Tag: Women’s Reproductive Rights

Blog Posts (25)

October 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.

October 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.

August 25, 2016

More on the Male Pill: Social Reasons Why It Is Good for Women and Men

In my previous blog , I discussed how the lack of male contraception reduces men’s reproductive autonomy and burdens women with the health-related and financial consequences of being the one responsible for contraception. In this blog, I want to explore some of the social burdens women face when contracepting, especially those that men do not and would not face when using contraception.

Women face the social burdens of contraception, which include medicalization of one’s reproductive health, the stress and worry about the possibility of an unintended pregnancy, social repercussions of one’s contraceptive decisions, and possible moral reproach for contraceptive failures. While men could potentially face some of these social burdens, several of them are specific to women. For example, since pregnancy occurs in a woman’s body, she will physically embody the stigma and shame of an unintended pregnancy whereas the man will not carry any physical reminder of it.

Another burden unique to women is the double-bind they face regarding contraceptive use. Women who use contraceptive may be seen as violating the feminine norm of chastity. Yet, if single women do not use contraception, they risk an unintended pregnancy, which is associated with irresponsibility and trying to “trap” a man.

Since men are not held to the norm of chastity, but rather are frequently lauded for sexual promiscuity, they are not socially penalized for engaging in sexual activity and using contraception. Thus, the development of male contraceptives could help women avoid this no-win situation while empowering men to control their reproduction.

The need for male contraceptives is often looked overlooked because contraception is often conflated with women, thereby marginalizing and even ignoring men. For instance, unmet need for contraception is generally calculated using only women’s information: their fertility intentions and their contraceptive use. Excluding men from questions about unmet contraceptive needs fails to recognize their role in and responsibility for contraception both in their personal relationships and on the social level. It moreover fails to acknowledge that men may also have unmet contraceptive needs.

One study in Western Africa that interviewed both women and men regarding unmet contraceptive need found that between 15 – 23% of husbands had unmet contraceptive need even though their wives did not. These men were not interested in having children, at least at that time, but the dearth of reversible male contraceptives limited their options for controlling their reproduction since their partner did not have unmet contraceptive need and was consequently not using female or shared methods (and the male condom is frequently considered a shared method).

One of the benefits of female LARCs is that the woman’s partner does not need to be involved in or even know about their use. This is a good option for women if they and their partner disagree about contraceptive use. Unfortunately, men have no alternative available to them that they can use without their partner’s involvement or knowledge, which raises justice concerns and highlights men’s diminished reproductive autonomy.

 

 


 [LC1]Hyperlink to my previous blog.

August 25, 2016

More on the Male Pill: Social Reasons Why It Is Good for Women and Men

In my previous blog , I discussed how the lack of male contraception reduces men’s reproductive autonomy and burdens women with the health-related and financial consequences of being the one responsible for contraception. In this blog, I want to explore some of the social burdens women face when contracepting, especially those that men do not and would not face when using contraception.

Women face the social burdens of contraception, which include medicalization of one’s reproductive health, the stress and worry about the possibility of an unintended pregnancy, social repercussions of one’s contraceptive decisions, and possible moral reproach for contraceptive failures. While men could potentially face some of these social burdens, several of them are specific to women. For example, since pregnancy occurs in a woman’s body, she will physically embody the stigma and shame of an unintended pregnancy whereas the man will not carry any physical reminder of it.

Another burden unique to women is the double-bind they face regarding contraceptive use. Women who use contraceptive may be seen as violating the feminine norm of chastity. Yet, if single women do not use contraception, they risk an unintended pregnancy, which is associated with irresponsibility and trying to “trap” a man.

Since men are not held to the norm of chastity, but rather are frequently lauded for sexual promiscuity, they are not socially penalized for engaging in sexual activity and using contraception. Thus, the development of male contraceptives could help women avoid this no-win situation while empowering men to control their reproduction.

The need for male contraceptives is often looked overlooked because contraception is often conflated with women, thereby marginalizing and even ignoring men. For instance, unmet need for contraception is generally calculated using only women’s information: their fertility intentions and their contraceptive use. Excluding men from questions about unmet contraceptive needs fails to recognize their role in and responsibility for contraception both in their personal relationships and on the social level. It moreover fails to acknowledge that men may also have unmet contraceptive needs.

One study in Western Africa that interviewed both women and men regarding unmet contraceptive need found that between 15 – 23% of husbands had unmet contraceptive need even though their wives did not. These men were not interested in having children, at least at that time, but the dearth of reversible male contraceptives limited their options for controlling their reproduction since their partner did not have unmet contraceptive need and was consequently not using female or shared methods (and the male condom is frequently considered a shared method).

One of the benefits of female LARCs is that the woman’s partner does not need to be involved in or even know about their use. This is a good option for women if they and their partner disagree about contraceptive use. Unfortunately, men have no alternative available to them that they can use without their partner’s involvement or knowledge, which raises justice concerns and highlights men’s diminished reproductive autonomy.

 

 


 [LC1]Hyperlink to my previous blog.

June 20, 2016

The Politics of Fetal Pain: Why This Is Not A Legislative Issue

I read with interest the recent blog by my colleagues Paul Burcher and Claire Horner entitled “The Politics of Fetal Pain”. In their blog they discuss the recent fetal pain bill passed in Utah, which “requires the use of general anesthesia on women seeking abortions at 20 weeks gestation or later.” At stake is the concern that fetuses may be capable of experiencing pain by 20 weeks, which has prompted 12 states to restrict or prohibit abortions from that point on, instead of 24 weeks, which is the current standard.

Burcher and Horner remind us that the issue of fetal pain has been a source of contention for some time, which has led to “several states restricting or prohibiting abortions 20 weeks or later on the basis of potential fetal pain.” The authors are very much aware of the possibility that anti-abortion advocates may be using this issue as a convenient means by which to place additional limits on abortion rights of women. Which is to say, anti-abortion advocates supporting these restrictions on women’s reproductive rights may be using the fetal pain issue as a means to restrict abortion rights. Even if they do have a bias in creating this law, Burcher and Horner still believe that the law itself is justified.

Though I would share a concern about the possibility of fetal pain, if I had reason to believe there were evidence to support it, I disagree that the appropriate next move ethically is to join forces with a legislative agenda of politicians whose interests go far beyond the issue of fetal pain. My worry is that such legislative actions in fact usurp the professional role of physicians as medical experts of scientific data to set appropriate standards for medical care.

I accept that the possibility of fetal pain at 20 weeks is a theoretical possibility. But to the extent I find such a claim plausible I would do so by placing my confidence in scientific evidence, which to date is questionable. The paper from which Burcher and Horner take their evidence about fetal pain comes from an author who makes it clear in his writing that he believes abortion is an act of unjust killing. This is not an unreasonable moral position nor does it mean that he is not accurate in his assessment of the medical and scientific evidence regarding fetal pain. But it does raise concerns about his ability to assess and write about data of fetal pain without bias. Is he following the evidence or is he interpreting the evidence to support his preexisting moral views? The answer is we just don’t know, in the same way we don’t know if the Utah state legislature is really concerned about the possibility of fetal pain beginning at 20 weeks or is their real goal to place additional restrictions on abortions?

I want to make it clear that people, including bioethicists, legislators, and the public at large, have every right to advocate, based on their understanding of the evidence, to ensure that fetuses do not suffer during abortions from 20 weeks and beyond. My only point is that such advocacy should not be expressed in laws that impose standards of care on how physicians practice medicine. Such advocates may retort, but why should I think that the medical profession or the scientific community is unbiased? Could it be the case that these professional bodies are abdicating their professional, moral obligations to reduce the possibility of human suffering? Of course that is a theoretical possibility. But in an era where the role of science is grossly misunderstood and under attack by many advocacy groups, those of us in bioethics must champion the standards of scientific research and judgment by medical professionals to produce evidence that is unbiased and reflects the best available understanding of important empirical questions, such as, can fetuses feel pain? This is not an ethical question, i.e. it has nothing to do with whether or not fetuses have moral standing as human beings—rather the question is purely a matter of getting the facts as clear as possible in determining at what point in the development of a human fetus is there a physiological basis for experiencing pain. This is exclusively the scientific issue about which scientific and medical experts must decide based on the best available evidence.

So where should we look for such an understanding of the data on fetal pain? The answer is we should rely on the experts on such matters as reflected in the opinion from the American Congress of Obstetricians and Gynecologists (ACOG), which concluded “fetal perception of pain is unlikely before the third trimester. Although ultrasound monitoring can show intrauterine fetal movement, no studies since 2005 demonstrate fetal recognition of pain.”

I hasten to make it clear that it is always possible current scientific opinions will need to be revised based on new data. There are many examples that bear out this point. But we should realize just how procedurally disruptive and even iconoclastic it is to impose standards legislatively onto medicine because, in effect, we don’t trust or have faith in the integrity of medical experts to be fair or unbiased themselves. For doing so indicts the institution within our democratic system whose defined role and responsibility is to be the arbiters of empirical disputes. The process, i.e. the scientific method they use is by definition one that has the least chance of bias. And without robust confidence in the scientific enterprise and the knowledge that is generated, bioethics loses its footing to make moral assessments and judgments. Thus I agree with the view of ACOG:

“Sound health policy is best based on scientific fact and evidence-based medicine. The best health care is provided free of governmental interference in the patient-physician relationship. Personal decision making by women and their doctors should not be replaced by political ideology.”

Committing ourselves to make decisions based on scientific evidence, both in individual cases and at the policy level, requires us to always stipulate that our knowledge today may not be getting things exactly right. Advocates for the possibility of fetal pain, and I may be one of them, should not be quiet. They have every right and perhaps an obligation to express their concerns. But to conclude that ACOG refuses to accept the possibility of fetal pain because of politics—the fear of having to possibly create new standards about which they may fear a backlash from prochoice advocates or that they really do not believe a fetus has full moral standing—is to lose trust and confidence in an essential democratic institution, and indeed risks becoming cynical and riding roughshod over the role of professional medical expertise.

Thus, I conclude the Utah bill was not an appropriate action for the legislature to take, even if there is eventually scientific evidence that supports their concerns. I understand that there are some medical concerns about which a state legislature may appropriately pass laws—assisted suicide or narcotics—if there is a clear and compelling public interest. But I submit, since there is no clear and compelling evidence, the issue of fetal pain is not one of them.

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.

May 23, 2016

The Politics of Fetal Pain

Earlier this year, Utah passed a fetal pain bill that requires the use of general anesthesia on women seeking abortions at 20 weeks gestation or later.  This bill, which relies on a controversial claim that fetuses may feel pain as early as 20 weeks, has been heavily criticized as an attempt to abrogate abortion rights rather than serving a legitimate protective purpose. 

The issue of fetal pain has long been a source of contention in the scientific community, and the dispute has led to several states restricting or prohibiting abortions 20 weeks or later on the basis of potential fetal pain.  While many argue that this law is just one of many across the country aimed not at protecting health, but at restricting or eliminating abortion rights, this law, in fact, seems to be justified in its goal of minimizing the possible experience of suffering by the fetus. 

While studies have not proven that a fetus can feel pain prior to the third trimester, reasonable doubt about the possibility of fetal experience of pain exists.  As E. Christian Brugger argues in his article entitled “The Problem of Fetal Pain and Abortion: Toward an Ethical Consensus for Appropriate Behavior,” there is no moral certitude that fetuses do not feel pain after 20 weeks, and “a preponderance of evidence supports the conclusion that fetal-pain experience beginning in the second trimester of pregnancy is a real possibility.”  Brugger makes the argument, drawing from several researchers of fetal neuroanatomy that all the neural structures for both pain perception and consciousness are in place by 18-20 weeks.  Furthermore, he argues that those who deny fetal consciousness until much later in pregnancy may be relying on outdated assumptions which place the seat of consciousness in the cerebral cortex, despite growing evidence that the upper brainstem and subcortical tissues may actually play a greater role.

If it is reasonable to believe that the fetal experience of pain is possible after 20 weeks, it seems equally reasonable to consider requiring anesthetic or analgesia for such fetuses to prevent unnecessary suffering.  Despite statements from ACOG and others supporting the assertion that fetal pain is not likely before the third trimester, even the possibility that the fetus may experience significant pain and distress supports the notion that, in the face of uncertainty, we should err on the side of preventing such pain.

Opponents of such requirements argue that anesthesia can pose significant and disproportionate risks to the woman with no corresponding benefit, and that the use of anesthesia will increase the cost of abortion significantly, potentially limiting access to the procedure for many women for financial reasons.  While mandating anesthesia or analgesia is not without risks, these risks are not disproportionate if the benefit is eliminating possible pain experienced by the fetus. 

Whether or not the primary purpose of this law is to curtail abortion rights, its effect is, in fact humane; that is, it is an attempt, in light of scientific and moral uncertainty, to prevent unnecessary fetal pain if, in fact, the fetus can and does experience it.  This compassionate approach seems eminently reasonable, and should be supported.

 

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.

April 1, 2016

The ethics of Indiana HB 1337: Outlawing abortion based on race, sex, and disability

In March, the Indiana legislature passed and the Indiana governor signed into law HB 1337, a bill that bans abortions for women seeking them based solely on certain characteristics of the fetus, such as race, sex, and disability. Specifically, the bill:

 “Prohibits a person from performing an abortion if the person knows that the pregnant woman is seeking the abortion solely because of: (1) the race, color, national origin, ancestry, or sex of the fetus; or (2) a diagnosis or potential diagnosis of the fetus having Down syndrome or any other disability. Provides for disciplinary sanctions and civil liability for wrongful death if a person knowingly or intentionally performs a sex selective abortion or an abortion conducted because of a diagnosis or potential diagnosis of Down syndrome or any other disability.”

As I have discussed in a previous blog, sex selection is a frequent occurrence in certain countries, such as India and China, where there is a strong preference for sons. Yet, there is little to no evidence that sex selection abortion is commonplace in the US. Abortion based on the race of the fetus is similarly rare in the US. While the purpose of any law is to prohibit actions it deems unethical or contrary to social norms, regardless of their frequency, due to limited time and resources, it makes sense to focus on bills that address common occurrences or things that are so morally repugnant that the state must take a stand. The main motivating factor for this bill does not seem to be avoiding discrimination based on sex and race, but rather trying to undermine legal access to abortion. Indiana is one of only five states that does not have a hate crime law and it recently rejected another attempt to pass hate crime legislation. It seems odd, and even contradictory, that Indiana is so worried about discrimination against fetuses, but not against legal persons.

The provision outlawing abortion due to disability is also troubling. Women and their families are often faced with very difficult decisions if they find out a fetus they are carrying has a disability and they should have the autonomous right to make decisions that are best for themselves and their families. This bill does allow women carrying fetuses with lethal abnormalities to abort, but they first have to receive materials about perinatal hospice care and complete documentation stating that they received such materials. The knowledge that the fetus has a lethal abnormality is devastating to many women and the idea of carrying the pregnancy to term is often psychologically distressing for them. Requiring them to be counseled about perinatal hospice care seems unnecessary and insensitive. Good physicians already ensure that their patients are adequately informed about their options and this seems to be a form of directive, morally laden counseling that will just make women feel guilty, rather than expanding their choices.

Another aspect of this bill that is quite problematic is that it “Provides that a miscarried or aborted fetus must be interred or cremated by a facility having possession of the remains.” For most abortions, the fetal remains are disposed of with other medical waste. This law, however, requires that the fetal remains are buried or cremated. This is clearly an attempt to elevate the status of the fetus and give it equal rights to legal persons.

This law means that Indiana now has some of the most restrictive abortion laws in the country. While many antiabortion supporters are in favor of this law, it is worth noting that some antiabortion legislators think this bill goes too far. They are concerned that this bill lacks compassion and demeans women. I agree with these concerns and am troubled by the passage of this law for the reasons I have outlined here.

 

 

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. 

March 24, 2016

A Few Thoughts On Abortion and Valuing Human Life

Who could be against life? Ancient natural law theory in the Catholic tradition tells us that human beings desire to live, and that life is good, therefore humans have an obligation to live and not kill other human beings. This ancient wisdom has been instilled into western ways of moral thinking. So, who could not be prolife in terms of how we place value on all individual human life?

Who could be against human freedom? Individual human beings should be free to live peacefully in accordance with their own values and life goals. This is a basic tenet of democracy that has shaped moral and political thinking in the West for the past four centuries. So, who could not be against the exercise of free choice, especially about something so basic as having control over our bodies?

The two value perspectives contained in the prior two paragraphs, all things equal, are eminently reasonable and most ethically unproblematic. These two value positions represent two fundamental principles of ethics—the intrinsic value of all individual human lives and the right of free individuals to govern their own lives and bodies—that guide us in living an ethical life and making ethical decisions. It is when these fundamental principles come into direct conflict that a serious, a near irresolvable, ethical conflict arises. There is no greater direct conflict of these two ethical principles than right of women to have an abortion. It is commonly assumed that one is either on one side of this moral abyss or the other and the twain shall never meet. It seems to me one of the central tasks of ethical reflection on this issue is to find as much meaningful middle ground as possible. In this brief blog I’ll offer a few ideas in this regard, which advocates on either extreme will likely find unsatisfactory.

 

Once a fetus reaches full term and emerges at birth into the world as a separate human being, there is no question about its full moral standing—from my perspective this would include babies with the most serious birth defects, including anencephaly. Some bioethicists believe that a being must have interests to have full moral standing. Since babies with anencephaly, if they survive a short time after birth, have no brain, no capacity to experience pain or pleasure, and no future life, they have no interests. The latter may be true descriptions of babies with this disorder, but they are unequivocally individual human beings. And there is no reason, as the law currently supports, to justify killing or euthanizing the lives of these babies in my view. So can’t the same be said of a fetus from the moment of conception?

It is true that a human embryo is a biologically a distinct form of individual human life and because of that fact has moral worth and deserves respect. But there is a basic aspect of fetal life even after viability and prior to birth that is inescapable: the fetus is dependent on the mother for its life and is part of the woman’s body. There is no protecting the fetus prior to birth without controlling the bodies of pregnant women. At the same time, at the very least, abortion as I am defining my terms is morally concerning and even problematic. I realize many of my pro-choice friends will find that conclusion concerning, but it is simply a consequence of recognizing the moral humanity of fetal life. So the key question then becomes who should make this moral or ethical decision and how should abortion services be regulated under the law?

A moderate position that seeks to preserve as many values as possible in this conflict, it seems to me, will recognize elective abortion as a moral issue but will reject the notion that it should be restricted as a service under the law. For if the law seeks to protect fetal life by restricting abortions, ipso facto, it also seeks to restrict the liberty of the woman to control her body as she so desires. The idea of requiring a woman to keep an unwanted pregnancy is an assault to her dignity as free human being. We cannot pretend to live in a free society where men and women have equal moral worth if we do not extend full moral autonomy to both men and women equally.

I conclude abortion is a moral issue and like many moral issues they are decisions that individual free human people should make and should not be the business of government to regulate. But it is not trivial to recognize abortion as a moral issue. We should not only talk, but also act, like all human life as value. We can provide adequate healthcare to all people, which should include family planning, prenatal, and birth control services for woman. We should provide more day care for parents, particularly single parents and other support services to make having children easier.

In short we can be a society that acts like it values all human life, of which fetal life is a part. But the ethical position of valuing all human life in terms of ascribing full moral standing to individual human beings cannot extend individual fetal life if we are to full value women as autonomous human beings.

 

 

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.

March 15, 2016

Should providers offer oncofertility to patients with a poor prognosis?

Whereas quality of life issues for cancer patients used to minimized, and sometimes even ignored, today there is more of a focus on cancer patients’ quality of life post-cancer. One such quality of life issue is oncofertility, which is fertility preservation for cancer patients. In many places, oncofertility is, or is becoming, the standard of care for cancer patients. But should it be offered to all patients? What about patients who have a very bad prognosis?

 Fertility preservation for patients with a poor prognosis raises a host of ethical issues. Providers may worry that discussing fertility preservation will give patients false hope about their prognosis. In other words, these patients may feel their providers deceived them by mentioning fertility preservation, leading them to believe that their prognosis is not as bad as they originally thought.

Yet, at the same time, pursuing fertility preservation may be a source of hope and happiness for patients during difficult times. It may furnish them with mental and physical strength, making them even more motivated to survive for the sake of their potential future children. Additionally, these patients, and their families, may feel a degree of inner peace knowing that part of their lives will continue on in the reproductive material even if they are never used.

Nevertheless, some may argue that, despite any personal and emotional benefits they may experience, offering patients with a poor prognosis fertility preservation options is an unjust allocation of resources. From a utilitarian perspective, it does not make sense to devote resources to patients who will likely not benefit from them. Put differently, resources should be allocated to those who have a high probability of a positive outcome, which means individuals with a poor prognosis should be placed lower on the priority list for receiving fertility preservation resources than individuals with a good prognosis.

On the other hand, if we take a deontological (duty-based, individual rights) approach, providers have a duty to care for their patients. Not offering fertility preservation to all of their patients, including those with a poor prognosis, may be seen as diminishing patient autonomy. According to this view, providers should be more concerned with the needs and rights of their individual patients than with social justice (i.e., fair allocation of resources).

For more on this topic, see my book chapter “Addressing the Three Most Frequently Asked Questions of a Bioethicist in an Oncofertility Setting” in Oncofertility Medical Practice, edited by T.K. Woodruff and C. Gracia.

 

 

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.

January 28, 2016

My Child, Your Womb

Gestational surrogacy contracts have been in the news again recently as a gestational surrogate reports that the intended father, having discovered that she is expecting triplets, is demanding that she undergo selective reduction to abort one of the fetuses.  Situations such as these, while often not reported, are not necessarily uncommon.  In 2013, a gestational carrier was offered $10,000 to abort when a second trimester ultrasound discovered congenital heart and brain abnormalities.  Despite a well-established Constitutional right to privacy that includes a pregnant woman’s right to procure – or refuse – an abortion, surrogacy contracts routinely include provisions that not only prohibit a surrogate from having an abortion unless there is a medical need, but also give the intended parents sole discretion to determine whether the surrogate should abort where there is evidence of a physical abnormality or other issue.  Such provisions have not been tested in court, but would almost certainly be unenforceable based on the surrogate’s Constitutionally-protected right to reproductive autonomy.


In India, where there is an estimated $400 million surrogate tourism industry, women agree to be surrogates in exchange for $5,000-7,000, which is far more than they could make otherwise.  In many clinics, surrogates live in dormitories for the duration of the pregnancy and their food and medical care is provided by the clinic.  There are also reports that some clinics have policies against pregnancies of 3 or more fetuses – meaning that selective reduction may occur as a matter of course to reduce the number of fetuses to 2 or 1.  If this is in fact happening, are the surrogates (or even the intended parents) aware of what is happening?  Are they given a voice in the medical care and treatments they receive?  Or are the decisions made by the intended parents or the clinic, and simply imposed on the surrogate?


Surrogacy, as with other assisted reproductive techniques, has been promoted in the name of reproductive autonomy – the right and ability to have more options and exert more control over reproduction.  But in cases such as these, where surrogates are pressured legally, financially and socially to have an abortion, whose reproductive autonomy are we honoring?  While it may be the child of the intended parents, it is the uterus of the surrogate.  The intended parents have an interest in the healthy development and birth of their child, which can be affected by congenital abnormalities, surrogate behavior, or the presence of multiples.  The surrogate has an interest in her own bodily integrity, her own health, and the treatments or procedures performed on her, even in connection with the gestation of another’s child.  Where these interests conflict, whose rights are stronger: the intended parents of the child, or the woman carrying it? 


It seems unconscionable that a woman could be forced to undergo an abortion based on enforcement of a contract.  It is equally disturbing to think that an intended parent would be prevented from objecting to an abortion of his or her child because the surrogate was making the decision to abort.  While both of these decisions in the context of a commercial surrogacy arrangement may be considered a breach of contract, and therefore may have monetary damages, what is left in the aftermath?  A parent whose unborn child was aborted without the parent’s permission?  A surrogate who has been abandoned with a newborn she never intended to keep?  These consequences are far weightier than could be compensated for by money.

 

The problem with blending the rights of reproductive autonomy is trying to separate them again when there is a conflict.  A surrogate will always have the right to determine what happens to her body, which includes the right to have or refuse an abortion, even if the child belongs to someone else.  Is it possible, then, to simultaneously protect the reproductive rights of both the surrogate and the intended parents?  Or will there always be an inherent imbalance of reproductive rights and the potential for coercion in the enforcement of commercial surrogacy agreements?


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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