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Foreign Aid for Abortion Author(s): Donald P. Warwick Source: The Hastings Center Report, Vol. 10, No.

2 (Apr., 1980), pp. 30-37 Published by: The Hastings Center Stable URL: http://www.jstor.org/stable/3561278 . Accessed: 04/03/2011 13:01
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--POLITICS,
l

ETHICS & PRACTICE

Foreign

Aid

for

Abortion

by DONALDP. WARWICK

1A id for abortionis the most sensitive subject in the entirefield of nonmilitary foreign assistance.No topic will make a foreign aid official blanchmore quickly, and none will be greetedwith greaterwarinessin disclosing information. The questionis so emotionallychargedthat virtually nothing has been written about it. Data on international abortionactivities are typically not reportedat all, are reserved for classifieddocumentsof restrictedcirculation,or are buried under such generic names and euphemismsas regu"surgicalmethodsof family planning"or "menstrual lation." As a consequenceit has not been easy to gather datafor this article, which is the first attemptto surveythe field. Officialsinvolved with foreign aid for abortionwere generally willing to discuss their work, but were vague about details and wary of public attention. However, by from interviewswith scattered fragcombininginformation ments of existing data one can begin to constructa comabortionscene.' posite pictureof the international

The CurrentScene: An Overview


Before consideringthe activitiesof specific agencies, it is worthnotingthe broadfeaturesof the terrainin which they markedby complexity, ambioperate.It is an environment guity, human misery, political tension, and bureaucratic trepidations. First, apartfrom any outside intervention,inducedabortion is a commonpracticein the developingcountries.Not only is abortionfrequent, but it is a prominentcause of death and illness among women of childbearingage. In often accountfor LatinAmericancountriesillegal abortions a third of maternaldeaths; women whose abortionshave been mishandledfill half or more of the country'shospital beds. And unlike the situationin the United States, where is contraception generally availableto those who want it, of the poor women who resort to this method are many unawareof or do not have readyaccess to moder meansof birth control. While the statistics cited are often used to arguefor legalizedabortion,they have also been a sourceof concern to those categoricallyopposed to abortion.They
is DONALDP. WARWICK an InstituteFellow at the Harvard Institutefor InternationalDevelopment. This article is adapted from a presentation at the National Conference on Abortion, University of Notre Dame, October 1979, and will appear in J.T. Burtchaell, ed., Abortion Parley (Mission, Kansas: Andrews and McMeel, 1980).

have led some Catholicbishopsto soften theiroppositionto which they saw as the lesser of two evils for contraception, women faced with unwanted children. Whatever one's moralviews on abortion,the figurespoint to a humantragedy that cannotbe ignored. Second, foreign aid for abortionis but a small proportion of the total aid for populationactivities. Despite occasional rumorsthatabortionis a mainstayof populationassistance, of foreign aid for this purposeaddsup to less thana quarter one percentof the total spentfor population.On the supply side foreigndonorshave been preventedby law or inhibited by politics from pouringvast amountsinto this controversial area. On the demandside, despitethe widespread practice of abortionby individualwomen, it remainsillegal in many countriesand a point of moraland political debatein the domestic politics of these countries.Hence even if the total volume of funds availablefor abortionwere increased tenfold, the money would not be quickly or easily spent. Third, with the exception of United Nations agencies, most organizations supplyingfundsfor abortions operateon a clandestineand usually illegal basis. As one expertcommented, "Not even yourbest friendswill tell you whatthey are doing overseas." In some countries,includingthe Philippines, aid for abortionis both againstthe law, andagainst the country'sofficialpopulation policies. This is not to deny that there are many ambiguitiesabout what, precisely, is "legal," or that officials who speak publicly againstabortion may give tacit supportto clandestineforeign aid supportingit. The gap between rhetoricand reality is greater here thanin most spheresof development,for understandable reasons. Nevertheless,severe legal and culturalrestrictions on abortioncreatea climatein which privateagencies providingabortionservices may behave more like intelligence operativesthan bearersof foreign aid. Fourth,the most commontype of foreignaid involves the techniqueknown as uterineaspiration.This goes undervarious code phrases, especially "menstrualregulation"and "menstrualinduction." The essential feature is that the womb is efficientlyemptiedwithoutforcefuldilationof the cervix.2 The InternationalProjects Assistance Service the (IPAS) manufactures requiredequipment, and almost active overseas distributekits for this all the organizations purpose. In many countries doctors, nurses, paramedics, and midwives are being providedwith such kits andtrained in their use. Fifth, abortionin the developingcountriescan be a profitmakingproposition.Especiallyin urbanareasand where a countryhas tasted the fruits of development,as in Taiwan
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30

and Korea, women are willing to pay for abortionservices. Wherein the typicalfamily planningclinic client fees meet of only a small proportion total costs, with abortiona small amountof money, even a loan, can go a long way toward expandingservices. This point has not been lost on business-mindedagencies seeking a maximumreturnon their investment.In severalcountriesAmericandonorshave provided loans to one abortionclinic, which repaid the loan and generatedenough profitsto open new clinics. Finally, the politics of abortionin the United Stateshave had an overwhelmingimpact on foreign aid for abortion. in The highly chargedatmosphere this countryhas led not only to the Helms Amendmentof 1973 specificallybanning the use of foreign aid monies for abortion,but to a series of indirect effects. Established philanthropicorganizations will not fund abortionservicesfor fear of jeopardizing their core activities. Federal officials, fearing violations of the from theirsuperilaw, abusefrom Congress,or reprimands ors, use theirdiscretionto keep U.S. overseasinvolvement with abortionto a minimum.These repercussions extendto thatreceive Americanfunds, such as the Internaagencies tionalPlannedParenthood Federation.Faced with demands for tightaccountingon abortion anxiousto avoidAmerand ican reaction to visible initiatives in this field, recipient agencies walk a more narrowpath than they would prefer. Hence the United Stateshas become both the prime source of capitalfor abortionservices and the foremostinstigator of constraintson activism. Agency Activities donors were As of 1979 only a handful of international of involvedin directsupport abortionactivitiesin the developing countries;othersprovidedindirectassistancefor reactivities. With most of search, meetings, and information fromvisibilitymuchof the action the largedonorsshrinking has fallen to more intrepidand flexible smalleragencies. The Agency for International Development (AID), the of aid organization the U.S. government, principalforeign untilit was broughtto a of was an ardentsupporter abortion standstillby the Helms Amendment.Fromits beginningsin the 1960s until the Helms Amendmentwas passed in 1973 the AID's Office of Populationactively supported development of new techniquesfor abortion,includingthe uterine The Office Directorat that time, Dr. ReimertT. aspirator. Ravenholt, was a strong advocate of all methods of birth advocate control, including abortion, and an international for "postconfor the aspirator.But even with his keenness ceptive" methodsof birthcontrol, AID did not invest great amounts of money in abortionprogramsoverseas, essentially becausepoliticalleadersinterestedin family planning did not wish to jeopardizetheirotherwork. The prevailing sentiment was that contraceptionwas sensitive enough withoutaddingthe complexitiesof abortion.Hence despite Ravenholt'sstrongsupportfor improvedabortionmethods,
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there were not, until 1973, many recipientnations. In 1973, SenatorJesse Helms of NorthCarolinaamended the Foreign Assistance Act by drasticallycurtailingAID's activities on abortion.The Amendmentreads:
Section 114. Limiting use of funds for abortion-None of the funds made available to carry out this part (PartI of the Foreign Assistance Act of 1961) shall be used to pay for the performance of abortions as a method of family planning or to motivate or coerce any person to practice abortions.

As this languagewas necessarilyvague aboutoperational of implications,the Administrator AID issued the following on "policy determination" June 10, 1974.3
1. No AID funds will be used to ". .. procure or distrib-

ute equipmentprovidedfor the purposeof inducing abortions as a methodof family planning." 2. AID funds will not be used for the direct supportof abortionactivities in the developing countries. 3. "A.I.D does not and will not fund information,educathat seek to protion, training,or communication programs mote abortionas a methodof family planning.A.I.D. will financetrainingof developingcountrydoctorsin the latest techniquesused in OB-GYN practice.A.I.D. will not disqualify such trainingprogramsif they include pregnancy termination within the overall curriculum. However, A.I.D. funds will not be used to expandthe pregnancyterminationcomponentof such programs,andA.I.D. will pay of only the extracosts of financingthe participation develdoctorsin existingprograms.Such trainingis oping country providedonly at the election of the participants." 4. "A.I.D. will continue to supportresearchprograms designed to identify safer, simpler, and more effective means of fertility control. This work includes researchon both foresight and hindsightmethods of fertility control." [Hindsightmethods, of course, are those involving some form of abortion.] 5. "A.I.D. funds are not and will not be used to pay women in the developing countriesto have abortionsas a methodof family planning.Likewise, A.I.D. funds are not and will not be used to pay personsto performabortionsor to solicit persons to undergoabortions." In short, AID could provide no funds for the direct supor for portof abortion motivation abortion,but it could continue certain kinds of training and research involving abortion.It could also contributeto organizations,such as the PathfinderFund, which were involved in providing abortionservices providedthat AID's money was not used directlyfor that purpose. In practice, this restrictionhas forced AID to withdraw from most abortionactivities. In 1979 less thanone-half of fundswere spenton any aspect one percentof its population of abortion.A good part of these funds go to the International FertilityResearchProgramin NorthCarolina,which conducts studies on effective methods of birth limitation. Among these are various abortionmethods, includingdifferent techniquesof "menstrualregulation."Research on 31

these methods, which is conductedby collaborators sevin eralcountries,does involve abortion,butunderthe termsof the Helms Amendmentit is permissibleso long as there is no active promotionor provisionof services. AID also supportstrainingprogramsin which medicaldoctorsare given instructionin abortionmethods under the conditions outlined earlier. Coupled with the political controversies surrounding abortion,the Helms Amendmenthas affected AID and its the fundingrecipientsin manyways. Most important, overall level of monitoring controlin this field has increased and at least fivefold. Sensitive to the political dangersat stake for themselves and the agency, administrators, lawyers, contractofficers, and auditorsin AID and elsewherein the government keep a close watchon any activitieseven close to abortion. Within AID, officials must be exceptionally carefulof whatthey do in the firstinstanceandthenclearall proposalsthroughmultiplelevels of approvals.Needless to say, this process dampens the enthusiasmof those most committedto providingabortionservices. Organizations reAID funds, most notablythe International Planned ceiving Parenthood Federation Fund, are (IPPF)and the Pathfinder also under strong pressure to maintain detailed records showing that AID funds have not been used for abortion. Wherethereis doubt, the burdenof proof is on the receivThis is a classicalcase of the politicalconing organization. text of administrationconstraining public officials to minimize controversy. Recipient organizationshave also been forcedto changetheirentirereporting system and add their own auditorsto deal with the demandsand questions of monitorsfrom the government. The only two majoragencies that do operateopenly in this field, thoughwithoutpublicityandon a small scale, are the World Bank and the United Nations Fund for Population Activities (UNFPA). The UNFPA's policy is to respond to country requests for assistance for all kinds of populationprograms,providedthat they are within the organization'smandateand do not violate UN policies on humanrights. The UNFPA places no restrictions methon ods of fertilitycontrol, and is willing to entertainrequests for abortionassistance.To date it has providedsuch assistance to India, Thailand,and Tunisia.It also contributes to the Special Programof the World Health Organization, which includesresearchon methodsof abortion,andto university researchprogramsinvestigatingabortionmethods. In 1979 UNFPA assistance for all activities in abortion came to less than one-quarter one percent of its total of budget. The World Bank operatesunder similar policies, and spendsan even smallerproportion its funds on aborof tion. While both organizations receive substantialfunding from the United States for a wide variety of aid projects, their position is that the monies providedmust come with no spendingrestrictions.They will thus resist any attempt to by contributors impose a curbon abortionexpenditures. Major philanthropicorganizations, including the Ford 32

and RockefellerFoundations, have always shied away from funding abortion projects. While Ford has long been a in frontrunner supportfor populationactivities, and for a time was the largest single contributor the field, it has to consistentlyturneddown projectsinvolving abortionservices. The Rockefeller Foundationhas been similarly inclined. Despite some urging from AID and other agencies to fill the gap created by the Helms Amendment, established foundations apparentlydecided to avoid abortion projects. Two reasons were cited by persons familiarwith these organizations.The first is that associationwith abortion could touchoff controversies wouldimpairworkin that less volatile areasof higherpriority.The second is that the illegal natureof abortionin many countriesand the common use of clandestine techniquesto promoteabortionservices would cause considerable squeamishness among professionalstaff membersat the foundations. Critics accuse these organizationsof excessive caution springing from a desireto protecttheirimage in the "establishment," while moresympathetic observerscommendthem for common sense and adherenceto the law and to their basic institutional values. Whateverthe case, the large foundations have given little more than moral supportto international programsfor abortionservices. The PopulationCouncil of New York falls somewhere between the foundationswhich help to keep it in existence and more activist agencies. Perhaps the single most rein spectedprofessionalorganization populationstudies, the Council has had a notable impact on populationpolicies, programs,and researchin many nations. In legal constitution, internalorganization,staff composition, and institutional demeanorit is much like a large foundation. The word "professionalism" was cited by many staff members as a keynoteof the Council'sbehavior,while the desirefor cooperativerelationshipswith governmentshas generally led to an "above board"approachin technicalassistance. One mightthus expect thatit would have some of the same to antipathies abortionprojectsas the Fordand Rockefeller Foundations,with which it is in close contact. At the same time the Council has undertakenadvisory assignmentsin the developing countries,includingprojectscarriedout in very delicate political environments.It also did not shrink from controversy when it developed and promoted the Lippesloop, and when it becamea frankadvocateof voluntary family planningprograms.But from its inception in 1952 until 1976 its activities on abortionwere confined to researchand writing. During his presidencythe late Bernard Berelson had serious ethical and prudentialreservations about foreign aid for abortion,and his boardseemed to share those misgivings. In 1976the presidencypassedto GeorgeZeidenstein,and in a reportto the boardthat June, Zeidensteinmade three relatedto abortion:(1) that the Council's recommendations should be, inter alia, to "stimulate, encourage, purpose promote, conduct, support. . . abortion;"(2) that its Bio-

HastingsCenter Report,April1980

Medical Centerengage in "mission-oriented research"on abortion and (3) thatthe organization aboradd technology; tion to the "range of services" it provides.4This recommended change drew a strong dissent from trustee John Noonan, Jr., who resigned in protest. Despite this shift in policy, over the past three years the PopulationCouncil's involvementwith abortion been minimal,and not strikhas different from the period before 1976. Christopher ingly Tietze continuesto conduct statisticalresearchon various facets of abortionand thereare some small researchefforts overseas, but on the whole the PopulationCouncilremains more like the FordFoundation thanmore activistagencies. The reasonsare probablythe same as in the foundations-a fearthatcontroversy over abortion cripplethe organizawill tion in otherareas, problemsof professionalself-imagefor staff members,and difficultyin actingwithoutbreaking the laws of othercountries. The InternationalPlanned Parenthood Federation of London (IPPF) has been the most outspokenadvocate of legal abortionservices in the developingcountries,though not the most ardentpromoterof such services. The IPPF is the centraloffice for several dozen semi-autonomous private national family planning associations. As a central donors, including body it receives funds from international AID, and passes money and suppliesalong to the local associations.It also triesto set policies and standards applicable to all associations,includingpolicies on abortion.The IPPF's stated position is that abortion should be legally availableto those who desire it and that local associations, when possible, should assist in providing the necessary services. But while it has considerableleverage from its fundingposition, the IPPFmustalso respectthe constraints andpreferencesof its local affiliates.In practicethe central office can recommend, lobby, and cajole, but it cannot force a memberassociationto take action on abortion. on Despite its frequentpronouncements the need for safe and legal abortionservices andits lobbyingeffortsin many countries,the IPPF spendsonly aboutone-thirdof one percent of its total funds on abortion.As of 1978 it had carried out specific projectsin ten countriesas well as variousregional and global efforts, mostly in training. In the Philippines,where abortionis both illegal and explicitly againstofficialpopulation policy, the IPPFprovided 200 "menstrualregulation" kits for demonstrationpurposes. IPPF also conducted a local seminar that set off sharpcontroversy.Beginningin 1974the IPPFaffiliate,the of FamilyPlanningOrganization the Philippines(FPOP)organizeda series of meetingsunderthe title of "Symposiaon Advances in Fertility."5The topics included medical and legal aspects of abortion, proceduresand techniques of healthrisksof aborabortion,andthe dangersand attendant tion. The first meeting touchedoff a stormof protestfrom religious and civic leaders, and led the governmentto reaffirmits official oppositionto abortion.Nevertheless,the FPOPcontinuedits symposia, which were clearly aimed at
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legitimizing discussion of abortionin the Philippinesand which were made possible by fundingfrom IPPF. Furthercontroversy arose when the FPOP distributed "menstrual regulation"kits to local doctors. Although the governmenthad laws specifically prohibitingthe importation of abortivedevices, these kits were broughtinto the to countryas "medicalinstruments" obtain "sampletissue for examination."While awarethat the vacuum aspirators had been importedand were being distributedto private doctors, the government'sofficial body in this field, the Commissionon Population,chose not to take action. Since the FPOPdid not take a public standfavoringabortion,and since it did not use these devices in its own clinics, the Commission felt that its regulatorypowers were limited. OtherobserversconcludedthatPOPCOMofficials were de activitiesso long as facto not opposedto such underground they generatedno public uproar.These examples show the for potentialof the IPPFand its collaborating organizations nationallaws and policies, and also suggest circumventing that officials responsiblefor enforcing those policies may themselves not be totally opposed to their violation. One of IPPF's largest projects, totalling about $62,000, was in Bangladesh, where 5,000 vacuum aspirationkits were provided to the local family planning association. These kits have also been supplied to Korea, Singapore, Hong Kong, Thailand,Vietnam, and India. Althoughmost of these projectshave been relativelysmall-usually under $30,000-the IPPFhas not provideddetailsof its activities in its publishedreports, even in its main reportto donor agencies.6One reason, apartfromthe illegal and controversial natureof these activities, may be thatthe federationis underconstantscrutinyfrom the U.S. government insure to that it is not violating the Helms Amendment. Anotheractivistagency, andone thathas been more willFund ing to "go public" with its activities,is the Pathfinder of Boston. Pathfinder foundedin 1929by Dr. Clarence was Gamble to find new ways of promotingbirth control. Its characteristics have been innovation,small size and quick action. In recent years innovationhas meant activities in the abortion,particularly promotionof the uterineaspirator. A Pathfinder flyer issued around1975 states:
as Abortion-safe, legal, and available-is important a backup for contraceptivefailure, and as a way to bring women into at programsof contraception the momentthey are most susceptible to persuasion. But because of the Helms Amendmentto the foreign-aid law, no AID money can be spent to promote abortion. Therefore we do this importantwork with money raised from the private sector. Pathfinderis encouraging the establishmentof abortion as a woman'sright. We arepromotingthe early-abortion procedure known as "menstrualinduction"-through publications, dishas tributionof instruments,and direct grants. And Pathfinder sponsored a major conference.7

has In recent years Pathfinder engaged in two kinds of abortionactivities:helping to establishclinics in countries 33

whereabortionservices are illegal but toleratedby the govvacuum aspirationkits to clinics ernment;and distributing andprivatepractitioners who wish to use them. Thus it has recentlyworkedwith a local doctorto open a privateabortion clinic in Colombia,andhas similaractivitieselsewhere in Latin America. When asked about the legality of this move in Colombia, an individualfamiliarwith the project said that the clinic was indeed illegal, but that prosecution was unlikely, if only because the childrenof public figures commented: were using its services. A staff memberfurther we don'tthinkthat "Whereabortionis culturally acceptable the law is restrictivein an ethical sense. We are also conlevel-will it be enforcedor not." He cernedat the practical likewise raiseda crucialpoint aboutlegality:the difference between the laws on the books and the laws as interpreted by the government.In Bangladesh, abortionis still technically illegal in most cases, but the governmenthas instructedmedical schools that by 1981 the country's 420 local health centers should offer "menstrualregulation" services. There is thus a difference between the law and executive regulations,with the lattertaking precedencein Bangladesh. The Pathfinder Fund, which receives over 90 percentof its fundsfromAID, has been hardhit by the Helms Amendment. The net effect has been to force the organizationto choose betweenprovidingfamily planningservices without abortionor abortionwithoutbroaderservices. If Pathfinder wantsto help establisha family planningunit withoutabortion, AID will cover all or most of the costs. But if abortion As is included,AID will provideonly the contraceptives. a Pathfinder official put it, "The Helms Amendmenthas disby astrouslyaffected populationprogramming destroying recruitall the linkagesbetween abortionand contraceptive has Pathfinder also been forcedto changeits accounting." ing and auditingsystem in orderto convince government monitorsthatno federalfundsarebeing spentfor abortions. One of the most influentialand yet anomalousorganizaCrisisCommittee,which tions in this field is the Population has been a powerfullobbyist for birthcontrolin Washinghas ton. This organization been very much "up front" on the UnitedStatesdomesticscene. Withits boardmadeup of and retiredambassadors generals, prominentbusinessmen, and othernotablepublic figures, it would seem an unlikely supporterof illegal abortionactivities overseas. And yet that is precisely what it does outside the United States, thoughnever underits own name. A recentUN document on populationprogramsand projectscontainsthis descripFund: tion of the PopulationCrisis Committee/Draper
PCC/DFworks to generatesupportfor reducingworld population growth in two basic ways: throughhigh-level advocacy at home and abroad to increase government commitment to and strong, effective family planningprogrammes; throughits selective support of innovative, cost-effective private highly family planningprojectsin developing countries . . . Through arrangingprivate support of special projects overseas, PCC

makes possible indigenous activities that can be readily expanded or replicated.8

While abortionis not specifically mentionedin this description,closer checkingrevealsthatthis is its majorform of "innovative,cost-effective,privatefamily planningprojects." Abortionactivitiesaccountfor aboutone half of the
Committee's "Special Projects" and about one-fourth of its international budget. The organization works as follows: PCC has no overseas operations. Instead, it funds or finds funding for selected high-leverageprojectsinitiatedby or recommendedto PCC by IPPF and otherfamily planning/population organizationsthat have a proven trackrecord in overseas in operations.Projectsare undertaken collaborationwith indigenous leadersand groups . . . Projectsselected for supportare those thatpromise exceptionalreturnin lowered birthratesper dollar invested. Typically such projectsinvolve one of the ten most populous ThirdWorld countries;they demonstrateor extend an approachto delivery of family planning services that has provencost-effective in lowering birthrates in similarconditions elsewhere;they requireprivatemoney because the governmentis not ready to accept a new approachuntil it has been proven successful; and they include a sensible plan for expansion or replication.9 At present the Population Crisis Committee leans strongly

towardprogramsinvolving the participation local busiof of a three-legged nessmen.In abortion they speak programs
stool involving a doctor, who provides the services, the woman, who receives them, and the businessman, who organizes them to generate a profit. In practice, PCC looks for projects in which a small amount of seed money can be used by local entrepreneurs to launch self-funding abortion activities on a much larger scale. PCC officials offer as an

example a projectin Taiwanin which a loan for one clinic


ultimately led to a total of nineteen, all patterned exactly after the first. PCC prefers projects in which abortion services are closely linked to contraception so that the experience is not repeated. The following are some of its projects: Philippines: Menstrual Regulation Training. To train and equip doctors to performmenstrualregulationon the island of Mindinao. $34,000 committed for two years beginning May 1978 to International Projects Assistance Services.10 Colombia: Bogota PregnancyClinic. To provide inexpensive, for humanetreatment incompleteabortionsusing the new techabortion, to train nology developed for simple first-trimester doctors throughoutLatin America in these abortion clean-up techniques, and to reduce the incidence of abortionin Colombia by using the occasion of botched abortion to involve women in appropriate family planning practices." Bangladesh: (1) AbortionTrainingand Supplies. Trainingfor doctors from government health centers, mobile camps and health districtsin the use of the latest abortiontechniquesand supply of non-electricalvacuum aspirators.$8,356 committed for one year to International Projects Assistance Services. (2) Abortion training. To train new doctors and qualified paramedics in early abortion, menstrualregulation and the treatment of incomplete abortions as well as contraceptive

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counselingin 6 regional and 2 Dacca medical colleges. for Fund.12 $35,000 committed one yearto the Pathfinder The agencies most often chosen for projectexecutionare the PathfinderFund and International Project Assistance Service (IPAS). PCC officials feel that private abortion services have a bright future in the developing countries, mainly because they are profitableand thus appeal to the instinctsof local people. They also feel that entrepreneurial the Helms Amendmentmay have been a blessing in disguise, for it has forced abortionadvocatesto rely less on large donorsand the public sectorand makeproductiveexplorationsinto abortionas a business venture. Beyond its catalyticrole in stimulatingabortionactivities, the PCC is the Americanpurchasing agent for the IPPFand suppliesit with vacuum aspirationkits manufactured the IPAS. by in Thoughunobtrusive its international operations,the PCC is undoubtedlyone of the most influentialagencies in this field. And besides its own indirectfundingof abortionand other projects, PCC takes an active role in fundraising. The most agressiveorganization this arenais the Interin national Projects Assistance Service (IPAS), formerly known as the International PregnancyAdvisory Service. This is an organization that is disreputable proudof it. and Its policy is to move in whereverit can to promoteabortion. As a formerstaff membersaid, "Ourpolicy is thatthe more it abortionis illegal, the moreattractive is becauseit is neccan essary. If it is legal other organizations handle it." At presentIPAS works in three areas:(1) providingloans for the establishmentof abortion clinics; (2) manufacturing vacuum aspirationequipmentfor sale to other organizaand tions, such as Pathfinder the IPPF;and (3) directabortion services. Their strategyon this last front is to identify doctorswho areinterested abortion,whetherit is legal or in not, and then help them to initiatenew services. They are now supporting clinics in some twenty countries,including Brazil and Indonesia, where abortionis illegal. Mexico, midwivesin the Philippinesto use the They arealso training vacuumaspirator, even thoughthis techniqueis specifically banned by the government.In Bangladesh, Pakistan, Sri Lanka,Thailand,and Mexico, IPAS offers vacuumaspiratorkits througha directmail program,andprovidestraining in their use. They find themselves handicapped raising in funds, mainly because their direct action tactics leave potential donors uncomfortableabout supportinga "pariah."Foundations such as FordandRockefellerareunwilling to supportthem, while AID is unable to do so. Hence they mustdependon grantsfrom the PCC and otherprivate sources as well as on the revenuesgeneratedby theirloan programand manufacturing operations.Although, as they it, "ourresponseis always yes," the ExecutiveDirector put claims that the funds available are much smaller than the interestthey find in expandingabortionservices. involved in some aspects of abortion Otherorganizations are Family PlanningInternational Assistance, the interna-

tional division of the Planned ParenthoodFederationof America; Population Services International;and Johns HopkinsUniversity, which providestrainingin techniques of abortion. But the most critical actors are IPPF, Pathfinder, the PopulationCrisis Committee,and IPAS.

TowardNew Groundfor Ethical Debate


Foreignaid for abortionraises a host of ethicalquestions. The most basic is, of course, the moralityof abortionitself. Debate on this issue is not simple withinthe United States, but it becomes immensely more complicated when the scene of action involves two or more nations. The root problemis that thereis no universallyacceptedethics, nor even a common languagefor debatingmoral issues across countriesandcultures.Thus when we ask whatethicalprinciples should guide the UN in aid for abortion,we quickly stumbleover the questionsof what and whose moralviews should prevail. Should we opt for a franknationalrelativism, allowing each government to announce its moral standardsand then having the UN respect those judgements? This position is appealingin its simplicity, but it clashes with the conceptof universalhumanrightsalso endorsed by the UN. And where governments have unequivocally stated their oppositionto abortionon religious, moral, or politicalgrounds,shouldpro-choiceadvocatestry to claim thattheirconceptionsof individual rightstakeprecedence over national sovereignty?These are tough questions that will not be resolved with instant absolutes or ready relativisms.And the debate is not likely to progress very far without much more systematic work on a crossculturaland cross-national ethics. At this time our poverty of principlesis outdone only by the richness of rhetorical flourishesin the abortiondebate. While the moralityof abortionwill remainthe paramount questionin evaluatingforeign aid for thatpurpose,it is not the only issue at stake. Otherquestionsarisefromthe objecassistance tives, processes, andcompositionof international in this field. Theremay well be situationsin which the most staunch pro-choice advocate would concede that certain kinds of foreign aid for abortionare unjustified,and where might grantthat aid equally ardentpro-life representatives for problemsrelatedto abortionis ethically acceptable.To stakeout some new groundfor ethicaldebateit will be helpful to begin with three workingprinciples. The first is that the overarching goal of foreign aid should be individualandfamily welfare. All assistanceto the developing countriesshould aim to promote such universallysoughtgoods as health,education,a decentlevel of living, self-respect,and the abilityto controlsignificantaspects of one's existence. While this principlehas been used by pro-choice as well as pro-life groups to supporttheir the respectiveclaims, thereare questionstranscending usual debates.The broadestimplicationof the welfareprincipleis that foreign aid should be used to remove or reduce the

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conditionsleadingpoor women to seek abortions the first in these conditions are poverty and ignoplace. Basically, rance. A welfare orientationwould argue strongly against foreign aid for abortionthatdoes nothingto change the socio-economicconditionsleading to high fertility. A singleminded concern with the fertilityvariableseems inconsistent with the promotionof individualand family welfare. The same criticismwould applyto pro-lifegroupsthatseem more intent on stopping foreign aid for abortionthan on increasingthe amountsspenton generaldevelopmentactivities. Indeed, if pro-life forces align themselves with antiUN lobbies to cut off all Americanfundsto the WorldBank and the UNFPA, as has been threatened the past, they in wouldjoin theirantagonists an obsession with fertilityto in the detrimentof economic justice. The welfareprinciplefurthersuggests thatforeignaid for wouldnot be justifiedif its sole or primary was aim abortion to bringdown the birthrate. It would seem a flagrant violation of welfareto use the desperation women for populaof tion control while doing nothing to remove the conditions producingsuch desperation.Specifically,programs providing only abortionservices, with no assistancefor healthor contraception, would be ethically suspect on welfare grounds,and doubly so when they yield a profit. The welfare criterionmight also argue for foreign aid to treat incomplete abortions. Human compassion calls for helping women who incur the risk of death or serious illness from badly performedabortions,even if one disapprovesof the sourcesof thatrisk. Manyphysiciansof pro-lifesympathies have no moralqualmsaboutprovidingmedical services in these circumstances, althoughthey would rejectthe preventive step of medicallysupervisedabortions.In short,raising the questionof welfare may help to take the debate about foreign aid to at least a few steps beyond the polarization that has been its hallmarkto date. A second principle is thatforeign aid for population should respect national autonomy. The WorldPopulation Plan of Action, approvedin Bucharestin 1974, sets forth the following guideline:"Theformulation implementaand tion of populationpolicies is the sovereign right of each nation. This rightis to be exercisedin accordancewith national objectives and needs and without external intertion policies and programs with nationalauthorities."13 lies Adherenceto this principlewould seem a primafacie oblidonors. Accordingto this normthe gation for international UNFPA and the World Bank would be justified, on proceduralgrounds, in supplyingaid for abortionto countries requestingtheir help. By the same token the clandestine activitiesreviewedearlierwouldbe unjustified, particularly when abortionis not only technically illegal but directly contravenesa country'sofficial populationpolicy. Threeoverlapping have been raisedagainstrearguments spect for nationalautonomy.The firstis thatin many countrieslaws aboutabortion have no moralforce since they are 36
ference. . . . The main responsibility for national popula-

merelyvestiges of colonialismandare not observedin practice. One pro-choicephysiciancomparedthem to the antiquated laws on the books in many states, such as those governing the positions of men and women walking together. A specific case cited was Bangladesh, where laws and executive edicts were patentlycontradictory. This exdoes suggest that there are legitimate grounds for ample debate about what really constitutesa country'spolicies. Where the governmentitself openly requestsaid for abortion, donor agencies would obviously not be violating its autonomyby providingsuch assistance.But wherethe governmentis manifestlyand forcefullyon recordas being opposed to abortion, as in the Philippines, and assures its critics that abortionis not being practicedwith the consent of national authorities,covert foreign aid for abortionto nongovernmental recipientswould violate autonomy. A second argumentis that foreign aid programsshould honor not the laws that are on the books, but the laws of culturalpreferenceas expressedin citizen's behavior.Thus when largenumbersof women by theiractionsshow a clear preferencefor abortion,donorsshould respecttheir wishes rather thanoutmodedlaws restricting safe abortions.Sometimes this argumentis premisedon the notion of universal humanrights for women, sometimes on the principlethat cultureis a higher law than legislation. The problemswith this argument both substantive procedural.On subare and stantive grounds one would want to know if all cultural preferences, including the execution of minority groups, cannibalism,and female circumcision, should override a country'slaws, or if a universalright to life of the fetus should be cited as a basis for subvertinglaws permitting abortion.Froma procedural the standpoint criticaldifficulty lies in deciding who should make decisions about the relative meritsof a country'slaws vis-a-vis competingsources of legitimacy.It hardlyseems justifiablefor donoragencies to take it upon themselves to make this judgement, since their own bureaucratic political interestsare usually at or stake in the decision. At the very least one would want the matterto be adjudicated some neutralcourt of appeals. by A thirdargument aboragainstrespectfor laws restricting tion is that governmentsthemselves are often divided on this question.In such pluralisticsettingssome groupsare in favorof actionand othersopposed. Underthese conditions, donorrepresentatives have argued,foreign agencies have a to work with supportiveofficials, even if abortionis right illegal and against the country's official policy. In other words, when opinion is split on abortionpolicy there is nothingwrongwith donorstakingsides since therewill also be nationalson that side. But here, too, there are ethical difficulties. By taking sides, particularly when supportis a generousinfusionof foreign monies, the accompanied by donors are, in fact, infringingon nationalautonomy in a delicate area. Foreignintervention becomes esparticularly pecially questionablewhen externalfinancingis used as a bargaining chip in negotiating what is fundamentallya

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moralandpolitical questionon the nationalscene. Second, international agencies supplyingaid for abortionunderconditions of secrecy are themselves being hypocriticaland aiding governmental double-dealing.This approachseems denies highly unjustifiedif the governmentsimultaneously taking aid for abortionand accepts funds for that purpose. In such circumstances domestic critics of abortion,such as the RomanCatholichierarchyin the Philippines,are being deceived aboutthe government's intentionsand deliberately the donor's actions, and are thus deprivedof their right to commenton populationactivities. The ethical problemsof covert interventionare compoundedwhen, as is often the case, the donor'saim is to establisha beachheadof services which will be extremely difficult to dislodge even when they are made public. While such issues arise in other spheresof foreign assistance,they are of particular significanceherebecauseof the deep moralandreligiousvalues at stake in abortion. A great drawbackto violations of nationalautonomyis thatthey cannotbe turnedinto a workableuniversalprinciple. One "categoricalimperative"might read: "Whenever a donoragency considersnationalautonomysubservientto its own conception of human rights or public policy, its conceptionshouldprevail."Accordingto this criterionforeign organizations opposingthe U.S. SupremeCourt's1973 decision on abortionwould have a moral warrantto use clandestinemeansin supporting proposedconstitutional the amendment abortion.Hence SaudiArabiaand other against conservativeIslamiccountrieswould be justifiedin supplying the United States Right to Life movement with, say, $100 million for undercoveractivities in support of this amendment.Most of us would find this a horrifyingprospect, yet this is very close to what is being done on a smallerscale to promoteabortionin developing countries. A thirdguidingprincipleis thatforeign aid for abortion should notjeopardizeforeign aidfor socioeconomicdevelopment. The greatbulk of economic assistancetoday goes for activities other than population, including agriculture and nutrition,education, health, and public works. Most aid programstry to improvehumanwelfareby findingbetter ways of producingrice and wheat, by increasingaccess to schoolingfor the ruralpoor, by experimenting with lowcost methodsof deliveringhealthcare, and throughsimilar means. To work well in promotingdevelopment, foreign aid requiresan atmosphereof mutualtrust and collaboration, not only between the donor agency and the government but with other segments of the society as well. The greatestrisk of covert aid for abortionis thatit will pollute this environmentand place all foreign assistance under a cloud of controversyand doubt. There are already suspicions in some quarters,particularly Latin America and in Africa, that donorsbootleg as much birthcontrolas possible into countriesthat do not want it. These suspicionsare abettedby evidence that a decade ago, when family planning programswere coming into their own, donors im-

tree portedthe Lippes loop underthe billing of "Christmas ornaments"and other contraceptives "fungicides."The as point here is that fears about hidden agendas and surreptitious activities on abortion can undercutthe efforts of agenciesthatoperatecompletelyabove board,even in areas seeminglyunconnectedto birthcontrol.And in the population field itself doubts about donor integrity can make a reluctant open the doorfor assistanceto famto government ily planningservices or even research.If an AfricanMinister of Health fears that a family planningprogramwill be takenover by abortionadvocatesand latercause a political explosion, he may be reluctantto move down that path at all. No programis an island in foreign aid. In the end we must ask what constitutesethical foreign aid. Is assistance to other countriesprimarilya means to help governmentsattaintheir own purpose, or is it an instrumentfor subvertingthose purposes?The issues raised here can fruitfullybe debatedby persons who differ on the moralityof abortionbut who sharea common commitment to the promotionof nationaldevelopmentand international cooperation.It is a debate that is badly needed.
REFERENCES 'This articleis based on several interrelated sources:the author'sown researchon foreign aid agencies; unpublishedcountrystudies prepared for the Hastings Center's Project on CulturalValues and Population Policies by scholars in several of the developing countries;and recent interviews dealing specifically with foreign aid for abortion. Persons contacted included present or former staff members of the Population DeCouncil, the Office of Populationof the Agency for International velopment, the PopulationCrisis Committee, the PathfinderFund, the International ProjectsAssistance Service, the International FertilityResearch Program,and the U.S. Senate. 2H.R. Holtrop and R.S. Waife, Uterine Aspiration Techniques in Family Planning (ChestnutHill, Mass.: The PathfinderFund, 1976), p. 1. 3U.S. Departmentof State, Agency for International Development, "A.I.D. Policies Relative to Abortion-Related Activities." Policy Determination,PD-56, June 10, 1974. 4GeorgeZeidenstein, "FutureDirectionsof the PopulationCouncil." for Reportprepared the meeting of the Board of Trusteesof the Population Council, June 8-9, 1976. 5Material describing this incident is contained in M.E. Lopez, A.M.R. Nemenzo, L. Quisumbing-Baybay, and N. Lopez-Fitzpatrick, Cultural Values and Population Policy: Philippines. The Sociological Study (Quezon City: Instituteof PhilippineCulture,Ateneo de Manila University, 1978). 6The informationsummarizedhere was obtained from an informal reporton abortionpreparedby IPPF in 1979. 7The PathfinderFund, "Pathwaysin PopulationPlanning." Promotional flyer issued circa 1975. 8United Nations Fund for Population Activities, Population Programmesand Projects. Vol. I: Guide to Sources of InternationalPopulation Assistance (New York: United Nations Fund for Population Activities, 1979), p. 297. 91bid. I?UnitedNations Fund for Population Activities, Population Programmes and Projects. Vol. II: Inventory of Population Projects in Developing CountriesAround the World 1977/78 (New York: United Nations Fund for PopulationActivities, 1979), p. 303. "Ibid., p. 71. 2Ibid., p. 31. 3United Nations, World Population Conference, Action Taken at Bucharest(United Nations, New York:Centerfor Economic and Social Information/OPI the World PopulationConference, 1974), p. 10. for

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