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10/20/2016

The Ethics of Crisis Pregnancy Centers

“Pregnant? Scared? Need Help?”
read signs along major thoroughfares in the southern United States. Many
Americans have seen signs like these, often simultaneously advertising free
pregnancy and sexually transmitted infection (STI) testing. Unless experiencing
a unplanned pregnancy, most people pass by these signs without a second
thought. However, for some of our most vulnerable patients, the
establishments posting these advertisements – known as crisis
pregnancy centers – represent a significant ethical difficulty in
reproductive healthcare. Although these organizations are almost exclusively
run by community volunteers, they represent themselves as healthcare workers by
wearing lab coats and scrubs, providing lab testing and ultrasounds, and setting
up offices that look like medical clinics. This would be problematic in itself
from a legal perspective but the political and religious perspectives of these
organizations provides serious ethical questions as well. Far from
unbiased, crisis pregnancy centers (CPCs) are usually religiously
affiliated organizations with a hard right agenda of
preventing abortion at any cost. Medical evidence and scientific fact are
not considered in this equation so clients of CPCs are often told that abortion
causes breast cancer, infertility, psychiatric disorders (such as the entirely
fictitious post-abortion syndrome), and even, in one case, kidney
failure and subsequent dialysis. Furthermore, results of testing done at
CPCs are frequently fabricated or ignored – clients are given falsely
negative pregnancy test results or incorrect dating ultrasounds to prevent
those considering an abortion from pursuing other care. CPC clients are usually
unaware that these organizations do not employ trained medical providers or that
they have a political agenda. However, the intent is clearly to strongly imply
to CPC clients that they are being given information by medical personnel. As
such, it seems fair to evaluate CPCs using principles of medical ethics, such
as the four basic principles of beneficence, nonmaleficence, autonomy, and
justice.

There is no question that the principle
of autonomy is violated at these centers egregiously – purposefully providing
misleading or false information takes away a person’s ability to make informed
decisions. However, the other three principles come into play with CPCs as
well. Since there are rarely real medical providers at these centers, patients
with serious health issues may be given advice that is, at best, suboptimal
and, at worst, dangerous, arguably violating the principle of nonmaleficence.
When
a patient is told they are not pregnant when they are, they will not be able to
seek timely prenatal care and are potentially put at risk for complications of
pregnancy. When a non-expert performs an ultrasound and provides inaccurate
results, fetal abnormalities, ectopic pregnancies, and other concerns go
unrecognized. One center in Texas was documented
telling a patient with a history of transposition of the great vessels that
pregnancy was likely uncomplicated for her and would require “occasional
monitoring,” rather than the extensive cardiologic and obstetric care that she
would need throughout her pregnancy. These scenarios are not uncommon at CPCs
and clearly have the potential to cause harm to patients seen in their offices.
The principle of justice should also be considered in the case of CPCs as well
– most situate themselves in areas of low socioeconomic status and target low
income people as primary clients. These are generally the patients who can
least afford access to healthcare and typically have lower levels of education,
making them the least able to afford to care for an additional child and most
vulnerable to the tactics of CPCs. It is hardly just when vulnerable patients,
frequently people of color, are targeted to receive radically different
healthcare and information than those with greater financial means, who would
be less likely to be looking for low cost services.

Beneficence is the only
principle of the four that could be debated depending on one’s political and
ethical leanings. A more pro-life leaning position might argue that the
beneficence attributable to the fetus by potentially preventing an abortion
should be considered with the discussion surrounding CPCs. This, of
course, is predicated on the assumption that CPCs help to prevent abortions at
all, which has yet to be adequately studied, although many CPCs tout the
numbers of supposedly prevented abortions on promotional materials. Conversely,
a pro-choice argument would be more concerned with the pregnant person, the
potential benefits and risks of continuing a pregnancy and abortion, and the
beneficence attributable to them. Overall, the patient should be able to
determine for themselves what beneficence is for them and whether the patient
should be treated as a patient. Regardless of stance, any ethical analysis
would involve weighing multiple factors to determine whether or not a
particular practice should be considered ethical. Looking at the complete
picture surrounding CPCs and considering the violations of nonbeneficence,
autonomy, and justice as previously outlined, it is not difficult to conclude
that the practices of CPCs are not ethical and should not be endorsed by
mainstream medical providers.

Although the ethical
violations are clear, the course of action with regard to CPCs is not. These
centers tend to fall into a legal gray area, as they are not officially bound
by rules regarding medical practitioners and generally fall under
non-commercial and/or speech stipulations when it comes to false advertisement
litigation. Complicating the issue further is the fact that not every CPC
operates this way – some centers follow strict guidelines regarding usage of
scientific evidence and disclosure of non-medical personnel status, usually in
states that regulate these centers. There is also no question that there is a
need for services in populations targeted by CPCs and that, if operated
appropriately, they could be a force for good in low income communities. Thus,
although it’s difficult to universally condemn the practice, advocacy for
regulation of CPCs, especially those who receive state funding, seems key. As
medical practitioners, it is important to be aware of the existence of CPCs and
their ethical problems. Furthermore, one of the best things we can do for our
patients is make sure they do not fall prey to such predatory practices by
advocating for laws that plainly identify CPCs as non-medical practices and/or
require fact-based counseling, particularly in those centers that receive state
and federal funding. Regardless of personal feelings on abortion, honest and
ethical practices with patients should be an issue that all medical
practitioners can agree with. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI’s online graduate programs, please visit our website.

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