Upholding Medical Ethics Principles by Performing Abortion: A Provider's Perspective

Introduction

More than 620,000 abortion procedures were performed in the United States in 2019; ∼ half were surgical abortions at <13 weeks' gestation, ∼42% were medication abortions, and ∼8% surgical were abortions at >13 weeks of gestation. ¹ To place this into perspective, ∼600,000 hysterectomies—one of the most commonly performed procedures for reproductive-age women—are performed annually in this country. ² Despite decreases in abortion rates during the past 20 years, nearly 1 in 4 women will have an abortion by age 45. ³ No procedure so commonly performed has such precarious legal and ethical standing in U.S. society.

In 2021 a record number of abortion restrictions were passed in the United States, a total of 108 restrictions in 19 states. This is the highest number of restrictions passed within 1 year since 1973. ⁴ Conservative legislators across the country passed them in an effort to limit access to abortion in real time, with the hope of sending a case to the U.S. Supreme Court to overturn the precedent set by Roe v. Wade and subsequent cases (Planned Parenthood v. Casey, Whole Woman's Health v. Hellerstedt). ⁵

As things stand currently, abortion access has been stripped back in an unprecedented decision by the Supreme Court in Dobbs v. Jackson Women's Health Organization. This case judged the constitutionality of the Mississippi Gestational Age Act, a law that banned all abortion procedures past 15 weeks of gestation outside of medical emergencies or severe fetal anomalies. The case was brought by Mississippi's only abortion clinic against the state. In November 2018, the U.S. District Court for the Southern District of Mississippi ruled in favor of the clinic. In his opinion, Judge Reeves stated that “the real reason we are here is simple. The State chose to pass a law it knew was unconstitutional to endorse a decades-long campaign, fueled by national interest groups, to ask the Supreme Court to overturn Roe v. Wade.”

After appeals and rulings in lower courts that affirmed the original Mississippi court ruling, the case was accepted by the Supreme Court. ⁶ Arguments were heard on December 1, 2021. In a 6–3 decision by the Supreme Court justices, Roe v. Wade was overturned, now allowing states to completely ban and even criminalize abortion care. ⁷ There is no more apt a time to discuss the ethics of abortion provision.

Often, abortion care is depicted as a necessary evil, an unfortunate circumstance that is to be hidden in the shadows of society. The following sections outline how the physician providing abortions is upholding the medical ethical principles of autonomy, nonmaleficence, beneficence, and justice toward a moral good.

Upholding Patient Autonomy

Much of the modern discourse around abortion provision, from media to law and even interpersonal conversations, centers around pitting the fetus and its purported rights and moral status versus those of the pregnant person's. This is an unnecessary premise with dangerous implications for patient safety and the freedom for self-determination. No one group or authority in society has sufficiently agreed upon the moral status nor the personhood status of the embryo or fetus. Due to this, it has been affirmed in cases such as Davis v. Davis in which frozen embryos are disputed in a disposition that a fetus or embryo does not have personhood status under the law:

Nor do preembryos enjoy protection as “persons” under federal law. In Roe v. Wade, the United States Supreme Court explicitly refused to hold that the fetus possesses independent rights under law, based upon a thorough examination of the federal constitution, relevant common law principles, and the lack of scientific consensus as to when life begins. ⁵

To create a decision-making balance scale that places a pregnant person on one end and the fetus at another end holds the implication that fetal moral status and/or rights have the power to supersede the personal autonomy of the pregnant person over the fetus' own life. The reality is that the questions of when life and personhood begin are intimate and personal ones that are influenced by a person's community, religion, education, and more. Given the intimate and personal nature of such questions, is strict government regulation and intervention required to enforce black-and-white regulations onto every pregnant person, based upon questions with answers in all shades of moral gray? What Roe v. Wade and subsequent cases had achieved was preventing states from having carte blanche to ban and criminalize a medical procedure and allowing each individual to make a personal choice on the matter. Preventing pregnant people from ever legally accessing the abortion procedure and being forced into pregnancy, birth, and parenthood is a serious breach of the principle of autonomy.

Importantly, pregnant people acting as free agents are confident about their decisions to terminate pregnancy, and abortion providers are upholding these patients' right to self-determination. In the Turnaway Study, ∼1000 women seeking abortion from 30 facilities around the United States were interviewed over 5 years, and trajectories of women who received a wanted abortion were compared to the trajectories of women who were turned away because their pregnancy was past the facility's gestational-age limit. Of the women interviewed, 95% felt that abortion was the right decision for them. ⁸ Subsequent analysis also clarified the important distinction that having negative emotions after abortion was not the same as regret nor did it negate women's feelings of decision rightness. ⁹ For some women, abortion can be easy, healing, and simple. For some women, it can be challenging, grief-stricken and complicated. However, both groups of women can ultimately feel it was the best and correct decision for them at the time they made it.

The moral framework of fetus-versus–pregnant person would allow physicians to make moral judgement calls on behalf of their patients that directly affects their care in a way that does not happen for any other procedure or patient population in medicine. This framework strips pregnant people of their power and personhood in a manner that is not in line with a profession where physicians take an oath to place one's personal beliefs aside to provide the best care possible to all patients. The current authors assert that, from the physician's perspective, the singular moral entity to be considered in the provision of abortion is the person carrying the fetus. To do so is to stand for the simple belief that pregnant people are capable of making sound decisions for their own bodies, safety, and lives.

Upholding Beneficence and Nonmaleficence

The principles of beneficence (relieving harm, providing good, and balancing risks and benefits) and nonmaleficence (avoiding causing harm) go hand-in-hand, and this is no exception when it comes to abortion care. ¹⁰

Abortion provision is known to decrease maternal mortality, both because an abortion induced by a medical professional is vastly safer than carrying a pregnancy to term and access to safe, professionally provided abortion reduces death and injury from self-inflicted, unsafe abortion procedures.^11,12 Applying the principle of beneficence in medical care is not only providing physical health benefits and relieving the harm of disease/physiologic derangements, but also improving quality of life (QoL) through the provision of medical care. In abortion care, benefits outside of physical health include improving optimism about one's future, achieving economic prosperity, improving care of current children, and decreasing the odds of domestic violence, among many other benefits. This discussion provides an overview of some of these benefits but is by no means exhaustive of the potential benefit to women and pregnant persons' lives from receiving abortion care.

In a study by Budig and England, in the American Sociological Review, after controlling for work experience, a wage penalty of 5% per child a woman birthed was discovered. ¹³ Arguments supporting the reason for such a penalty include reduced productivity as a result of the demands of motherhood, a tendency to work part time, and discrimination by employers against mothers. ¹³ Women of all backgrounds consistently share stories of harassment by coworkers, remarks on their performance capacity, and denial of appropriate work accommodations while at work and during maternity leave—if they are even granted maternity leave. ¹⁴

Beyond the economic discrimination against motherhood affecting salaries, women are still often tasked with the majority of uncompensated household duties of cleaning, cooking, and child rearing in their personal partnerships as well. ¹⁵ Data from the Turnaway study revealed that women who were able to access pregnancy termination were more likely to have a positive outlook on the future and set 5-year goals. ¹⁶ Women who were turned away had almost 4 times greater odds of a household income below the federal poverty level and 3 times greater odds of being unemployed. ¹⁷ Allowing women to opt out of unwanted pregnancy enables them to have less burden in the workplace, greater chances for setting goals, and further economic freedom than they would otherwise experience.

Data from 2014 revealed that 59% of abortions were obtained by women who already had at least 1 child. ¹⁸ There are numerous reasons, personal and financial, why a woman may not feel able to parent another child. In a 2004 study (published in 2005), researchers conducted indepth interviews with women about the reasons for obtaining an abortion. Of the respondents, 74% reported “having a baby would dramatically change my life,” with 38% of that subset reporting that this was due to having other children or dependents. ¹⁹ In another study, for up to 4.5 years after being denied a sought-after abortion, a woman's existing children had lower child development scores and were more likely to live below the federal poverty line, compared to the children of women who were able to obtain a sought-after abortion. ²⁰ The ability to obtain an abortion for an unintended pregnancy can improve outcomes for a woman's current children.

Intimate-partner violence (IPV) is common and pervasive in the United States. About 1 in 4 women report contact sexual violence, physical violence, and/or stalking by an intimate partner in their lifetimes. ²¹ In a sample from the Turnaway Study, 5% of participants reported physical abuse and 3% reported psychologic abuse from their partners before and during pregnancy. Following them over time, receiving an abortion was associated with a decrease in violence over time, whereas carrying a pregnancy to term was not. ²² In a survey of men seeking to assess the prevalence of IPV perpetration and involvement in abortions and abortion-related conflict, nearly 1 in 3 reported perpetrating such violence. The risk of being involved in 3 or more abortions was greater for abusive men. Additionally, men who reported perpetrating abuse were more likely to be involved in abortion-related conflict with the perpetration of IPV associated with men's attempts to both promote and restrict their female partners who were seeking abortion services. ²³ Analysis shows that, both from the male and female perspectives, there is a greater risk to women when they are denied wanted abortion.

Severe complications from medication abortion—such as infection, hemorrhage, or needing hospitalization—are rare, ranging from 0.03% to0.9%. Severe complications from aspiration abortion procedures within the first trimester are also rare, ranging from ∼0% to 3%. D&E abortion procedures—most performed between 14 and 20 weeks' gestation—are also relatively low-risk, with adverse-event rates ∼0.4%–5%. ²⁴ Thus, performing abortion procedures, both medical and surgical, at varying gestational ages, respects the principle of nonmaleficence in addition to promoting beneficence. To provide abortions is to be a steward of maternal health and QoL outcomes.

Upholding Justice

As defined by the organization SisterSong, reproductive justice is “the human right to maintain personal bodily autonomy, have children, not have children, and parent the children we have in safe and sustainable communities.” ²⁵ Advocates for reproductive justice go beyond advocating for access (i.e., legal access to sex education, contraception, and abortion) and advocate for a holistic model in which communities create a system of equity and opportunity for women to make whatever choices they desire regarding their reproductive health.

An essential part of patient autonomy in the setting of reproductive health is the control of if, when, and how one may have children. This is the core of reproductive justice as defined above. The care involved in reproductive health includes everything from contraception counseling to fertility treatments and, for many women, abortion. Whether a woman is simply finished having children, never wants to have children, or desperately wants a healthy pregnancy but is faced with a diagnosis necessitating abortion due to a fetal or maternal diagnosis, an abortion may be what a woman considers the most selfless decision for her and her family. Abortion is a key component of family planning in conjunction with contraception. No method of contraception, even permanent sterilization, is 100% effective. ²⁶ Thus, if one's contraception fails, abortion care is an essential option a patient must have available to have full control of her reproductive health. We must also veer away from the moral judgement of “using abortion as birth control” as a personal fault. Abortion can be and often is the safest and most effective option for a woman seeking to control her reproductive future.^12,24

Reproductive justice models consider that women of color and minorities are disproportionately affected by issues of access and inequity. ²⁷ Abortion is certainly a tenet within this framework, and lack of safe abortion access will undoubtedly disproportionately affect BIPOC [black, indigenous, and people of color] communities. Black and Hispanic women accounted for 59% of abortions performed in 2019, while white women accounted for 33% of these procedures. ¹ As these women find themselves in states with restricted abortion access, they are less likely to have access to means of transportation across state lines, less likely to have savings for travel and abortion costs, and more likely to have concerns around travel due to noncitizen status or risk of deportation. ²⁸

The economic and health impacts of having a forced pregnancy and delivery outlined above are multiplied for women of color. Indigenous, black, and Hispanic women are nearly twice as likely to be low-income as white women before the potential impact of being turned away from an abortion and raising another child affects a minority woman's livelihood. ²⁸ When it comes to maternal mortality rate, Black women have 3 times the mortality rate of white women during pregnancy and 1 year after pregnancy. ²⁹ It is estimated that a total abortion ban in the United States would increase the number of pregnancy-related deaths by 21% for all women and 33% among black women. ¹¹

The medical ethical principle of justice requires consideration of fairly distributing risks, costs, and benefits. ¹⁰ Physicians can apply this by recognizing the importance of abortion care to prevent inequitable distributions of risks and harms in our communities.