SB 49-MEDICAID PAYMENT FOR ABORTIONS; TERMS  1:34:43 PM CHAIR COGHILL announced the consideration of SSSB 49. Speaking as the prime sponsor, he stated that the bill intends to add clarification. 1:35:54 PM CHAD HUTCHINSON, staff to Senator John Coghill, sponsor of SB 49, stated that this legislation has been years in the making and has gone through a thorough, clinical analysis by both legal and medical experts. It is about defining what a medically necessary abortion is for the purposes of making payments under Medicaid. He clarified that there is no intent to reargue the 2001 Planned Parenthood case. The sponsor recognizes that Alaska has the constitutional guarantee to provide medically necessary care for qualified people of limited resources, including women requesting medically necessary abortions. The difficulty is that no one has defined what that is, so SB 49 seeks to provide that definition. MR. HUTCHINSON stated that the definition provided in the bill incorporates the statutory foundation required by the federal Hyde Amendment. That amendment is an important component in a lot of abortion legislation and was included in an executive order by President Barak Obama in 2010. 1:38:27 PM SENATOR OLSON joined the committee. MR. HUTCHINSON read a portion of the policy stated in Section 1 of Executive Order 13535 of March 24, 2010 as follows: Following the recent enactment of the Patient Protection and Affordable Care Act, it is necessary to establish an adequate enforcement mechanism to ensure that Federal funds are not used for abortion services (except in cases of rape or incest, or when the life of the woman would be endangered), consistent with a longstanding Federal statutory restriction that is commonly known as the Hyde Amendment. MR. HUTCHINSON relayed that those provisions are included in the definitional language of SB 49. He directed attention to tab 7, which has up to date language with regard to what the Hyde Amendment says, and suggested members compare that language with what is included in the bill. He pointed out that the Alaska Constitution requires protection that is higher than the federal standard, and the bill reflects that added protection in subsection (b)(4) on page 2. He noted that the provisions in this section were taken directly from the 2001 Planned Parenthood case or provided by the sponsor's medical experts. 1:41:55 PM MR. HUTCHINSON directed attention to the sectional under tab 3 and explained that it contains the foundational elements for putting the bill in context. He reiterated that the bill only defines medically necessary abortions for the purposes of making payments under Medicaid. The intent is to distinguish between what constitutes a medically necessary abortion and an elective abortion. He clarified that Medicaid does not fund elective procedures and, therefore, should not fund elective abortions. Medicaid is required to fund medically necessary procedures and, therefore, is required to fund medically necessary abortions. MR. HUTCHINSON directed attention to tab 4a and the Guttmacher Institute document titled "State Policies in Brief as of February 1, 2013 - State Funding of Abortion Under Medicaid." He pointed out that the background statement, in part, says, "At a minimum, states must cover those abortions that meet the federal exceptions." The document highlights that 32 states and the District of Columbia meet the minimum federal standard and allow state funding of abortion under Medicaid in the circumstance of life endangerment, rape, or incest. It further highlights that 17 other states, including Alaska, fund all or most medically necessary abortions either voluntarily or by court order. Mr. Hutchinson noted that the court order refers to the 2001 Planned Parenthood case. He directed attention to tab 4c, which contains the Supreme Court of Alaska case State of Alaska, Department of Health & Social Services v. Planned Parenthood of Alaska, Inc. The conclusion, found on page 16, includes the following statement: The State, having undertaken to provide health care for poor Alaskans, must adhere to neutral criteria in distributing that care. It may not deny medically necessary services to eligible individuals based on criteria unrelated to the purposes of the public health care program. MR. HUTCHINSON stated that SB 49 seeks to define medically necessary services based on mutual criteria, directly related to a health care program. He said the committee would hear testimony from experts who would clarify specifically what they believe to be a medically necessary condition in order to qualify for Medicaid funding for an abortion. He highlighted that the sponsor reasonably believes that Medicaid is currently paying for both elective abortions and medically necessary abortions. 1:46:03 PM MR. HUTCHINSON directed attention to tab 8 and the document from the Alaska Bureau of Vital Statistics showing induced termination of pregnancy statistics for 2011. He reported that Table 18 shows that the total number of induced terminations was 1,627. The total paid for by Medicaid was 623, or approximately 38.3 percent. He said the general presumption is that those women who qualified stated that there was a rape, incest, it was medically necessary, or the life of the mother was at stake. MR. HUTCHINSON directed attention to tab 9 and the article from the Guttmacher Institute titled "Reasons U.S. Women Have Abortions: Quantitative and Qualitative Perspectives." On page 114, Table 3 indicates that in 2004, only 4 percent of women having an abortion listed a physical problem with their health as their most important reason for having the abortion, and less than 0.5 percent listed being a victim of rape as their most important reason for having the abortion. Mr. Hutchinson said that these statistics demonstrate that only a small portion of abortions are medically necessary. He emphasized that the foregoing statistics show that the definition is unclear and that there are no clear guidelines to differentiate between elective and medically necessary. He again stated that SB 49 corrects that by bringing clarity to the definition. MR. HUTCHINSON noted that tabs 11, 12, and 13 have the curricula vitae (CV) of the experts providing testimony today. 1:48:56 PM SENATOR WIELECHOWSKI asked if under the Medicaid provisions, Alaska is required to pay for abortions when a doctor certifies that it is medically necessary. MR. HUTCHINSON deferred the question to someone from the Department of Health and Social Services (DHSS). SENATOR WIELECHOWSKI asked if he was saying that Medicaid was paying for elective abortions in Alaska. MR. HUTCHINSON responded that elective procedures are not supposed to be covered under Medicaid. Only medically necessary procedures qualify for Medicaid funding. SENATOR WIELECHOWSKI asked if he had any evidence of any abortions in the state of Alaska that have been paid for by Medicaid and were elective as opposed to medically necessary. MR. HUTCHINSON replied that the statistics he cited show that is occurring. 1:51:01 PM SENATOR WIELECHOWSKI asked if the law in Alaska is that Medicaid funds medically necessary abortions. MR. HUTCHINSON agreed that is correct. SENATOR WIELECHOWSKI asked if he had any specific case evidence of any abortions that Medicaid paid for that were not deemed medically necessary by a doctor. MR. HUTCHINSON responded that in coordination with the Department of Health and Social Services (DHSS) he would follow up with additional information. SENATOR WIELECHOWSKI asked if he agreed that under current law it would be illegal to fund an abortion that is not medically necessary. MR. HUTCHINSON agreed that the Alaska Supreme Court said the state has to fund medically necessary abortions under Medicaid. CHAIR COGHILL, speaking as the prime sponsor, said he believes the state has been funding elective abortions, and the bill seeks to answer the question definitively. SENATOR WIELECHOWSKI asked if he was aware of a single case in Alaska where a doctor certified that an abortion performed under Medicaid was elective. MR. HUTCHINSON responded that the sponsor is aware in the sense that the statistics support the fact that medically necessary has included both elective abortions and medically necessary abortions under the definitions provided in tabs 8 and 9. He offered to follow up and provide additional information. 1:53:05 PM CHAIR COGHILL added that to his knowledge there has been no prosecution of an elective abortion funded under Medicaid. He offered his belief that the Supreme Court case caused doctors to question when it is medically necessary, and the proposed definition goes to that question. SENATOR WIELECHOWSKI asked if a woman's physician or a bunch of politicians is in a better position to decide whether a medical procedure is medically necessary. MR. HUTCHINSON offered his belief that clarification is necessary so that doctors have a clear understanding of the definition for purposes of payment under [Medicaid]. He added that women can still get an abortion; the issue is whether it is paid for by Medicaid. SENATOR WIELECHOWSKI offered his belief that the issue actually is constitutional rights according to the Alaska Supreme Court. MR. HUTCHINSON responded that the purpose of the bill is to clarify the overly broad definition so everyone understands the difference between an elective procedure and a medically necessary procedure. SENATOR COGHILL, speaking as the prime sponsor, stated that the bill does not address the constitutional issue. The issue is one of payment. At this point, it is not to restrict abortion. He said the question is when is an abortion elective and therefore paid by for by the woman, and when is it medically necessary and therefore paid for by Medicaid. 1:55:40 PM CHAIR COGHILL noted that he called on three professionals to help make the medical case today, but that there would be opportunities for other professionals to provide testimony. 1:56:11 PM PRICILLA K. COLEMAN, PhD., Professor, Bowling Green State University, said she is a developmental psychologist and professor of human development and family studies. She has published over 50 peer-reviewed scientific articles, 37 of which are on the psychology of abortion. She relayed that based on her expertise she is often called upon to serve as a content expert in state civil cases involving abortion. She said that the opinions expressed in her testimony are based on her education, professional experience, her personal psychological research, and her ongoing review of the abortion and mental health literature. She stated that, with a reasonable degree of scientific and medical certainty, she can say that abortion is a substantial contributing factor in women's mental health problems. She continued to offer her opinion that abortion is a particularly risky choice for women with preexisting mental illness. She said there is no empirical evidence that documents mental health benefits to women with or without preexisting mental illness, but there is abundant literature that documents the association between abortion and declining mental health. Dr. Coleman said it is therefore her opinion that abortion is never justified based on mental health and the State of Alaska should not pay for an abortion when a woman has any form of mental illness. DR. COLEMAN reported that the formal study of the psychology of induced abortion has gathered considerable momentum in the past several decades and the scientific rigor of published studies has likewise increased. She said the literature has focused on the potential negative psychological consequences of induced abortion and the risk factors for such consequences. At the same time, there has been a growing awareness in the medical community of the need for evidence-based practice. DR. COLEMAN said that most of the scientific evidence indicates that abortion is a substantial contributing factor in women's mental health problems, including depression and death from suicide. Anxiety, substance abuse, and relationship problems are also associated with abortion. She said that this scientific evidence is published in leading peer-reviewed journals and fortified by many prospective studies, so there is confidence in the results. She noted that the testimony she submitted includes: Exhibit A - "Bibliography of Peer-Reviewed Studies on Abortion and Mental Health;" Exhibit B - "Evidence for a Causal Association between Abortion and Mental Health Problems;" and Exhibit C - a report of a meta-analysis she conducted that was published September 1, 2011 in the "British Journal of Psychiatry" titled Abortion and Mental Health: A Quantitative Synthesis and Analysis of Research Published from 1995-2009. DR. COLEMAN explained that a meta-analysis is a quantitative statistical review of literature wherein the data is converted to a common metric to derive the overall measure of effect. This methodology gives the results more credibility than the results from any individual empirical study or narrative review. She explained that in a meta-analysis, the weighting of any particular study to the final result is based on scientific criteria, not an individual opinion. She reported that the sample in this meta-analysis consisted of 22 studies, 36 measures of effect, and 877,297 participants, 163,880 of which experienced an abortion. The results indicate that women who aborted experienced an 81 percent increased risk for mental health issues. She said that when compared specifically to unintended pregnancy delivered, the women had a 55 percent increased risk of experiencing mental health problems. DR. COLEMAN said that separate effects were calculated based on the type of mental health outcome and the results showed the following increased risks: anxiety disorders 34 percent, depression 37 percent, alcohol use/abuse 110 percent, marijuana use/abuse 220 percent, and suicide behaviors 155 percent. The composite population attributable risk (PAR) statistic indicated that 10 percent of the mental health problems were directly attributable to abortion. She emphasized that stringent inclusion criteria were used to avoid bias. She said that the literature on risk factors for adverse post- abortion psychological consequences is well developed. These include: prior mental health problems, difficulty with the decision, emotional investment in the pregnancy, timing during adolescence or being unmarried, involvement in unstable or violent relationships, conservative views of abortion and/or religious affiliation, second trimester abortions, and feelings of being forced into abortion. She said that internalized beliefs about the humanity of the fetus, moral, religious, and ethical objections to abortion, and feelings of bereavement or loss also distinguish those who suffer. DR. COLEMAN reported that a well-known abortion provider in 1990 emphasized the role of pre-abortion counseling to evaluate mental status and abortion readiness while stressing the importance of a supportive relationship between the counselor and patient to prevent complications. She related that for the purpose of litigation in South Dakota she searched professional literature for studies published between 1970 and 2011, documenting personal, demographic, situational, and relational factors that increase the likelihood of post-abortion psychological problems. She identified 12 risk factors that were documented in at least 10 peer-reviewed journal articles. The risk factors include: 1) Character traits indicative of emotional immaturity, emotional instability, or difficulties coping - 42 studies. 2) Pre-abortion mental health or psychiatric problems - 35 studies. 3) Decision ambivalence, decision doubt, or decisional distress - 29 studies. 4) Conflicted, unsupportive relationships with others - 28 studies. 5) Conflicted, unsupportive relationship with father of child - 24 studies. 6) Desire for the pregnancy, psychological investment in the pregnancy, belief in the humanity of the fetus and/or attachment to the fetus - 21 studies. 7) Repeat or second trimester abortion - 19 studies. 8) Timing during adolescence or younger age - 18 studies. 9) Religious, frequent church attendance, personal values conflict with abortion - 18 studies. 10) Negative feelings and attitudes related to the abortion - 16 studies. 11) Pressure or coercion to get the abortion - 10 studies. 12) Indicators of poor quality abortion care - 10 studies. 2:07:46 PM DR. COLEMAN concluded that her opinion is that there is never justification for abortion on mental health grounds, because the evidence suggests that an abortion will exacerbate pre-existing mental illness and has significant potential to initiate mental illness in women without a prior history. She continued that there is no scientific evidence that women with mental illness are best served by the provision of abortion services when facing an unplanned pregnancy, and she does not believe that public funds should be used for this purpose. 2:08:51 PM SENATOR WIELECHOWSKI asked if she prepared and delivered a PowerPoint presentation on abortion where she said: We need to develop organized research communities to continue the research, apply for grants, recruit young academics, critic data produced by pro-choice researchers, challenge politically biased professional organizations, train experts to testify, and disseminate cohesive summaries of evidence. DR. COLEMAN said yes; it was in the context of a presentation to the American Association of Prolife OBGYNs. SENATOR WIELECHOWSKI asked if she issued a report in 2009 for the Journal of Psychiatric Research linking abortion and mental health, much like the testimony today. DR. COLEMAN said yes; an abundance of research documents that increased risk. SENATOR WIELECHOWSKI asked if the Guttmacher Institute wrote an article about her report in the Journal of Psychiatric Research titled, "Study Purporting to Show Link between Abortion and Mental Health Outcomes Decisively Debunked." DR. COLEMAN said that article was not related to the meta- analysis. It refers to one paper that had an error that was corrected. The article is still a publication in the journal and the findings are considered credible. She acknowledged that the meta-analysis was challenged many times, and opined that it was because she was providing information that was not politically correct and contrary to some agendas. She said she was able to address the criticisms, but she believes that the problem is that people aren't familiar with a quantitative review. They're more accustomed to the biased, politically driven summaries offered by professional organizations. For example, the American Psychological Association over three decades ago declared a prochoice position without data to support that position. CHAIR COGHILL asked if it was true that the Guttmacher Institute has a particular point of view. DR. COLEMAN said that is her belief. 2:12:17 PM SENATOR DYSON asked Dr. Coleman her perspective, because he always thought the Guttmacher Institute reporting was credible with regard to numbers of abortions. DR. COLEMAN said it is the largest body providing data on abortions, and it also has a history of being connected with prochoice groups. SENATOR DYSON recalled seeing statistics from the Guttmacher Institute that show that a small percentage of abortions are done for medical reasons. He said he assumes that the statistics are reasonable accurate. DR. COLEMAN said she was not prepared to critique their methods, but the basic information is likely accurate. 2:14:30 PM SENATOR WIELECHOWSKI asked if she agreed with the statement Julia Steinberg made after the Journal of Psychiatric Research reviewed her article in 2009. Dr. Steinberg said: This is not a scholarly difference of opinion; their facts were flatly wrong. This was an abuse of the scientific process to reach conclusions that are not supported by the data. The shifting explanations and misleading statements that they offered over the past two years served to mask their serious methodological errors. DR. COLEMAN refuted Dr. Steinberg's statement. CHAIR COGHILL asked if her perspective is that mental conditions like bipolar should not be included in the definition of medical necessity. DR. COLEMAN agreed saying that it's likely that providing abortions for women who have serious mental health problems will result in more claims related to mental health problems following the abortion. She continued that it is her opinion that nothing in the literature justifies providing abortion services for mental health reasons, so an abortion is never medically necessary. 2:16:16 PM SENATOR WIELECHOWSKI asked if she believes that she is in a better position to evaluate a woman's need for medical care than the woman's personal physician. DR. COLEMAN said that doctors ought to be informed by the literature, and their advice should be based on what multiple professions know. She said she would ask the doctor the basis of his/her opinion. SENATOR WIELECHOWSKI asked if it was correct that she couldn't have that conversation if this bill were to pass. DR. COLEMAN said the point is that anyone dealing with a woman who is trying to decide whether to have an abortion or not should be informed by the literature. She said it is her opinion that it would be unethical for a doctor to tell a woman with a medical health problem that she would be better served if she aborted. SENATOR WIELECHOWSKI pointed out that she is saying that she is in a better position to make that determination than the woman's doctor.  CHAIR COGHILL summarized his understanding of the testimony, which is that there is no psychological reason to abort a child. DR. COLEMAN said that is correct. 2:18:54 PM JOHN THORP, MD., University of North Carolina, said he is an obstetrician who has practiced maternal fetal medicine, high- risk obstetrics, since 1983. He provided his credentials as a professor in the schools of medicine and public health. He noted he has had over 300 peer-reviewed publications. DR. THORP related that he worked with the sponsor's staff to develop a list of conditions that unequivocally threaten the life of a mother and would constitute a solid medical indication for a termination of pregnancy. These are conditions that would be recommended as options to protect a woman's health, even for women who wanted to continue their pregnancy or who would not consider abortion. He noted that he has had experience in suburban/rural areas with a large Native American population and many military personnel, where the issue of the use of federal or state funds for pregnancy termination is a frequent topic. He opined that the comprehensive list in the bill of conditions has enough specificity about the degree of severity that would be helpful to the state of Alaska as it tries to work on the legislation. 2:22:55 PM CHAIR COGHILL mentioned the previous testimony talking about psychological issues, and noted Dr. Thorp's testimony is about the physical risk to the life and physical health of the mother. He inquired if most of the situations listed in the bill are in the category of life endangering. DR. THORP said yes. CHAIR COGHILL noted that, for the most part, the list came from the Supreme Court. 2:24:27 PM SENATOR DYSON suspected that after a pregnant woman has been subject to an accident, there may be circumstances to consider that would lead to the termination of the pregnancy. DR. THORP replied that, short of massive bleeding, termination of pregnancy is always an elective procedure. He said that the physician would treat the trauma and a pregnancy makes little difference in these traumas. He couldn't recall a time when a termination would have saved a mother's life. SENATOR WIELECHOWSKI asked if he would agree that an ultrasound scan for a pregnant woman is a medically necessary procedure. DR. THORP said not necessarily. SENATOR WIELECHOWSKI asked if he testifies in other states about abortion issues. DR. THORP said yes, and recalled that he was in Anchorage at this time last year. SENATOR WIELECHOWSKI asked if he testified in North Carolina about a requirement for trans-vaginal ultrasounds for most abortions. DR. THORP said he didn't recall ever having testified in North Carolina. SENATOR WIELECHOWSKI asked if he attempted to intervene in a lawsuit in North Carolina requiring ultrasounds for abortions. DR. THORP said not that he recalled. SENATOR WIELECHOWSKI asked if he made a statement saying, "In my medical opinion, receiving an ultrasound scan and accompanying descriptive information, as mandated by the Act, is essential for a women's consent to be fully formed and voluntary." DR. THORP said he didn't recall making that statement. SENATOR WIELECHOWSKI asked if he agrees with that statement. DR. THORP said he would need the context in order to agree or disagree. SENATOR WIELECHOWSKI asked if he would agree that providing ultrasonic images and accompanying embryonic fetal developmental information, particularly for a pregnant patient, is the standard of care in obstetrics and gynecology. DR. THORP said it's usually done. SENATOR WIELECHOWSKI asked if he had ever made that statement. DR. THORP said he didn't recall making it. 2:29:19 PM SENATOR WIELECHOWSKI asked if an ultrasound is a medically necessary procedure for a woman considering an abortion. DR. THORP said it is a usual part of termination of pregnancy care. SENATOR WIELECHOWSKI asked if it is usual and customary procedure in Alaska. DR. THORP said he didn't know. He imagined there is a lot of ultrasound done in Alaska like there is in other states. 2:30:01 PM SENATOR WIELECHOWSKI asked if he believes that providing counseling information to women considering undergoing abortion is medically necessary. DR. THORP said it is medically necessary and ethically obligated. SENATOR WIELECHOWSKI asked if it could potentially endanger a woman's life if counseling is not provided to a woman considering an abortion. DR. THORP said he did not understand the question. SENATOR WIELECHOWSKI asked if he believes that not providing counseling to a woman considering abortion would potentially endanger her life. DR. THORP said there would be a small risk of endangerment to her life and an ethical breach of her autonomy. 2:31:24 PM SENATOR OLSON said the questions are less than specific and, as a medical doctor, he wouldn't necessarily agree with the line of questioning. He stressed that for any procedure, a physician would have to provide information about the risks of such a procedure. He agreed that there would have to be counseling of some sort. SENATOR WIELECHOWSKI asked if it is medically necessary to counsel a woman about fetal pain that may occur. DR. THORP said he didn't think doctors know enough about fetal pain to provide much counseling. CHAIR COGHILL said he was allowing the questions in order to determine Senator Wielechowski's thinking about what is or is not a medically necessary procedure. SENATOR WIELECHOWSKI explained that he was trying to figure out the line between what is medically necessary and what is not. 2:33:38 PM DR. THORP asked Senator Wielechowski to define "medically necessary." SENATOR WIELECHOWSKI asked Dr. Thorp how he defines it. DR. THORP clarified that he has tried to define conditions that threaten the life or long-term physical health of the mother to such an extent that the state should be obliged to fund a termination of pregnancy procedure, should the mother choose that. Other than that, "medically necessary" is vague. He suggested that the bill states that physicians and patients can do whatever they want, so there are probably some less-than- life-threatening reasons why women are ending their pregnancies. 2:35:14 PM SUSAN RUTHERFORD, MD., said she works as an OBGYN physician and in 1990 started a program in maternal fetal medicine at Evergreen Hospital. She explained that her primary role is as a practicing maternal fetal medicine specialist. She reviewed her medical credentials. DR. RUTHERFORD said the bill is a good effort and helpful in establishing medical necessity. She opined that most doctors would generally agree about what is medically necessary. The statistics quoted about the rarity of "medical necessity" are valid, but it's mostly the patient's choice. She said patients all come with a medical history and it's rare to see a patient with a history of an abortion that was medically necessary. She said she has only seen one person in 30 years who medically required an abortion. 2:39:48 PM DR. RUTHERFORD agreed with the list of conditions when a medically necessary abortion is warranted. She suggested, from a medical standpoint, that some of the items be reordered. Such as, she would put epilepsy and seizures with convulsions. She said she would add a maternal history of myocardial infarction and gestational trophoblastic disease, an abnormal pregnancy situation. She noted that kidney infections are common during pregnancy, but shouldn't be on the list. DR. RUTHERFORD addressed several subjects Dr. Thorp mentioned during his presentation. Regarding trauma, she said that it is unwise to add abortion to a patient who is unstable due to major trauma. She opined that an ultrasound is absolutely indicated prior to an abortion. A trans-vaginal ultrasound should be used when a regular ultrasound does not work. She opined that fetal abnormalities could be added to the list. She noted that she does not perform pregnancy terminations. 2:42:57 PM CHAIR COGHILL said he would take her suggestions seriously. 2:43:30 PM SENATOR WIELECHOWSKI asked Dr. Rutherford if she wrote an article that stated abortion is linked to an increase in risk of breast cancer. DR. RUTHERFORD said she didn't write any articles on breast cancer, but she believes there is evidence to that effect. The idea should not be summarily dismissed because that question has not been answered yet. SENATOR WIELECHOWSKI asked if she disagrees with the evidence from the National Institute of Health and the National Cancer Institute that state just the opposite. DR. RUTHERFORD said she listened to Dr. Coleman's testimony and agreed that there are flaws in medical literature, physician statements by national organizations, and state laws. She stated that she disagrees with the statement that there is no link between abortion and breast cancer. SENATOR OLSON asked if she agrees that somebody with a kidney infection who is becoming septic needs to be treated. DR. RUTHERFORD said yes; sepsis needs to be treated and someone who is pregnant is more prone to pulmonary edema and acute respiratory distress syndrome. She suggested adding to the list sever infection, including sepsis, exacerbated by pregnancy. SENATOR OLSON asked about adding disseminated intravascular coagulopathy (DIC) related to eclampsia or preeclampsia. DR. RUTHERFORD agreed that DIC could be added to the list. 2:48:28 PM SENATOR DYSON asked Dr. Rutherford if she has dealt with any pregnant women who had a terminal disease and opted not to abort. DR. RUTHERFORD said she recalled one instance, but noted there are treatments for cancer during pregnancy. She suggested that the items on the list be discussed with the patient for consideration and should not automatically result in a termination. There are exceptions to many of these situations, such as those with epilepsy and treatable cancer. She said she hasn't been personally involved with a pregnancy where the mother has a terminal disease; it's extremely rare. CHAIR COGHILL thanked the participants. He noted public testimony would continue on Monday. CHAIR COGHILL held SB 49 in committee.