATEMENT OF MARK G. NEERHOF, ASSOCIATE PROFESSOR

OF OBSTETRICS AND GYNECOLOGY, NORTHWESTERN UNIVERSITY MEDICAL SCHOOL, ATTENDING PHYSICIAN DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, NORTHWESTERN HEALTH CARE

Dr. NEERHOF. Mr. Chairman and Committee Members, thank

you for the opportunity to come and speak with you today. My

name is Mark Neerhof. I am an associate professor of obstetrics

and gynecology at Northwestern University Medical School. I am

an attending physician in the Department of Obstetrics and Gynecology in the division of maternal-fetal medicine at Evanston

Northwestern Health Care in Evanston, Illinois.

I have been practicing maternal-fetal medicine for 14 years. I am

very familiar with fetal anomalies of all sorts, and am familiar

with the options available for termination of pregnancy.

I have done many deliveries at the gestational ages where an intact D&X is performed. As a consequence, I am very familiar with

the mechanism of delivery, including at these early gestational

ages.

I came here today to express my support for a ban on intact

D&X. I will divide my reasons into three categories; maternal,

fetal, and ethical.

Maternal considerations: There exist no credible studies on intact

D&X that evaluate or attest to its safety. The procedure is not recognized in medical textbooks. Intact D&X poses serious medical

risks to the mother. Patients who undergo an intact D&X are at

risk for the potential complications associated with any surgical

7

midtrimester termination which include: hemorrhage, infection,

and uterine perforation.

However, intact D&X places these patients at increased risk of

additional complications. First, the risk of uterine rupture may be

increased. An integral part of the D&X procedure is an internal podalic version, during which the physician instrumentally reaches

into the uterus, grasps the fetus’s feet, and pulls the feet down into

the cervix, thus converting the lie to a breach.

The internal version carries risks of uterine rupture, abruption,

amniotic fluid embolus, and trauma to the uterus. These risks have

never been adequately quantified.

The second potential complication of intact D&X is the risk of

iatrogenic laceration and secondary hemorrhage. Following internal

version and partial breech extraction, scissors are forced into the

base of the fetal skull while it is lodged in the birth canal.

This blind procedure risks maternal injury from laceration of the

uterus or cervix by the scissors and could result in severe bleeding

and the threat of shock or even maternal death. These risks have

not been adequately quantified.

None of these risks are medically necessary because other procedures are available to physicians who deem it necessary to perform

an abortion late in pregnancy. ASCOG policy states clearly, intact

D&X is never the only procedure available.

Some clinicians have considered intact D&X necessary when hydrocephalus is present. However, a hydrocephalic fetus could be

aborted by traditional means by first draining the excess fluid from

the fetal skull through ultrasound guided cephalocentesis.

Some physicians who perform abortions have been concerned

that a ban on late term abortions would affect their ability to provide other abortion services. Because of the proposed changes in

Federal legislation, it is clear that only intact D&X would be

banned.

It is my opinion that this legislation will not affect the total number of terminations done in this country. It will simply and appropriately eliminate one of the procedures by which termination can

be accomplished.

Fetal considerations: Intact D&X is an extremely painful procedure for the fetus. The majority of intact D&Xs are performed on

periviable fetuses. Fetuses and newborns at these gestational ages

are fully capable of experiencing pain. The scientific evidence supporting this is abundant. If one still has questions in one’s mind

regarding this fact, in spite of the scientific evidence, one simply

needs to visit a neonatal intensive care unit and your remaining

doubts will be short-lived.

When infants of similar gestational ages are delivered, pain management is an important part of the care rendered to them in the

intensive care nursery. However, with intact D&X, pain management is not provided for the fetus who is literally within inches of

being delivered.

Forcibly incising the cranium with scissors and then suctioning

out the intracranial contents is unquestionably excruciatingly painful. I happen to serve as the chairman of the Institutional Animal

Care and Use Committee at my hospital. I am well aware of the

Federal standards regulating the use of animals in research.

8

It is beyond ironic to me that the pain management practice for

an intact D&X on a human fetus would not meet Federal standards

for the humane care of animals used in medical research. The

needlessly inhumane treatment of periviable fetuses argues against

intact D&X as a means of pregnancy termination.

Ethical considerations: Intact D&X is most commonly performed

between 20 and 24 weeks, and thereby raises the question of potential viability of the fetuses. Recent unpublished data from my institution indicates an 88 percent survival rate at 24 weeks gestation.

These numbers will undoubtedly continue to improve over time.

Beyond the argument of potential viability, many pro- choice organizations and individuals assert that a woman should maintain

control over that which is part of her own body, i.e., the autonomy

argument. In this context, the physical position of the fetus with

respect to the mother’s body becomes relevant.

However, once the fetus is outside of the woman’s body, the autonomy argument is invalid. The intact D&X procedure involves literal delivering the fetus so that only the head remains within the

cervix. Based on my experience, I can tell you that if the fetal head

remains in the cervix, insertion of scissors into the base of the scull

is, by necessity, a blind procedure and consequently it is potentially

hazardous.

If, however, as I suspect, the head is out of the cervix, and in

the vagina, that fetus is essentially delivered, because there is

nothing left to hold that fetal head in. At this juncture, the fetus

is merely inches from being delivered and obtaining full legal

rights of personhood under the U.S. Constitution.

What happens when, as must occasionally occur during the performance of an intact D&X, the fetal head inadvertently slips out

of the mother, and a live infant is fully delivered? For this reason,

many otherwise pro-choice individuals have found intact D&X too

close to infanticide to ethically justify its continued use.

In summary, the arguments for banning this procedure are based

on maternal safety, fetal pain, and ethical considerations. I regret

the necessity to support the development of legislation which will

regulate medical care, because in general, that is not desirable.

However, in this case, it is born out of the reluctance of the medical

community to stand up for what is right.

Mr. Chairman, I would like to ask that a 1998 Journal of the

American Medical Association article that I authored in which I expand on the subject of my testimony in front of you today be submitted to the record.

Mr. CHABOT. Without objection.

Dr. NEERHOF. I thank you.

Mr. CHABOT. Thank you.

[The prepared statement of Dr. Neerhof follows:]

PREPARED STATEMENT OF DR. MARK G. NEERHOF

Mr. Chairman and committee members, Thank you for the opportunity to come

and speak with you today.

My name is Mark Neerhof. I am an associate professor of Obstetrics and Gynecology at Northwestern University Medical School. I am an attending physician in

the Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine

at Evanston Northwestern Healthcare in Evanston, Illinois. I have been practicing

Maternal-Fetal Medicine for 14 years. I am very familiar with fetal anomalies of all

sorts, and am familiar with the options available for termination of pregnancy. I

9

have done many deliveries at the gestational ages where an intact D&X is performed, and as a consequence, I am very familiar with the mechanism of delivery,

including at these early gestational ages.

I came here today to express my support for a ban on intact D&X. I will divide

my reasons into 3 categories: maternal, fetal, and ethical.

Maternal Considerations

There exist no credible studies on intact D&X that evaluate or attest its safety.

The procedure is not recognized in medical textbooks. Intact D&X poses serious

medical risks to the mother. Patients who undergo an intact D&X are at risk for

the potential complications associated with any surgical mid-trimester termination,

including hemorrhage, infection, and uterine perforation. However, intact D&X

places these patients at increased risk of 2 additional complications. First, the risk

of uterine rupture may be increased. An integral part of the D&X procedure is an

internal podalic version, during which the physician instrumentally reaches into the

uterus, grasps the fetus’ feet, and pulls the feet down into the cervix, thus converting the lie to a footling breech. The internal version carries risk of uterine rupture, abruption, amniotic fluid embolus, and trauma to the uterus.

The second potential complication of intact D&X is the risk of iatrogenic laceration and secondary hemorrhage. Following internal version and partial breech extraction, scissors are forced into the base of the fetal skull while it is lodged in the

birth canal. This blind procedure risks maternal injury from laceration of the uterus

or cervix by the scissors and could result in severe bleeding and the threat of shock

or even maternal death. These risks have not been adequately quantified.

None of these risks are medically necessary because other procedures are available to physicians who deem it necessary to perform an abortion late in pregnancy.

As ACOG policy states clearly, intact D&X is never the only procedure available.

Some clinicians have considered intact D&X necessary when hydrocephalus is

present. However, a hydrocephalic fetus could be aborted by first draining the excess fluid from the fetal skull through ultrasound-guided cephalocentesis. Some physicians who perform abortions have been concerned that a ban on late abortions

would affect their ability to provide other abortion services. Because of the proposed

changes in federal legislation, it is clear that only intact D&X would be banned. It

is my opinion that this legislation will not affect the total number of terminations

done in this country, it will simply eliminate one of the procedures by which termination can be accomplished.

Fetal Considerations

Intact D&X is an extremely painful procedure for the fetus. The majority of intact

D&X are performed on periviable fetuses. Fetuses or newborns at these gestational

ages are fully capable of experiencing pain. The scientific evidence supporting this

is abundant. If one still has a question in one’s mind regarding this fact, one simply

needs to visit a Neonatal Intensive Care Unit, and your remaining doubts will be

short-lived. When infants of similar gestational ages are delivered, pain management is an important part of the care rendered to them in the intensive care nursery. However, with intact D&X, pain management is not provided for the fetus, who

is literally within inches of being delivered. Forcibly incising the cranium with a

scissors and then suctioning out the intracranial contents is certainly excruciatingly

painful. I happen to serve as chairman of the Institutional Animal Care and Use

Committee at my hospital. I am well aware of the federal standard regulating the

use of animals in research. It is beyond ironic that the pain management practiced

for an intact D&X on a human fetus would not meet federal standards for the humane care of animals used in medical research. The needlessly inhumane treatment

of periviable fetuses argues against intact D&X as a means of pregnancy termination.

Ethical Considerations

Intact D&X is most commonly performed between 20 and 24 weeks and thereby

raises the question of the potential viability of the fetus. Recent unpublished data

from my institution indicates an 88% survival rate at 24 weeks. These numbers will

undoubtedly continue to improve over time.

Beyond the argument of potential viability, many pro-choice organizations and individuals assert that a woman should maintain control over that which is part of

her own body (i.e., the autonomy argument). In this context, the physical position

of the fetus with respect to the mother’s body becomes relevant. However, once the

fetus is outside the woman’s body, the autonomy argument is invalid. The intact

D&X procedure involves literally delivering the fetus so that only the head remains

within the cervix. Based on my own experience, I can tell you that if the fetal head

remains in the cervix, insertion of scissors into the base of the skull is, by necessity,

10

a blind procedure, and consequently, potentially hazardous. If, as I suspect, the

head is out of the cervix and in the vagina, that fetus is essentially delivered because there is nothing left to hold the fetal head in. At this juncture, the fetus is

merely inches from being delivered and obtaining full legal rights of personhood

under the US Constitution. What happens when, as must occasionally occur during

the performance of an intact D&X, the fetal head inadvertently slips out of the

mother and a live infant is fully delivered? For this reason, many otherwise prochoice individuals have found intact D&X too close to infanticide to ethically justify

its continued use.

In summary, the arguments for banning this procedure are based on maternal

safety, fetal pain, and ethical considerations. I regret the necessity to support the

development of legislation which will regulate medical care because, in general, that

is not desirable. However, in this case, it is born out of the reluctance of the medical

community to stand up for what is right.

Thank you for the opportunity to come and speak with you today.

Mr. Chairman, I’d like to request that a 1998 Journal of the American Medical

Association article that I authored, in which I expand upon the subject of my testimony in front of you today, be submitted to the record.

Mr. CHABOT. Mr. Heller, I am going to give you some additional

time, because the doctor went over by about four minutes. And so

it was about nine minutes all together. So I think it is fair to give

you the same time, if you need it.

STATEMENT OF SIMON HELLER, DIRECTOR, CENTER FOR

REPRODUCTIVE RIGHTS

Mr. HELLER. I appreciate that. Well, I want to thank the Subcommittee for inviting me here to speak. Again, this is—I believe

I was here last summer. My field of expertise is Constitutional law,

specifically, the jurisprudence that the United States Supreme

Court has developed with respect to abortion and contraception.

Nevertheless, in the course of doing many cases involving abortion and contraception, I have become familiar with some of the

medical information that exists in this area as well. From a legal

standpoint, the bill you are considering today is flatly unconstitutional under a Supreme Court decision, Stenberg v. Carhart that

was decided only three years ago.

There has been no change in the composition of the Supreme

Court. As Mr. Nadler pointed out, Justice O’Connor, the crucial

fifth vote in deciding Stenberg v. Carhart, pointed out very clearly,

precisely what States or Congress must do in order for a bill regulating abortion methods to pass constitutional muster. This bill

does neither of the two things she specifically directed must be

done.

And I think the question one should ask oneself in considering

this legislation, if one is perhaps still not decided on the question,

is to imagine a Federal judge looking at this bill, and looking at

the Supreme Court’s decision in Stenberg v. Carhart, and deciding

what the law of the land is.

And is the law of the land going to be determined in the eyes

of the Federal judge, or appellate judge or Supreme Court Justice

by what the Supreme Court has said, or by slightly altered legislative language with legislative findings that have—that are based

not on substantial evidence, but on hardly any evidence whatsoever.

I will come back to that briefly in a moment. The reasons that

the bill is unconstitutional are pretty obvious. I mean, you just

11

read Stenberg v. Carhart, and it applies almost word for word to

the bill. It is not limited to a single procedure.

It talks about a single procedure, and Dr. Neerhof spoke about

a single procedure in the beginning of the bill. But, then goes on

to use different language in its operative language.

Secondly, it has no health exception. I am really going to limit

most of my comments to the second flaw, the lack of a health exception, because this is where the bill goes on at length, putting

forth so-called congressional findings of fact in an effort to, I suppose, displace the facts that actually exist in the real world. But,

the Supreme Court has already rejected these facts once, and it

will do so again. Now, I will explain that in a moment.

Much of the conversation here has been about Stenberg v.

Carhart, and does this bill answer the objections the Supreme

Court had? But that was not the only partial birth abortion case

before the United States Supreme Court in the year 2000. In fact,

there was another one from Wisconsin that was also in front of the

Supreme Court.

And let me tell you a little bit about that case. In that case, a

Federal district judge in Wisconsin upheld Wisconsin’s partial birth

abortion law. That judge said, this law is constitutional. Why did

the judge do that?

Among other things, he said things like, and this was Judge

Shabaz from the western district of Wisconsin, that the D&X procedure poses risks to women, he said there are no published, medically-recognized studies comparing the risks of D&E to D&X. He

testified that major medical associations are reluctant to—he wrote

that major medical associations are reluctant to endorse the D&X

procedure.

He concluded: In light of this substantial evidence, the Court

concludes that partial birth abortion is never medically necessary

to preserve the life or health of a woman, and abolition of the procedure did not subject to women to materially greater health risks.

Moreover, induction is safer than D&E and can be used in those

rare pregnancies, et cetera. He reached the findings that this bill

contains.

The 7th Circuit heard the appeal. And by a 5-to-4 vote the 7th

Circuit affirmed Judge Shabaz. Judge Easterbook, a noted conservative jurist, repeated much of the district court’s findings. The district court in the Wisconsin case concluded that the D&X procedure

is never necessary from the perspective of the patient’s health.

And Judge Easterbook said that findings is not clearly erroneous,

so we have to uphold it. What did the Supreme Court do? The Supreme Court vacated the 7th Circuit’s decision. The same—maybe

the day after Carhart was decided, and on remand, the 7th Circuit

unanimously, 9 to 0, said that the same Wisconsin statute they had

upheld under these type of legislative—findings similar to these

legislative findings was unconstitutional because it lacked a health

exception and it was too broad.

In other words, all of the judges of the 7th Circuit, Judge

Easterbook, Judge Posner, noted conservative judges, all agreed

that under the Supreme Court’s decision in Carhart, despite facts

found by a district court to the contrary, Wisconsin’s law was unconstitutional. That is because the health exception is required as

12

a matter of law, and because there is sufficient, I guess, disagreement about the facts that neither Congress nor the States is free

to legislate in this area.

So the Supreme Court has already heard these facts. It has

looked at them, and it has rejected them, despite the fact that the

clearly erroneous law of course applied in the Wisconsin case as

well.

There is no room for play here. The Supreme Court has rejected

the old versions of this bill that were used by Congress in Congressional bills that President Clinton vetoed, and has rejected these

very legislative findings that Congress is now trying to slip past

the Supreme Court.

The honorable thing to do, when Congress disagrees with the Supreme Court decision, is to propose an amendment to the United

States Constitution, have it passed, I believe, by a two-thirds vote

of Congress, and have it ratified by three-quarters of the States.

This is not that. This is, as Mr. Nadler said, thumbing its nose at

the Supreme Court. It should be rejected. In fact, it was rejected

by the voters of three States who were actually asked to vote on

whether they wanted such a law or not, in Maine, Washington and

Colorado, the voters rejected this type of statute. So the only public

opinion polls that count, the ones at the ballot box, have rejected

this type of legislation.

I urge the Committee to do so as well. Thank you.

Mr. CHABOT. Thank you.

[The prepared statement of Mr. Heller follows:]

PREPARED STATEMENT OF SIMON HELLER

Mr. Chairman:

Thank you for giving me the opportunity to testify this afternoon. My name is

Simon Heller. I acted as the lead trial attorney in the Stenberg v. Carhart Nebraska

abortion ban case and had the privilege of arguing the case before the Supreme

Court in April of 2000.

I. INTRODUCTION

H.R. 760 is not a ban on one clearly defined, late-term abortion method, as its

proponents deceptively claim. Instead, it is an extreme measure that sacrifices women’s health to further the ideological agenda of the anti-choice movement. It is

therefore unconstitutional under controlling Supreme Court precedent. Since Roe v.

Wade, 410 U.S. 113 (1973), the Supreme Court has consistently held that the right

to privacy under our Constitution gives primacy to the pregnant woman’s health:

she has the right to end a pregnancy that threatens her health, Roe, 410 U.S. at

164, and she has the right to the safest method of ending the pregnancy. See

Thornburgh v. ACOG, 476 U.S. 747, 768-69 (1986). H.R. 760, captioned as a ban

on ‘‘partial-birth abortion,’’ is unconstitutional in that it suffers from precisely the

two flaws identified by the United States Supreme Court in its recent decision striking down Nebraska’s ban on ‘‘partial-birth abortion.’’ Stenberg v. Carhart, 530 U.S.

914 (2000). In Carhart, the Court invalidated the Nebraska law for ‘‘at least two

independent reasons’’:

First, the law lacks any exception ‘‘’for the preservation of the . . . health of

the mother.’’ [Planned Parenthood v.] Casey, 505 U.S. [833 (2000)], at 879 (joint

opinion of O’Connor, Kennedy, and Souter, JJ.). Second, it ‘‘imposes an undue

burden on a woman’s ability’’ to choose a [dilation and evacuation] abortion,

thereby unduly burdening the right to choose abortion itself. Id., at 874.

Carhart, 530 U.S. at 930 (parallel citations omitted). Importantly, Justice O’Connor’s concurrence re-emphasized these very same constitutional infirmities. Carhart,

530 U.S. at 947 (O’Connor, J., concurring). The sponsors of the bill seek to evade

the Carhart ruling in two ways. Neither is successful.

13

1The Supreme Court’s abortion jurisprudence has also consistently recognized that only two

government interests—the interest in the potential life of the fetus and the interest in the

health of the pregnant woman—can justify restrictions on abortion. Since a ban on some abortion methods simply steers women towards other abortion methods, such a ban does not serve

the interest in potential life. Because the ban contained in H.R. 760 also does not promote women’s health, several eminent judges have questioned whether such a ban even passes muster

under the most deferential form of judicial review, often called rational basis review. For example, then Chief Judge Posner of the United States Court of Appeals for the Seventh Circuit

wrote: ‘‘Even if the standard for judicial review of state abortion laws challenged under the due

process clause of the Fourteenth Amendment were merely that of rational relation to a legitimate state interest, Wisconsin’s partial birth statute would be in trouble. Not because states

do not have legitimate interests in the regulation of abortion, especially late-term abortions, but

because the Wisconsin statute does not seem rationally related to any of those interests, and

in particular to the interest of preservation of fetal life ‘‘ Planned Parenthood of Wisconsin v. Doyle, 162 F.3d 463, 470 (7th Cir. 1998). Similarly, Justice Stevens wrote that he could not understand ‘‘how a State has any legitimate interest in requiring a doctor to follow any procedure

other than the one that he or she reasonably believes will best protect the woman in her exercise of this constitutional liberty [to choose abortion].’’ 530 U.S. at 946 (Stevens, J., concurring). 2The sponsors could have, but did not, use more specific language quoted approvingly by Justice O’Connor in her concurrence in Carhart, namely language used in state statutes which Justice O’Connor believed applied only to a narrowly defined abortion technique. See 530 U.S. at

950 (O’Connor, J., concurring) (quoting Kansas, Montana and Utah statutes at length). Indeed,

the sponsors do not even consistently describe the same technique within the findings. Compare

Finding ¶1 (partial-birth abortion involves delivery until ‘‘only the head remains in the womb’’)

with Finding ¶14(A) (partial-birth abortion involves conversion to a footling breech presentation)

and Finding 14(J) (partial-birth abortion involves delivery of ‘‘all but the head, out of the

womb’’). 3 And contrary to Justice O’Connor’s concurrence: ‘‘First, the Nebraska statute is inconsistent

with Casey because it lacks an exception for those instances when the banned procedure is necessary to preserve the health of the mother.’’ 530 U.S. at 947. 4Of course, any physician who knowingly (or even negligently) performed an abortion using an unsafe method (e.g., using non-sterile instruments) would be both civilly liable for malpractice and subject to professional discipline in most states. Significant questions are raised

under the Fifth Amendment’s equal protection component by a Congressional effort to target

one area of medicine, namely abortion care, for federal criminal regulation when all medical care

is already extensively regulated by the States. Indeed, surgical abortion is among the safest surgical procedures performed in the United States.

II. H.R. 760 IMPOSES AN UNDUE BURDEN ON THE RIGHT TO CHOOSE ABORTION

The Supreme Court found that the language of Nebraska’s statute was broad

enough to prohibit the dilation and evacuation [‘‘D&E’’] method of performing an

abortion. Because D&E is the most commonly used method in the second trimester

of pregnancy, a law that bans that method is tantamount to a ban on second-trimester abortions. Abortion bans have been unconstitutional since Roe v. Wade was decided nearly thirty years ago.1

The sponsors of H.R. 760 have altered the definition of ‘‘partial-birth abortion,’’ which is not a medical term, but instead a propaganda term designed to inflame

public opinion against all abortions. Yet this alteration still does not result in a prohibition on a narrowly circumscribed category of abortion techniques. Instead, just

like the language of Nebraska’s statute, it could still prohibit many pre-viability

abortions using the D&E method, of which the specific technique described in the

first paragraph of the bill’s findings is simply one type.2 In fact, the prohibitory language of the bill is quite plainly broader than the abortion technique described in

paragraph one of the bill’s ‘‘findings.’’ Compare H.R. 760 § 2, ¶1 (describing breech

presentation technique) with § 3, ch. 74 § 1531(b)(1)(A) (prohibiting both breech and

cephalic presentation techniques). The bill perpetuates the problem of Nebraska’s law: it uses language which sweeps more broadly than the single technique described in the ‘‘findings’’ by the sponsors.

III. H.R. 760 WILL HARM WOMEN’S HEALTH

The sponsors have simply put forward the bald assertion that, contrary to the Supreme Court’s holding in Carhart,3 no health exception is necessary in their bill because the technique described in paragraph one of the bill’s findings is never medically necessary and is actually harmful to women’s health.4 Both assertions are,

however, false. It is thus of little moment that the sponsors seek to label these particular false statements as ‘‘Congressional findings.’’ Whatever deference the Judiciary may owe to Congressional findings, no deference is due where the findings are

demonstrably false. As Justice Thomas has written:

We know of no support . . . for the proposition that if the constitutionality of

a statute depends in part on the existence of certain facts, a court may not review [Congress’s] judgment that the facts exist. If [Congress] could make a statVerDate 11-MAY-2000 23:23 Jun 03, 2003 Jkt 000000 PO 00000 Frm 00017 Fmt 6633 Sfmt 6621 G:\WORK\CONST\032503\85987.000 HJUD3 PsN: HJUD3
14

5The more detailed ‘‘findings’’ on the harm of ‘‘partial-birth abortion’’ to women are at best

opaque, and at worst misleading and false. Paragraph 14(A) of the findings purports to list risks

of ‘‘partial-birth abortion,’’ but does not quantify those risks or compare them in any meaningful

way to the risks of abortion methods (like hysterotomy which involves abdominal rather than

vaginal removal of the fetus) that are clearly permitted under the bill, or to the risks of carrying

a pregnancy to term. Paragraph 14(B) seems to focus on the lack of controlled studies of ‘‘partial-birth abortion,’’ but the lack of studies does not prove that any technique is not safe, it simply leaves the question open. Paragraph 14(C) tendentiously cites an unnamed medical association’s views, but fails to disclose that the medical organization specializing in reproductive

health care for women, ACOG, disagrees with these views.

ute constitutional simply by ‘‘finding’’ that black is white or freedom, slavery,

judicial review would be an elaborate farce. At least since Marbury v. Madison,

5 U.S. (1 Cranch) 137, 2 L.Ed. 60 (1803), that has not been the law.

Lamprecht v. FCC, 958 F.2d 382, 392 n.2 (D.C. Cir. 1992) (per Thomas, Circuit Justice).

‘‘Medically necessary,’’ in the case of abortion, has two distinct meanings: whether

the abortion itself is medically necessary, and whether a particular method of abortion is medically necessary. The sponsors intentionally conflate the two meanings,

even though only the latter meaning is relevant in the case of an ban on abortion

methods. Thus, for example, paragraph 14(E) of the findings asserts that the physician ‘‘credited with developing the partial-birth abortion procedure’’ ‘‘has never encountered a situation where a partial-birth abortion was medically necessary to

achieve the desired outcomee...’’ (Paragraph 14(D) similarly mischaracterizes and

misconstrues Dr. Carhart’s testimony.) Of course, as with other medical treatments,

a pregnant woman and her physician typically choose from among a few alternative

techniques to end the pregnancy. But one technique may be the safest and most

medically appropriate technique. The bill removes the determination of which technique is the safest and most appropriate from the hands of physicians and patients

and places it in the hands of federal prosecutors.

But the Supreme Court has removed this medical determination from the political

arena. As the Court stated in Carhart, ‘‘[we have] made clear that a State may promote but not endanger a woman’s health when it regulates the methods of abortion.’’ 530 U.S. at 931 (citing Thornburgh v. American College of Obstetricians and

Gynecologists, 476 U.S. 747, 768-69 (1986); Colautti v. Franklin, 439 U.S. 379, 400

(1979); Planned Parenthood v. Danforth, 428 U.S. 52, 76-79 (1976); Doe v. Bolton,

410 U.S. 179, 197 (1973)). The sponsors of H.R. 760 assert in their findings that

the abortion techniques they are prohibiting are not only ‘‘unnecessary to preserve

the health of the mother, but in fact pose[] serious risks to the long-term health of

women and in some circumstances, their lives.’’ § 2 (‘‘Findings’’), ¶2.5 As is very clear

from the factual record not only in the Carhart case itself, but in many other cases

challenging partial-birth abortion bans, there is, at a minimum, significant evidence

that no technique banned by H.R. 760 is harmful to women.

Instead, there is significant evidence that one technique banned by H.R. 760,

called dilation and extraction (D&X) by the Supreme Court, see Carhart, 530 U.S.

at 927, is in fact the safest and best abortion technique in some cases. Thus, though

acknowledging the lack of statistical studies comparing the safety of the D&X technique with other abortion methods, federal judges reviewing statutes from the following states made the following factual determinations about the D&X technique

based on testimony both favoring and disfavoring the D&X technique:

Arizona: The D&X method is one of several ‘‘safe, medically acceptable abortion methods in the second-trimester.’’ Planned Parenthood v. Woods, 982 F.

Supp. 1369, 1376 (D. Ariz. 1997) (Bilby, J., appointed by President Carter).

Illinois: ‘‘[D&X] reduces the risk of retained tissue and reduces the risk

of uterine perforation and cervical laceration because the procedure requires less instrumentation in the uterus. [It] may also result in less blood

loss and less trauma for some patients and may take less operating time.’’

Hope Clinic v. Ryan, 995 F. Supp. 847, 852 (N.D. Ill. 1998) (Korcoras, J., appointed

by President Carter).

New Jersey: ‘‘The intact dilatation and extraction, or intact D&X, has not

been the subject of clinical trials or peer-reviewed studies and, as a result,

there are no valid statistics on its safety. As its ’elements are part of established obstetric techniques,’ the procedure may be presumed to pose similar risks of cervical laceration and uterine perforation. However, because

the procedure requires less instrumentation, it may pose a lesser risk.

Moreover, the intact D&X may be particularly helpful where an intact fetus

is desirable for diagnostic purposes.’’ Planned Parenthood of Central New JerVerDate 11-MAY-2000 23:23 Jun 03, 2003 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6621 G:\WORK\CONST\032503\85987.000 HJUD3 PsN: HJUD3
15

sey v. Verneiro, 41 F. Supp. 2d 478, 484-85 (D.N.J. 1998) (Thompson, C.J., appointed

by President Carter) (citation to ACOG Statement on Intact D&X omitted).

Ohio: ‘‘[T]his Court finds that use of the D&X procedure in the late second

trimester appears to pose less of a risk to maternal health than does the

D&E procedure, because it is less invasive—that is, it does not require

sharp instruments to be inserted into the uterus with the same frequency

or extent—and does not pose the same degree of risk of uterine and cervical lacerations . . . [T]he D&X procedure appears to have the potential

of being a safer procedure than all other available abortion

procedures...’’ Women’s Medical Professional Corp. v. Voinovich, 911 F. Supp.

1051, 1070 (S.D. Ohio 1995) (Rice, J., appointed by President Carter).

Rhode Island: ‘‘Doctors have not done statistical studies as to the relative

risk of a D&X, although the doctors testified that it was equal to or less

than the risk of a D&E.’’ Rhode Island Medical Society v. Whitehouse, 66 F. Supp.

2d 288, 298 (D.R.I. 1999) (Lagueux, C.J., appointed by President Reagan).

Virginia: ‘‘When the relative safety of the D&E is compared to the D&X,

there is evidence that the D&X (which is but a type of D&E . . .) has many

advantages from a safety perspective. . . . For some women, then, the D&X

may be the safest procedure.’’ Richmond Medical Center for Women v. Gilmore,

55 F. Supp. 2d 441, 491 (E.D. Va. 1999) (Payne, J., appointed by President Bush)

(citations to the trial record omitted).

Wisconsin: ‘‘The D&X procedure is a variant of D&E designed to avoid

both labor and the occasional failures of induction as a method of aborting

the fetus, while also avoiding the potential complications of a D&E. For

some women, it may be the safest procedure. So at least the plaintiff physicians believe, and these beliefs are detailed in affidavits submitted in the

district court. This is also the opinion of the most reputable medical authorities

in the United States to have addressed the issue: the American Medical Association

and the American College of Obstetricians and Gynecologists.’’ Planned Parenthood

of Wisconsin v. Doyle, 162 F.3d 463, 467-468 (7th Cir. 1998) (per Posner, C.J., appointed by President Reagan, joined by Rovner, J., appointed by President Bush)

(emphasis added).

Perhaps most importantly, the Supreme Court held that the absence of medical

consensus about the safety or benefits of a particular abortion technique does not

authorize the government to ban the technique: ‘‘Where a significant body of medical opinion believes a procedure may bring with it greater safety for some patients

and explains the medical reasons supporting that view,’’ 530 U.S. at 937, neither

Congress nor the States may ban the procedure. H.R. 760 directly contravenes this

legal holding by choosing one side in the medical debate about abortion methods via

the device of Congressional findings. Yet this is a debate the Supreme Court has

required the government to stay out of.

IV. THE BILL THREATENS THE SEPARATION OF POWERS

The bill also presents a greater threat to our constitutional system of government.

Where constitutional rights are at stake, the Judiciary conducts its own independent

review of the facts. See, e.g., Landmark Communications, Inc. v. Virginia, 435 U.S.

829, 843-44 (1978). Even where constitutional rights are not at stake, the Court has

recently viewed with skepticism Congressional findings purportedly supporting its

exercise of powers under Article I or Section 5 of the Fourteenth Amendment. See,

e.g., United States v. Morrison, 529 U.S. 598, 614 (2000). Here, the sponsors assert

that factual findings made by the Judiciary can be, in essence, set aside by contrary

Congressional findings. Under this novel regime, Congress could have overturned

Brown v. Board of Education by ‘‘finding’’ that racially separate schools were, in fact

‘‘equal,’’ or could, in line with this bill’s approach, ban all D&E abortions by ‘‘finding’’ that all D&E procedures were unsafe and that, contrary to actual fact, D&E’s

were rarely performed. Ultimately, Congressional findings that seek to defy the Supreme Court and the function of the federal courts as triers of facts will not only

threaten the independence of the Judiciary, but undermine the value of Congressional findings in other contexts where such findings may, unlike in this bill, actually be a legitimate and appropriate exercise of Congressional power.

Congressional attempts to overturn Supreme Court precedents have always failed.

For example, Congress passed the Religious Freedom Restoration Act (RFRA) in response to an earlier Supreme Court decision. Employment Div., Dept. of Human Resources of Oregon v. Smith, 494 U.S. 872 (1990) (holding that neutral, generally applicable laws may be applied to religious practices even when not supported by a

compelling state interest). Congress held separate hearings to assess the issues and

made independent findings, prior to enacting the law. In striking down RFRA, the

16

Supreme Court held that Congress ‘‘has been given the power ’to enforce,’ not the

power to determine what constitutes a constitutional violation.’’ City of Boerne v.

Flores, 521 U.S. 507, 519 (1997). The Court further held that ‘‘The power to interpret the Constitution in a case or controversy remains in the Judiciary,’’ id. at 524,

and ‘‘RFRA contradicts vital principles necessary to maintain separation of powers

and the federal balance.’’ Id. at 536.

Similarly, Congress attempted to overturn the Supreme Court’s Miranda requirements by enacting a new ‘‘voluntariness’’ standard in their place. In Dickerson v.

United States, 530 U.S. 428, 435-36 (2000), the Supreme Court reviewed the law,

and in striking it down held that ‘‘Miranda, being a constitutional decision of this

Court, may not be in effect overruled by an Act of Congress,’’ id. at 432, and ‘‘Congress may not legislatively supersede our decisions interpreting and applying the

Constitution.’’ Id. at 437.

Here, again, Congress is attempting to overturn Supreme Court constitutional

precedent by enacting a law that fails to adhere to the precedent. As in these cases,

Congress has overstepped its bounds - the bill does not pass constitutional muster.

V. CONCLUSION

The Supreme Court’s decision in Stenberg v. Carhart is clear: even a specific, narrowly worded ban on the D&X abortion technique must contain a health exception

because significant evidence supports the likelihood that the D&X technique is the

safest technique in some cases. Carhart also re-affirms that a ban on commonly

used abortion methods cannot masquerade as a prohibition on a specific technique,

for such a ban imposes an undue burden. This decision is in keeping with the Supreme Court’s long-held principle that the health of the pregnant woman must be

protected when government regulates abortion, and that government must respect

the reasonable medical judgment of physicians and their women patients. Congress

would do well to heed the Supreme Court’s pronouncement by rejecting this bill.

Mr. CHABOT. Professor Bradley.

STATEMENT OF GERARD V. BRADLEY, PROFESSOR OF LAW,

UNIVERSITY OF NOTRE DAME

Mr. BRADLEY. I thank the Members of the Subcommittee. Thank

you for this opportunity to address the constitutionality of H.R.

760, especially in light of the decision of the Court in Stenberg v.

Carhart.

My written testimony addresses several issues, but in these brief

opening remarks, I will limit myself to what I take to be the most

important Constitutional question, the question about a health exception and medical necessity.

H.R. 760 says that medical necessity is a question of fact. H.R.

760 says that the fact is, there are no cases of medical necessity

for D&X abortion, hence, there is no need for a health exception in

the bill.

The Carhart Court also said that medical necessity is ‘‘a factual

question,’’ not a question of law, which was the matter, by the way,

in the Boerne case, and it was the Freedom of Restoration Act that

Representative Nadler referred to. There was a dispute there between Congress and the court, really about the meaning of the free

exercise clause. That is not this situation.

And it was also not a case in Stenberg v. Carhart of legal characterization of facts, nor did the Court say it was a question a mix

of law and fact. Now, the Supreme Court implicitly conceded, in my

view, in Carhart, that if it is true, that there are no factual cases

of medical necessity, there is no need for a health exception in the

law.

So what is the problem? Well, the Carhart Court surely does not

say, as does H.R. 760, that there are no cases of medical necessity.

17

On the other hand, the Carhart Court does not contraindicate H.R.

760.

For in my view, the Carhart opinion does not say, the Carhart

majority, does not assert, that there are cases of medical necessity.

But, what does the Carhart majority opinion say? It seems to me

that the majority statements on this matter can be divided up into

basically two groups, two different types, two kinds.

The first kind: The Carhart Court says, in so many words, the

district court found that there are cases of medical necessity, and

the record supports that finding. But this type of statement presents no constitutional problem, no constitutional impediment to

H.R. 760. For saying that the record in a particular trial supports

a verdict is not at all to say that the verdict is true, or even that

a reviewing court would have reached the same verdict on the

same record.

And we all know of cases of a record in a criminal trial which

could well support, in fact, does well support, a judgment of conviction, even for an entirely innocent person. The fact is, an appellate

court does not view the fact of the matter head on, sort of in real

life in real time, without restriction, and in light of all the relevant

research.

The Supreme Court in Carhart viewed the fact of the matter as

if through a glass darkly. Appellate courts, including the Supreme

Court in Carhart, is encumbered by the record below, and by a

whole complex of assumptions, presumptions and legal rules governing the relationship between superior and inferior courts; all

matters peculiar to judicial proceedings.

As the Supreme Court has often said, Congress is free of these

peculiar judicial constrains, and for that reason, among others,

Congress, the Supreme Court has often said, is a superior fact finder.

Now, the second type of statement in Carhart. Second type of

statement is, in so many words, some medical authorities, the

Court says substantial at one point, significant at another point,

but the Court says, some medical authorities say there are cases

of medical necessity and Nebraska has not demonstrated that they

are wrong. Some voices say there are such cases, and the Court is

unable or not in a position to say that they are wrong.

But this too is not a constitutional impediment to voting in favor

of the H.R. 760. For the Court did not say that these authorities

are right. The Court did not say that, in fact, there are cases of

medical necessity. H.R. 760 obviously holds that these voices are

mistaken, that there are no cases of medical necessity.

And what Nebraska failed to demonstrate in 1997, may well be

shown to the satisfaction of Congress in 2003. The Supreme Court

said that the question of medical necessity was uncertain. A confession, in my view, I think, that it just did not know what the fact

of the matter truly was. But, the Court did not say that is a question that can’t be answered or that is a matter to which the answer

can never be known. H.R. 760 contains Congress’s answer to the

factual question, the factual question which I submit the Court was

not in a position to answer in Stenberg v. Carhart.

Mr. CHABOT. Thank you very much.

[The prepared statement of Mr. Bradley follows:]

18

PREPARED STATEMENT OF GERARD V. BRADLEY

I am grateful to the Subcommittee for this opportunity to provide an opinion on

the constitutionality of HR 760, especially in light of the Supreme Court’s decision

in Stenberg v. Carhart.

I. ENUMERATED POWERS

The first question about the Constitution and this—or any—act of Congress is not

about limits, such as might be found in Roe v. Wade, Casey v. Planned Parenthood,

and Stenberg v. Carhart. The first question is whether the proposed legislation is

within an enumerated congressional power, powers granted by the people and listed

(chiefly) in Article I of the Constitution. Our national government does not possess

general, much less unlimited, lawmaking authority; in our federal system the states

possess general police power, understood as an undifferentiated authority to care for

the whole common good of political society. Given this federal structure, the first

question is always: is this bill within the power Congress has chosen to exercise,

as that power has been authoritatively interpreted by the Supreme Court?

Congress intends HR 760 to be an exercise of its power over ‘‘commerce . . .

among the several states.’’ U.S. Const, art I, sec. 8. The scope of this interstate commerce power has been reduced somewhat by recent decisions of the Supreme Court

in U.S. v. Lopez, 514 U.S.549 (1995)) and U.S. v. Morrison 529 U.S. 598 (2000). But

HR 760 is surely within the commerce power; this bill includes a jurisdictional element of the sort which, Lopez and Morrison suggest, satisfies constitutional requirements. See 529 U.S. at 613, relying upon Lopez.

An element of every prosecution (or civil suit) under HR 760 is that the partialbirth abortion be performed by a physician ‘‘in or affecting interstate or foreign commerce.’’ In each case the federal prosecutor (or plaintiff’s attorney) must establish

a connection between the particular act being prosecuted (or sued upon), and interstate commerce. Proof of this element, like all the elements of a criminal offense,

must satisfy a jury beyond a reasonable doubt. HR 760 wisely leaves the question

of sufficient proof of this ‘‘effect’’ to trial courts charging juries and deciding postverdict motions, and to appellate courts. We can speculate, though, that the element

would be proved by evidence that a patient communicated from out-of-state with an

abortion provider, and subsequently crossed state lines to procure the abortion.

I turn to the question of applicable limits arising from the Supreme Court’s abortion cases, most pertinently Carhart.

II. D&E, D&X AND ‘‘UNDUE BURDEN’’

The Supreme Court in Carhart gave two reasons for concluding that Nebraska’s

partial-birth abortion ban violated the Constitution. One was that the ban placed

an ‘‘undue burden’’ upon some women’s abortion liberty. Why? Because the Nebraska statute’s definition covered not only the prohibited D&X procedure, but some

permitted D&E procedures, too. In the Court’s words: ‘‘[U]sing this law some

present prosecutors and future Attorneys General may choose to pursue physicians

who use D&E procedures, the most commonly used method for performing

previability second trimester abortions. All those who perform abortion procedures

using that method must fear prosecution, conviction, and imprisonment. The result

is an undue burden upon a woman’s right to make an abortion decision.’’

The problem in Carhart was shoddy legislative draftsmanship. Nebraska’s drafters aimed at D&X and carelessly hit D&E too. Nowhere did the Carhart Court suggest that the fatal indeterminacy and overlap were features of medical reality. In

reality D&X is not a vague, uncertain thing, such as (to use some standard legal

examples) ‘‘unreasonable noise’’ or ‘‘due diligence’’ or ‘‘harmful effects’’ are vague.

Those phrases may well convey a core of settled, easy applications. But they also

point to gray, contested areas of uncertain application. These vague terms could be

applied to many doubtful or borderline cases; persons of good faith trying to conform

their conduct to law may not know which side of the line they tread. A boom box

on a subway may make ‘‘unreasonable noise.’’ Maybe not. Is it too loud on a beach?

At the park? Who is to say? What is a music lover to do?

D&X is surely not an ambiguous term, pointing more or less equally to two separate procedures. ‘‘USC’’ is ambiguous, for it could refer to the University of Southern

California, or to the University of South Carolina. D&X points to an unmistakable,

distinct medical procedure.

If partial-birth abortion blended into and was often indistinguishable from D&E

(or any other permitted procedure), even the best drafters might not be able to draw

a line clear enough to surmount the ‘‘undue burden’’ hurdle of Carhart. But D&X

is distinguishable; the definition in HR 760 reliably separates it from D&E.

19

The Carhart Court implicitly assumed that D&X is a distinct, readily identifiable

procedure, distinguishable from D&E. This assumption is evident in Carhart’s discussion of D&X and its benefits compared to D&E abortions. How could Supreme

Court Justices intelligently weigh the question of health risks and benefits of two

medical procedures, unless the procedures were different, did not overlap, and were

not confused by, or confusing to, medical practitioners and researchers? How could

anyone?

In other words: no intelligent discussion of the central question before this committee—the necessity of a ‘‘health’’ exception to any law prohibiting D&X abortions—is possible, save by supposing that D&X can be reliably and systematically

distinguished from other abortion procedures. One cannot debate which is the better

football team—USC or UCLA—save by knowing that they are two different schools,

albeit both in the California public system, and possessed of similar-sounding acronyms. Again: were not those who perform and study the effects of abortion able to

know what is, and what is not, a D&X procedure it would be impossible to state

firmly that D&X is safe, or safer, or safest, compared to other procedures. But this

is precisely the position of those who oppose HR 760.

What was shoddy about the Nebraska law? Its use of the phrase ‘‘substantial portion’’ of a living unborn child. Because a D&E procedure may commonly involve

pulling from the birth canal a limb or extremity—the Court referred repeatedly to

‘‘arm and a leg’’ and, at one telling point, ‘‘as small a portion as a foot’’—Nebraska

caught some (many?) D&E procedures in its D&X net.

HR 760 avoids entirely the asserted defects of the Nebraska law. This bill’s definition of the prohibited procedure—most pointedly, delivery of ‘‘the entire fetal head’’

or, in the case of breech delivery, ‘‘any part of the fetal trunk past the naval’’—overcomes the vagueness and uncertain application of the analogous Nebraska language—‘‘substantial portion’’ of the unborn child. No abortion doctor could confuse

what it prohibited by HR 760, and a D&E abortion.

The Carhart majority all but conceded that a statute drafted as is HR 760 would

pass constitutional muster under the ‘‘undue burden’’ analysis. The Nebraska Attorney General urged the Court to read ‘‘substantial portion’’ to mean ‘‘the child up to

the head.’’ The Court said that such a reading—treating the statute as if it said,

‘‘the child up to the head’’—would reliably distinguish D&X from D&E, where ‘‘the

physician introduces into the birth canal a fetal arm or leg.’’ But, the Carhart majority rejected the Attorney General’s limiting instruction because it conflicted with

the statutory definition—‘‘substantial portion.’’ The Court nonetheless said: ‘‘We are

aware that adopting the Attorney General’s interpretation might avoid the constitutional problem.’’

HR 760 actually does say, ‘‘the entire fetal head is outside the body of the mother.’’

III. A ‘‘HEALTH’’ EXCEPTION

The most controverted feature of HR 760 is the absence of a ‘‘health’’ exception,

the second ground of the Carhart opinion. Since there is no doubt that Roe and succeeding cases generally require a ‘‘health’’ exception, the constitutionality of HR 760

depends upon its superfluity: if a D&X is never necessary to preserve a woman’s

health, then the absence of a ‘‘health’’ exception is constitutionally unobjectionable.

HR 760 recites Congress’s relevant finding of fact: D&X is never necessary to preserve a woman’s health.

I possess no special competence or expertise to judge the truth of this assertion.

My competence permits me to address, however, a related and, I think, important

constitutional question: for any member of Congress who judges the assertion to be

supported by the evidence and the best conclusion available, is there some reason

arising in Roe, Carhart or any place else in constitutional law why that member

should hesitate to vote for HR 760?

My answer is no.

Effectively the same question is found paragraph (8) of the Findings part of HR

760. It says that ‘‘under well-settled Supreme Court jurisprudence, the United

States Congress is not bound to accept the same factual findings that the Supreme

Court was bound to accept in Carhart under the ‘clearly erroneous’ standard. Rather, the United States Congress is entitled to reach its own factual findings—findings

that the Supreme Court accords great deference—and to enact legislation based

upon these findings so long as it seeks to pursue a legitimate interest that is within

the scope of the Constitution, and draws reasonable inferences based upon substantial evidence’’ I judge this to be an accurate statement of the law.

Since there appears to be no doubt that Congress is pursuing a legitimate interest, is basing its judgments upon substantial evidence, and that as a general matter

20

the Supreme Court accords great deference to Congressional fact-finding (the findings portion of HR 760 contains ample citation to the cases), I turn to what to the

heart of the controversy over the proffered factual finding: whether it runs afoul of

the Court’s opinion in Carhart.

I think it does not.

The most pertinent passage of Carhart is this: Nebraska ‘‘fails to demonstrate

that banning D&X without a health exception may not create significant health

risks for women because the record shows that significant medical authority supports

the proposition that in some circumstances, D&X would be the safest procedure.’’

[emphasis added]

The question about HR 760 is, then, whether the proffered Congressional finding—that D&X is never medically indicated for a woman’s health—is neutralized,

or rendered inoperative, or is somehow in conflict with the quoted passage from

Carhart. My answer is, again no.

Why?

My reasoning includes four important preliminary points. First. With HR 760 we

are in no way talking about a Congressional power to preclude independent judicial

evaluation of the facts. We are talking about the appropriate level of judicial deference to congressional fact finding, not about judicial abdication.

Second. With HR 760 we are not talking about Congress dictating to the Court

what that appropriate level is, or should be. That matter is left to the Court. We

are talking about the Court’s doctrines about deference, not about a congressional

putsch.

Third. The alleged conflict is about a question of simple fact, colored by professional medical judgment: are there cases of medical necessity? The ‘‘conflict’’ here

is thus radically unlike the conflict in, for example, City of Boerne v. Flores, the

1995 Supreme Court decision invalidating the Religious Freedom Restoration Act.

There the conflict was about the law of the Constitution, pure and simple. Congress

aimed in RFRA to reverse a prior judicial interpretation of the Free Exercise

Clause, namely, the holding in Employment Division v. Smith.

HR 760 is not nearly so audacious as RFRA. HR 760 rewrites no law and aims

at no novel interpretation of the Constitution. A Boerne situation here would be if

Congress asserted in HR 760 that the Court misinterpreted the Constitution in Roe.

We would have Boerne here if Congress asserted, for example, that no health exception was required by the Constitution. Instead, Congress says in HR 760 that non

is required by the facts.

HR 760 is not a case like Brown v. Board of Education, either. There is indeed

a sense in which the Brown Court invalidated the ‘‘separate but equal’’ doctrine

upon factual considerations, insofar as the inhibiting psychological effects of segregation upon black children’s learning amount to a ‘‘fact.’’ But Brown is unlike this

situation for two reasons. One is that, even if the Brown psychological findings are

‘‘facts’’ which, at least in theory, Congress could have judged differently, the critical

part of Brown was not the raw fact of the matter. It was the Court’s legal characterization of those facts as unconstitutional inequality. Besides, if Congress could have

revised Brown by visiting the factual question, the fault lies not with the doctrine

of Congressional ascendancy over fact-finding—which is solidly supported by precedent and prudential considerations—but with the Brown Court, which chose to

stake its holding, not on the sure high terrain of moral principle, but in the prosaic

and slippery ground of psychological testing.

Fourth. Nothing in the relevant Supreme Court precedents suggests that the

question at issue here—medical necessity, if any, for D&X abortion—is beyond the

ordinary competence of Congress. Nothing in the cases suggests that the Court

would, or should, deviate from its ususal standard of according great deference to

a Congressional finding. The grounds for that deference were stated with

unsurpassable clarity by Archibald Cox, in a classic law review article:

The greater number of members [of a legislature] and their varied backgrounds

and experience make it virtually certain that the typical legislature will command wider knowledge and keener appreciation of current social and economic

conditions than will the typical court. The legislative committee, especially

when armed with able counsel and the power of subpoena, is better equipped

to develop the relevant data. Courts have always found it hard to develop the

background facts in constitutional cases. Judicial notice often means only intuition or prejudice. Occasionally, special masters have been appointed to make

elaborate studies of economic conditions, as where a particular industry has

been subjected to novel legislation. A court may hear expert witnesses, but they

are seldom more than special pleaders.

21

A. Cox, The Role of Congress in Constitutional Determinations, 40 U. Cinn. L. Rev.

199 (1971).

IV. CONGRESS AND COURT IN CONFLICT?

HR 760 finds that there is no medical necessity for a D&X abortion. Does this

finding conflict with what the Supreme Court says in Carhart? There are no expressions in Carhart which clearly show that the Court, speaking in its own voice, evaluated the factual question head on, all things considered, and rendered a de novo

judgment of its own. The expressions are all suggestive of a more limited, refracted

and conditional judgment. Some examples: ‘‘In sum, Nebraska has not convinced us

that a health exception is never necessary to preserve the health of the woman.’’

‘‘The upshot is a District Court finding that D&X significantly obviates health risks

in certain circumstances, a highly plausible record-based explanation of why that

might be so.... ’’ See also the expression quoted earlier in this testimony on this

record Nebraska has not demonstrated the truth of its assertion that there are no

cases of medical necessity.

These expressions can be read in two slightly different ways. But on neither reading does HR 760 conflict with Carhart.

On one reading of Carhart, the Supreme Court asserted no judgment of its own

about medical necessity. On this first reading, the Supreme Court left undisturbed

the lower court’s conclusions because they were not ‘‘clearly erroneous.’’ Findings

which are not ‘‘clearly erroneous,’’ however, could be false. On this reading the Supreme Court could actually agree with HR 760 that there are no cases of medical

necessity. On this view, by enacting HR 760 Congress would be presenting the Supreme Court a welcome opportunity to implement its—the Court’s—judgment that

there are no cases of medical necessity, a judgment stifled by the incorrect though

plausible findings of the District Court.

On this first reading, Carhart is no impediment whatsoever to Congressional factfinding, save that which presupposes a single District Court judge can bind, for all

time, the great coordinate branches of government on a question of fact. One sorely

hopes that such questions cannot be settled by who wins the race to the courthouse,

and on the luck of the judicial draw on race day.

The second possible reading of Carhart is this: the Supreme Court itself is heard

to judge the record. On this reading the high Court would be saying: we (along with

the District court) do not think Nebraska has made its case, as far as proof in this

record goes. This reading of Carhart is not in conflict with HR 760.

The Carhart Court was inescapably limited to opining upon the record compiled

below. That a judicial proceeding suffered all the limitations and comparative disadvantages identified by Archibald Cox. Cox’s caution about ‘‘special pleader’’ experts is perhaps most noteworthy: it would be difficult to overstate the role of one

man’s ‘‘expert’’ testimony in the compilation of that record—the defendant, Dr.

Leroy Carhart. The Supreme Court expressed its judgment most tellingly: ‘‘the findings and evidence support Dr. Carhart.’’

Those findings were, moreover, about Dr. Carhart: ‘‘The District Court concluded,’’

said the Supreme Court, ‘‘that ‘the evidence is both clear and convincing that

Carhart’s D&X procedure is superior to, and safer than, the other abortion procedures used during the relevant gestational period in the 10 to 20 cases a year that

present to Dr. Carhart.’ The District Court made no findings, the Supreme Court

added, about the procedure’s ‘‘overall safety;’’ the record contained evidence of no

‘‘controlled studies that would help answer’’ the question of medical necessity.

The high Court stressed repeatedly the ‘‘uncertainty’’ of medical opinion about the

safety of D&X, an ‘‘uncertainty’’ which itself became the reason for the Court’s judgment: ‘‘the uncertainty means a significant likelihood that those who believe that

D&X is a safer abortion method in certain circumstances may turn out to be right.’’

This, I submit, is the Carhart Court’s independent judgment about medical necessity: we simply do not know if there is a medical necessity, said the Justices. Not

knowing, we choose to err on the side of safety for women, just in case Dr. Carhart

is right.

The Carhart Court did not find facts. The Carhart Court appealed for facts. HR

760 responds to that appeal.

The record upon which the Supreme Court relied in Carhart was compiled in

1997–98. The record consisted of data and experiences older than that. That record

indeed contained ‘‘medical authority’’ (which the Court described as ‘‘significant’’) indicating that D&X might be the safest abortion procedure in some circumstances.

But the Court never said that these authorities were right. The Court said that the

opinion expressed in those authorities—that D&X was sometimes safest—was not

proved wrong by the state of Nebraska.

22

As anyone with courtroom experience will tel you, what is not proved wrong in

a single trial might well be true.

Congress is not limited by any judicial record. Its members may rely upon the latest knowledge about D&X and medical necessity. Given the dearth of knowledge

about D&X in the 1990’s and the always improving levels of neo-natal and maternal

medical care, what was—or may have been—not proved in 1997 might now be proven, now even clearly true.

The Findings in HR 760 assert an emergent consensus of medical and moral opinion, supported by the ‘‘great weight’’ of the evidence available: ‘‘partial-birth abortion is never necessary to preserve the health of a woman.’’ Affirming this proposition does not, in my judgment, give insult to the Supreme Court, or to its decision

in Carhart.

Mr. CHABOT. At this time, the Members of the panel will have

an opportunity to ask questions of the witnesses here this afternoon. I will begin with myself, and I recognize myself for 5 minutes.

I am going to start with Dr. Neerhof. Doctor, is it possible for a

physician to begin a D&E abortion or another abortion procedure

and find themselves performing an abortion that would be prohibited under this bill?

Dr. NEERHOF. Whenever you ask the question, is it possible, you

are using the ever’s and never’s and so forth. I think that the likelihood of that occurring would be extremely remote because the nature of a D&X is different than the nature of a D&E. The destructive nature of a D&E takes place in utero. A D&X, it is an intact

extraction. There is no attempt to be destructive in utero.

Because of the different nature of those procedures, that would

be extraordinarily unlikely.

Mr. CHABOT. Thank you. Let me follow up in another question.

In your opinion, when would a physician cross the line under H.R.

760’s definition of the prohibited procedures?

Dr. NEERHOF. A physician would cross the line by intentionally

trying to deliver a fetus intact, with the intention of delivering all

but the tip of that head before terminating that pregnancy.

Mr. CHABOT. Let me follow up again. Another question.

Many have made the claims that a partial birth abortion or a

D&X abortion is just as safe as, if not safer, than a D&E abortion,

or induction.

Yet, as you state, there still exists no educational materials or

other clinical studies of the relative safety or medical efficacy of

this procedure 10 years after Dr. Haskell’s 1992 presentation.

Can you briefly describe for us what is the appropriate procedure

for evaluating the safety and effectiveness of an obstetrical or gynecological medical procedure, or to ask it another way, what type of

information would you and do you look for when evaluating whether to incorporate a newly developed technique or procedure into

your medical practice?

Dr. NEERHOF. The appropriate way of evaluating that would be

to take a group of patients who are candidates for a given procedures, or two given procedures, and to prospectively randomize in

a blinded fashion, to either one of those two procedures, to have

end possibilities in mind from the start that you are looking for,

end points, for example, such as hemorrhage, blood loss, infection

rate, uterine perforations, et cetera. From the beginning of that

study, randomizing patients to either one of the two procedures,

23

and at the conclusion of that study, determining which of those two

procedures is a safer procedure to do.

Mr. CHABOT. Thank you.

Professor Bradley, let me ask you a question. Do you believe that

there is a minimal amount of evidence that must be in front of

Congress before the Court will accord its legislative facts deference? Clearly, Congress can’t find that the sky is red when the

sky is obviously blue. So there must be some sort of reasonable

basis upon which Congress can reach its conclusions.

It can’t, as Mr. Heller had said, as he asserted in his written

statement, we can’t just find certain facts if there does not exist

any evidence to support those facts. Is that correct?

Mr. BRADLEY. That is quite right. The Congress is bound to draw

plausible inferences from substantial evidence. There is no question

of in any sense Congress preempting or precluding the Court from

finally and ultimately judging the constitutionally of this bill. We

are not talking about Congress being in a position because of deference to fact finding, or displacing Supreme Court judgment.

The Court will, I suppose eventually, pass its own independent

judgment upon this bill. The question is what standard of deference

will the Court use when it does so? And will Congress be able to

show the Court that it relied upon a substantial record.

Mr. CHABOT. Finally, let me ask you, Doctor, Brenda PrattShaffer, who was a registered nurse, who had observed Dr. Haskell, the person who came up with this partial birth abortion procedure, she observed this going on at least in three different procedures.

And she testified describing a partial birth abortion that she witnessed on a baby that was 26-1/2 old as follows: ‘‘Dr. Haskell went

in with forceps and grabbed the baby’s leg, and pulled them down

into the birth canal. Then he delivered the baby’s body and the

arms, everything but the head.

The doctor kept the head right inside the uterus. The baby’s little

fingers were clasping and unclasping, and his little feet were kicking. Then the doctor stuck the scissors in the back of his head, and

the baby’s arms jerked out, like a startled reaction, like a flinch,

like a baby does when he thinks he is going to fall.

The doctor opened the scissors, stuck a high-powered section tube

into the opening and sucked the baby’s brains out. Now the baby

went completely limp.

He cut the umbilical cord and delivered the placenta. He threw

the baby in a pan, along with the placenta and the instruments he

had used. I saw the baby move in the pan. I asked another nurse,

and she said it was just reflexes.

The baby boy had the most perfect angelic face I think that I

have ever seen in my life’’, this nurse who testified that she had

witnessed this particular procedure.

The procedure that I have just described, is that the procedure

that we have termed partial birth abortion or D&X, that is the nature of this legislation that we are talking about today? Is that an

accurate description of what we are talking about here?

Dr. NEERHOF. Yes.

24

Mr. CHABOT. Thank you. I will yield back the balance of my time.

The gentleman from New York, Mr. Nadler, is recognized for 5

minutes.

Mr. NADLER. Thank you. Before starting my questions, I will observe that glancing out the window the sky appears gray, not blue.

Mr. Heller, in Dr. Neerhof’s, I am sorry, in Professor Bradley’s

written testimony, he states the following: That the Nebraska law

that was struck down by Stenberg v. Carhart was shoddily drafted,

because it used the phrase substantial portion of a living unborn

child being outside the mother.

H.R. 760 says, because the D&E procedure—the Court had said,

among other things, that the law was defective because it didn’t

giver proper notice of what was being banned, it could be a D&E

as well as a D&X, because a D&E procedure may commonly involve

pulling from the birth canal a limb or extremity. The Court referred repeatedly to an arm and a leg. The one telling point, a

small portion as a foot, the Nebraska court, some D&E procedures

in its D&X met.

But this bill avoids entirely the asserted defects in the Nebraska

law. This bill’s definition of the prohibited procedure most pointedly delivery of the entire fetal head, unquote, or in the case of

breech delivery, any part of the fetal trunk, overcomes the vagueness and uncertain application of the analogous Nebraska language, substantial portion of the unborn child. No abortion doctor

could confuse what is prohibited by H.R. 760 in a D&E abortion.

In your opinion, does the logic of Professor Bradley here, is it

persuasive? Would it be persuasive to the Supreme Court? Does it

cure that defect in the Nebraska statute as found in Stenberg?

Mr. HELLER. It does not. Let me elaborate on that for a moment.

One of the recurring themes of this debate, which has now been

going on for many years, for almost 7 years, I suppose, is that new

versions of so called partial birth abortion bans are proposed and

modify the language previously used after courts strike that language down.

And the proponents claim, this time we have been precise. In

fact, all the words that are used to describe the intact D&X procedure, whether they are the words that are used in American College of Obstetricians and Gynecologists, or the words used in the

introductory section of this very bill, those words didn’t occur again

in the operative text.

The operative text is much broader. It talks not only about, as

Dr. Neerhof said, a footling presentation, where the feet present

first, but the opposite presentation.

Mr. NADLER. So in other words, the language that Professor

Bradley is referring to in H.R. 760 is in the findings, but not in the

operative language of the bill?

Mr. HELLER. There, in the first paragraph, I guess it is actually

page 17 of the bill, there is a description of what the bill does that

differs from what the actual, what the bill itself does.

Mr. NADLER. So this entire reasoning is not correct, because it

doesn’t refer to the proper language in the bill?

Mr. HELLER. It is not correct. Dr. Neerhof asked for an article

to be put in the record that he published in the Journal of the

American Medical Association. The very first page, I believe of that

25

article, he states, now this new 1998 version that has been proposed in Congress of a partial birth abortion bill will meet all of

the objections because it is so much more precise. That is the language that the Supreme Court struck down in Stenberg. Mr. NADLER. So that language was struck down in Stenberg. And

the language that Professor Bradley cites is not the operative language of the bill?

Mr. HELLER. I believe it is not.

Mr. NADLER. Thank you. We got the gist of your answer. Dr.

Neerhof. Could can you tell me whether you are aware of any medical textbook in current use in medical schools today that uses the

term ‘‘partial birth abortion’’?

Dr. NEERHOF. In medical schools? No.

Mr. NADLER. Secondly, Dr. Neerhof, you stated that you oppose

intact D&X. But, of course, this bill doesn’t talk about intact D&X.

I have to conclude that you don’t support the legislation as drafted,

because it doesn’t talk about intact D&X. It brings us back to the

question of why not say in the bill what you said?

You also refer to late term abortions on viable fetuses. This bill

doesn’t make, of course, any references to gestational age.

Dr. NEERHOF. It does, indirectly.

Mr. NADLER. Why not do it directly?

Dr. NEERHOF. There is a gestational age category at which this

procedure is done. So indirectly it does.

Mr. NADLER. Okay. Dr. Heller, would you comment on this?

Mr. HELLER. The question is, what procedure are we talking

about? Are we talking about the one that Dr. Neerhof described, or

that he answered from the Chairman, or are we talking about some

other procedure?

Mr. NADLER. He says it indirectly refers to it.

Mr. HELLER. It doesn’t refer to it at all. If a statute is to refer

to post viability, it can use those words. In fact, 41 States do it.

And there is no reason Congress couldn’t.

Mr. CHABOT. The gentleman’s time has expired. Mr. King is recognized for 5 minutes.

Mr. KING. Thank you, Mr. Chairman.

I will direct my initial question to Mr. Bradley. And, Mr. Bradley, Dr. Neerhof testified that at this juncture, the fetus is merely

inches from being delivered and obtaining the full legal rights of

personhood under the Constitution.

Can you give us a definition of, at that moment, when these full

legal rights of personhood are achieved? How is that defined in

law? Can you tell us?

Mr. BRADLEY. Well, by the best definition of when a person—a

child acquires that kind of legal personality, is probably the definition that you would find in the Born Alive Infants Protection Act,

passed in the last couple of years, I know I testified in the last couple of years in favor of that bill, where you find a quite precise and

involved definition of that moment at which the—the child is

emerged from the woman and has acquired, you might say, autonomy, or independence sufficient to be recognized as a person in his

or her own rights.

So I think that bill probably has the best definition you will find.

Mr. KING. Is there constitutional protection as well, statutory?

26

Mr. BRADLEY. Well, at that point sure, because the Constitution

protects all persons born in the United States. They are entitled at

that point to the equal protection of the laws, including the laws

against homicide, assault, et cetera.

Mr. KING. And the statement was made earlier at the opening

of these proceedings that 41 States already ban post viability abortions. Can you advise this Committee as to whether, in fact, there

are any bans on abortion in place anywhere in America today; if

so, under what circumstances?

Mr. BRADLEY. Well, I don’t think any State bans all abortions,

even post viability. Even post viability, the Supreme Court cases

made clear you have to have a life of the mother and health of the

mother exception.

Mr. NADLER. Is that in this bill, this exception?

Mr. BRADLEY. Certainly no health exception.

Mr. KING. However, are there any circumstances in fact where

if a doctor determined that it affected the health of the mother,

that at any stage of gestation, an abortion would be illegal or

banned?

Mr. BRADLEY. If I understand the question, is there a case where

a woman’s health is in danger where a doctor is not under our law

permitted to perform an abortion? I think the answer is no. And,

of course, this outlaws a particular type of abortion, but it doesn’t

try to outlaw all abortions at a particular stage of pregnancy or

when the mother’s health is threatened in a particular way.

Mr. KING. And if, in fact, there were an amendment to go on this

bill that would allow an exception of the health of the mother,

would there be any circumstances at that point where this ban on

partial-birth abortion would be in effect, or could the physician at

that point determine then that any and all effect on the health of

the mother was a justifiable reason to proceed?

Mr. BRADLEY. I myself have no medical competence obviously,

but I understand the logic of the draftsmanship here, and that is

the fear, which I think to be reasonable and well grounded, that

if there is a health exception engrafted or put into this bill, then

the prohibition itself would be become toothless and ineffective in

light of the fact, if it is the fact, that there are no cases of genuine

health necessity or medical necessity. It would seem to me that a

health exception would be mischievous.

Mr. KING. And to me. Under what circumstances—I will say

would the courts be bound by congressional findings, and what is

your anticipation of that should this go before the Supreme Court?

Mr. BRADLEY. I don’t think the Court is ever bound, strictly

speaking, to a congressional fact-finding. It is a matter of greater

or lesser deference. I mentioned this in passing in response to an

earlier question. It is not possible for Congress to preclude the

Court from looking into the fact of the matter, but given what the

Court has said in prior occasions and stressed, frankly, on prior occasions, that Congress is a superior fact-finder and as a general

matter the Court defers to congressional findings, so what that

cashes out as in simple terms, to say that the Court defers to congressional fact-finding is to say that the Court presumes that when

Congress say something is so, then it is so. That is the Court’s presumption.

27

Mr. KING. Thank you, Mr. Bradley.

And, Dr. Neerhof, can you describe what happens when a baby

is accidentally born? What would you anticipate takes place if an

abortion procedure is attempted and the baby is accidentally born?

Dr. NEERHOF. I don’t know, and I kind of shudder to think of it.

And you know the truth of the matter is when I said in my testimony when the head is out of the cervix, there is nothing really

holding that head in outside of an obstetrician. So, in effect, I

would say that actually happens commonly with the intact D&X.

Mr. CHABOT. The gentleman’s time has expired.

Mr. KING. Could I ask for an extra 30 seconds?

Mr. CHABOT. I ask unanimous consent that the gentleman be

granted an additional 30 seconds.

Mr. KING. At that point could that baby scream for its own

mercy?

Dr. NEERHOF. I am sure it could.

Mr. CHABOT. The gentleman’s time has expired.

The gentleman from Virginia Mr. Scott is recognized for 5 minutes.

Mr. SCOTT. Are you familiar with the American College of Obstetricians and Gynecologists?

Dr. NEERHOF. Yes.

Mr. SCOTT. Is that a respected organization in the medical community?

Dr. NEERHOF. Yes.

Mr. SCOTT. Mr. Heller, does the Colorado Stenberg case require

a health exception for any abortion ban?

Mr. HELLER. Yes, it does.

Mr. SCOTT. Does this bill include one?

Mr. HELLER. No, it does not.

Mr. SCOTT. Did the Stenberg case outline what a health exception looked like?

Mr. HELLER. It didn’t have to outline it because it said it must

be an exception for the woman’s health and didn’t specify further

than that.

Mr. SCOTT. Did it say, ‘‘Necessary and appropriate medical judgment for the preservation of the life of the mother,’’ five times both

in italics and in quotation marks?

Mr. HELLER. I believe so, and that also reiterates holdings of the

Supreme Court that go back as far as 1973.

Mr. SCOTT. Did you find those words in the bill?

Mr. HELLER. No. They are not in the bill.

Mr. SCOTT. Professor, did you want to say anything?

Mr. BRADLEY. No.

Mr. SCOTT. I yield back.

Mr. CHABOT. Gentleman’s time has expired.

The gentleman from Indiana Mr. Hostettler is recognized for 5

minutes.

Mr. HOSTETTLER. Mr. Chairman, I wasn’t here for any of your

opening statements or that of the panel of the Subcommittee, but

I will say for the record that there is ample evidence and history

that Congress has repeatedly thumbed its nose at the United

States Supreme Court. Dr. Louis Fisher of the Congressional Research Service has done an excellent paper on judicial checks on

28

the judiciary and also notes points in there where the executive

branch likewise has disregarded the findings of the Supreme Court

with regards to Beck v. Communication Workers of America and

the previous Administration’s executive order to lift the ban of

union employees in the Federal Government from having to give

union dues for political purposes. So for the record, this is not unusual what we are doing here today.

I will ask Dr. Neerhof, are you familiar with the reference book

Williams Obstetrics?

Dr. NEERHOF. Yes, I am.

Mr. HOSTETTLER. I am quoting from the 20th edition, so I apologize if that is outdated. I don’t know if that is the latest edition

or not, but in the 20th edition, which I believe is the latest, it says,

and I quote, under definition, it says, ‘‘Abortion is the termination

of pregnancy by any means before the fetus is sufficiently developed to survive. In the United States, this definition is confined to

the termination of pregnancy before 20 weeks based upon the day

of the first day of the last normal menses.’’ . Now, if abortion is strictly limited in medical terms to that process by any means of terminating pregnancy before 20 weeks, what

is the term for termination of pregnancy after 20 weeks?

Dr. NEERHOF. It is termination of pregnancy. You are talking

about terminology as per a textbook as opposed to how it is used

clinically. That prior-to-20-week cut-off just refers to how obstetricians talk about a given patient’s obstetrical history; i.e., whether

they delivered before 20 or after 20 weeks in any given prior pregnancy. Termination of pregnancy certainly frequently occurs before

20 weeks, but in essence, a very similar thing happens subsequent

to 20 weeks. It is still termination of pregnancy.

Mr. HOSTETTLER. What if it is other means, by a spontaneous

abortion?

Dr. NEERHOF. How is it termed?

Mr. HOSTETTLER. Yes.

Dr. NEERHOF. It is a good question. I guess preterm delivery.

Mr. HOSTETTLER. So a live birth and abortion—and a termination of pregnancy are both preterm births?

Dr. NEERHOF. They would be described as so because from an obstetrician’s viewpoint, it is of clinical significance how far in the

pregnancy that patient got. So, yes, it would be described as a

preterm delivery, but not as a surviving preterm delivery.

Mr. HOSTETTLER. Not a surviving preterm delivery.

Dr. NEERHOF. Correct.

Mr. HOSTETTLER. I thank the gentleman very much.

Yield back the balance of my time.

Mr. CHABOT. Thank the gentleman for yielding back, and

gentlelady from Pennsylvania is recognized for 5 minutes.

Ms. HART. I want to thank you for bringing this bill up shortly

in good order since the Senate has already considered it. Professor

Bradley, we have had quite a bit discussion about the findings and

how the difference between the bill last session and this session is

basically the findings of fact.

Mr. BRADLEY. As well as a description of the prohibited act. I

think it is less vague than it has been.

Ms. HART. Right. Thank you for that.

29

I am interested in the reviewability or appropriateness of the review by the Court of the findings. In Carhart, they didn’t spend

much time on doing their own independent research from what we

can tell. What we understand is that our review of what they did

in our attempts to make sure that when we dealt with the issue

this time, it would be more clear, an expansion of the findings and,

as you said, the change in the description of the procedure. I am

interested in what you see is the appropriateness of Congress reviewing our own work in that way as to whether that should make

a difference when the Court has a chance to review it again.

Mr. BRADLEY. I am not sure if I understand the question, but I

think I do. The question is the duty of Congress or the responsibility of Congress to take its own best shot at the truth of the matter?

Ms. HART. Right. It is our—legislators do this all the time. They

look at what the Court does in regard to a law, and they go back

and redraft it. And perhaps the Court will review it again; perhaps

they won’t. I mean, do you see anything wrong with that is what

I am asking?

Mr. BRADLEY. I don’t think there is anything wrong with it. As

I read Stenberg v. Carhart, it is too strong to say that the Court

is asking for help from Congress, but certainly that account is consistent with what the Carhart Court says. It is uncertain.

The Supreme Court does not in Carhart take a critical and independent attitude toward the evidence. It looks at the record and

sees that there is evidence, substantial authority saying that there

could be a danger to a woman’s health, but the Court does not critically evaluate that, as Congress can and perhaps should; I mean,

any number of situations in which one could identify credible authority holding a position which turns out to be false. And I think

what Congress is thinking of doing in this situation is taking a look

at the matter afresh, recognizing as the Carhart Court did that

says there are authorities that say it is a medical necessity, but I

take Congress in H.R. 760 is saying they are mistaken, their studies are not reliable, and that the truth is there aren’t any cases of

medical necessity. Not only do I think there is nothing is wrong

with that, I think it is probably Congress’s duty.

Ms. HART. From what we know in past cases that Congress has

gone back and changed things that were further upheld, it has

often been because of a change in societal attitude, for example, a

change in this case. And a lot of this case is the change in the perception and the science around the medical necessity. And I think

actually—tell me if you think I am wrong, but we actually have a

stronger case than some other cases that the Court held one way

and the Congress decided to do something different.

Mr. BRADLEY. I think that is true. The Supreme Court in

Carhart is looking at a record that is limited and therefore incomplete. It expresses uncertainty on its own part as to what the truth

of the matter is. But it does say there have been no studies of the

overall safety of the D&X procedure. There is a great deal of textural evidence and opinion that the Court simply doesn’t know, and

I think that is unusual compared to other situations in which Congress has revisited a matter after a contrary Court holding. This

is a case where the Court is really saying, we are not speaking in

30

our own voice to the truth of the matter. We don’t know what the

truth of the matter is, and that, I think, invites at least congressional legislation on the subject.

Ms. HART. Thank you. I think the vagueness of the concern for

the, ‘‘health of the mother’’ is so kind of ridiculous, because any

pregnancy actually can place a mother’s health in danger.

So I yield back. Thank you, Mr. Chairman.

Mr. CHABOT. Thank you.

The gentleman from Florida, Mr. Feeney, is recognized for 5 minutes.

Mr. FEENEY. Thank you, Mr. Chairman.

Professor Bradley, if I could elicit some brief responses from you,

because I would like to get on to Mr. Heller, and I want to take

you back to con. law 101, since you have some background there.

Is it a fair reading of President Johnson’s position when he vetoed

the second Federal banning bill on the grounds that he felt it was

unconstitutional that he didn’t particularly care what the U.S. Supreme Court had found in the first banning case?

Mr. BRADLEY. President Jackson, I take it?

Mr. FEENEY. Yes.

Mr. BRADLEY. I think it is fair to say.

Mr. FEENEY. When he debated Douglas, Lincoln made it clear

that while he had the respect, in his opinion, of the Constitution,

the decision the U.S. Supreme Court as it applied to Dred Scott,

that it certainly didn’t affect his thinking as to the certain liberties

and rights of other African Americans in the country.

Mr. BRADLEY. I think that is correct. Lincoln’s view that he had

to respect Dred Scott—the decision—which meant he couldn’t interfere with the execution of the judgment in that case, but Lincoln

did not feel bound by the Supreme Court’s interpretation of the

Constitution and felt himself free to act with regard to other people, other situations, while not interfering with the execution of the

judgment in the case itself.

Mr. FEENEY. Thank you. In light of that, Mr. Heller, I mean, if

it has been the position of several Presidents of the United States

that they have at least—and I don’t want to get into a debate of

Marbury or judicial supremacy here, although that would be fascinating, but in light of the responsibility that executives have

found with respect to the importance of interpreting the United

States Constitution and what it means at an equal level, perhaps

as the U.S. Supreme Court, and in light of Katzenbach, it seems

rather strange to me that the major premise of your argument, and

you were intimately involved in the case, is that based on a very

limited and specific set of facts, based on a very specific piece of

legislation that was drafted—by the way, the only unicameral legislation in the country—and based on very specific findings by one

appointed and not elected appellate court, and based on the limitations on the U.S. Supreme Court in the case that you participated

in, that they are bound by the specific facts which may never be

duplicated, the specific piece of legislation which isn’t the same as

any other in the 49 continental States, as far as I know, and the

specific findings of one judge; that because they are bound by the

only factual findings in front of them, that it is your position that

for all times, all purposes, and all factual cases and all pieces of

31

legislation, that the U.S. Supreme Court’s findings in that one limited case would override the fact that the United States Congress

now has had the benefit of—I don’t want to say benefit, actually

to our detriment. We have lived through the experience of hundreds of partial-birth abortion cases. We have been advised by the

American Medical Association on the question of medical necessity.

We have been advised by the American College of Obstetrics and

Gynecology and all sorts of fact-finding that the elected representatives of the entire populace of the United States are limited, and

that our findings of fact should be—it seems to me, based on your

testimony, that we are thumbing our nose, having done all this research, and that those specific facts of one case and specific pieces

of legislation, and one judge ought to override the empirical evidence that we have delved into? Is that fair to describe your position?

Mr. HELLER. Not exactly. First of all, it wasn’t one Federal judge

in Nebraska hearing facts and conclusions about one law. There

was a Federal judge in Virginia that reached the same conclusion.

There was a Federal judge in West Virginia that reached the same

conclusion. There was a Federal judge in Iowa that reached the

same conclusion. There was a Federal judge in Illinois that reached

the same conclusion. There was a Federal judge in Arizona that

reached the same conclusion. There was a Federal judge in Louisiana that reached the same conclusion. There was a Federal

judge in Rhode Island that reached the same conclusion. There was

a Federal judge in New Jersey that reached the same conclusion.

There was a Federal judge in Ohio that reached the same conclusion. There was a Federal judge in Kentucky that reached the

same conclusion. There was a Federal judge in Arkansas that

reached the same conclusion. There were Federal appeals court

judges in the third circuit, Fourth Circuit, Fifth Circuit, Sixth Circuit, Seventh Circuit, in the Eighth Circuit, the Eleventh Circuit

and the First Circuit that all reached the same conclusion based

on evidence from numerous witnesses on both sides of the issue

subject to cross examination that far exceeds the evidence that

Congress has heard.

And let me add these States were represented by zealous advocates. They got the best witnesses they could find. The one judge

who reached the opposite conclusion, reached the conclusion that is

harmonious with findings in this bill, had his findings vacated by

the Supreme Court of the United States. Given that, I think it is

unfair to describe the Nebraska judge as the one judge viewing the

unicameral law, et cetera, et cetera. This was judges across the

United States at the trial court level, at the appeals court level.

State judges as well in Alaska who were called upon to review

Alaska’s law struck it down as well because it lacked the health exception, and it was too broad. This is consensus around the legal

community with the exception of one judge who was ultimately

overturned by the Supreme Court.

There is far, far broader evidence that a health exception is required and that this type of statute, this one which doesn’t match

the language used to describe the very specific procedure, is too

broad, is not written with precision. So in that sense, I disagree

with your characterization.

32

Mr. CHABOT. By unanimous consent, the gentleman from Florida

is recognized for an additional 30 seconds in order to respond.

Mr. FEENEY. Thank you, and I do appreciate your position that

there are apparently a dozen cases or so where specific facts and

specific pieces of interpretation have been interpreted by judges,

but is it then your opinion—and perhaps maybe Professor Bradley

could respond and give his—that the best place to do findings of

facts about the empirical facts that affects some 280 million Americans is anecdotally and case by case a situation of what is and is

not a life and what is or what isn’t medically necessary, or is it appropriate for the United States Congress, the elected representatives of the people, of an issue of this high import to make the ultimate decisions? Because I think, Professor Bradley, because what

the U.S. Supreme Court has done is to say that in the absence of

the finding by the people who are empirical judges on a generalist

proposition, we have no choice but to take specific cases.

Mr. HELLER. Actually that is not—what the Supreme Court said,

in the absence of a medical consensus, not a consensus by politicians or legislators. In the absence of a medical consensus about

specific procedures being safe or unsafe, this decision about how an

abortion must be performed must be left to the woman and her

physician. This bill intrudes into that relationship in a manner I

think unprecedented in American history by telling a physician

how to do surgery, by putting the woman in a position of having

to sacrifice her health for the agenda of a political movement.

All that being said, I think that ultimately the Supreme Court

did not say we are going to listen to what Congress says and then

just do that. That is contrary to the nature of judicial review,

which you said we could debate. But if judicial review is part of our

democracy, and it is accepted as such——

Mr. CHABOT. The gentleman’s question was also directed at Professor Bradley.

Mr. BRADLEY. I don’t disagree about judicial review, although we

might disagree about its precise contours and how it works. It is

consistent with the warm devotion to judicial review to think that

Congress is a superior fact-finder. And it would seem to me the Supreme Court is second to none at being a fan to judicial review, but

yet the Supreme Court persistently recurringly says for a variety

of reasons that Congress is in general the superior fact-finder.

Now, Mr. Feeney’s question, going back to the original question,

it is true that despite the fact that other courts have opined upon

the matter, which was at the heart of Stenberg v. Carhart, the

thrust of his question, I think, is sound, and that is the Supreme

Court, which is the decision we are talking about, was basically

hemmed in in its position; not determined, but strongly influenced

by the decision of one Federal district court judge. That is the individual who helped compile the record and made the initial determination as to what the record amounted to. And the Supreme

Court, as an appellate court, is bound by rules of intrasystemic deference, judicial deference to the fact-finding below.

So I do think that when you turn to Congress, you are free of

these types of systemic constraints, and with the passage of 5, 6

years or 7 years, or whatever it has been since that record was put

together, it seems to me that Carhart is not a stop sign or red light

33

to Congress. And I would just challenge Mr. Heller to show where

the Carhart Court says the matter is settled.

Here is the fact of the matter, and I don’t remember the Carhart

Court saying or using the phrase ‘‘in the absence of a medical consensus that there is no case of medical necessity.’’ I don’t think the

Court referred to the presence or absence of a medical consensus

at all. The Court did say there is substantial authority in favor of

the view that there could be a health necessity. The Court did not

say those authorities were correct, and the Court itself did not say

that it is true that there are cases of medical necessity.

Mr. CHABOT. The gentleman’s time has expired.

The gentleman from Virginia Mr. Forbes is recognized for 5 minutes.

Mr. FORBES. Thank you, Mr. Chairman, and I want to thank the

gentlemen for being here, many of you again with us. I respect the

fact that reasonable people can disagree over this issue, and we

certainly have opposing views.

One of the concerns I have always had has been with the pain

in this procedure to the unborn fetus or the unborn child. One of

the things I can’t respect is, Dr. Neerhof, when you are testifying,

I look out in the audience and see five or six people smiling when

you are talking about that pain. And even though you can disagree

on issues, that I can’t respect. That I find absolutely appalling.

I want to ask you a few questions relative to the pain, and I

want to tell you as I ask those, if you need to expound on them

more, please feel free to put whatever you need to in the record.

But I have only a few minutes to ask you the questions, so I ask

that you keep them as brief as you can.

Mr. Heller, you were with us several months ago, and we appreciated you coming back. At that time you were not a licensed physician, and I take it nothing has changed in between that time?

Mr. HELLER. Not that fast, no.

Mr. FORBES. You don’t have any privileges to practice medicine

in any hospital?

Mr. HELLER. No.

Mr. FORBES. And you never had the right to prescribe pain killers or pain management to any patient, nor have you done that,

I take it?

Mr. HELLER. No, I haven’t.

Mr. FORBES. Switching to your constitutional expertise, because

recognized from the medical point of view you are not trained in

that area, is there any threshold of pain to an unborn child that,

if established, would be so great or so horrible that it would outweigh the convenience of a partial-birth abortion no matter how

trivial or small that convenience might be found to be?

Mr. HELLER. I am not sure what you mean by convenience, but

I will say this. First of all, the Supreme Court has, as far as I am

aware, never directly addressed the issue of fetal pain. That being

said, I think prior to viability, there is no State interest, whether

it be in pain or anything else, that can override the woman’s interest in her own life and health and that persists even postviability

under the Supreme Court.

Mr. FORBES. So your answer, and again just trying to be clear,

is there would be no threshold pain.

34

Mr. HELLER. No. What I said was that the woman’s life and

health predominate over any countervailing State interest. Convenience, which is the word used—I don’t even know what that means.

Mr. FORBES. The health question that you talk about, you would

suggest to us today that no matter how great the pain to the unborn fetus was determined to be ultimately by a fact-finder, there

would be no threshold of pain so great as to override the health

concern that you would have for the mother. That would be your

understanding.

Mr. HELLER. Not the health concern that I would have for the

mother, but the health concern that the United States Supreme

Court has for the mother—that our Constitution has for the mother.

Mr. FORBES. Let me ask you personally, is there any threshold

of pain to an unborn child that if it was established that would be

so great or so horrible that you think would justify—and your word

earlier was doing the honorable thing—that the honorable thing for

this Committee would be to try to ban partial-birth abortion?

Mr. HELLER. I think if this Committee wants to ban previability

abortions for any reason without exceptions for a woman’s health,

it should do so by constitutional amendment.

Mr. FORBES. Could we legally require that a neurosurgeon or a

neurologist be present at a partial-birth abortion?

Mr. HELLER. I am not aware of any precedent that would support

that. I do know that the Supreme Court has said that the—it is

sufficient for the abortion procedure that the doctor performing the

abortion is present, and additional physicians are not—cannot be

required prior to viability. But the precise issue of a neurosurgeon

has never been tested, nor do we know.

Mr. FORBES. Dr. Neerhof, I am out of time almost, but you wrote

in 1998, I believe, that there is no pain management currently

given for the unborn fetus. Has anything changed in that, or is

there currently?

Dr. NEERHOF. Not to my knowledge.

Mr. FORBES. You indicated that the pain standards for the

human fetus in a partial-birth abortion would be less than those

we require for humane care of animals used in medical research.

Is that still accurate?

Dr. NEERHOF. That is correct.

Mr. FORBES. The other thing I would ask you, if it is not true

that the pain suffered by an unborn fetus is actually greater than

pain suffered for a similar procedure for a child that has been more

fully developed than perhaps born?

Dr. NEERHOF. I am sorry. I didn’t understand what you asked.

Mr. FORBES. I am out of time, and I will try to submit that in

writing.

Mr. CHABOT. I will give the gentleman an additional 30 seconds.

Mr. FORBES. Some studies have indicated that actually the pain

felt by an unborn fetus in a partial-birth abortion, because of the

development stages of their brain, could actually be greater than

a similar pain felt by a more fully developed brain in an older child

or adult for the same procedure. Do you have any information to

substantiate that?

Dr. NEERHOF. I do not.

35

Mr. CHABOT. The gentleman’s time has expired.

If there are no further questions, I want to thank the panel for

their testimony here this afternoon, and it has been helpful to this

Committee, and at this point you are free to go.

Mr. NADLER. Mr. Chairman, may I be recognized for a unanimous consent request? Mr. Chairman, because the Minority is restricted to only one witness per hearing, we are unable to provide

both legal and medical testimony. Our witness was a legal expert.

I want to ensure that Congress does not consider this legislation

without access to the medical facts, so I ask unanimous consent

that the testimony that I have here from the Planned Parenthood

Federation of America, from Felicia Stewart, M.D., from the American Medical Women’s Association, from the Physicians Reproductive Choice and Health, from Anne Davis, M.D., from the American

College of Obstetricians and Gynecologists, and from the University

of California at San Francisco Center for Reproductive Health, Research and Policy, and from the American Association of University

Women be admitted into the record.

Mr. CHABOT. Without objection.

[The information referred to follows in the Appendix]

Mr. CHABOT. I would also ask unanimous consent that all Members may have 5 legislative days in which to revise and extend

their remarks and include extraneous material. So ordered.

[The information referred to follows:]

Mr. CHABOT. I want to thank the panel for being here this afternoon.

[Whereupon, at 3:35 p.m., the Subcommittee proceeded to other

business.]

(37)

A P P E N D I X

MATERIAL SUBMITTED FOR THE HEARING RECORD

PREPARED STATEMENT OF THE HONORABLE STEVE CHABOT, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF OHIO

We have convened this afternoon to receive testimony on H.R. 760, the ‘‘PartialBirth Abortion Ban Act of 2003.’’

On February 13, on behalf of over 100 original co-sponsors, I introduced H.R. 760,

the ‘‘Partial-Birth Abortion Ban Act of 2003’’ which will ban the dangerous and inhumane procedure during which a physician delivers an unborn child’s body until

only the head remains inside the womb, punctures the back of the child’s skull with

a sharp instrument, and sucks the child’s brains out before completing delivery of

the dead infant. An abortionist who violates this ban would be subject to fines or

a maximum of two years imprisonment, or both. H.R. 760 also establishes a civil

cause of action for damages against an abortionist who violates the ban and includes

an exception for those situations in which a partial-birth abortion is necessary to

save the life of the mother. On March 13, 2003, the Senate approved S. 3, which

is virtually identical to H.R. 760, by a 64 to 33 vote.

A moral, medical, and ethical consensus exists that partial-birth abortion is an

inhumane procedure that is never medically necessary and should be prohibited.

Contrary to the claims of those who proclaim the medical necessity of this barbaric

procedure, partial-birth abortion is, in fact, a dangerous medical procedure that can

pose serious risks to the long-term health of women. As testimony received by the

Subcommittee on during the 107th Congress demonstrates, there is never any situation in which the procedure H.R. 760 would ban is medically necessary. In fact, ten

years after Dr. Martin Haskell presented this procedure to the mainstream abortion

community, partial-birth abortions have failed to become the standard of medical

practice for any circumstance under which a woman might seek an abortion.

As a result, the United States Congress voted to ban partial-birth abortions during the 104th, 105th, and 106th Congresses and at least 27 states enacted bans on

the procedure. Unfortunately, the two federal bans that reached President Clinton’s

desk were promptly vetoed.

To address the concerns raised by the majority opinion of the United States Supreme Court in Stenberg v. Carhart, H.R. 760 differs from these previous proposals

in two areas.

First, the bill contains a new, more precise, definition of the prohibited procedure

to address the Court’s concerns that Nebraska’s definition of the prohibited procedure might be interpreted to encompass a more commonly performed late second trimester abortion procedure. As previous testimony indicates, H.R. 760 clearly distinguishes the procedure it would ban from other abortion procedures.

The second difference addresses the majority’s opinion that the Nebraska ban

placed an ‘‘undue burden’’ on women seeking abortions because it failed to include

an exception for partial-birth abortions deemed necessary to preserve the ‘‘health’’

of the mother. The Stenberg Court based its conclusion on the trial court’s factual

findings regarding the relative health and safety benefits of partial-birth abortions—findings which were highly disputed. The Court was required to accept these

findings because of the highly deferential ‘‘clearly erroneous’’ standard that is applied to lower court factual findings.

Those factual findings, however, are inconsistent with the overwhelming weight

of authority regarding the safety and medical necessity of the partial-birth abortion

procedure—including evidence received during extensive legislative hearings during

the 104th, 105th, and 107th Congresses—which indicates that a partial-birth abortion is never medically necessary to preserve the health of a woman, poses serious

risks to a woman’s health, and lies outside the standard of medical care.

38

Under well-settled Supreme Court jurisprudence, the United States Congress is

not bound to accept the same factual findings that the Supreme Court was bound

to accept in Stenberg under the ‘‘clearly erroneous’’ standard. Rather, the United

States Congress is entitled to reach its own factual findings—findings that the Supreme Court consistently relies upon and accords great deference—and to enact legislation based upon these findings so long as it seeks to pursue a legitimate interest

that is within the scope of the Constitution, and draws reasonable inferences based

upon substantial evidence. Thus, the first section of H.R. 760 contains Congress’s extensive factual findings that, based upon extensive medical evidence compiled

during congressional hearings, a partial-birth abortion is never necessary to preserve the health of a woman.

H.R. 760’s findings are not ‘‘false’’ as its opponents have charged. They are based

upon the very opinions of doctors, medical associations, and a review of the practices

of the medical profession as whole. Thus they are ‘‘legislative facts’’ drawn from reasonable inferences based upon substantial evidence. The fact that the abortion lobby

disagrees with these inferences only demonstrates how out of step they are with

public opinion and the mainstream medical community.

Despite overwhelming support from the public, past efforts to ban partial-birth

abortion were blocked by President Clinton. We now have a President who has

promised to stand with Congress in its efforts to ban this barbaric and dangerous

procedure. It is time for Congress to end the national tragedy of partial-birth abortion and protect the lives of these helpless, defenseless, little babies.

PREPARED STATEMENT OF THE HONORABLE JERROLD NADLER, A REPRESENTATIVE IN

CONGRESS FROM THE STATE OF NEW YORK

Thank you, Mr. Chairman. Today we have a very bad combination: Members of

Congress who want to play doctor, and Members of Congress who want to play Supreme Court. When you put the two together, you have a prescription for some very

bad medicine for women in this country.

We have been through this debate often enough to know that you will not find

the term ‘‘partial birth abortion’’ in any medical text book. There are procedures

that you will find in medical text books, but apparently, the authors of this legislation would prefer to use the language of propaganda rather than of science.

This bill, as written, fails every test the Supreme Court has laid down for what

may or may not be a constitutional regulation on abortion. It reads almost as if the

authors went through the Supreme Court’s recent decision in Stenberg v. Carhart

and went out of their way to thumb their noses at the Supreme Court, and especially at Justice O’Connor who is generally viewed as the swing vote on such matters, and who wrote a concurring opinion stating specifically what would be needed

for her to uphold a statute. Unless the authors think that when the Court has made

repeated and clear statements over the years of what the Constitution requires in

this area they were just pulling our leg, this bill has to be considered facially unconstitutional.

First and foremost, it does health exception which the Court has repeatedly said

is necessary even with respect to post-viability abortions. The exception for a woman’s life is more narrowly drawn than is required by the Constitution, and will place

doctors in the position of trying to guess just how grave a danger a pregnancy must

pose to a woman before they can be confident that protecting her will not result in

jail time.

I know that some of my colleagues do not like the constitutional rule that has

been in place and reaffirmed by the court for thirty years, but that is the law supreme law of the land, and no amount of rhetoric, even if written into a piece of

legislation, will change that. Even the Ashcroft Justice Department, in its brief defending an Ohio statute, has acknowledged that a health exception is required by

law. While I may disagree with the Department’s views on whether the Ohio statute

adequately protects women’s health, there is at least an acknowledgment that the

law requires that protection.

This bill is mostly findings. If there is one thing this activist court has made clear,

it is that it is not very deferential to Congress’ determinations of fact. While Congress is entitled to declare anything it wants, the courts are not duty bound to accept everything we say at face value simply because it appears in a footnote in the

United States Code.

While I realize that many of the proponents of this bill view all abortion as tantamount to infanticide, that is not a mainstream view. This bill attempts to foist a

marginal view on the general public by characterizing this bill as having to do only

with abortions involving healthy, full term fetuses. If the proponents of this bill

39

really want to deal with post-viability abortions, in situations in which a woman’s

life and health are not in jeopardy, then let them write a bill dealing with that

issue, although such a bill would be of marginal utility, since 41 states already ban

post-viability abortions. Very few people would oppose such a bill.

As one of the lead sponsors of the Religious Freedom Restoration Act, I know

what comes of Congress ignoring the will of the Supreme Court. Whatever power

Congress had under section 5 of the 14th Amendment as a result of Katzenbach v.

Morgan, which is copiously cited in the bill’s findings, I think the more recent

Boerne decision vastly undercut those powers. Even if Katzenbach were still fully

in force, as I wish it were, that case only empowered Congress to expand, not curtail

rights under the 14th Amendment. This bill, of course, aims to do the exact opposite.

I doubt the Majority is interested in a bill that could pass into law and actually

be upheld as constitutional. What they want is an inflammatory piece of rhetoric

which, even if passed, would most certainly be struck down by the Supreme Court.

The real purpose of this bill is not, as we have been told, to ‘‘save babies,’’ but to

save elections.

We now have a President who has expressed a willingness to sign this bill. He

may in fact get his chance. Unfortunately, there are dire consequences for American

women if this legislation passes. Perhaps, here in the halls of Congress, the health

of women takes a back seat to the most extreme views of the anti-choice movement.

Fortunately, the Constitution still serves as a bulwark against such efforts.

Thank you, Mr. Chairman.

40

41

42

43

44

DOCUMENTS SUBMITTED BY CHAIRMAN STEVE CHABOT

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

PREPARED STATEMENT OF KATHI A. AULTMAN, MD

Chairman Chabot and distinguished members of the House Judiciary Subcommittee on the Constitution, Thank you for allowing me to testify before you regarding H.R.4965, the ‘‘Partial-Birth Abortion Ban Act of 2002’’.

My name is Kathi A. Aultman, MD. I am a board certified obstetrician gynecologist, a fellow of the American College of Obstetricians and Gynecologists

(ACOG), and a member in good standing with the American Medical Association

(AMA). I have been in private practice in Orange Park, Florida for 21 years. I am

on the Ethics Commission of the Christian Medical and Dental Associations (CMDA)

and a member of Physicians’ Ad Hoc Coalition for Truth (PHACT).

81

I have spent my entire career as a women’s advocate and have a keen interest

in issues that impact women’s health. I was the co-founder and co-director of the

first Rape Treatment Center of Jacksonville, Florida and performed sexual assault

exams as a medical examiner for Duval and Clay Counties. I also served as the

Medical Director for Planned Parenthood of Jacksonville from 1981 to 1983.

After mastering first trimester and early second trimester dilation and curettage

with suction (D&C with suction) procedures I was able to ‘‘moonlight’’ at an abortion

clinic in Gainesville, FL. I sought out special training with a local abortionist in

order to learn mid second trimester dilation and evacuation (D&E) procedures. Although I do not currently perform abortions, I have continued to dialogue with abortion providers regarding current practices and have studied the medical literature

on abortion. I continue to perform D&C with suction and rarely D&E and Inductions in cases of incomplete abortion and fetal demise.

I see and treat women with medical and psychological complications from abortion

and have managed and delivered women with pregnancies complicated by fetal

anomalies, and medical, obstetrical, and psychological problems. I have personally

had an abortion and I have a delightful adopted cousin who survived after her

mother aborted her.

I have first hand knowledge and familiarity with the partial-birth abortion issue,

having testified before legislative bodies in Florida and Vermont. I also testified in

court as an expert witness in Arkansas and Virginia and assisted Florida and several other states in designing and/or defending their bans.

I support HR4965, the ‘‘Partial-Birth Abortion Ban Act of 2002’’, for the following reasons:

1) This bill clearly distinguishes Partial-Birth Abortion from other abortion procedures.

2) This bill will not endanger women’s health.

3) It protects women from being subjected to a dangerous unproven experimental procedure.

4) Partial-Birth Abortion has blurred the line between abortion and infanticide.

5) It bans a procedure that is abhorrent to the vast majority of Americans.

1) HR 4965 CLEARLY DISTINGUISHES PARTIAL-BIRTH ABORTION FROM

OTHER ABORTION PROCEDURES.

Partial-Birth Abortion is a legal term that covers a set of circumstances that culminate in the physician intentionally killing the fetus after it has been partially born.

As defined in the act:

‘‘the term ‘‘partial-birth abortion’’ means an abortion in which (A) the person

performing the abortion deliberately and intentional vaginally delivers a living

fetus until, in the case of a head-first presentation, the entire fetal head is outside the body of the mother, or, in the case of breech presentation, any part of

the fetal trunk past the navel is outside the body of the mother for the purpose

of performing an overt act that the person knows will kill the partially delivered

living fetus: and (B) performs the overt act, other than completion of delivery,

that kills the partially delivered living fetus;’’

(In the rest of the text the term ‘‘partially born’’ will be defined as the position of

the fetus as described in HR 4965.)

Partial-Birth Abortion includes but is not limited to D&X performed on live

fetuses. It would also include a procedure used in China where formaldehyde is injected into the baby’s brain through its fontanel (soft spot), after the head has been

delivered, in order to kill it prior to completing the delivery. It does not prohibit

medical abortions, D&C with suction, or D&E procedures. It would not cover Induction unless the physician intentionally intervened during the delivery portion of the

procedure and killed the fetus after it had been ‘‘partially born. It would not cover

a D&X on a dead fetus nor would it cover the accidental death of baby during the

normal birth process. Under HR 4965 a Partial-Birth Abortion is allowed if it is

‘‘necessary to save the life of a mother whose life is endangered by a physical disorder, illness, or injury.

The ‘‘Partial-Birth Abortion Ban Act of 2002’’ eliminates the concern that D&E is

prohibited under the act by more precisely defining what is meant by a Partial Birth

Abortion. According to the Supreme Court in Stenberg v Carhart, the Nebraska

statute banning Partial-Birth Abortion was unconstitutional because it applied to

dilation and evacuation (D&E) as well as to dilation and extraction (D&X). The

court held that the statute was unconstitutional because it imposed an undue burden on a woman’s ability to choose D&E (the most common 2nd trimester abortion

82

procedure), thereby unduly burdening her right to choose abortion itself. The Court

commented, however, that if the definition were more narrowly defined to clearly

differentiate D&E, a ban might be constitutional.

Despite assertions to the contrary by some abortionists, both the American Medical

Association (AMA) and the American College of Obstetricians and Gynecologists

(ACOG) clearly distinguish between D&X and D&E.

D&X (dilation and extraction or intact dilation and evacuation) is generally performed from about 20–22 weeks gestation and beyond and has been done as late as

40 weeks (full term). It is prohibited by HR 4965 if it is performed on a live fetus.

In D&X the fetus is delivered intact except for the decompressed head. In order to

accomplish this, Laminaria (dried seaweed) or a synthetic substitute, is inserted into

the cervix over the course of several days. The goal is to dilate the cervix just

enough to allow the body, but not the head, to be pulled through the cervix. The

membranes are ruptured and the lower extremities are grasped under ultrasound

guidance. If the fetus is not already breech (feet or bottom first) the baby is converted to that position using forceps. The fetus is then delivered except for its head

by a method called breech extraction. The abortionist then thrusts a scissors into

the base of the skull, suctions out the brains, and then completes the delivery. The

placenta is then extracted using forceps and the cavity is curetted to remove any

additional tissue. Prostaglandins and/or oxytocin may be used to help ‘‘ripen’’ the

cervix and/or help the uterus contract. (There are times when the head may be

pulled through the cervix as the abortionist is extracting the body. In that circumstance, if the abortionist isn’t careful to hold the fetus in the vagina prior to

killing it, he will be faced with the complication of an unwanted live baby.)

D&E (dilation and evacuation) is generally used from about 13–15 weeks up until

20–22 weeks and occasionally 24 weeks gestation (early to mid second trimester) and

is not prohibited under HR‘4965 because the fetus is removed in pieces. In D&E the

cervix is dilated usually using Laminaria over the course of 1–2 days. It is dilated

just enough to allow the forceps to be inserted into the uterine cavity and for body

parts to be removed. The membranes are ruptured and the fluid is generally

suctioned. The forceps are inserted into the uterine cavity with or without

ultrasound guidance. Usually an extremity is grasped first and brought down into

the vagina. The rest of the body cannot pass through the cervix so the abortionist

is able to detach it by continuing to pull on it. After the smaller parts have been

removed, the thorax and head would be crushed and removed from the uterine cavity. The ability to dismember the fetus is based on not over-dilating the cervix.

Prostaglandins and/or oxytocin may be used to help ‘‘ripen’’ the cervix and/or help

the uterus contract. D&E is not prohibited under the act because fetus dies as a

result of being dismembered or crushed while the majority of the body is still within

the uterus and not after it has been ‘‘partially born’’. D&C with Suction (dilation and curettage with suction) is generally used from 6

weeks up until 14–16 weeks gestation (first and early second trimester). It is not prohibited by HR 4965. In this procedure the cervix is generally dilated with metal or

plastic rods at the time of the procedure, but occasionally Laminaria are inserted

the night before for the later gestations. A suction curette is then inserted and the

contents of the uterus are suctioned into a bottle. The cavity is then usually checked

with a sharp curette to make sure all the tissue has been removed. At times forceps

are needed to remove some of the fetal parts in the later gestations. Prostaglandins

and/or oxytocin may be used to help ‘‘ripen’’ the cervix and/or help the uterus contract. It would not be prohibited under this act because the fetus or fetal parts pass

from the uterus through the suction tubing directly into a suction bottle. The fetus

is therefore not intentionally killed while it is ‘‘partially born’’. The fetus is usually

killed as it is pulled through the tip of the suction curette or on impact in the suction bottle.

Medical Induction is generally performed from 16 weeks gestation to term. This

method induces labor and subsequent delivery of an intact fetus and would not be

prohibited by HR 4965. Labor may be induced in several ways. The older methods

are termed Instillation Methods because they involve injecting something into the

uterus. Saline (a salt solution) injected into the amniotic cavity generally kills the

fetus and then causes the woman to go into labor but is associated with significant

risk. Urea may also be instilled and appears safer than saline but there is a higher

incidence of delivering a live baby. It may also need to be augmented with

prostaglandins. In another method a prostaglandin called carboprost (Hemabate) is

injected into the amniotic cavity or given IM to stimulate labor but may not always

kill the fetus. An intra-fetal injection of KCL or Digoxin may be necessary to prevent a live birth. (Gynecologic and Obstetric Surgery, Nichols 1993, 1026–1027)

Newer methods employ the use of prostaglandins. PGE1 (misoprostol) and PGE2 are

generally used vaginally, often in conjunction with oxytocin. These methods genVerDate 11-MAY-2000 23:23 Jun 03, 2003 Jkt 000000 PO 00000 Frm 00086 Fmt 6601 Sfmt 6621 G:\WORK\CONST\032503\85987.000 HJUD3 PsN: HJUD3
83

erally result in the delivery of a live baby so if an abortion is intended an intrafetal injection of KCL or Digoxin is generally utilized. PGE2 and oxytocin may be

used in cases of previous C-section or uterine surgery. HR 4965 would not prohibit

a Medical Induction unless the abortionist purposely halted the birth process in

order to intentionally kill a still living ‘‘partially born’’ fetus.

Some of the concerns expressed about Inductions, as opposed to surgical methods

(D&E and D&X), include 1) the psychological and physical pain of labor, 2) the time

involved, and 3) the fact that they are often done in a hospital and are therefore more

costly. Especially if an abortion is the goal, the pain and even the memory of labor

can be eliminated with medication. All three procedures generally require more than

one day except perhaps in the case of an early D&E. The mean Induction time with

vaginal prostaglandins is 13.4 hours and 90 % are delivered by 24 hours. All of

these methods have been performed in both inpatient and outpatient settings, however, as the gestational age and therefore the risk increases, the inpatient setting

generally becomes safer.

Cephalocentesis is a medical procedure during which a needle is inserted into the

head of a fetus with hydrocephalus (water on the brain) in order to drain the fluid.

It would not be prohibited by HR4965. This procedure can be lifesaving for the fetus

and may prevent brain damage by taking pressure off the brain. The needle is usually inserted through the abdomen but may also be inserted vaginally if the fetus

is in the head first position. This is done while the fetus is still inside the womb.

This would not be prohibited even if the fetus had been delivered breech if were

done to draw off fluid (not brain tissue) in order to shrink the head to allow delivery

of an entrapped hydrocephalic head.

Death during the birth process would not be prosecuted under HR 4965, whether

or not labor was induced, as long as the fetus was not intentionally killed while it

was partially born.

Passage of RH 4965 will not create an undue burden on a woman seeking an

abortion because its narrow definition of Partial-Birth Abortion excludes the commonly used methods of abortion which provide alternatives at every gestational

level.

Some abortionists have begun to use parts of the D&X technique on earlier gestations. The mere fact that it is possible to use this procedure on pre-viable fetuses

should not prevent it from being banned.

2) HR 4965 WOULD NOT ENDANGER WOMAN’S HEALTH .

Obstetricians regularly handle medical complications of pregnancy that may

threaten a woman’s health or life without having to resort to using a Partial-birth

Abortion. When the baby is wanted and the pregnancy must be terminated after or

near viability, Induction and C-section are commonly used in an attempt to save

both the mother and the baby. Destructive procedures are only considered pre-viability or if the pregnancy is unwanted. Standard procedures such as D&C with suction, D&E, and Induction may be used to terminate an unwanted pregnancy. In an

emergency situation, when immediate delivery is necessary D&X would not be used

because of the length of time required to dilate the cervix. In it’s report on Late

Term Pregnancy Termination Techniques, the AMA stated, ‘‘Except in extraordinary

circumstances, maternal health factors which demand termination of the pregnancy

can be accommodated without sacrifice of the fetus, and the near certainty of the

independent viability of the fetus argues for ending the pregnancy by appropriate

delivery.’’ (AMA PolicyFinder HOD, A–99, H–5.982 Late Term Pregnancy Termination Techniques).

Although a Partial-Birth Abortion is never necessary to safeguard the health of the

mother, HR 4965 provides an exception just in case ‘‘it is necessary to save the life

of a mother whose life is endangered by a physical disorder, illness or injury.’’ The

AMA report on Late Term Pregnancy Termination Techniques states that, ‘‘According to the scientific literature, there does not appear to be any identified situation

in which intact D&X is the only appropriate procedure to induce abortion and ethical concerns have been raised about intact D&X.’’ (AMA PolicyFinder HOD, A–99,

H–5.982 Late Term Pregnancy Termination Techniques). Even if there were such

a situation, however, the fetus could be injected with Digoxin or KCL, or the cord

could be cut at the start of the procedure, in order to kill the fetus so that the procedure could be performed without risking prosecution.

In my opinion the health exception required under current case law is so broad

that it basically allows elective abortion through term.

84

3) IT PROTECTS WOMEN FROM BEING SUBJECTED TO A DANGEROUS UNPROVEN

EXPERIMENTAL PROCEDURE.

D&X is an experimental procedure that has not been adequately evaluated. There

have been no peer reviewed controlled studies that have looked at the benefits and

risks of D&X as compared to D&E, Induction, Delivery, or C-Section. We do not

have adequate data on its mortality or morbidity. The complications of D&X include

hemorrhage, infection, DIC, embolus, retained tissue, injury to the pelvic organs including the bowel and bladder, as well as an increased risk of cervical incompetence.

These risks are the similar to those associated with D&E, however, these risks increase with increasing gestational age and D&X may be done at much later gestational ages. There was some suggestion in earlier studies that greater artificial cervical dilation increases the risk cervical incompetence. With D&X the cervix must

be dilated significantly more than with D&E.

One of the problems in determining both the frequency and mortality and morbidity of the various abortion procedures is that the reporting of the numbers and

types of abortion procedures at various gestational ages is grossly inadequate. Four

states including California don’t report their statistics to the CDC and many don’t

record the necessary details. D&X is not reported separately nor is it clear which

category it should be reported under. There is also inadequate reporting of the complications of abortion.

At times I am called to see women in the ER with complications of abortions. I

had always assumed that when I wrote the diagnosis on the hospital face sheet that

those cases would be reported to the state. I was shocked when I found out that

they aren’t reported to anyone and that there is no requirement to report them. In

light of that, how can we determine what the true complication rate is for any of

these procedures since many never return to their abortion provider.

D&X is often done in outpatient settings. The abortionist may not have hospital

privileges or know how to handle the complications of the procedure especially if he

is not an OB/GYN.

Although, previous C-section has been cited as a reason why D&X might be preferred over Induction, Dr.Haskell, the originator of the procedure, excluded those

cases. It is now accepted practice to use prostaglandin E2 and /or oxytocin for Induction after previous C-section.

4) PARTIAL-BIRTH ABORTION HAS BLURRED THE LINE BETWEEN ABORTION

AND INFANTICIDE.

When I first heard the term I thought it strange that it would called Partial-Birth

Abortion and not Partial-Birth Infanticide. I didn’t understand why Drs. Haskell

and McMahon weren’t charged with murder, or at least lose their license to practice

medicine, once they revealed what they were doing in a D&X. The fact that the babies weren’t 100% born when they were killed seemed to me like an awfully flimsy

technicality.

Who decided that just because a fetus was within the birth canal, the abortionist

could still kill it? Does this mean that the abortionist may kill a baby that has just

one foot still in the vagina? Can a woman request, even demand, that the physician

attending her delivery, kill her child once it’s head has been delivered if she finds

it is the wrong race or has a cleft lip? Currently, her claim would be valid if she

stated that the birth would damage her psychologically and might actually place her

life at risk if her abusive husband found out.

We already have had cases where an infant was not treated with the same care

because the mother had intended to abort it. We had several cases where teens

killed their babies after delivery and we were horrified. What hypocrites we are.

Had they been smart enough to leave a foot in the vagina prior to killing the baby

they could only have been charged with practicing medicine without a license.

When my daughter was working on a paper on the Holocaust for school, I became

particularly interested in one of her sources. It discussed the mindset of the medical

community in Germany right before the holocaust. I was saddened and concerned

when I considered where we are as well. Not only are we killing babies during the

process of birth, but there are also those in the medical community who are advocating. euthanizing babies up to 3 months at the request of the parent. In Nazi Germany defective babies were the first to be eliminated.

In light of current case law, the passage of HR 4965 is necessary in order to reestablish a bright line between abortion and infanticide.

85

5) HR 4965 BANS A PROCEDURE THAT IS ABHORRENT TO THE VAST

MAJORITY OF AMERICANS.

Even though I had done mid 2nd trimester D&Es, I was appalled when I heard

about D&X and really didn’t believe it was being done. The majority of Americans

also have found Partial Birth Abortion abhorrent and have supported legislation in

numerous states banning its use.

When Nebraska’s Partial-birth Abortion Ban was ruled unconstitutional several

things happened:

(1) The line between abortion and infanticide was blurred,

(2) The State’s ability to regulate abortion at any gestation even in the case of

a procedure as repugnant as PBA was effectively blocked and

(3) The State’s ability to promote any interest in the potentiality of human life,

even post viability, was lost.

For these reasons I feel that this committee is justified in sponsoring legislation to

once again attempt ban partial-birth abortion.

Both Roe and Casey stated that the State has an interest in potential life and could

even proscribe certain techniques as long as it did not create an undue burden for

women obtaining abortions.

The court emphasizes that ‘‘By no means must a State grant physicians unfettered discretion in their selection of abortion methods,’’ and yet with this decision

they have done just that. The fact that a D&X can be done on a nonviable fetus

does not mean that it cannot be banned as long as the prohibition does not unduly

burden a woman’s ability to obtain an abortion. Since there are other more acceptable procedures available this is not an issue.

As a former abortionist I can tell you that the worst complication for an abortionist is a live baby at the end of the procedure. The goal is a dead baby.

At our hospital a fetal death before 20 weeks it is considered a spontaneous abortion or miscarriage. After that time it is considered a stillbirth and a death certificate must be filled out and the baby must be sent to the funeral home. If a baby

of any gestation is born alive and exhibits definite signs of life, it is considered a

birth and a birth certificate is filled out.

Unlike D&E, which is limited to about 20–22 weeks by the toughness of the tissue,

D&X allows a surgical delivery of the fetus through term. Unlike induction and Csection, however, the fetus has no possibility of survival with D&X.

Even ACOG, a staunch supporter of abortion rights states in its Abortion Statement of Policy, ‘‘The College continues to affirm the legal right of a woman to obtain

an abortion prior to fetal viability. ACOG is opposed to abortion of the healthy fetus

that has attained viability in a healthy woman.’’

When I reviewed Dr. McMahon’s testimony given to the House Subcommittee on

the Constitution June 23, 1995 I found that the maternal indications he listed for

D&Xs he had performed were generally not serious and the vast majority were actually done for fetal indications, many of which were minor. Depression accounted for

39, Induction failure 14, Sexual Assault 19, Down’s Syndrome 175, and cleft lip 9.

Dr. Haskell admitted that he did the vast majority of his D&Xs on normal fetuses

and pregnancies. During the course of this debate I received a letter from an abortionist in Orlando offering termination of pregnancy up to 28 weeks for fetal indications. He went on to say that, ‘‘To obtain a pregnancy termination beyond 24 weeks

gestation, Florida State Law requires that a patient receive a written statement

from her personal physician indicating it would be a threat to her health to continue

her pregnancy.’’ (Letter from Dr. James S. Pendergraft dated April 14, 1999) As the

court currently defines health, even continuing a normal pregnancy threatens a

woman’s health.

I am concerned that some of the effort to preserve this technique is being fueled

by the fetal organ trade in addition to the abortion industries desire to have no restrictions on abortion.

As a moral people there are some things that just should not be allowed and the

killing of an infant in the process of birth is one of them. Although the courts have

given a woman the right to empty her womb they have not given her the right to

a dead child. As technology and Induction techniques improve we will hopefully be

able to give a woman the right to terminate her pregnancy without the necessity

of terminating her child.

When Dr. McMahon first testified regarding D&X he claimed that the fetus was

killed by the anesthetic given the mother. That was soundly refuted by several

prominent anesthesiologists. We also now know that the fetus feels pain, which

makes this procedure even more ghastly.

86

I have been accused of being anti-abortion because of my religious beliefs but actually I stopped doing abortions while I was an atheist.

When I started my OB/GYN Residency I was very pro-abortion. I felt no woman

should have go through a pregnancy she didn’t want. I felt abortion was a necessary

evil and I was determined to provide women with the best abortion care possible.

I perfected my D&C with suction technique and then convinced one of our local

abortionists to teach me to do D&Es. I moonlighted at an abortion clinic in Gainesville as much as I could. The only time I felt uneasy was when I was on my neonatal

rotation and I realized that the babies I was trying to save were the same size as

the babies I had been aborting.

I continued to do abortions almost the entire time I was pregnant (with my eldest

daughter) without it bothering me. It wasn’t until I delivered my daughter and

made the connection between fetus and baby that I stopped doing abortions. I found

out later that few doctors are able to do abortions for very long. OB/GYNs especially, often experience a conflict of interest because they normally are concerned

about the welfare of both their patients but in an abortion they are killing one of

them. It’s hard for most doctors to deliver babies and do abortions. It also has to

do with the fact that to almost everyone else the pregnancy is just a blob of tissue,

but the abortionist knows exactly what he is doing because he has to count all the

parts after each abortion. I never had any doubt that I was killing little people but

somehow I was able to justify and compartmentalize that.

Even though I later became a Christian, I continued to be a staunch supporter

of abortion rights. I just couldn’t stomach doing them myself anymore. It wasn’t

until I read an article that compared abortion to the Holocaust that I changed my

opinion. I had always wondered how the German Doctors could do what they did

to people. I realized that I was no better than they were. I had dehumanized the

fetus and therefor felt no moral responsibility towards it.

I joined the fight to ban this procedure only because I felt we were no longer really dealing with abortion but rather a form of infanticide. This bill safeguards women

and does not unduly interfere with their ability to obtain an abortion. It clearly does

not cover D&E or other commonly performed abortion techniques. It reestablishes

a bright line between abortion and infanticide and it bans a procedure that is abhorrent to most Americans.

I urge you to pass HR 4965 ‘‘The Partial-Birth Abortion Act of 2002.’’

Thank you.

87

88

PREPARED STATEMENT OF CURTIS COOK, M.D.

My name is Dr. Curtis Cook and I am a board-certified Maternal-Fetal Medicine

specialist (perinatologist) practicing and teaching in the state of Michigan. I provide

care exclusively to women experiencing complicated pregnancies. These include

women with preexisting medical conditions such as diabetes, hypertension and even

cardiac disease and cancer. This group of complicated pregnancies also entails those

with suspected fetal abnormalities including lethal fetal anomalies such as

anencephaly (absent brain) and renal agenesis (absent kidneys). Additionally, this

group of complicated pregnancies includes those women who have developed obstetrical complications during the course of their gestation. This would include situations such as the premature onset of labor or early leaking of the amniotic fluid.

Never in the ten years I have been providing perinatal care to women with complicated pregnancies have I ever experienced a clinical situation where the late-term

abortion procedure being considered before this committee (partial-birth abortion)

has ever been required or even considered as a clinically superior procedure to other

well-known and readily available medical and surgical options. This includes the

clinical situations where this technique has been used by some physicians, and even

the theoretical situations proposed by zealous advocates of this rogue procedure. Additionally, I have queried many colleagues with decades of clinical experience and

have yet to find one individual who has experienced a clinical situation that would

require this procedure. This procedure has been discussed very publicly for more

than five years and yet we have not seen it embraced by the medical community

simply for its lack of merit in modern obstetrics.

As part of my professional responsibilities, I also teach medical students and residents the clinical management of pregnant women. This includes the various medical and surgical options for facilitating a birth or emptying a uterus in all three

trimesters of pregnancy. I have never encountered teaching materials on this technique (PBA) except for the information presented by Dr. Haskell at a National Abortion Federation seminar. I am also a fellow of both the American College of ObsteVerDate 11-MAY-2000 23:23 Jun 03, 2003 Jkt 000000 PO 00000 Frm 00092 Fmt 6601 Sfmt 6621 G:\WORK\CONST\032503\85987.000 HJUD3 PsN: HJUD3
89

tricians and Gynecologists and the Society of Maternal-Fetal Medicine as well as a

member of the Association of Professors of Gynecology and Obstetrics. I am not

aware of any educational materials from any one of these groups discussing the specific technique of partial-birth abortion (or D&X/intact D&E), the appropriate clinical use of this procedure or even clinical reports of its use. This also leads me to

believe this is a rogue procedure with no role in modern obstetrics.

Frankly, I am appalled that any physician is providing such ‘‘services’’ given the

gruesome nature of this inhumane procedure. By their own admission these procedures are being performed primarily between 20–28 weeks gestation and sometimes

beyond on mostly healthy mothers carrying healthy babies. The current survivability of infants born at 23 weeks is greater than 30% and at 24 weeks it is almost

70%. By 28 weeks the survival rate exceeds 95%! Many of these infants are literally

inches away from enjoying the full rights afforded any American citizen including

the rights to life, liberty and the pursuit of happiness.

Every argument brought forth by the zealous advocates of this procedure has been

summarily dismissed in the light of the medical facts. This includes even early arguments that this procedure was never being performed. Later the argument proposed

was that this procedure was rarely performed and when it was performed it was

provided only to mothers or infants with severe medical problems. We know now

by the independent investigations of the Washington Post, the New Jersey Bergen

Record, the American Medical Association News and others that these procedures

are being performed by the thousands on mostly healthy mothers carrying healthy

babies as admitted to by high profile providers of this technique. It was even preposterously proclaimed that the anesthesia provided the mother during the procedure

was responsible for killing the fetus rather than the act of puncturing the base of

the skull and suctioning out the brain contents. This was roundly criticized by all

legitimate medical bodies putting to rest the concerns of thousands of other women

undergoing indicated surgical procedures during the course of their pregnancy. Indeed several pediatric pain specialists and obstetrical anesthesiologists have stated

that there is good evidence to support that this procedure would generate excruciating pain for the partially born infant. In fact, this technique would not even be

allowed for the purpose of euthanizing research laboratory animals.

Again I speak from the experience of providing medical and surgical care to infants at the same point in pregnancy at which these abortions are being performed.

I also regularly care for women with same diagnoses as those undergoing partialbirth abortion and have been able to safely deliver these women without having to

resort to these brutal techniques. This procedure does not protect the life nor preserve the health of pregnant women. It also does not enhance the ability of women

to have successful pregnancies in the future and may even hinder such efforts. I am

at a loss to think of any benefit of this procedure other than the guarantee of a dead

baby at the time of the completed delivery.

In summary, I feel this procedure (PBA) is unnecessary, unsavory and potentially

unsafe for women. Unfortunately it is still being perpetuated upon thousands of innocent partially-born children in this country every year. As I did before this committee five years ago, again I urge you to act quickly to prohibit this abomination

of American medicine.

I thank you again for the opportunity to share my testimony and my deep concern

for the women and children of this country.

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

110

111

112

113

114

115

116

117

118

119

120

121

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184

185

186

1See KENNETH E. NISWANDER & ARTHUR T. EVANS, MANUAL OF OBSTETRICS 15 (5th ed. 1996).

DOCUMENTS SUNBMITTED BY REPRESENTATIVE JERROLD NADLER

PREPARED STATEMENT OF VANESSA CULLINS

I am Vanessa Cullins, M.D., M.P.H., M.B.A. I am a board-certified obstetriciangynecologist with Masters degrees in both Public Health and Business Administration. I currently serve as the Vice President of Medical Affairs for Planned Parenthood Federation of America (PPFA), the nation’s largest and most trusted provider

of reproductive health care and education. Each year, nearly five million women,

men, and teenagers receive reproductive health services at the 875 centers operated

by the Planned Parenthood network of 125 affiliates, serving communities in 49

states and the District of Columbia.

I received my medical training (medical school, internship, and residency) from

the Johns Hopkins University School of Medicine/Johns Hopkins Hospital. I received

my Public Health degree from Johns Hopkins University School of Hygiene and

Public Health, and my M.B.A. degree from the Wharton School, University of Pennsylvania. I am currently a member of the National Medical Association (NMA), the

American Medical Association (AMA), and the American College of Obstetricians &

Gynecologists (ACOG).

Among other professional positions I held before beginning work for PPFA, I

served as an assistant professor at Johns Hopkins University School of Medicine,

and was an attending physician in the obstetrics and gynecology department at

Johns Hopkins Bayview Medical Center. In addition, I have published extensively

and made numerous presentations in the area of obstetrics and gynecology.

I submit this testimony in opposition to H.R. 760, the so-called ‘‘Partial-Birth

Abortion Ban Act of 2003’’ (the ‘‘2003 Abortion Ban Bill’’). Based on my extensive

training and clinical experience in the provision of health care for women, including

abortion, it is my medical judgment that the 2003 Abortion Ban Bill would harm

the health of many women in this country.

A. THE BILL PREVENTS DOCTORS FROM EXERCISING NECESSARY DISCRETION

Central to women’s ability to protect their health in the context of abortion (or

any other medical matter) is the ability of their physician to exercise appropriate

medical judgment. The physician’s main goal in performing any abortion is to terminate the pregnancy by the method that is safest for the patient. A physician, in consultation with his or her patient, chooses the most appropriate and safest procedure

for that patient based on a variety of factors, including the patient’s overall medical

condition; the physician’s training in the procedure; the gestational age, size, and

presentation of the fetus; the extent of dilatation of the cervix; the existence of fetal

abnormalities; and a patient’s desire, for example, to avoid prolonged labor and hospitalization.1

The risk of a particular abortion procedure varies in every case, depending on the

individual woman’s health, the skill of the physician, the medical facilities available,

and how the selected procedure proceeds. With any abortion procedure, several factors determine how the procedure will proceed—including the size and orientation

of the fetus, the amount of dilation, the condition of the cervix and uterus, and the

patient’s overall health and medical condition. The physician must adapt his or her

technique as the surgery proceeds in light of the individual patient’s needs. It is,

therefore, essential that in providing care, physicians have discretion to consider the

full panoply of safe methods and techniques of abortion and to proceed in the way

most appropriate for each patient.

By attempting to legislate which abortion procedures are permitted, and which

banned, this legislation takes away from physicians the full armamentarium of techniques that may be necessary in any particular case to provide an abortion in the

safest possible manner for each patient. It thus denies physicians the necessary discretion to provide medical care with the safety and health of their patients as their

foremost concern. If this bill were to become law and the physician continued to adhere to the medically and ethically appropriate course of treatment, he or she would

risk criminal prosecution and imprisonment, as well as civil lawsuits. And if the

physician strictly followed H.R. 760’s prescriptions, the inevitable result would be

to force some women to undergo less safe procedures than their physician would

otherwise perform. This is unacceptable.

For this reason, I fully endorse the conclusion of ACOG that ‘‘[t]he 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. The

187

2 ACOG’s Statement of Policy, Statement on Intact Dilatation and Extraction (Jan. 1997)

(‘‘ACOG Statement’’), at 2 (emphasis in original omitted); see also ACOG’s Statement on SoCalled ‘‘Partial Birth Abortion’’ Laws (Feb. 2002). 3 Joy Herndon et al., Abortion Surveillance—United States, 1998, in CDC Surveillance Summaries, 51 MMWR (No. SS–3) 32 (Table 18) (Centers for Disease Control, June 7, 2002). 4 Id.

5 In an induction, the physician uses one of several substances and methods to induce preterm labor. ACOG, Practice Bulletin No. 10, Induction of Labor at 1 (Nov. 1999). Some medical

authorities indicate that induction often is unsuccessful prior to approximately 16 weeks from

the woman’s last menstrual period (‘‘LMP’’) because the uterus is less responsive to the inducing

agents. See EUGENE GLICK, SURGICAL ABORTION at 46–48 (1998). In the case of an incomplete

or unsuccessful induction, a subsequent surgical abortion procedure is necessary. See A CLINICIAN’S GUIDE TO MEDICAL AND SURGICAL ABORTION at 125 (Maureen Paul et al. eds., 1999). 6 530 U.S. 914, 932 (2000).

7 Id. at 938. 8 ACOG Statement at 2.

intervention of legislative bodies into medical decision making is inappropriate, ill

advised, and dangerous.’’ 2

B. THE SCOPE OF THE BAN IS UNCLEAR, BUT EVEN IF IT BANNED ONLY D&X ABORTIONS

IT WOULD DEPRIVE WOMEN OF A SAFE ABORTION OPTION

Although the findings to the 2003 Abortion Ban Bill suggest that the sponsors intend to ban only the abortion procedure known (interchangeably) as intact dilation

and extraction or dilation and extraction (‘‘intact D&E’’ or ‘‘D&X’’) (see Finding

Number 1), the operative language of the bill, however, is not so limited. Indeed,

as I read the language of the bill itself (proposed 18 U.S.C. § 1531(b)), it would ban

not only the D&X procedure, as ACOG defines it, but also dilation and evacuation

(D&E) and induction abortions. D&E is the most commonly performed second-trimester abortion procedure. Together, D&E and D&X abortions comprise approximately 96% of all second-trimester abortions performed in this country.3 Induction

abortions account for most of the remaining 4% of second-trimester abortions.4 Induction abortions require hospitalization and are more expensive than D&E or D&X

abortion. While induction is a safe procedure, for some women, it poses unacceptable

risks.5

Given that almost all second-trimester abortions in this country are performed

using the D&E or D&X methods or by induction, a ban on these methods would constitute a virtual ban on previability second-trimester abortions in this country.

Therefore, if this bill became law, physicians in this country would be forced either:

(1) to perform virtually all second-trimester abortions under threat of criminal and

civil prosecution; (2) to alter their medical practices in ways that threaten maternal

health and increase the cost and burden of the abortion procedure, or (3) to cease

providing second-trimester abortions altogether. This would turn back the clock and

lower the standards of obstetrical and gynecological care in this country to a level

not seen since before abortion was legalized.

Even if the 2003 Abortion Ban Bill were limited to banning the D&X procedure,

it would nonetheless pose significant health risks for some women. I strongly disagree with the statements in the bill’s Findings that D&X is outside the standard

of medical care and poses serious risks to a woman’s health. (Findings Numbers 1,

13.) In fact, based on my clinical experience and observations, and my discussions

with other physicians, it is my professional opinion that D&X is within the accepted

standard of care and is not only safe, but for some women may be safer than other

abortion methods. As the Supreme Court explained in Stenberg v. Carhart, ‘‘the

record shows that significant medical authority supports the proposition that in

some circumstances, D&X would be the safest procedure.’’ 6 Indeed, the Court concluded that ‘‘a statute that altogether forbids D&X creates a significant health

risk.’’ 7

D&X abortions offer a variety of potential safety advantages over other procedures

used during the same gestational period.

First, compared to D&E abortions, D&X involves less risk of uterine perforation

or cervical laceration because it requires fewer passes into the uterus with sharp

instruments.

Second, there is considerable evidence that D&X reduces the risk of retained fetal

tissue, a serious complication that can cause maternal death or injury.

Third, D&X may be safer than available alternatives for women with particular

health conditions. As ACOG has concluded, D&X may be ‘‘the best or most appropriate procedure in a particular circumstance to save the life or preserve the health

of a woman.’’ 8 D&X may also be the most appropriate method in the presence of

certain fetal indications. For example, D&X ‘‘may be especially useful in the presVerDate 11-MAY-2000 23:23 Jun 03, 2003 Jkt 000000 PO 00000 Frm 00191 Fmt 6601 Sfmt 6621 G:\WORK\CONST\032503\85987.000 HJUD3 PsN: HJUD3
188

9David A. Grimes, The Continuing Need for Late Abortions, 280 JAMA 747, 748 (Aug. 26,

1998). 10 Id.

ence of fetal abnormalities, such as hydrocephalus’’ because it entails reducing the

size of the fetal skull ‘‘to allow a smaller diameter to pass through the cervix, thus

reducing risk of cervical injury.’’ 9 In addition, ‘‘intactness allows unhampered evaluation of structural abnormalities’’ in the fetus and can thus aid in diagnosing fetal

anomalies. Finally, an intact fetus can ‘‘aid . . . patients grieving a wanted pregnancy by providing the opportunity for a final act of bonding.’’ 10

Fourth, D&X procedures usually take less time than other abortion methods used

at a comparable stage of pregnancy, which can have significant health advantages.

Based on my clinical experience and knowledge of this field, there is no reliable

medical evidence to support the claim in H.R. 760’s Findings that D&X endangers

maternal health. (Finding Number 14(A).) The Findings claim that the amount of

cervical dilatation involved in D&X procedures heightens the risk of cervical incompetence or cervical trauma. Many D&E procedures, however, involve similar

amounts of dilatation, and of course childbirth involves even more dilatation. The

concern stated in the Findings about the risks posed by the physician repositioning

the fetus into a footling breech, is similarly misplaced. Some clinicians recommend

repositioning the fetus in some D&Es, depending on how the fetus initially presents.

Moreover, the Findings suggest that the use of sharp instruments to collapse the

head in a D&X is more dangerous than repeated instrument passes into the uterus

in a D&E. But the physician can visualize and feel the surgical field during a D&X

and therefore the instrument can be carefully guided, thus minimizing risk to the

woman.

Finally, H.R. 760’s sponsors attempt to rely on the lack of comparative studies or

peer-reviewed articles relating to the D&X procedure. (Finding Number 14(B).)

However, the development and medical acceptance of safe surgical procedures is not

always achieved by orderly and controlled testing. For example, the most common

abortion procedures used today were all developed years ago by physicians who

slightly varied their technique to achieve greater safety for their patients, found

that the variation did improve the safety, and then taught the new technique to

their colleagues. Similarly, open heart surgery (as an example) was not tested in

a randomized, controlled way. Rather, physicians figured out how to perform the

surgery, and did so. As patients lived, physicians kept doing it, and got better at

it.

Moreover, given the security concerns that are ever-present for doctors who perform abortions, physicians who use the D&X procedure may be understandably reluctant to publicly acknowledge that they use this procedure, and may be even more

reluctant to participate in a study and then publish the results. Therefore, the

dearth of peer-reviewed studies of D&X (described in Finding Number 14(B)), is not

surprising and does not indicate anything negative about the safety of D&X procedures.

C. H.R. 760 WILL HARM WOMEN’S HEALTH

The bill’s ban on safe abortion procedures that are within the standard of care

strips physicians of the discretion they need to make critical medical judgments.

This will result in an unacceptable risk to women’s health. Given the safety advantages of D&E, D&X and induction procedures over other abortion procedures, banning these procedures will necessarily harm women and deprive them of optimal

care. As a physician and a woman, I consider this result unacceptable.

It is unconscionable that Congress is attempting to legislatively ban safe and necessary medical procedures, and thereby to deny patients optimal medical care. The

practice of medicine must be left to doctors and medical professionals.

I strongly urge this Subcommittee to stop trying to practice medicine and to reject

H.R. 760.

189

190

191

PREPARED STATEMENT OF ANNE R. DAVIS

I am a physician licensed to practice medicine in New York and am board-certified in obstetrics and gynecology. I received my medical degree at Columbia University College of Physicians and Surgeons and completed my residency in Obstetrics and Gynecology at the University of Washington in Seattle. Since 1997, I have

192

1Laurie D. Elam-Evans et al., Abortion Surveillance—United States, 1999, in CDC Surveillance Summaries, 51 MMWR (No. SS–9) 4, 5, 12, 18 (Table 1, 6) (Centers for Disease Control,

Nov. 29, 2002). 2 Id.

been an Assistant Professor in Clinical Obstetrics and Gynecology at Columbia University. In addition to my teaching responsibilities, I provide direct patient care.

I am a Fellow of the American College of Obstetricians and Gynecologists, and

also am a member of, among other organizations, the American Medical Women’s

Association, Physicians for Reproductive Choice and Health, and the Association of

Reproductive Health Professionals. As detailed on my Curriculum Vitae, a copy of

which is attached, I have published and lectured in the area of obstetrics and gynecology.

I submit this testimony in opposition to H.R. 760, the so-called ‘‘Partial-Birth

Abortion Ban Act of 2003.’’ Based on my training and professional experience in the

field of women’s health care, it is my medical judgment that H.R. 760 would pose

a serious threat to women’s health.

H.R. 760 will severely limit physicians’ ability to provide the best medical care

to their patients. Because the bill is confusing and contradictory, it will be difficult

for physicians to interpret. However, the operative language of the bill appears to

ban safe and common abortion procedures used well before fetal viability, including

the most common methods of abortion used in the second-trimester, which starts at

approximately thirteen weeks of pregnancy. H.R. 760 is all the more harmful because it contains no exception for those instances when a procedure is necessary to

preserve a woman’s health, and includes only a dangerously inadequate exception

for those instances when a procedure is necessary to save a woman’s life.

H.R. 760, therefore, leaves physicians with the untenable choice of either performing procedures under threat of criminal prosecution or ceasing to provide the

medical care that we deem most appropriate for a particular patient. Either choice

poses grave risks to patient care.

I. BACKGROUND ON ABORTIONS IN THE UNITED STATES

In the United States, almost 90% of abortions take place during the first trimester

of pregnancy.1 Less than 2% of abortions in the United States take place at or after

twenty-one weeks measured from the date of the woman’s last menstrual period

(LMP).2

There are a variety of complicated circumstances that prompt women to terminate

pregnancies. Many women end unplanned pregnancies for a wide range of reasons

including their age, their family situation, and their personal circumstances. Some

women who seek abortions are pregnant as a result of rape or incest.

Still other women are forced to terminate wanted pregnancies. These include

women who learn that their fetuses have severe, potentially fatal, anomalies. Some

anomalies are sure to be fatal within days, if not minutes, of birth. Trisomy 13 and

trisomy 18, for example, cause severe malformations and usually lead to death within twenty-four hours of birth. Anencephaly—a condition characterized by markedly

defective development of the brain and skull—results in death before birth or soon

after. Other conditions might permit survival but cause severe, life-long impairment.

For example, Tay-Sachs disease usually results in death at three or four years of

age. Women carrying fetuses with such conditions often choose to terminate their

pregnancies due to the very poor prognosis.

Some women require abortions because their pregnancies compromise their

health. In some instances, the patient has a preexisting medical condition that is

exacerbated by her pregnancy. For example, women with certain kinds of heart disease are at increased risk during pregnancy, with the risk of maternal and fetal

death as high as fifty percent. Women who develop peripartum cardiomyopathy, a

condition in which the heart muscle does not pump blood sufficiently, are at serious

risk of cardiac failure. Women with conditions such as renal (kidney) and liver disease may experience exacerbation of those diseases as a result of the pregnancy.

Some women who have cancer learn that they are pregnant. In these cases, although the pregnancy does not threaten the patient’s life, she may require treatment with chemotheraphy or radiation, which is inconsistent with carrying a pregnancy to term.

Even for women without preexisting medical problems, dangerous conditions may

develop during pregnancy. One such condiction is pre-eclampsia, a pregnancy-induced hypertension that can result in cerebral hemorrhage, as well as liver dysfunction or failure, kidney failure, temporary or permanent visual disturbances or vision

193

3 Joy Herndon et al., Abortion Surveillance—United States, 1998, in CDC Surveillance Summaries, 51 MMWR (No. SS–3) 32 (Table 18) (Centers for Disease Control, June 7, 2002). 4 Id.

loss, and coma. In these situations, abortion may be indicated to preserve the patient’s health or life.

Although only 10% of abortions in this country take place in the second trimester

of pregnancy, these post-first-trimester abortions may take place because of the circumstances I have just described. This is because it is often not possible to diagnose

fetal abnormalities before the second trimester because the tests used to detect

these conditions are not accurate until later in pregnancy. And, the maternal health

conditions that necessitate abortion often worsen in the second trimester, requiring

women to seek abortions at this stage.

Physicians generally use two different techniques to perform abortions after the

first trimester: dilation and evacuation (D&E) and induction. In a D&E, the physician dilates the cervix and evacuates the uterus using a combination of forceps (a

grasping instrument), suction curettage, and sharp curettage (the use of an instrument with a sharp edge to ensure that the uterus is entirely empty). In a variation

of D&E called intact D&E (or dilation and extraction (D&X)), the physician maximizes the chances of an intact or relatively intact delivery in order to minimize risk

to the woman. In an induction procedure, one of several medications is used to induce premature labor.

D&E is the most commonly performed second-trimester abortion procedure. D&E,

including its intact variation, comprises approximately 96% of all second-trimester

abortions performed in this country.3 Induction abortions account for most of the remaining 4% of second-trimester abortions.4 Induction requires hospitalization and is

a more lengthy process than D&E. For most women, inductions are safe procedures.

Inductions may involve complications and physiological stress associated with labor

and delivery at term, including contractions that last from four to thirty hours or

more. That alone often makes induction contraindicated for women with certain

medical conditions, including cardiac disease or a prior hysterotomy or prior ‘‘classical’’ (high) cesarean section. Induction abortion can also be contraindicated when

the fetus has certain anomalies.

II. H.R. 760 BANS AN ARRAY OF SAFE AND COMMON ABORTION PROCEDURES.

The language of H.R. 760 is confusing and contradictory. It is therefore unclear

precisely what it prohibits. It refers to ‘‘partial-birth abortion,’’ a term that is not

used by doctors. I am aware, however, that many courts have concluded that this

term can refer to a variety of abortion methods. Moreover, there is no correlation

between the definition of banned abortions in the bill’s operative language and the

description of procedures included in the bill’s Findings. For example, the bill’s

Findings refer to ‘‘an abortion in which a physician delivers an unborn child’s body

until only the head remains inside the womb, punctures the back of the child’s skull

with a sharp instrument, and sucks the child’s brains out before completing delivery.’’ H.R. 760, Sec. 2(1). The Findings also refer to ‘‘cervical dilation’’ and ‘‘converting the child to a footling breech position.’’ H.R. 760, Sec. 2(14)(A). Yet the language in the actual ban does not mention any of those steps. In addition, the Findings refer to procedures performed at or after twenty weeks LMP, see H.R. 760, sec.

2(14)(I), but the ban contains no such limit. The language in the ban is thus unrelated to, and much broader than, the description contained in the bill’s Findings.

I understand that proponents of this bill have contended that it is intended to ban

only the abortion procedure known as intact D&E or D&X. H.R. 760 reaches those

procedures. But its terms would reach D&Es and inductions, as well. H.R. 760

therefore would ban every safe and common option for second-trimester pregnancy

termination.

H.R. 760 defines the banned procedures as any one in which: The physician ‘‘deliberately and intentionally vaginally delivers a living fetus until, in the case of a

head-first presentation, the entire fetal head is outside the body of the mother, or,

in the case of breech presentation, any part of the fetal trunk past the navel is outside the body of the mother for the purpose of performing an overt act that the person knows will kill the partially delivered living fetus; and performs the overt act,

other than completion of delivery, that kills the partially delivered living fetus.’’

H.R. 760, Sec.3(a). These words describe what happens in many D&E procedures.

H.R. 760 would ban D&Es as they proceed in any number of ways. Each D&E

is different, and the physician adapts his or her surgical technique based on the individual patient and on how the particular case progresses. The physician cannot

predict which steps will be safest during a D&E until the surgery has begun. But

194

5 Hysterotomy and hysterectomy are generally justified as abortion methods only when the

woman has some medical condition that independently requires such surgery. Hysterotomy is

a preterm cesarean section, in which an incision made in the uterine wall through which the

physician removes the fetus. Hysterotomy in the second trimester is significantly more dangerous than a cesarean section at term because it involves cutting through the uterine wall

when it is much thicker. During any future pregnancy—even before labor—a prior hysterotomy

can cause uterine rupture and catastrophic bleeding. Hysterectomy is the removal of the uterus,

which results in complete loss of fertility. Hysterectomy and hysterotomy thus entail significantly higher rates of morbidity and mortality than are associated with either D&E or induction.

in every D&E, each time the physician inserts instruments into the uterus, the physician then deliberately and intentionally delivers as much of the fetus as possible,

which can mean that ‘‘the entire fetal head is outside the body of the mother’’ or

that ‘‘any part of the fetal trunk past the navel is outside the body of the mother’’;

the physician does so for the purpose of evacuating the uterus as safely as possible

for the woman; and the physician knows that evacuating the uterus as safely as possible may entail ‘‘an overt act, other than the completion of delivery’’ that will cause

fetal demise. Any D&E can entail these steps. Thus, any doctor performing a D&E

is at risk of falling under the ban.

Any doctor performing an induction abortion would also be at risk under H.R.

760. After preterm labor is induced, a variety of complications may develop that will

necessitate taking the very steps used commonly in D&Es. Because any induction

can progress in this way, a physician starting any induction will know that the

safest way to proceed could turn out to involve using techniques that H.R. 760 prohibits.

H.R. 760 thus subjects any physician to the risk of prosecution for using any safe

and common second-trimester abortion method. This poses an intolerable threat to

women’s health. The only procedures a physician can safely perform without risk

of prosecution are hysterotomy or hysterectomy. Both of these procedures pose such

serious health risks that they have been all but abandoned as methods of pregnancy

termination.5 Thus, H.R. 760 seriously jeopardizes women’s health.

III. EVEN IF IT BANNED ONLY D&X PROCEDURES, H.R. 760

WOULD THREATEN WOMEN’S HEALTH.

Even if it were true, as some proponents of H.R. 760 claim, that the bill covers

only a single variation of abortion known as intact D&E or D&X, it would still endanger women’s health. A threat to women’s health always results when a safe medical procedure is removed from the physician’s array of options, as there are some

women for whom the banned procedure will be the safest.

In my medical judgment and in the judgment of many experienced physicians,

there is no question that intact D&E is a safe abortion procedure that may well be

the safest procedure for some women in certain circumstances. The American College of Obstetricians and Gynecologists (‘‘ACOG’’), of which I am a member, has articulated its safety advantages. According to ACOG, intact D&Es provide the following potential advantages: First and most important, intact D&E has the potential to greatly reduce the risk of uterine perforation or cervical laceration by reducing the number of times the physician must insert instruments through the cervix

and into the uterus. Second, intact D&E also reduces the risk of perforation and

laceration from sharp fetal parts. Third, intact D&E minimizes the risk of retained

fetal tissue in the uterus. Finally, intact D&E reduces blood loss, trauma, and operating time (and thus anesthesia exposure) for many patients. Based on my experience, I wholly agree with these conclusions.

I have read the discussion of the alleged safety risks of elements of certain intact

D&Es in the Findings section of H.R. 760. Based on my experience, these claims

are unfounded. There are no data supporting the assertion that the gradual and

gentle dilation involved in an intact D&E causes cervical incompetence, and, based

on my experience, I do not believe that it does. There is likewise no support for the

assertion that converting the pre-viable fetus to a breech presentation is dangerous.

Moreover, such conversion may occur in D&Es generally and does not always occur

in an intact D&E. Similarly, the risk of laceration and of damage from blind insertion of instruments is decreased—not increased—by removing the fetus intact. Because of these safety advantages, ACOG has stated that intact D&E ‘‘may be the

best or most appropriate procedure in a particular circumstance to save the life or

preserve the health of a woman.’’ ACOG, Statement of Policy, Abortion Policy at 3

(Sept. 2000).

195

IV. H.R. 760 LACKS NECESSARY EXCEPTIONS TO PROTECT WOMEN’S HEALTH AND LIVES.

In addition to the problems outlined above, H.R. 760 poses grave risks to women

by failing to include any exception for cases in which a banned procedure may be

needed to preserve a woman’s health. Women with the kind of medical complications I have described above will suffer serious harm if H.R. 760 prevents their physician from choosing the safest and most appropriate abortion procedure for their

particular health circumstances. It is simply not true, as the Findings in the bill

contend, that the procedures banned by this bill will never be necessary to preserve

a woman’s health.

The life exception in H.R. 760 is also dangerously inadequate. It applies only

when the abortion procedures otherwise banned by the bill are ‘‘necessary to save

the life of the mother whose life is endangered by a physical disorder, a physical

illness, or physical injury, including a life-endangering physical condition caused by

or arising from the pregnancy itself.’’ Rather than provide an exception to be used

whenever a woman’s life is at stake, this exception applies only when a banned procedure is ‘‘necessary’’ to save a woman’s life. But in almost every case, other procedures that are not banned, such as hysterotomy or hysterectomy, would likely save

the woman’s life, even though they pose far greater risks and can have irreversible

medical consequences for the woman. H.R. 760 thus forces women from safer to

riskier procedures.

V. H.R. 760 UNDERMINES PHYSICIANS’ ABILITY TO USE THEIR BEST

MEDICAL JUDGMENT IN CARING FOR PATIENTS.

A crucial component of effective health care is a physician’s ability to rely on his

or her best medical judgment in determining the appropriate treatment for a particular patient. H.R. 760 undermines patient care by preventing physicians from relying on their best medical judgment in providing abortions. The risk of a particular

abortion procedure varies in every case depending on a variety of factors including,

the individual woman’s health, the skill of the physician, the medical facilities available, and how the selected procedure progresses in a particular case. Given these

many variables, it is essential that a physician be able to choose from the full array

of safe techniques in providing abortions—or in providing any other medical treatment.

I urge this Subcommittee to leave decisions about the best surgical techniques for

women in the hands of doctors and patients. I urge you to reject H.R. 760.

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

DOCUMENTS SUBMITTED BY REPRESENTATIVE JOHN CONYERS

213

214

215

216

217

218

219

220

221

222

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

243

244

245

246

247

248

249

250

251

252

253

254

255

256

257

258

259

260

261

262

263

264

265

266

267

268

269

270

271

272

273

274

275

276

277

278

279

Æ