In the Crossfire: Nurses and the Ethics of Abortion
In the Crossfire: Nurses and the Ethics of Abortion
Nebraska's Attorney General, Jon Bruning, announced his efforts to revoke the license of the only nurse working at Dr. LeRoy Carhart's abortion clinic in a suburb of Omaha (Funk, 2013). The revocation proceedings are based on allegations of substandard care and the delegation of patient care to unlicensed staff. Should the Attorney General be successful, Carhart would be faced with the task of hiring another nurse at a clinic that has been the focus frequent and aggressive anti-abortion activities. The news article by Funk (2013) highlights Dr. Carhart's past successes in challenging restrictive abortion laws before the U.S. Supreme Court, thereby implying the most recent allegations may be contaminated by motivations other than a concern for patient health and safety.
Such events are no longer rare in the United States. An article published by the United Press International (2014) reported that 2013 was almost a record year for the number of abortion restrictions enacted at the state level. A total of 70 such bills were approved in 22 states, adding to the grand total of 205 abortion restrictions passed during the past three years. When compared to the previous decade, during which 189 abortion restrictions were enacted, the battle over abortion in the U.S. continues to escalate. This is relevant to the topic of this essay because many of these restrictions directly impact clinicians.
Whether they like it or not, many clinicians are caught in the crossfire between the diverse prolife and prochoice factions within American society. Successfully navigating the ethical intersection between the onslaught of new abortion legislation, best practice recommendations, and personal values may become even more difficult in the near future, especially in light of the Medicaid expansion extending contraceptive coverage to millions of minority Americans living near or below the poverty line (Burlone et al., 2013). The debate over mandated contraceptive coverage is inextricably linked to the battle over abortion, in light of recent data from Oregon showing that the expanded coverage would prevent 72 pregnancies for every 1,000 women within a 5-year period (Burlone et al., 2013).
In an effort to provide some guidance for nurses struggling with these issues this essay will present both sides of the abortion argument and then view these positions through the lens of nursing ethics. Virtue ethics will then be presented as the preferred ethical framework for guiding nursing practice, regardless of whether the nurse chooses to provide abortion services or decides to object based on religious or other closely-held beliefs.
Abortion in America
Based on the data collected by the U.S. Center for Disease Control and Prevention (CDC) abortion is defined as the termination of pregnancy by curettage or medications (Pozol, Creanga, Burley, Hayes, & Jamieson, 2013). Curettage, the mechanical removal of the fetus and supporting tissue, remains the primary method of abortion in the U.S., with 72.4% of all abortions being performed using this method. At 8 weeks gestation or earlier, the administration of mifepristone followed by misoprostol is generally used to induce an abortion, but after 8 weeks into the pregnancy vaginal prostaglandins are commonly used. Any intrauterine instillations performed at 12 weeks or earlier were not included in the study, but when this method was used after 12 weeks it still represented only 0.0003% of all abortion methods reported to the CDC. Although curettage represents the main method of abortion in the U.S., its use is slowly declining and being replaced by abortifacient drugs. Between 2001 and 2010, the use of drugs to induce abortions increased from 3.4 to 17.2%.
An estimated 6.6 million pregnancies occurred in the United States in 2008, which resulted in 4.25 million live births, 1.2 million abortions, and 1.1 million miscarriages (Ventura, Curtin, Abama, Division of Vital Statistics of the CDC, & Henshaw, 2012). In 2010, 765,651 abortions were reported to the CDC from 49 out of 52 reporting areas within the United States (Pozol et al., 2013). For the 46 reporting areas providing data from 2001 to 2010 there was a 9% decline in the number of abortions performed, which could be explained by the proliferation of abortion restrictions being enacted in many states during this period. In support of this explanation, the rate of abortions per woman between the ages of 15 and 44 years declined by 10% and the abortion rate per live birth declined by 8%. These statistics reveal that the decline in abortions within the majority of reporting areas was not due to a decline in fertility. Teen pregnancy was not a significant contributing factor, since this age group accounted for only 0.5% of all abortions. The most abortions (57.4%) were obtained by women between the ages of 20 and 29. When the data was stratified by race and ethnicity, Caucasian women were least likely to obtain an abortion (1.41% of live births) and African-American women were most likely (4.83% of live births).
A recent report examining the prevalence of contraceptive use along racial and ethnic lines looked at both age and contraceptive effectiveness (Dehlendorf et al., 2014). Among the 7,214 women between the ages of 15 and 44 who participated in the study, being African-American reduced the chances of contraceptive use [adjusted odds ratio (AOR), 0.65 (0.76-1/17), p = .0004] and increased the risk of unintended pregnancy. When the type of contraceptive used was examined, African-American [AOR, 0.49 (0.37-0.65), p < .0001] and Hispanic [AOR, 0.59 (0.43-0.76), p = .0001] women were significantly less likely to use highly or moderately effective contraceptive measures compared to Caucasian women. The classification of contraceptive method effectiveness was based on the recommendations of the World Health Organization, with the most effective being IUDs, implants, and sterilization. Moderately effective contraceptive methods were considered hormonal, while the least effective were barrier methods. Family planning and withdrawal were not considered to be contraceptive measures.
Based on the findings presented here the abortion debate should also include a discussion of health disparities along racial and ethnic boundaries, especially when it comes to access to effective contraceptive methods. The good news, however, is that national abortion rates have been declining significantly without any indication of a rise in illegal abortions or abortion-related deaths (Pozol et al., 2013, p. 8). If the recent avalanche of more restrictive abortion regulation being passed into law by state legislatures is responsible for this trend, then a detailed examination of the prolife and prochoice positions is warranted.
The Prolife Positions
The National Right to Life Committee (NRLC) has outlined five basic arguments they use to counter prochoice positions (Turner & Balch, 2013). The first is a response to the prochoice position that a fetus is not a person, but just a blob of tissue. The prolife position instead views the fetus, from the moment it becomes fertilized, is a complete human being and therefore deserving of the same rights and legal protections as the author of this essay. In essence, anyone having an abortion is guilty of infanticide and the clinicians assisting in the procedure are guilty of being accomplices in the crime of murder. Such persons should be prosecuted for the crime of murder by the relevant local and state law enforcement agencies. The NRLC supports this position by pointing out that most aborted fetuses have a beating heart and recognizable brain waves at the time of the procedure. The overall goal of this prolife argument is to give the fetus a human face, because, according the NRLC the goal of prochoice advocates is to dehumanize the fetus.
The second main prochoice claim, as articulated by the NRLC, is that women should have full control over their bodies including an unborn fetus residing in their wombs (Turner & Balch, 2013). In addition, this argument further suggests that many women would be economically and socially burdened by the birth of an unwanted child. The NRLC agrees that a pregnant woman has the right to control the destiny of her own body, but draws a line when it comes to intentionally terminating a pregnancy. From the prolife perspective, staunch prochoice activists are actually fighting to keep their right to commit infanticide based on the argument that a mother's rights trump the rights of the unborn fetus. The argument continues with the assertion that most women who obtain an abortion feel forced into the decision and unaware of the many alternatives available to them.
The third main prochoice argument presented by the NRLC is that a number of social problems contribute to the birth of unwanted children, including domestic abuse, poverty, and rape (Turner & Balch, 2013). In the absence of viable alternatives, abortion remains primary solution for unwanted births. The prolife counterargument is that poverty cannot serve as an excuse for abortion, because abortion will not end poverty or provide economic relief to the woman living in poverty. A similar framework is applied to the domestic abuse scenario, where abortion will…