The standards that pit "efficacy" against women’s health and wellbeing are at odds with feminist standards of reproductive freedom as they evolved in the 1970s. Both the contraceptive practices of women, as embodied in their increasing caution about the pill, and feminist ideology, as articulated by the women’s health movement, reject the notion that women must sacrifice their physical health, a necessary condition of their liberation, to access to reliable fertility control. In part, this view takes the form of a demand that society, particularly its highly politicized medical research structures, place an immediate priority on developing a genuinely safe and effective method of contraception. Family planners now tend to dismiss this demand as utopian (a "panacea"), but women are understandably dismayed by the failure of modern science to conquer reproductive biology, while space travel and weapons of global destruction have long been routine. Short of a "technological fix," however, the insistence on both reliability and safety grows out of the material conditions of fertility control that already exist, even though their potential is limited by current political forces. For we have a 100 percent effective and reasonably safe form of birth control: the diaphragm or condom (and now a new vaginal sponge) backed up by early legal abortion.
I do not believe women are "substituting" abortion for contraception, but I do believe they are less and less willing to trade off their health and physical well-being for technical reliability. As Marx pointed out, the standard of human needs is determined not only by technology but by a "historical and moral element" reflected in social consciousness. The need for abortion grows, not only as further medical complications of the pill and the IUD are "discovered," but also as women’s consciousness changes about the level of risk or discomfort that ought to be tolerated. If this is "hedonism," this concern with personal health and safety, it is surely the kind that Herbert Marcuse talked about as a necessary precondition to the development of social and sensual human beings. We can understand the pill "drop-out" and the rise in abortions as a historically particular form of resistance to the idea that it is "woman’s nature" to suffer.
Can still better contraceptive technologies be expected to relieve the necessity of abortion? In a sensible and sobering article, Malcolm Potts and Robert Wheeler demonstrate convincingly that within the context of existing biomedical research the quest for perfect fertility control in one package (a "magic bullet") is fraught with dangers for women’s bodies. There tends to be an "inverse association" between technical effectiveness (measured in pregnancy rates) and dangerous or troubling side effects: "In the case of oral contraceptives, the higher the dose and the more extensive the systemic effects, the greater the effectiveness and also the greater the probability of problems among users."69 This dilemma extends to most experimental techniques. Nearly every "revolutionary" contraceptive method now on the drawing board—chemical methods of female sterilization, injectables, female and male analogs of hormone-releasing hormones (LHRH); prostaglandins to induce menses—involves the use of chemicals that may carry as much risk to health as currently used contraceptives.70 Experiments with newer methods of tubal sterilization, such as plastic clips and silicone plugs, seem to promise a safer approach to fertility control and reversibility, since little damage is done to the Fallopian tubes; but these methods are still regarded as virtually permanent by researchers and have failed to work in 10 to 15 percent of the women tested.71
More important, women using the supposedly most effective methods of nonpermanent contraception now available may have greater likelihood of needing an abortion at some time than women who use less effective methods because of the pill’s and the IUD’s side effects and the consequent discontinuation rate. Using computer simulation techniques, Potts and Wheeler calculate that fewer conceptions will occur with "use of a traditional or simple method with a good continuation rate" than among pill and IUD users, who have a lower continuation rate.72 As I argued initially, the "contraceptive revolution," especially the pill, has increased rather than decreased women’s need for access to abortion. This is true because of two interacting developments: the widespread availability of the pill and legal abortion, reinforcing women’s awareness of fertility control as their right; and a newer political consciousness that refuses to accept risks to reproductive health as fate’s decree. The current status of contraceptive techniques underlines more than ever that as long as it remains possible for a woman to become pregnant without wanting to be, abortion will be a necessity and its denial a punishment of women—for having sex.
That rising abortions and increased contraceptive use are related trends contradicts the widely held impression that many women are substituting abortion for contraception. Among teenagers, a high proportion use some method of contraception prior to a pregnancy, and 7 out of 10 become regular contraceptive users after a first pregnancy.73 For some teenagers, an abortion becomes a rite de passage toward regular contraceptive use; the great majority of abortions in any given year are first-timers rather than "repeats." This is not to deny that some young, mainly poor teenagers continue to get pregnant after one or two abortions. But most of them have no intention of getting pregnant; they do so because contraception fails or because they are ignorant of reproductive processes. Even if they are "between" methods because of having "dropped out" of pill or IUD use, they do not usually "consider abortion either a primary or a backup method of birth control—indeed not a method of birth control at all."74
Something more general needs to be said here about the politics of "taking risks." The need to balance the dangers of individualism (exposure to exploitation or unfair risk) against the dangers of protection (invasion of privacy, paternalism, exclusion) is a favorite subject of philosophical and public health discourse.75 For feminists, however, it is not an academic conflict but one that lives and breathes in the history of the movement and of the treatment of women by those who exercise power. Historically, it comes up most bitterly in the split between feminists who supported the Equal Rights Amendment and women trade unionists who feared it would abolish hard-won protective legislation in employment. But it has resurfaced from time to time around issues related to sexuality—prostitution, rape, pornography—where one group of feminists fought to expose and regulate the dangers to women in the trafficking and exploitation of their bodies, their need for "protection," while others foresaw the dangers of protection, its tendency to be used as a pretext for denying women their capacity to be sexual, to work, or even to walk on the street.76 And, of course, both groups have been right, as we have learned recurrently in the case of "protective legislation" when its presence has been used as an exclusionary device to keep women out of male occupational strongholds, whereas its absence has left women vulnerable to economic and sexual abuse. Neither individualism—formulated as the "right to privacy" in liberal constitutional tradition—nor paternalism has ever provided adequate solutions to women’s collective oppression.
In reproductive politics, the tension between individual choice, which involves individual risk taking and responsibility, and protection from abuse, which may involve the socialization of responsibility and perhaps surveillance or suppression of choice, takes specific and sometimes dramatic forms. Feminists have confronted the contradictions implicit in the liberal rhetoric used to defend "reproductive choice" as it gets thrown back at them by the very power structures that oppose feminist goals. As in the history of women’s employment, we find the ideas of individual freedom and consumer choice brandished by drug companies and the medical establishment in their rigid opposition to government regulation of oral and injectable contraceptives and of sterilization abuse.77 Meanwhile, employers such as chemical corporations invoke the benevolent "protection" principle as a reason to screen pregnant women, or all women, out of jobs that carry reproductive hazards—or to require them to be sterilized. The Reagan administration and the New Right likewise claim to be "protecting" teenage women from "health hazards" by imposing a federal requirement that their parents be notified every time they seek birth control services.78
It is obvious that these uses of "individual freedom" and "protection from abuse" are rhetorical and specious. Drug companies and doctors, in the tradition of all capitalist defenders of "free market" principles, seek to expand their freedom to do business and make a profit, rather than the freedom of individual women to avoid "red tape." American Cyanamid and other corporations seek to protect themselves, not women workers, from lawsuits in behalf of damaged fetuses or liability for cleaner workplaces.79 And if the Reagan administration and Senator Denton seek to "protect" teenage girls, it is not their health they are worried about but their virginity. Still, while feminists recognize and continually need to expose the distorted and self-serving uses of "reproductive freedom" ideology by those who oppose it, this does not resolve the dilemmas inherent in the ideas.
On one level, reproductive freedom must involve an element of socially determined need, which implies common standards and general principles that are socially enforced. There is a degree of risk that is intolerable for anyone, certain products that ought not to be sold, a standard of health and well-being that the society ought to expect for all its members whether they consciously seek it or not. On the other hand, needs are particular to ages, occupations, genders, conditions of health, and a whole range of circumstances. The medical risks a woman runs from taking birth control pills are affected to an important degree by her age, the state of her health, and whether she smokes.80 For some younger women, the pill may be the best birth control option now available, the one that gives them the most possibility for sexual self-determination and good health.81
While I do not think the tension between individual control and social protection will ever be totally resolved, there is a helpful conceptual process for bringing them more closely together. This involves establishing the necessary preconditions for individual control or consent within the immediate social context. The Federal Sterilization Regulations exemplify public policy, drafted by feminists and health activists, that embodies this notion of preconditions, including the more familiar "right to know" (full disclosure, orally and in writing, of all risks, consequences, and alternatives) and prohibiting a range of contextual situations that would effectively eliminate choice. The threat, real or imagined, that one’s livelihood— welfare or medical benefits, or one’s job—may be lost as a penalty for refusing sterilization diminishes choice, no matter how thorough one’s knowledge of the risks. In an analogous way, as long as the contraceptive alternatives available to women (or men) involve irreversible sterility, an irreducible element of risk to health, or an indeterminate risk of error, the availability of cheap, legal, and safe abortion is a necessary precondition for any of those methods to be a real choice. Without safe, legal abortion as a backup, being "free" to decide against the pill or sterilization is like being "free" to lose your job to avert sterility or miscarriage. One is not choosing to take risks if there is no viable alternative.