SAN FRANCISCO -- A federal court in San Francisco Tuesday struck down Arizona's ban on abortions after 20 weeks of pregnancy.

The 9th U.S. Circuit Court of Appeals ruled that the law violates a string of U.S. Supreme Court rulings starting with Roe v. Wade that guarantees a woman's right to an abortion before a fetus is able to survive outside the womb. That's generally considered to be about 24 weeks. Normal pregnancies run about 40 weeks

Several states have enacted similar bans starting at 20 weeks. But the 9th Circuit's ruling is binding only in the nine Western states under the court's jurisdiction. Idaho is the only other state in the region covered by the 9th Circuit with a similar ban.

A trial judge had ruled that the ban could take effect. U.S. District Judge James Teilborg ruled it was constitutional, partly because of concerns about the health of women and possible pain for fetuses.

But abortion-rights groups appealed that decision, saying the 20-week ban would not give some women time to carefully decide whether to abort problem pregnancies.

The ban included an exception for medical emergencies.

Philadelphia prosecutors predicted two years ago that the indictment of an abortion provider charged with killing babies would be exploited by both sides of the nation's polarized abortion debate.

The seven-week murder trial, which moves to closing arguments Monday, has proved them right.

Abortion foes have accused the media of under-publicizing the trial out of fear it would weaken public support for abortion rights. Abortion-rights advocates have said the grim testimony points to the need for the procedure to be accessible, safe and legal.

"The case is not about that controversy; it is about disregard of the law and disdain for the lives and health of mothers and infants," prosecutors wrote in the 2011 grand jury report. "We find common ground in exposing what happened here."

They accuse 72-year-old Kermit Gosnell of operating a clinic where desperate women sought late-term abortions they could not get elsewhere. And he got rich doing so, they said, making millions over a 30-year career.

Prosecutors say Gosnell killed viable babies born alive after putting a steady stream of often low-income, minority women through labor and delivery.

Former employees have testified that Gosnell taught them to "snip" babies' necks after they were delivered to "ensure fetal demise."

"Why would you cut a baby in the back of the neck unless you were killing them?" Assistant District Attorney Ed Cameron argued last week, as he asked a judge to send all seven first-degree murder charges to the jury.

Common Pleas Judge Jeffrey Minehart, though, threw out three of those counts for lack of evidence they were viable, born alive and then killed.

Gosnell is also charged in the overdose death of a patient, 41-year-old refugee Karnamaya Mongar, of Woodbridge, Va.

The jury must now weigh the five murder counts, along with lesser charges that include racketeering, performing illegal abortions after 24 weeks, failing to observe the 24-hour waiting period and endangering a child's welfare for employing a 15-year-old in the procedure area.

Defense lawyer Jack McMahon has argued that there were no live births at the clinic, and he found some support from a prosecution witness, Philadelphia's top medical examiner. Dr. Sam Gulino, who examined 47 aborted fetuses stored in freezers at the clinic, said he could not definitively say if any had taken a breath because the lung tissue had deteriorated.

The prosecution's other evidence to support the live birth argument comes from former employees, who testified that they saw aborted babies move, breathe or even cry. McMahon challenged them on cross-examination, questioning whether they had instead seen post-mortem spasms.

"You have to have definite, voluntary movement," McMahon argued.

The jury has seen a graphic photograph of some of the aborted babies and a worker testified that Gosnell joked that one was so big "it could walk to the bus."

Lynda Williams, Adrianne Moton and Sherry West, all untrained clinic workers, and unlicensed doctor Stephen Massof have each pleaded guilty to third-degree murder charges and testified against Gosnell. And four others have pleaded guilty to lesser charges, including Gosnell's wife, Pearl.

Gosnell did not testify, but could take the stand in the penalty phase if he is convicted of first-degree murder. Prosecutors are seeking the death penalty.

Prosecutors say Gosnell is a misogynist for the way he treated female patients while the inner-city doctor described himself as an altruist in a 2010 interview with the Philadelphia Daily News.

"I wanted to be an effective, positive force in the minority community," Gosnell said.

Crystal Kelley got paid $22,000 to have a baby. But that wasn’t the only offer the 29-year-old Connecticut mother of two received. After an utrasound at 21-weeks revealed significant medical issues, the parents offered her $10,000 more if she agreed to an abortion.

The gross immorality of that second offer tells us that there is a lot wrong with the first arrangement. It is intolerable that our society continues to put up with an unregulated, free market in hiring cash-starved women to make babies. 

The couple, which had two other children, "were very attentive," Kelley told NBC Connecticut. "They wanted to be involved in the pregnancy. [The biological mother] said she really felt like she was living through me in this pregnancy and she wished she could experience it.”

But after the tests revealed complex heart problems, a cleft lift and palate and other issues, the would-be parents decided that the pregancy should be terminated. Kelley refused, even after the money was offered after she was told the parents would no longer adopt the baby.

Then things went from ethically bad to ethically despicable. According to a CNN report, Crystal Kelley then got a letter from an attorney named Douglas Fishman reminding her that her surrogacy contract required her to get an abortion in the case “of severe fetus abnormality.” The lawyer told her that if she did not promptly get an abortion the no-longer-wannabe-parents would sue her to get back the money they’d paid along with the money they’d spent on Crystal’s medical bills and legal fees.

This crummy story goes on and on (for those who are curious, Kelley did eventually give birth and was able to find another couple to adopt the child), but there is enough on the ethical plate to see that there is plenty wrong with commercial surrogacy if a woman can be bribed or bullied into an abortion.

Let’s do the low hanging ethical fruit first.

No one can contract with a woman to have an abortion. Under any circumstances. For any reason. Never. A woman controls her body and no one can make her do anything she does not want to do in terms of medical intervention with her body no matter what she has said before, signed or promised. The lawyer who tried to coerce and threaten Crystal Kelley to have an abortion should be subject to loss of his license to practice law. Any surrogate agency which conveyed an offer of money to encourage an abortion is guilty of at best bribery and an attempt to crassly manipulate a vulnerable woman. And any surrogacy agency that sticks abortion language into its contracts is guilty of gross misconduct.

Now let’s go for the broader moral lessons evident from this horrific tale.

Surrogacy for money is about money -- not love, or help, or altruism or doing good. Money is most attractive to those who need it most. Young single mothers with kids to feed and bills to pay and the rent in arrears are not likely to read the small print. If we are going to put up with markets in wombs, then the least we can do is mandate by law that the potential surrogate has her own lawyer that she picks but that is paid for by the couple who want to rent her womb.

In addition, we need legislation that makes it absolutely clear that if you hire a surrogate you will legally be bound to accept and raise any child that results. Would-be parents who use surrogates must understand that if a fetus is found to have problems, it is their responsibility, not the surrogate’s, to resolve them. If you enter the genetic lottery via surrogacy, you have to live with the consequences: that is the only way to insure the interests of children made via surrogacy are protected.

Lastly, we need tighter control over those in the commercial surrogacy broker business. If Crystal Kelley’s story is any indication, there are a lot of brokers out there who are far more interested in making an easy dollar then protecting the women whose wombs they offer for sale or the children who may result from surrogacy arrangements.

Technology has given us many new and valuable ways to make babies. The free market – complete with its shady middlemen and lawyers -- is not up to the task of deciding how best to use that technology.

Arthur Caplan, Ph.D., is the head of the Division of Medical Ethics at NYU Langone Medical Center.

A dramatic new study with implications for next month’s presidential election finds that offering women free birth control can reduce unplanned pregnancies -- and send the abortion rate spiraling downward.

When more than 9,000 women ages 14 to 45 in the St. Louis area were given no-cost contraception for three years, abortion rates dropped from two-thirds to three-quarters lower than the national rate, according to a new report by Washington University School of Medicine in St. Louis researchers.

From 2008 to 2010, annual abortion rates among participants in the Contraceptive Choice Project  -- dubbed CHOICE -- ranged from 4.4 abortions per 1,000 women to 7.5 abortions per 1,000. That’s far less than the 19.6 abortions per 1,000 women nationwide reported in 2008, the latest year for which figures are available.

Among teen girls ages 15 to 19 who participated in the study, the annual birth rate was 6.3 per 1,000 girls, far below the U.S. rate of 34.3 per 1,000 for girls the same age.

The study’s lead author, Dr. Jeffrey Peipert, a professor of obstetrics and gynecology at Washington University, expected both measures to fall, but even he said he was “very surprised” by the magnitude.

In all, Peipert said, one abortion was prevented for approximately every 100 women who took part (the actual estimate is 1 per every 79 to 135 women). 

The results were so dramatic, in fact, that Peipert asked the journal of Obstetrics & Gynecology to publish the study before the Nov. 6 presidential election, knowing that the Affordable Care Act, and its reproductive health provisions, are major issues in the campaign.

“It just has so many implications for our society,” he told NBC News.

Several factors contributed to the declines, he argued. First, a large majority of the women in the study were encouraged -- and chose -- to use intrauterine devices, or IUDs, and hormonal implants over more commonly used birth control pills.

Because birth control pills require strict adherence, and people forget to take them, that method fails about 8 percent of the time. IUDs and implants are over 99 percent effective.

Second, program enrollees included high-risk populations like women and girls who’ve already used abortion services once -- and are more likely to have a second abortion -- and women and girls who are economically distressed and may not have means to obtain contraceptive products and services.

That’s important because an IUD, including the device and the physician’s service to place it in the uterus, can cost between $800 and $1,000. Since an IUD lasts at least five years, it saves money in the long run over a monthly cost of roughly $15-$25 for pills, but the up-front charge is prohibitive for many women.

James Trussell, a Princeton University professor of economics and public affairs and an expert in family planning called the results “terrific, great work, and a very important demonstration project.” 

But it’s also politically fraught. The Affordable Care Act requires insurance plans to cover contraceptive costs. That’s led to conflicts among the Obama administration, the Catholic church, and the church’s political allies who argue that requiring a Catholic employer to provide such insurance contradicts the church’s teaching and represents a breach of religious freedom.

Conservatives have also objected to contraceptive coverage on cost grounds. Some have focused their anger at Sandra Fluke, a Georgetown University law student who agitated for the Catholic school to offer an insurance plan that covers contraception. Radio host Rush Limbaugh famously called her a “slut” and a “prostitute.”

But experts, including Peipert, point out that no-cost contraception saves money.

According to a 2011 study from the Guttmacher Institute, unplanned pregnancies costs the United States a conservatively estimated $11 billion per year. 

“The way I look at it as a gynecologist with an interest in women’s health and public health and family planning, is that this saves money,” Peipert said. “When you provide no-cost contraception, and you remove that barrier, you finally reduce unintended pregnancy rates. It doesn’t matter what side one is on politically, that’s a good thing.”

The Catholic Church is unlikely to be moved. “If, as supporters of the contraceptive mandate argue, it will pay for itself in reduced medical expenses, so will free embryo engineering and other eugenic services, including infanticide, doctor-assisted suicide, organ harvesting, and genetic manipulation,” wrote Thomas Joseph White, director of the Thomistic Institute at the Dominican House of Studies in Washington, D.C., and R.R. Reno, in the conservative journal First Things.

But to academic experts, the results of CHOICE are clear. “What the study suggests to me,” said John Santelli, professor at Columbia University’s Mailman School of Public Health, “is that it’s totally supportive of the president’s provisions on reproductive care and preventive services for women in the Affordable Care Act.”

In a 2009 study, Trussell and colleagues reported that long-acting contraceptives like IUDs were far cheaper than an unintended birth, an abortion, and especially an ectopic pregnancy.

Trussell argued that cost savings go “well beyond” those immediate medical savings. They don’t, for example, take into account costs associated with longer term issues such as economic stress on the mother and family, a teenager who doesn’t finish high school or skips college because she’s had a baby.

Research has also shown that neglect, stress, anxiety, or simply a low level of nurturing in early life has effects on a child that can last far into adulthood. It may influence, for example, the cycle of teen pregnancy and crime. 

“It’s hard to imagine how politicians wouldn’t like to spend a dollar to save four,” Trussell said. As to the objections like those of White, he concluded that “it makes no sense whatsoever. Regardless of your views on abortion, virtually everybody says preventing unintended pregnancies is smart.”

Brian Alexander (www.BrianRAlexander.com) is co-author, with Larry Young Ph.D., of "The Chemistry Between Us: Love, Sex and the Science of Attraction," (www.TheChemistryBetweenUs.com), now on sale.

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CHICAGO - An Illinois appellate court Friday affirmed a lower court finding that the state cannot force pharmacies and pharmacists to sell emergency contraceptives - also known as "morning after" pills - if they have religious objections.

In 2005, former Illinois Gov. Rod Blagojevich mandated that all pharmacists and pharmacies sell "Plan B," the brand name for a drug designed to prevent pregnancy following unprotected sex or a known or suspected contraceptive failure if taken within 72 hours.

Some anti-abortion advocates object to the drugs, which work by preventing the release of an egg, preventing fertilization or stopping a fertilized egg from attaching to the uterus.

College vending machine dispenses 'morning after' pill

In 2011, an Illinois judge entered an injunction against the rule, finding no evidence that the drugs had ever been denied on religious grounds, and that the law was not neutral since it was designed to target religious objectors.

The Illinois appellate court agreed that the Illinois Health Care Right of Conscience Act protects pharmacists' decision not to dispense the contraceptives due to their beliefs.

Free birth control under health law begins

"This decision is a great victory for religious freedom," said Mark Rienzi, senior counsel for the Becket Fund, quoted in a statement about the decision.

Earlier this year, a federal court in Washington struck down a similar state rule, according to the Becket Fund, a non-profit law firm.

The American Civil Liberties Union of Illinois, which had filed an amicus brief on behalf of the state, expressed dismay at the court's decision.

Long-term contraceptives, like IUDs, gaining popularity

"We are dismayed that the court expressly refused to consider the interests of women who are seeking lawful prescription medication and essentially held that the religious practice of individuals trumps women's health care," said ACLU spokesman Ed Yohnka. "We think the court could not be more wrong."

A spokesperson for Illinois Governor Pat Quinn was not immediately available for comment.

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A 32-year-old pregnant woman from Massachusetts, known only as Mary Moe, is at the center of a heated battle over abortion and sterilization, in a case so complex you could use it to teach an entire course on bioethics.

Moe suffers from severe schizophrenia and bipolar mood disorder. She has been pregnant before: The first time she had an abortion, and the second pregnancy resulted in a boy now being raised by Moe’s parents. Between her abortion and the birth of her son, she suffered what court papers refer to as a “psychotic break," and had to be hospitalized. She now takes medication, but her diseases are so severe that she is still not in touch with reality.

Forced abortion for mentally ill woman? No way, court says

At a court hearing last December the state Department of Mental Health asked that her parents be made her guardians. The parents wanted their daughter, then two months pregnant, to have an abortion. During that hearing doctors testified that the drugs Moe is taking threatened the health of her fetus. They also said stopping them would place her at serious risk of going "deeper into madness."  

The judge found the argument for an abortion persuasive. She ordered that Moe's parents be appointed as co-guardians, and said they could do whatever was necessary including having their daughter "coaxed, bribed, or even enticed ... by ruse" into a hospital where the abortion could be performed. The judge added that Moe should be sterilized after the abortion so that the same situation did not come up again.

The decision was immediately appealed. Now, a Massachusetts appellate court has overturned the lower court, and sterilization is off the table. The appellate court said that if Moe were competent she would not want an abortion, since she has said she does not want one. So no abortion is in store either.

Did the appellate court make the right decision? I think so -- but for the wrong reasons.

The state of North Carolina just paid out big sums of money to people who had been sterilized without their consent in the 1960s and 1970s. Sterilization has been abused again and again in this and other countries. There is no reversing it. Whatever needs to be done to help Moe, it is not sterilizing her.

If she is not to be sterilized, can severely mentally ill persons like Moe be told never to have sex? The court didn't broach the subject, but it is a key ethical question.

It is probably impossible to prevent Moe from having sex.  But given her mental state she is hardly capable of consent.  I think she needs to be on permanent birth control until and unless she somehow recovers from her mental illnesses. Then, and only then, should she be free to have a child.

What about the abortion? She cannot consent to it. The Massachusetts courts are trying to guess what she would want if she were competent using some of her statements to guide them. That is a hopeless quest. Moe is too sick to tell us anything. And, despite the judges’ efforts, it is pointless to pretend to know her wishes about this pregnancy.

Her poor parents do not want to worry about their daughter, raise one of her children and find themselves with another. But their stake in all this disqualifies them to decide what ought to happen.

What we are left with when autonomy is gone and family are conflicted is trying to do what is best for Moe and her fetus. I do not think an abortion clearly meets that principle.

If Moe’s medicines put the fetus at risk, then try to lower the dose. If Moe herself becomes even more impaired, stop. If Moe cannot possibly raise the baby and her parents cannot either, then adoption is the best road to follow.

Allowing Mary Moe to become pregnant again is not in her best interest. Ending the life of her fetus when she cannot tell us what to do is not in the best interest of the fetus. There is a lot to think about in the case of Moe, but forced sterilization and non-consensual abortion should not be part of that thinking.

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Fertilized eggs could be granted human rights, depending on how Mississippi voters cast their ballots Tuesday on Initiative 26. The ballot measure, otherwise known as the "personhood" amendment, proposes to amend the state's constitution to redefine "person" to include "every human being from the moment of fertilization, cloning, or the functional equivalent thereof." Among other things, it could mean that couples who have turned to fertility clinics for help becoming parents won’t be allowed to ever destroy their unused fertilized eggs.

The polls say the anti-abortion referendum is likely to pass. 

First Read: Personhood measure divides conservative ranks

It shouldn’t.  

Not because passage would mean the end of all abortions, even for rape and incest. And not because its passage would create absurd public policy consequences: Do embryos get counted in the census? Could they inherit property? 

The reason this law makes for bad public policy is that it is completely at odds with what science knows to be true about embryos and fetuses.

Those who defend the amendment say they have science on their side. "The unborn child in the womb is scientifically proven to be a human being,” says Jennifer Mason, communications director for Personhood USA, the Arvada, Col.-based national advocacy group pushing for passage of Initiative 26. But Mason has no idea what she is talking about.

It is true that for centuries science has shown that all human beings begin as fertilized eggs.  But it is not true that all fertilized eggs can or do produce human beings.  In fact, it is so utterly wrong to say that every fertilized egg is a person, that to even suggest that science provides support for enacting the initiative is utterly absurd.

What are the odds of a fertilized egg becoming a person?

This is what we know: During the period of embryonic development that begins with fertilization and ends with successful implantation, about 50 percent of human conceptions fail to survive. The main reason for this high failure rate is the inability of huge numbers of fertilized eggs to implant.  

What science has found is that around half of all conceptions don't make it to implantation. Calling a fertilized egg a person flies in the face of this cruel biological reality. Half of all fertilized eggs cannot even become an embryo, much less a person.

Indeed, given the grim odds that face fertilized eggs, no one in science or medicine refers to a fertilized egg as an embryo unless it manages to implant. By talking about embryos and fertilized eggs as equivalent, supporters of Initiative 26 are not even using the correct scientific definition of an embryo.

First Read: Personhood measure divides conservative ranks

If the rest of the story of human reproduction -- as medicine and science know the facts to be -- is brought to bear, things only get worse for Initiative 26.

Sadly, all too many couples know about the high rate of spontaneous abortion and stillbirth that haunts embryonic and fetal development. Roughly, one in six embryos will spontaneously abort or produce fetuses that do not develop properly and die in utero. 

There are a huge number of embryos that are not properly genetically programmed for life. Nearly all of these completely lack the biological ability to develop into anything resembling a viable baby.  Legislation -- like that about to be voted on in Mississippi -- that declares fertilized eggs to be persons from the moment of conception simply ignores that the failure rate of human embryos is very high.  A considerable number of embryos and fetuses never have any chance of producing a baby. 

Medicine and science know very well what many millions of heart-broken would be parents around the world know first-hand: To call all embryos “persons” flies in the face of spontaneous abortion, stillbirth and fetal death.

In the push to declare fertilized eggs “persons” advocates claim science is on their side.  But it is only by ignoring what science has learned about the long odds that face fertilized eggs that anyone could even suggest that a fertilized egg is a person.

Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.