Medical Economics

Why Conservatives Should Fund Planned Parenthood

I know what you’re thinking about the title of this post: “Didn’t he mean defund Planned Parenthood?” No, you read the title right, I am going to make the argument that social conservatives should donate to and fund Planned Parenthood and similar organizations. The reason why? Because by funding Planned Parenthood, we can decrease the number of U.S. abortions. Now you’re thinking: “That makes absolutely no sense and he is totally crazy“. However, if we apply root cause analysis to U.S. abortions, it turns out to make perfect sense.

Sakichi Toyoda

Root cause analysis is the process that we use in hospitals to figure out why a medical error occurred in order to fix the root cause of that error. The father of root cause analysis was Sakichi Toyoda, a Japanese inventor and entrepreneur who invented the automatic power loom used in textile manufacturing. His company later evolved into the Toyota automobile manufacturing company. Sakichi Toyoda championed the 5 whys: when a manufacturing problem occurs, ask “why” five times to find the true source of the problem in order to correct it. The 5 whys are the basis of the principle of lean manufacturing, a method of improving production efficiency and are a key component of the Six Sigma manufacturing process improvement training program.

A case study using the 5 whys

The best way to understand the 5 whys is by looking at an example of how we use the process in hospital quality control. Let’s take a hypothetical hospital that finds it has a very high rate of post-operative surgical infections. Now, let’s ask the 5 whys and see what the hospital’s solution would be if it stopped before getting to the fifth and last why:

If we only ask 1 why, then the hospital’s solution to the high post-operative wound infection rate would be to close down the operating rooms on Thursdays. This would be terribly unpopular with the surgeons and anesthesiologists who would see a 20% drop in their billable income. The surgery schedule will get backed up with the result that patients become unhappy because they have to wait a long time to get their surgeries. And the hospital’s financial margin would suffer as surgical revenue falls. So, let’s ask a second why:

In this case, Thursday is the day that all of the orthopedic surgeons do their knee replacement surgeries during the Thursday orthopedic surgery OR block time. But if the hospital stops doing knee replacement surgeries, the orthopedic surgeons will be irate because that is one of their primary surgical procedures. Patients will be irate because they will have to go to another hospital to get their knee replacements. And the hospital chief finance officer will be irate because the hospital makes more money on knee replacements than any other surgery. How about the third why:

Drilling down further, it turns out that just one orthopedic surgeon, Dr. Smith, has all of the post-op knee replacement surgical wound infections. If we stop with the third why, then the solution is to take away Dr. Smith’s knee replacement surgery privileges. He will be upset and will have to re-tool his practice to start doing other types of orthopedic surgical procedures, such as hip replacement surgeries. And as we will see, this will not fix the root cause of the problem. So, we now go to the fourth why:

An astute epidemiology nurse discovers that Dr. Smith’s sterile surgical gloves frequently break in the middle of his operations, thus potentially contaminating the surgical field with the bacteria on his skin. Therefore, the medical director of infection control recommends that Dr. Smith double glove so that if the outer glove breaks, there is a back-up inner glove to prevent contamination. But what about if we go all the way to the fifth why:

By asking the final why, we determine that Dr. Smith has unusually large hands and he needs size #9 sterile gloves. But the operating room only stocks size #7 and #8 gloves so Dr. Smith has been using gloves that are too small. The result is that his gloves frequently break, causing his patients to frequently have infections. The root cause of the hospital’s post-op surgical infection rate was that the operating room was not stocking the correct size gloves. The solution was to stock large gloves in the O.R.

If the hospital stopped with the first why, the orthopedic surgeons would just operate on a different day. If the hospital had stopped with the second why, the orthopedic surgeons would just do surgeries other than knee replacements. If the hospital stopped with the third why, Dr. Smith would start doing hip replacements rather than knee replacements. If the hospital stopped with the fourth why, Dr. Smith would have breaks in 2 pairs of gloves instead of just 1 pair of gloves. In all four of these situations, there would have been no effect on the hospital’s post-op surgical infection rate. It is only when the hospital gets to the fifth why that the infection rate actually drops. Now let’s see how we can apply the 5 whys to the problem of abortion.

Abortion and the 5 whys

Just about every American, both conservative and liberal, will agree that we do too many abortions in the U.S. In 2020, there were 930,160 abortions performed in the U.S. To put this number in perspective, there were 350,000 COVID deaths in the U.S. in 2020, the first year of the pandemic. In other words, there were more than two and a half times more abortions than COVID deaths. Overall, 20.6% of all pregnancies ended in abortion and one out of every four American women has had an abortion at some time in her life. So our challenge is to reduce the number of abortions and to do that, we need to do a root cause analysis. So, let’s apply the 5 whys to the problem of abortion in the United States.

If we only ask the most superficial why, we determine that we have a lot of abortions in the U.S. because organizations like Planned Parenthood offer abortion services. When the U.S. was living in the era of Roe v. Wade, this was the approach taken by those opposed to abortion. Conservative states prohibited public funds to be used for abortion and created laws to make it as hard as possible for organizations like Planned Parenthood to perform abortions. But the 930,160 abortions performed in the United States in 2020 indicates pretty clearly that stopping at the first why did not significantly reduce the number of abortions in our country. So, let’s ask a second why:

With the Supreme Court ruling on Dobbs v. Jackson Women’s Health Organization a year ago, those opposed to abortion focused on the second why. The result is that many states have passed or plan to pass laws making it illegal for doctors to perform abortion in most situations. These laws will certainly stop doctors from performing abortions but they will not stop women from pharmacologically inducing abortions on their own and these laws will most certainly not get at the root cause. Now let’s see what happens at the third why:

Here, we find that the doctors were not actively seeking women to convince them to have abortions. Instead, the women were seeking the doctors and requesting abortions. If we stop with this why, then the solution is to make it illegal for a woman to have an abortion. This would not prevent some women from pharmacologically inducing an abortion on their own. For example by buying misoprostol on the street the way people by cocaine on the street or by taking a high dose of FDA-approved drugs like methotrexate or non-steroidal anti-inflammatory drugs. State laws making it illegal for a woman to willingly undergo an abortion will not eliminate abortion any more than laws making marijuana illegal has stopped marijuana use. Such state laws also would not stop women from traveling to another state to get an abortion where it is legal. What about the fourth why:

Now we find that America’s abortion problem is actually an unwanted pregnancy problem. If we stop with the fourth why, then the solution would seem to be to tell women and men that it is illegal or immoral to have sexual intercourse unless they are married and are doing it in an attempt to have children. The Catholic Church has been trying this tactic for nearly 2,000 years and it hasn’t worked yet. I can confidently say with 100% certainty that telling people in their teens and 20’s that they can’t have sex outside of marriage will not work. You can’t stop people from having sex any more than you can stop the sun from rising. So let’s look at the fifth why:

Now we see that abortions are performed because of unwanted pregnancies that in turn resulted because adequate birth control methods were not used and because of a lack of sex education. And where do many women (particularly low income women and teenage girls) go to get birth control? …Planned Parenthood. In addition, organizations such as Planned Parenthood provide free community sex education and this fills an unmet need in those communities that lack effective sex education in their schools – either because of state laws or school board decisions in the case of public schools or religious doctrines in the case of private schools.

The economics of abortion

If we approach abortion from an economic viewpoint, it all comes down to supply and demand. Focusing on laws that penalize doctors from performing abortion or penalize women from having an abortion is supply-side economics. If social conservatives really want to reduce the number of abortions, then it is necessary to focus on demand-side economics. And that means finding ways to reduce unwanted pregnancies and redirecting efforts to address the fifth why. So, what should pragmatic conservatives do to really make a difference in the number of abortions performed in the United States?

  1. Restore effective sex education in schools. Avoiding talking about sex with teenagers in schools and banning books about sex in libraries will only increase unwanted pregnancies. Similarly, teaching that abstinence is the only way to get to heaven in our private schools is out of touch with reality. Sure, it would be nice if every parent had “the talk” with each of their children at age 12 but history has proven that this just does not always happen. Schools are the only realistic venue for universal sex education.
  2. Make effective birth control available. The emphasis here is on the word “effective“. Not all forms of birth control are equally effective. Condoms are frequently ineffective and birth control pills are sometimes ineffective. A law requiring all commercial health insurance policies and all state Medicaid programs to provide IUDs, hormonal implants, vasectomies, and tubal ligations with no co-pays would eliminate far more abortions than defunding Planned Parenthood or making abortion illegal in your state. What are effective birth control methods?
    1. > 13 pregnancies per 100 women per year: withdrawal, condoms, spermicides, diaphragms, calendar methods
    2. 4 – 7 pregnancies per 100 women per year: birth control pills, hormonal patches, cervical rings, hormone injections
    3. < 1 pregnancy per 100 women per year: IUDs, implants, vasectomy, tubal ligation
  3. Donate money to Planned Parenthood for pregnancy prevention programs. Who goes to Planned Parenthood for birth control? It’s women who do not have a primary care provider, women who lack health insurance coverage for effective birth control, and girls who do not want their parents to know that they are sexually active (Sorry to tell you this America, but your kids did not have sex because they went to Planned Parenthood, they went to Planned Parenthood because they were having sex). This is actually a huge part of what Planned Parenthood really does and this is often neglected in public discussion. If you really want to reduce abortions, then pay organizations like Planned Parenthood to reduce unwanted pregnancies.

You can’t stop all unwanted pregnancies

Not every unwanted pregnancy can be avoided. Sometimes, even diligent use of an effective method of birth control does not work. Sometimes people have unplanned consensual sex or unplanned sex when intoxicated. Sometimes pregnancy results from rape. Sometimes complications of pregnancy pose a health risk to the woman. And sometimes there are severe fetal abnormalities even when pregnancy was intentional. So, we cannot totally eliminate the demand for abortion but by focusing on birth control availability and sex education, we can substantially reduce the demand for abortion. By doing so, we can reserve abortion for these other situations where there is perhaps less controversy about whether abortion should be accessible. That would be fare less polarizing and decisive than making abortion illegal except in these situations.

By stopping at the first, second, third, or fourth why of abortion, all we do as a society is engender anger and cause Americans to face off against each other, without actually reducing the demand for abortion. It is just like the analogy with the hospital with a high post-op surgical infection rate. It is only by reaching the fifth why that we can actually make a difference in abortion demand and reduce the number of abortions in our county.

I fear that history will judge us as foolish. Instead of directing our efforts at the underlying root cause of abortion, we as a society have put all of our energy into the downstream effects of that underlying root cause. In this way, we are like the man who kept blasting away every night at the snakes and wrecking his house rather than simply closing the back door so that the snakes could not get into the house in the first place.

June 26, 2023

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital