Virtue ethics as a framework for nurses navigating abortion care

Nurses and the Ethics of Abortion

Abortion and Virtue Ethics

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 not prevent future spousal abuse. From the perspective of the NRLC, the 3,000 mother-helping centers that have been established around the country undermine the proposition that unwanted children actually exist. These centers provide crisis intervention for pregnant women, including medical assistance, educational opportunities, housing, and when available, job training. In addition, the NRLC reports that there are up to 36 couples waitlisted for every adoption taking place in this country. In light of these statistics and from the perspective of the NRLC, an unwanted birth is nothing more than a convenient argument to justify infanticide and fill the bank accounts of abortionists.

The fourth main prochoice argument discussed by the NRLC is that ending legalized abortion will not end abortion, because abortions will be performed illegally (Turner & Balch, 2013). The overall result will be an increase in the number of adverse outcomes, including the death of both mother and fetus. To counter this claim, the NRLC quotes mid-20th century statistics generated by Planned Parenthood, which reveal that 90% of illegal abortions were performed safely by physicians and that most adverse outcome arose during self-induced abortions. In fact, during the year before Roe v. Wade (1973) was decided by the U.S. Supreme Court the CDC reported a total of 39 deaths due to illegal abortions. The NRLC does not provide any recent statistics on the number of illegal abortions and deaths since Roe v. Wade, but does cite the comparatively large number of deaths (> 200) during legal abortions for the entire period since 1974, which seems to be an intentional way of creating the perception that legal abortion is unsafe. In fact, the number of deaths from legalized abortions has varied between 4 and 12 annually for many years, which seems a relatively tiny number given that nearly a million abortions are conducted each year (Ventura et al., 2012; Pozol et al., 2013). The point the NRLC (2013) is trying to make is that there is little difference in the safety of legal and illegal abortions, which implies the prochoice argument cannot withstand a detailed examination of the facts. The NRLC goes further and suggests that legalized abortion is nothing more than a way to increase an abortionist's profit margins.

The fifth and final main prochoice argument presented by the NRLC is that abortion is the only viable option in cases of a severe congenital defects, rape, and incest (Turner & Balch, 2013). To counter this argument, the NRLC cites Planned Parenthood statistics suggesting that less than 6% of all U.S. abortions are done for any of these reasons and then tackles each one separately. Performing an abortion to prevent the birth of a severely handicapped child was equated to discrimination against the disabled, thereby implying the prochoice position includes the sentiment that some lives are not worth living. The NRLC then goes on to describe how some of the deformities and diseases used to justify an abortion are quite minor, with the list growing longer every year despite remarkable advancements in medicine. With respect to rape and incest, the NRLC encourages prolife activists to acknowledge that real violence has been perpetrated against the mother, while suggesting that the unborn child is also a victim of the same violence. The idea that abortion could ever be a viable solution to these acts of violence, according to the NRLC, ignores the fact that one act of violence is used as an excuse to commit another act of violence (abortion).

While the policy positions of the NRLC have merit there is also a prominent 'us against them' theme underlying all of their arguments, in addition to manipulation of both the message and facts. No attempt is made to find a more rational and less divisive middle ground. Anyone seeking to find this middle ground would likely find these arguments unhelpful.

Prochoice Positions

The National Abortion Federation (NAF, 2010) takes the position that abortion is one of many legitimate reproductive choices available to women in the United States and deserving of active protection. The purpose of abortion, in addition to the other reproductive choices of parenthood and adoption, is to reduce the number of unplanned pregnancies and thus unwanted children being brought into the world. Compared to the prolife positions presented above, however, NAF does not draw any moral or ethical distinction between abortion, adoption, or keeping the child. The prochoice position is based on the principle of empowering women with the ability to choose if and when to have a family, without the government interfering in what is a very personal choice. Under this principle, women are viewed as fully capable of intelligently and responsibly determining their own reproductive fate. The prochoice position, as articulated by NAF, does not attempt to promote abortion, only to protect the right of women to decide whether or not abortion is the right choice for them. Since the focus is on protecting the reproductive freedom of women, promoting and protecting easy access to contraception is also a prominent feature of prochoice policies (NARAL, 2014).

A divisive tone is also evident among the information provided by prochoice organizations (NAF, 2010; NARAL, 2014), so any effort to find a rational middle ground is made all the more difficult by the many inflammatory statements that can be found on these websites. What seems clear, however, is that the prolife and prochoice organizations are viewing legal abortion through two distinct lenses. The prolife position seems to be mainly premised on the belief that all life is sacred, even a recently fertilized oocyte. By comparison, the prochoice perspective appears to be mainly based on the principle of protecting a woman's right and responsibility for determining her reproductive fate. On the one hand abortion destroys life and on the other it represents just one of several equivalent choices along a reproductive decision-making continuum.

Virtue Ethics and Abortion

Aristotle defined virtue as distinct from passion or faculties by declaring them states of character (Armstrong, 2006). Virtue was further divided into the moral and intellectual forms, with moral virtue arising through the habitual practice of intellectual virtues. Intellectual virtues consisted of scientific knowledge, intelligence, technical skill, wisdom, and common sense, all valuable traits in the nursing profession. Other traits, such as kindness, patience, tolerance, and compassion have been linked to high-quality nursing care and some would even suggest these represent the most important aspect of patient care. Armstrong (2006), however, points out that the nursing role tends to define which virtues are most important to providing high-quality patient care for a given situation.

A distinction is drawn between virtues as inherent character traits defining a person's identity and moral obligations and principles being imposed by an external agency, such as a professional nursing association (Armstrong, 2006). Accordingly, conflict may occur between a person's virtues and their professional obligations; however, Armstrong (2006) invokes Aristotle when she argues that moral virtues must be exercised in order to live a morally good life and doing so will naturally generate a set of rules, thereby rendering many of the externally-imposed moral obligations redundant. Both Aristotle and Armstrong (2006) also emphasize the principle of 'hitting the mean,' which implies, for example, that no one should become excessively compassionate or completely devoid of any compassion. Somewhere between these two extremes, as defined by a person's reason and moral judgment, is the best way to live a virtuous life. By comparison, deontological ethics provides no such guidance and is therefore wanting.

Armstrong (2006) then takes issue with the rules and regulations that dominate most health care organizations, because they are too simplistic and incomplete to provide sufficient moral guidance for the care environment. She chooses three examples to make her point: (1) moral dilemmas, (2) the value of moral wisdom and judgment, and (3) conflicting obligations and duties. Moral dilemmas are viewed by most health care organizations as resolvable, but some experts in nursing ethics believe in the existence of at least three types of moral dilemmas: resolvable, irresolvable, and tragic. The emotional aftermath of moral dilemmas, for both the patient and nurse, also tends to be ignored. The hard-earned moral wisdom and judgment many nurses develop is also ignored under a rules-based system, potentially limiting the quality of care provided. Finally, a rules-based system may attempt to resolve conflicts between a nurse's duties and obligations, but often these are insufficient to the task.

Armstrong (2006) then proposes a virtue ethics model of nursing that emphasizes the following: (1) exercising the virtues most closely associated with the nursing profession, such as kindness, honesty, and compassion, (2) using moral judgment, and (3) using moral wisdom. Moral wisdom, in turn, can be divided into moral perception, sensitivity, and imagination. Moral perception is the ability to understand the moral implications of one's actions, decisions, and experiences, while moral sensitivity is the ability to sense a person's needs and provide a morally appropriate response. The ability to understand the moral implications of one's actions and decisions concerning a patient is the virtue of moral imagination. The main framework that Armstrong (2006) used to help define a virtue ethics model for nursing is the concept of a nurse-patient helping relationship. Although unwilling to list all the virtues that may be relevant to this relationship, she does mention those she feels are most important: compassion, benevolence, kindness, courage, honesty, respectfulness, patience, trustworthiness, tolerance, and justice.

Nowhere in the above discussion on virtue ethics has abortion been mentioned, but Armstrong's (2006) discussion of moral conflicts is directly relevant. Among the many authors Armstrong (2006) cites frequently is Rosalind Hursthouse. Hursthouse (1991) has tackled the question of abortion from the perspective of virtue ethics and provides a convincing argument for why this theory is more valuable than a deontological or utilitarian perspective. As mentioned above, the main frameworks for the prolife and prochoice positions are based on two distinct perspectives, the sanctity of all life, even a single-cell fertilized embryo, and the right of a woman to determine her own reproductive fate free of outside influence, respectively. Hursthouse (1991) came to the same conclusion, yet rendered each position as irrelevant to virtue theory from a secular perspective. Both positions fail to capture the entirety of the moral implications that an abortion decision can generate. What is often involved in an abortion decision is the quality of the relationship between the prospective parents and what an abortion would mean, what an abortion means to an unmarried woman or adolescent, maternal age (the ticking biological clock), nine months devoted to gestation, the pains, risks, and emotions surrounding the birth of a child, the often unwanted responsibility of choosing between life and death, the envisioned responsibilities of parenthood, the impact that birth or abortion would have on the extended family, and the prospect of living with one or the other decision. The sheer complexity of an abortion decision on an individual basis and the web of future consequences it would create, regardless of the choice made, renders the prolife and prochoice positions almost laughable in their simplicity. This is what virtue ethics can add to the debate over abortion. Hursthouse (1991) makes the smart decision and provides no solution to the moral dilemma of abortion; however, her application of virtue ethics to this issue seems to provide a more relevant and thus valuable moral framework for nurses facing the tough decision of whether to provide abortion care.

Faith Integration

Hursthouse (1991) provides a secular ethical framework for nurses wishing to maintain a buffer between any religious beliefs they may hold and their professional responsibilities. Nurses who would prefer to incorporate their religious or spiritual values into their professional life can still find support for this decision among the guidelines published by the ANA and NYSNA and within virtue ethics, as long as these views do not stray too far from the mean. For example, the principle of tolerance can be found in the practice of respecting a patient's personal values or in the professional guidelines allowing nurses to choose whether to participate in abortion care. The latter could be based on respect for an embryo's personhood and the nursing virtue of compassion for an unborn life. Professional guidelines and virtue ethics therefore provide plenty of room for faith integration.

Discussion

Virtue ethics naturally encompasses all the complex factors and emotions that feed into an abortion decision by a patient, without excluding the emotional impact a decision will have on the nursing professional who has chosen to provide abortion care. Virtue ethics does not pretend to have an easy answer, but its recognition that abortion is often a life-changing and difficult decision for the patient and her family makes it ideally suited for what is often a messy process that must still be navigated. Virtue ethics also welcomes nurses who believe abortion is religiously and therefore morally objectionable and invites them to make the decision not to provide care for women undergoing an elective abortion. The virtues listed by Armstrong (2006) that seem most relevant to the decision not to provide abortion care are respectfulness for the sanctity of life, compassion for the unborn, and the courage to respect one's own beliefs. Aristotle would encourage both the exercise of these virtues and hitting the mean, with the latter implying that the extreme position advocated by the NRLC (2013) would be inappropriate for anyone who seeks a morally good life, especially a professional nurse.

Another aspect of virtue ethics is that is does not shy away from the hard facts of life. It requires nurses who choose to counsel patients faced with an abortion decision to recognize all the different obstacles that the woman may be facing, including racial and ethnic discrimination and a lack of access to effective and affordable contraception. Young, poverty stricken, little prospect for a better future are realistic considerations during deliberations about whether or not to have an abortion. In addition, contrary to what the NRLC (2013) would like the public to believe, the vast majority of women understands what an abortion means for the fetus and do not make this decision lightly. The nursing virtues of compassion, respectfulness, and tolerance would probably be highly valued by these patients.

Virtue ethics will not protect nurses, who choose to provide abortion care, from vindictive attorney generals or legislative restrictions, but it will provide guidance on how to remain professional and caring in the face of angry opposition and when provided patient-centered care for women faced with a reproductive choice that may include abortion.