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Case example
Dr. Gold, an obstetrician-gynecologist, spends one day a week seeing patients at a rural clinic affiliated with the teaching hospital where she has admitting privileges. The clinic is about an hour drive from the city in which her teaching hospital is located. Mrs. Farmer, a 26-year-old mother of four, has made an appointment with Dr. Gold today at the rural clinic. Dr. Gold delivered Mrs. Farmer’s youngest child two years ago, but has not seen her since then. Mrs. Farmer reports that she has missed a menstrual period and fears that she might be pregnant again. A pregnancy test is done; it confirms that Mrs. Farmer is pregnant, and the pregnancy is estimated at about seven weeks. Mrs. Farmer immediately states that she does not want to have another baby. She tells Dr. Gold that her husband will be furious when he finds out that she is pregnant and could pose a danger to her and her children – he was physically violent with her during her last pregnancy. She relates that she has been using birth control to prevent pregnancy, but it has obviously failed. The couple can barely afford to support their four children. Mrs. Farmer asks Dr. Gold to terminate the pregnancy.
The multi-institution health system in which Dr. Gold works has a firm policy about abortion. It states that, if an abortion is necessary for a therapeutic reason, that is, to protect the life or health of the pregnant woman, a physician may perform the procedure. Physicians are not, however, permitted to perform elective abortions in system facilities. Dr. Gold explains this to Mrs. Farmer and tells her that the nearest clinic that performs elective abortions is located about a three-hour drive away. Mrs. Farmer begins to weep and says that she cannot travel to have the procedure because she does not have access to a car and has no one to watch her children for more than a few hours. She pleads with Dr. Gold to consider her case to be one in which the pregnancy must be terminated to protect her health, and to perform the abortion. How should Dr. Gold respond?
Abortion: an intractable problem in health care ethics
Abortion has long been a high-profile ethical and public policy issue, and it is a standard topic in undergraduate, graduate, and professional school bioethics courses. Despite its high visibility, however, my students over the years have sometimes confessed that they dread discussion of this topic and have suggested that we just skip over it. When asked why they feel this way, students cite a number of reasons. Some point out that, because the issue is highly complicated, one or two class discussions can do little more than scratch the surface, and the risk of oversimplification is great. Others observe that abortion is an emotionally charged topic, and so discussions may generate more “heat” than “light,” and more ill will than understanding. Still others argue that positions on abortion are both entrenched and deeply divided; people’s minds are made up, and they are reluctant to subject their views to scrutiny or challenge. All of these concerns are highly plausible. Perhaps more than any other topic in bioethics, abortion seems to be an intractable conflict, with little progress toward public resolution over many decades.
This is not a complete account of the abortion issue, however, and there are also persuasive reasons why bioethics students should confront the issue directly. Precisely because abortion is such a highly visible and hotly debated topic, it demands our attention in order to appreciate why it is so difficult to resolve, if nothing else. Abortion is, after all, not a trivial or minor issue, but rather an issue with life and death implications for fetuses, and serious health and life consequences for pregnant women. Abortion is also an issue that is fraught with confusion and misunderstanding about key concepts, relevant factual information, and leading moral arguments. Discussion may thus at least dispel common misunderstandings and enable a better assessment of the arguments. Abortion is certainly a subject with deep disagreements, but it also offers some potential for common ground among those who disagree, and it is worth noting where there are areas of agreement and possible cooperation. Finally, abortion is an issue that health care professionals are likely to encounter in their practices, certainly if they work in obstetrics and gynecology, and also if they provide any type of primary health care for women. Professionals must be prepared, therefore, to respond to questions about abortion that will arise in a wide variety of practice settings. For all of these reasons, the topic of abortion deserves our attention and should not be ignored.
The many dimensions of abortion
As befits a book on health care ethics, this chapter will focus on moral arguments regarding the practice of abortion. It is, however, important to acknowledge that there are many other kinds of questions about abortion and other ways to approach the issue. These different dimensions of abortion may inform moral conclusions in important ways.
Empirical dimensions
There are, for example, a variety of empirical questions about the practice of abortion. Among these are demographic questions, as, for example, how many abortions are performed, where they are performed, who performs them, on what patients, and at what stage of gestation.1 There are also multiple and controversial questions about the medical and psychological consequences of both abortion and childbirth, as, for example, what risks these procedures pose to the physical and mental health of the women who undergo them.2
Religious dimensions
Many people adopt a position on the practice of abortion based on the doctrines of their faith community. Religious views on abortion vary widely, from strict condemnation to qualified acceptance of this practice, and there is lively theological debate both within and among religious traditions about abortion, both in general and in specific circumstances.3 Members of different faith traditions may claim respect for their views on abortion as a matter of freedom of religion.4
Legal dimensions
Popular attitudes toward abortion are also strongly influenced by the laws governing this practice. As with religion, there is wide variation in national laws on abortion, from prohibition of virtually all abortions to acceptance of abortion on demand throughout pregnancy.5 In the United States, the 1973 Supreme Court decision in Roe v. Wade recognized basic constitutional principles that remain in force.6 In that decision, the Court ruled that a woman’s choice of abortion is protected by a basic right of privacy, but that states may limit or prohibit abortion to protect the fetus after it has reached viability, unless an abortion is necessary to preserve the life or the health of the pregnant woman. This legal right to abortion in the United States is a negative right, that is, a right to freedom from interference by others in obtaining an abortion, not an entitlement to receive abortion services on demand, regardless of one’s ability to pay for this service or to find a willing provider.
Within the broad framework of US federal law on abortion, there is significant variation among individual state abortion statutes. Some but not all states impose additional legal requirements on abortion procedures, including waiting periods of twenty-four to seventy-two hours, provision of specific types of information to patients seeking abortion, limits on which physicians and facilities may perform abortions, and parental consent for abortions on patients who are minors.7
Professional dimensions
Physicians and other health care providers recognize that questions regarding abortion may arise in their professional relationships with patients. They may, therefore, wonder whether there are specific professional responsibilities or privileges that should guide their response to questions about abortion. If professional principles do bear on these questions, how do these principles relate to any personal moral beliefs about abortion that particular professionals may hold? Laws and institutional policies in many jurisdictions recognize a professional right of conscientious refusal to participate in abortion procedures.8 Chapter 10, “Professionalism,” discusses the scope and limits of conscientious refusal as a protection for the moral integrity of health care professionals. The case analysis at the end of this chapter will also consider the relationship between professional responsibilities and personal beliefs.
The morality of abortion: examining two representative positions
For more than half a century, abortion has been both a highly significant and a deeply controversial topic in ethics and public policy. Not surprisingly, therefore, there is an abundance of nuanced positions and arguments on the morality of abortion in the bioethics literature, and I cannot do justice to the great variety of these positions and arguments in a single short chapter. I can, however, identify two general and opposed views on the morality of abortion. Most contributions to the literature can be grouped into one of these two general views. The “pro-choice” view asserts that women should be morally and legally permitted to choose abortion in most circumstances. The “pro-life” view asserts that abortion is, in most circumstances, an immoral life-ending practice that should be legally prohibited.
My intention in this section of the chapter is to examine two representative articles on abortion, one pro-choice and one pro-life. The articles I will examine are “The Wrong of Abortion,” by Patrick Lee and Robert P. George, and “Abortion,” by Mary Anne Warren.9 I have chosen these two articles as examples of reasonably clear and well-developed philosophical positions on the morality of abortion. As their title suggests, Lee and George articulate and defend a pro-life position on abortion; Warren defends a pro-choice position. I will identify several areas of agreement between the two positions, followed by areas of disagreement. Then I will pose a concluding question for each position. My goal is not to propose and defend a solution to the abortion controversy (that is a much larger task!), but rather to show that there is at least some common ground on this issue, to focus on key claims that divide the two approaches, and thereby to help readers come to a clearer understanding of both their own position on abortion and of opposing positions.
Areas of agreement
Lee/George and Warren reach very similar conclusions about a number of important issues. Both articles recognize that becoming pregnant is not an entirely voluntary choice for many women and that unwanted pregnancy and procreation may have unwelcome consequences for women and others, including health risks, economic hardships, and social problems of overpopulation. Both articles also recognize, however, that these negative consequences do not provide sufficient reason to justify abortion, if the fetus10 has the full complement of moral rights ascribed to human persons, including a robust right to life. One cannot, in other words, kill a person simply because that person’s existence creates a hardship for oneself.11
Because they both acknowledge that claims based on the interests of women and others are not generally powerful enough by themselves to justify abortion, both Lee/George and Warren also agree that the key question in determining the morality of abortion is, “What is the moral status of the fetus?” If the fetus qualifies as a person with full moral rights, including a right to life, abortion will not be morally permissible, except perhaps in a few exceptional circumstances, such as a pregnancy that poses a clear threat to the life of the woman. If, in contrast, the fetus does not have a moral right to life, abortion may be justifiable in many or most circumstances in order to respect the self-determination or promote the welfare of the pregnant woman.
Other areas of agreement between the two articles have to do with the physical and developmental characteristics of the fetus. Both articles recognize that, after conception occurs, the fetus has all of the following characteristics:
1. It is a distinct organism, initially dependent on but not a part of the woman’s body.
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