Reproduction and Family Health

After a speech on AIDS at the National Press Club in Washington in late March 1987, reporters pressed U.S. Surgeon General C. Everett Koop whether a pregnant woman with AIDS should be counseled about abortion. Koop responded that even though he would never personally recommend an abortion, the woman should receive advice on abortion because of the risk of transmitting the disease to her child. His offhand comment, distorted further, he complained, by the press, was interpreted by many abortion foes as a betrayal of his anti-abortion principles. Coming not long after the release of his report on AIDS, a report that had incensed conservatives with its frank discussion of sexuality and condom use, his remark further alienated his former supporters. Abortion proved the most vexing issue of Koop's tenure because it blurred the boundary between public health and personal moral choices.

Koop was exasperated by criticism that he had abandoned his stance on abortion, which as an evangelical Christian he had strongly opposed throughout his life. "My concern for the unborn followed as the night the day my concern about the newly born," he explained. "How could I ever accept the destruction of the unborn after a career devoted to the repair of imperfect newborns, knowing the joy and fulfillment they brought to their families?" Moreover, he feared that the abortion of unwanted babies prepared the moral ground for the decimation of other groups who often imposed a burden on their caretakers and on society, namely persons with disabilities and the elderly, through euthanasia and assisted suicide. Koop opposed these measures as much as he opposed abortion. After the U.S. Supreme Court's Roe v. Wade decision legalized abortion in 1973, Koop made his concerns public in a book, The Right to Live, The Right to Die, and in Whatever Happened to the Human Race?, a multimedia project of five films and complementary lectures and seminars he produced together with the theologian Francis Shaeffer. Although he continued to perform operations, Koop assigned patients who required long-term care to other doctors while he lectured against abortion and euthanasia across the country. In his own mind, if not in the minds of his conservative critics, his opposition to abortion was unquestioned.

For Koop, refusing to take an official stand on abortion was consistent with his anti-abortion beliefs. He had been chosen as Surgeon General by President Ronald Reagan, and had been supported by conservatives, with the expectation that he would use his office to promote an anti-abortion agenda. Yet, while he continued to express his views on abortion privately before pro-life and evangelical religious groups, including pro-life audiences invited by President Reagan to the White House, he avoided the issue in his official function as Surgeon General. As Koop explained, he conceived of abortion as a moral issue that could only be resolved through moral inquiry and reform, not as a public health issue that was amenable to medical or scientific solutions.

Pro-life activists continued to misunderstand and, Koop charged, in some cases deliberately to misconstrue his position on abortion during his final two years in office. They felt confirmed in their view that Koop was a traitor to the pro-life cause. Koop himself, on the other hand, became disillusioned with their single-minded approach to politics. Tension between pro-life activists and Koop heightened when in 1988 President Reagan asked Koop to prepare a Surgeon General's report on the effects of abortion on women's health. During two terms in office, Reagan had done little to deliver on his campaign promise to restrict abortion. With the end of his presidency in sight, he sought to affirm his pro-life values by focusing on the psychological and physical effects of abortion on women, which he thought were pronounced enough to provide a rationale for reversing the nation's abortion laws and policies.

Koop accepted the assignment with great reluctance, suspecting that Reagan was concerned more with appeasing his political base than with improving women's health. As had become Koop's practice in drafting reports, he personally interviewed experts, activists, and people directly affected on both sides of the abortion controversy. He found that, even more so than in the debate over AIDS, the politics of abortion skewed scientific approaches. Researchers allowed the design of their studies as well as their results to be influenced by their moral and political commitments in regard to abortion. Koop concluded that there was no unbiased, rigorous scientific research on the effects of abortion on women's health that could serve as the basis for a Surgeon General's report on the issue. He had hoped to explain his conclusion to the president in person, but the issue was overtaken by the presidential election of November 1988, and by Reagan's preparations for his departure from office. Koop was able only to deliver a letter to White House staffers, dated January 9, 1989, in which he stated that "the available scientific evidence about the psychological sequelae of abortion simply cannot support either the preconceived notions of those pro-life or those pro-choice." Koop's careful qualification that there was at present no objective scientific data to help decide the issue was lost in some media reports, which announced, inaccurately, that the Surgeon General had found no evidence for abortion's harmful effect on women's health. Pro-life groups responded to these reports by denouncing Koop for apparently endorsing abortion rights.

Koop's refusal to take a pro-life position in the debate over the health effects of abortion on women made him unsuitable in the eyes of many conservatives for the position of Secretary of Health and Human Services in the new administration of President George H. W. Bush, a position in which Koop had expressed interest. When Bush did not offer him the job and sent signals that his services were no longer desired--for instance by firing his main assistant--Koop decided to leave office one month before the end of his second term. The issue that had dominated Koop's confirmation as Surgeon General--abortion--also heralded his exit from government service.

If abortion was the most controversial of the issues involving reproduction, sexuality, and family health, it was not the only such issue for Surgeon General Koop, nor was it the one to which he devoted most of his time and energy. To Koop, his own family had been the most formative influence on his life, character, moral values, and sense of self. He saw the health of the family, so essential to an individual's well-being, under threat from several directions, not only from the high number of abortions but also from health hazards that he, as the nation's top public health officer, could address by encouraging scientific study, disseminating health information, and fostering public debate and consensus. These health hazards included inadequate maternal and child health care as well as the poor diet of many Americans, both of longstanding concern to the federal government. Koop made these issues the subject, respectively, of the "Surgeon General's Workshop on Breastfeeding and Human Lactation," held in June 1984, and The Surgeon General's Report on Nutrition and Health, published in 1988. Koop addressed another well-established area of federal social and health policy, the welfare and health needs of the elderly, in his "Surgeon General's Workshop on Health Promotion and Aging," held in March 1988. During the workshop participants stressed that the later years of life were not just a prelude to death, but provided opportunities to share expertise and experience with younger generations in ways that could make the elderly a productive asset to their families and communities--the emphasis also of the many speeches Koop devoted to the medical, psychological, and social ramifications of the aging process.

In addition, Koop saw threats to family health arising from hazards that previously had not been a matter of federal health policy, namely from domestic and other forms of violence, such as pornography, child sexual abuse, drunk driving, and preventable household accidents. Koop acknowledged that these problems "were usually beyond the purview of the Surgeon General" because they were most often approached as problems of law and law enforcement, of private morality, and of free speech. But Koop was prepared to expand the definition of public health, and thus the scope of his office, to include these problems and to subject them to public health methods, namely epidemiological study, disease prevention strategies, and health promotion information.

In October 1985, Koop convened a "Surgeon General's Workshop on Violence and Public Health" that examined what he considered an epidemic of violence that claimed an estimated four million victims each year, most of them children, women, and the elderly. The workshop was concerned particularly with the role of violent images conveyed by popular entertainments and by the media in fostering violence, as well as with the long-term psychological effects of violence on victims, such as the suspected propensity of victims of violence to turn violent themselves. Participants also explored ways in which the medical, nursing, psychological, and social service professions could better prevent violence and help victims. As part of a task force on pornography assembled by U.S. Attorney General Edwin Meese III, in June 1986 Koop organized a "Surgeon General's Workshop on Pornography and Public Health" that explored the connection between the widespread availability of pornography and the incidence of domestic violence and sexual abuse. He issued a Surgeon General's Letter on Child Sexual Abuse in 1988. His last initiatives as Surgeon General were designed to reduce the number of preventable accidents, both accidents caused by drunk driving, the subject of a Surgeon General's workshop held in December 1988, and the large number of household accidents, especially those involving children.

To address these issues and health challenges facing the family and the nation, Koop favored not only stronger laws and governmental measures--such as stricter drunk driving laws and more explicit warning labels on cigarettes--he also encouraged patients, their families, and others directly affected by disease or chronic health problems to organize in mutual aid and self-help groups, the subject of a workshop Koop organized in September 1987. His successors have built upon Koop's expansive vision of the responsibilities of the U.S. Surgeon General by addressing a widening range of public health issues, including organ donation, mental health, suicide prevention, sexual health, and obesity.