9. Abortion ethics and the nursing profession

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CHAPTER 9. Abortion ethics and the nursing profession
L earning objectives

▪ Examine critically the definitions of abortion used respectively by pro-abortionists and anti-abortionists.
▪ Identify two key issues upon which the abortion issue turns.
▪ Discuss critically the following three positions on abortion:
1. the conservative position
2. the moderate position
3. the liberal position.
▪ Outline at least six contemporary developments informing the ‘new ethics of abortion’ and its possible implications for the abortion debate generally.
▪ Discuss briefly the common arguments advanced both for and against the view that the fetus is not a person.
▪ Discuss at least three instances in which the rights of a fetus (once granted) might come into conflict with the rights of others.
▪ Discuss critically whether the nursing profession should formulate a public position on the abortion issue.

I ntroduction

The World Health Organization (WHO) estimates that, each year, approximately 42 million women faced with an unplanned pregnancy will decide to have an abortion (WHO 2007b). Of these, around 20 million women (mostly in developing countries) will be forced, primarily because of restrictive abortion laws, to resort to unsafe abortions — defined as ‘a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or an environment that does not conform to minimum medical standards or both’ (Grimes et al 2006: 1908). Of those women undergoing unsafe abortion, WHO estimates that one in four will likely experience severe complications, including death, and that in the developing world a woman dies every 8 minutes from the complications of unsafe abortions. WHO further estimates that the ill-health arising from unsafe abortion accounts for at least 13% of global maternal mortality (around 68000 women annually) and around 20% of the ‘overall burden of maternal death and long-term sexual and reproductive health’ (WHO 2007b; see also Grimes et al 2006; Singh 2006).
Unsafe abortion has been identified as one of the most easily preventable causes of maternal ill-health and death, yet it continues to threaten the health and lives of women globally. This has led some commentators to declare that ‘ending the silent pandemic of unsafe abortion is an urgent public-health and human-rights imperative’ (Grimes et al 2006). In response to the issues and challenges raised by this situation, the WHO (2003, 2007b) has deemed ‘preventing unsafe abortion’ a strategic priority underpinned by the following two goals:
▪ in circumstances where abortion is not against the law, to ensure that abortion is safe and accessible
▪ in all cases, women should have access to quality services for the management of complications arising from abortion.
Even though the WHO has identified safe abortion as a strategic global priority, abortion as such remains a deeply contentious and divisive issue. Of all the bioethical issues that command public attention today, perhaps none is more controversial than the ethics of abortion. Although abortion has been legal in many countries for several decades now, its moral permissibility continues to be the subject of heated public debate. Significantly, the polarity of values and views underpinning the abortion controversy has threatened to divide nations, has seen abortion clinics firebombed and abortion workers fatally shot by pro-life fanatics, and has even brought down governments (Hadley 1996).
Despite the legislative and moral reforms of the past five decades, women’s so-called ‘reproductive rights’ (including the right to safe abortion) are still constantly being challenged (Cave 2004; Meredith 2005). And despite being ‘sensationally and bewilderingly public’, abortion for many women remains a deeply private, personal and even taboo subject (Hadley 1996: xi). Even in so-called ‘liberal’ democratic countries where individualism and a person’s right to make important life choices (including the right to choose death) is highly respected and even enshrined in law, women are often forced to justify their need of an abortion in a way ‘that many find to be degrading and intrusive’ (Greenwood 2001: ii3). And while there is much rhetoric about women having ‘reproductive autonomy’, doctors and the courts that legitimate their authority, ultimately have the power to decide if, when, how and under what circumstances a woman’s reproductive rights will be exercised (Cave 2004; Greenwood 2001; Hadley 1996; Meredith 2005; see also Gillon 2001; Hewson 2001; Wyatt 2001; Pojman & Beckwith 1994).
In recent years, a ‘new ethics of abortion’ has emerged (Greenwood 2001; Gillon 2001; Wyatt 2001). This ‘new ethic’ is rekindling the fires of old controversies surrounding the moral status of the fetus and posing new challenges to modern moral thought about the permissibility and impermissibility of abortion. Processes informing the ‘new ethics of abortion’ include the following five developments, which Wyatt (2001: ii15–ii18) believes ‘have irreversibly altered the ethical debate about abortion in Western societies’:
1. advances in fetal physiology (these have made it possible to confirm that fetuses have ‘a range of sophisticated abilities with well developed sensory perception in all systems: vision, hearing, touch, taste and smell’; it is now known that even very young fetuses have the capacity to imitate facial expressions, breathe and initiate hand–face contact, startle, sucking and swallowing movements)
2. development of fetal medicine as a speciality (making it possible to discern major abnormalities and to ‘provide seamless medical care for the fetus through the intrauterine period and on into the critical first hours and days of birth’; it is now possible to provide such intrauterine treatment as blood transfusions and curative surgery for congenital defects)
3. development of neonatal intensive care and improved survival of extremely preterm infants (with developments in specialised neonatal intensive care techniques, it is now commonplace for preterm babies of just 23–24 weeks of gestation to survive; the survival of preterm babies of just 22 weeks weighing less than 500 g at birth has also been described)
4. changed perspective on the rights of the disabled (many in the disabled rights movement regard the abortion of fetuses with genetic disorders or other disabling conditions to be discriminatory and as being prejudicial against disabled people)
5. changes in professional counselling (research has shown that the way information is given to parents can significantly influence the choices they make; this, in turn, has given rise to a new imperative for so-called ‘non-directive counselling’).
Other developments prompting ‘new’ debate on the abortion issue is the growth of ‘wrongful life’ or ‘wrongful birth’ lawsuits and, more recently, ‘wrongful abortion’ suits. ‘Wrongful birth’ suits are based broadly on the argument that a given infant ‘should never have been allowed to be born’ (Forrester & Griffiths 2005: 192). For example, a child may have been born with severe and irremediable disabilities in circumstances where, if appropriate medical advice and care had been provided, a decision not to continue the pregnancy would have been made (see, e.g. Forrester & Griffiths 2005: 192–4). In such cases, an infant’s mother generally seeks compensation on grounds that she was deprived of the opportunity to have an abortion within a relevant time because of a health worker’s (e.g. a doctor’s or a counsellor’s) negligence (e.g. failed abortion; misdiagnosis of fetal abnormality after screening; misdiagnosis of maternal illness which could have resulted in fetal abnormality) (Shapira 1998; Petersen 1997).
‘Wrongful abortion’ lawsuits, in contrast, concern situations in which a pregnant woman is ‘induced to undergo an abortion by a negligent conduct (usually a medical misrepresentation)’ (Perry & Adar 2005: 507). For example, a woman might decide to have an abortion based on advice received from her attending medical practitioner that her fetus is at risk of being born with severe birth defects because of a drug she has taken. After the abortion is performed, however, she learns that the medical advice she was given about the risks to her fetus ‘was a negligent misrepresentation, and that the termination of the pregnancy was unnecessary’ (Perry & Adar 2005: 507). In such cases, the woman might sue for compensation for the catastrophic loss she has suffered.
The above issues help to demonstrate the complexities of the abortion issue and the tensions involved. Just what the outcome of the ‘new ethics of abortion’ will be, remains an open question. What is clear, however, is that there is ‘no Olympian perspective from which these issues can be viewed in benign and omniscient neutrality’ (Wyatt 2001: ii19).
Despite the hardships that nurses have had to carry in the past and continue to carry in the present, the nursing profession globally has been relatively silent on the ‘abortion question’. Just why this silence has prevailed is a matter for speculation. Nevertheless, one thing is clear: this position cannot be sustained, at least not credibly. Given the WHO’s stance on safe abortion as a global health issue, and growing calls in some countries (e.g. the UK) for nurses to undertake first trimester abortions and to ‘take over from doctors’ who are otherwise opposed to undertaking abortion work (Boseley 2006; StaffNurse.com 2007), it is becoming increasingly evident that the nursing profession cannot avoid public debate on the matter and must prepare itself to take a stand. This, in turn, demands that attention be given to addressing a number of critical questions including, but not limited to, the following:
1. What is abortion?
2. Is abortion morally right or wrong?
3. If abortion is morally wrong, can members of the nursing profession be decently expected to assist with abortion work and/or care for the women who have had them?
4. If abortion is not morally wrong, can nurses justifiably refuse to assist with abortion work and/or care for the women who have had them?
5. If participating in abortion work, what are the obligations (if any) of nurses toward fathers of a pregnancy who are opposed to their fetus being aborted?
6. In the event of no substantive agreement being reached on whether abortion is morally right or wrong, what, if any, public position should the nursing profession take on the issue?
7. How should the nursing profession decide these things?
It is to addressing these and related questions that this chapter will now turn.

W hat is abortion?

Before advancing this discussion any further, it is important to first clarify the meaning of the term ‘abortion’. In keeping with lay dictionary definitions, abortion (from Latin abortāre, from aboriri to miscarry, from ab — wrongly, badly) may be defined simply as the ‘premature termination of a pregnancy by either spontaneous or induced expulsion of a nonviable fetus from a uterus’ ( Collins Australian Dictionary 2005), and usually entails the death of the fetus (Warren 2007). Not all participating in the abortion debate subscribe to such a ‘simple’ definition, however. Instead, most lean towards definitions of abortion that while appearing to be value-neutral (objective) are, in essence, ethically loaded and hence at risk of misleading moral debate on the issue. For instance, those who are opposed to abortion typically define abortion in such terms as ‘artificially causing the miscarriage of an unborn child’, or ‘killing an innocent human being’ (Fisher & Buckingham 1985). Definitions of abortion using these or similar terms are not just defining the ‘act’ of abortion, however. They also seem to be conveying the conclusion that abortion is morally wrong (at the very least, the terms used — ‘unborn child’/‘innocent human being’ — seem to appeal to our moral intuition that killing another person who is a non-aggressor is a morally terrible action). In contrast, those who support abortion tend to define abortion in such terms as ‘terminating pregnancy’ or ‘ridding the products of unwanted/unviable conception’. Definitions of abortion using these and similar terms seem to imply that abortion is not only not morally wrong but may even be morally neutral (the term used ‘ridding the products of unwanted conception’ seems to invite the ‘reasonable’ question of: What is so morally terrible about getting rid of something that is ‘unwanted’ and/or incapable of normal growth and development?).
It is unlikely that a consensus will be reached among contesting parties on a working definition of abortion and that variant ethically loaded definitions will continue to be used. Either way, it is important to remember that the issues at hand need to be decided by careful deliberation, not by definitions; they also need to be examined in a manner that will question rather than reinforce the status quo.

I s abortion morally permissible?

The permissibility of abortion has an interesting history. Anthropological studies suggest that abortion has been widely practised across cultures and throughout human history, and probably dates back even to prehistoric times (Thomas 1986: 77). Abortion techniques have been described in early Chinese, Egyptian and Greek texts, and continue to be widely practised in non-industrialised societies and other Third World countries. Muslim traditions permit abortion, so long as it is procured while ‘the embryo is unformed in human shape’ (Thomas 1986: 79). Japan did not introduce anti-abortion laws until the Meiji Restoration (1869–1912).
Contrary to what many Christian fundamentalists believe, opposition to abortion is not justified by appealing to either the Bible (it simply ‘does not discuss it’ [Badham 1987]), to church traditions or to Christian reasoning. The early religious fathers, including St Augustine, St Jerome and St Thomas Aquinas, did not believe that the embryo was a human being from the moment of conception, and ‘all insisted that early abortion could not be classed as homicide’ (Badham 1987: 11). They also drew a firm distinction between early and late abortions. As far as the ‘personhood’ of the fetus is concerned, this too ‘has virtually no significant support’ in the Christian tradition until the teachings of Pope Pius IX (1846–1878). And in the Hebrew version of Exodus 21, accidental abortion is seen as an offence (and one punishable by death) ‘only if the woman dies’ (Thomas 1986: 78).
From where then have contemporary views opposing the moral permissibility of abortion arisen? There is much to suggest that it is largely the product of Catholic dogma dating back to the 1854 proclamation of the Dogma of the Immaculate Conception and the subsequent series of papal decrees (e.g. in 1884, 1889 and 1908), ‘which forbade direct termination of a pregnancy even in circumstances where, as in ectopic pregnancies, the result of non-intervention was the certain death of both mother and child’ (Badham 1987: 12).
Religious dogma aside, the question remains of: Who, if anyone, ought to be permitted to have an abortion? Under what circumstances or conditions might abortion be allowed?
Generally speaking, there are three positions that can be taken on abortion: a conservative position, a moderate position and a liberal position. These three positions (which have changed little since they were first advanced in the early 1970s and 1980s) are considered briefly below.

T he conservative position

According to the conservative position (see, e.g. Brody 1982; Noonan 1983), abortion is an absolute moral wrong, and thus something which should never be permitted under any circumstances — not even in self-defence, such as cases where a continued pregnancy would almost certainly result in the mother’s death. A common concern among conservative anti-abortionists is that, if abortion is permitted, then respect for the sanctity of human life will be diminished, making it easier for human life to be taken in other circumstances. Arguments typically raised against abortion here are almost always based on the sanctity-of-life doctrine. One example of the kind of reasoning which might be employed to argue against abortion is as follows:
It is wrong to kill innocent human beings; fetuses are innocent human beings; therefore it is wrong to kill fetuses.
(Warren 1973: 53)
Or, to use another example:
Human beings have a natural right to life; fetuses are human beings; therefore fetuses have a natural right to life and killing them is wrong.
(Pojman & Beckwith 1994)
Whether human beings do in fact have a natural right to life, and whether fetuses are in fact human beings, are matters of ongoing philosophical controversy.

T he moderate position

According to the moderate position (see, e.g. Werner 1979; Bolton 1983) abortion is only a prima-facie moral wrong, and thus prohibitions against it may be overridden by stronger moral considerations. Werner (1979), for example, argues that abortion is permissible provided that it is procured during pre-sentience (i.e. before the fetus has the capacity to feel). Since a pre-sentient fetus cannot feel, it cannot be meaningfully harmed or benefited. Thus, as with other non-sentient or pre-sentient entities, it makes no sense to say a fetus has rights, much less a right to life. In the case of post-sentience, Werner argues that abortion may still be justified on carefully defined grounds, namely: self-defence (e.g. where the life or health of the mother would be at risk if the pregnancy was allowed to continue); or unavoidability (e.g. where abortion cannot be avoided, such as in the case of ectopic pregnancy or accidental injury). Abortions performed on lesser grounds are, according to Werner, unjustified. A more recent articulation of this position similarly holds that abortion is ‘seriously wrong’, except in rare instances — for example, after rape, during the first 14 days after conception when the fetus ‘is definitely not an individual’, where the woman’s life is threatened by the continuation of the pregnancy, and where the fetus has anencephaly (Marquis 2007: 137).
Bolton (1983) takes a slightly different line of reasoning. She argues that, since fetuses are not undisputed persons, they do not have the same rights not to be killed as do actual undisputed persons. Thus, in the case of life-threatening pregnancy, at least, a woman’s right to life overrides that of the fetus. Bolton also argues, controversially, that if women are not permitted to have abortions, the community might find itself deprived of the beneficial contributions that a woman freed of the burdens of child rearing would otherwise be free to make (p 335). She concedes, however, that there are also cases ‘in which others stand to benefit from the pregnant woman’s bearing a child’ (p 337), and that this too might contribute to the community’s benefit. The bottom line of Bolton’s position is that abortion is morally permitted in some situations, and might even be ‘morally required’ in others, but it is not morally permitted in some other types of situations. Either way, the facts of the matter need to be carefully assessed and analysed before an abortion decision is made.
Another moderate argument raised in defence of abortion is that a woman is under no moral obligation to bring a pregnancy to term, particularly in instances where the pregnancy has been forced upon her (as in the case of rape), or where the pregnancy has not resulted from a voluntary and informed choice (as in cases involving contraceptive failure or ignorance). In her classic and still widely cited article ‘A defence of abortion’ (reproduced in LaFollette 2007: 117–25), Judith Jarvis Thomson (1971) contends, for example, that even if it is conceded, for the sake of argument, that a fetus is a person, this still does not place an obligation on a woman to carry it to full term. This is because morality does not generally require individuals to make large sacrifices to keep another alive. Thus, if pregnancy requires a woman to make a large sacrifice — and one which she is not willing to make — it is morally permissible for her to terminate the pregnancy.
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