Perhaps not since the vituperative Civil Rights movement in the 1950s and ’60s, when ideology turned ugly and caused deaths and injury, has any subject been as vehemently argued as the issue of Abortion. This issue is neither academic nor even, perhaps, objective. A woman faced with an unwanted pregnancy generally understands at some visceral level that there is human life inside her, making that question moot. The fact is that most people agree that abortion should be a rare procedure Abortion is, and likely will always be, fraught with emotional and physical turmoil. The turmoil has brought into focus not merely legal accountings for the (at least) legal approval of abortion (Roe vs. Wade in 1973) but has divided much of society into two sometimes armed and irrational camps.
It is nearly impossible to find someone who doesn’t have an opinion about abortion, and probably a strong opinion at that. Both sides of the issue make a good case for their “side”. An unwanted child is a pitiful thing, and the attendant social problems (single motherhood, financial destitution, child neglect, and urban overcrowding, the need for welfare, to name just a few) do not have easy solutions. While medical progress has made aborting a fetus (even in later and later terms) feasible, safe, and not financially over-burdening, the crisis that the Abortion issue brings to society is engulfed in the ethics- it is against every aspect of humanity to “kill a defenseless human being” , the morality in the sense of shame borne throughout life, as a sort of invisible Hester Prynne “A”, and the legality as if the state should “rule” whether abortions can and should be legal and permitted, or ruled illegal and “murder” of sorts.
One must begin to discuss the moral and legal issues that confront us by starting at the most basic philosophical issues: First of all: What is a person? What is the concept of a person? When does life begin? With conception? With the first functioning of the fetus’ organs?
Another basic philosophical tenet concerns the “rights” of all involved. What sort of being have rights? Only persons? Only intelligent beings? And just what would those rights include?
We need also explore the role of the government, if any? Should our government remain neutral in moral disputes? Do laws against abortion violate the ban on establishing a religion? If there is a Constitutional right to privacy, does that include the right to terminate a pregnancy?
There are obviously no simple answers to any of these questions. If there were, the issue could be easily settled, even if it meant some sort of compromise. Dozens of books and hundreds of articles have been written, legal opinions handed down, even web sites established by pro-life and pro-abortion advocates. However, for purposes of this essay, the emphasis will be on the positions and feelings by those medical practitioners who may be closest and in greater contact with the subject: nurses. The subjects may be “I” or “We” referring to the nurses. The overview will provide some insight into the legal standing, decisions, and rulings. Then, the moral and ethical values, as seen, felt, and practiced by nurses will be explored. Nurses, it may be given a biased opinion, are seldom asked for ideas on weighty matters, Still, other than oncology, there is perhaps no greater need for understanding and compassion, and just BEING close at hand than in the case of abortion- the decision to go ahead with the procedure and the need for post-op follow-up.
First an overview and update of the legal actions and ramifications of abortion. Although the 1973 Roe vs. Wade decision legalized abortion, subsequent more conservative Supreme Court decisions have narrowed the scope severely. To quote Chief Justice William Rehnquist: “…Roe continues to exist, but only in the way a storefront on a western movie set exists, a mere façade to give the illusion of reality.” This sentiment, and more recent rulings such as the 1992 Planned Parenthood vs. Casey decision where the Court ruled that restrictions on abortion are constitutional provided they do not place an “undue burden” on a woman’s access to abortion. Such restrictions include parental notification and consent, gag rules, and mandatory waiting periods. While the Journal of the American Medical Association boasts that, since 1990, the year in which abortions were the highest, the annual number of abortions in the U.S. has decreased by 15%, organizations such as NOW (National Organization for Women) claims that the reduction is due to the fact that 84 percent of counties in the U.S. do not have an abortion provider.
The legal issues that continue to swirl around abortion have one important basis in fact: Is abortion a Constitutionally protected right? This is not merely discussed by the pro- and anti-abortion forces, but by the states who believe that their own rights were superceded by the Roe vs. Wade decision. We are thus faced with not only a quarrel among the courts as to who has the right to permit or not permit abortion within the states and the United States, we are up against the Constitutional guarantee of States’ rights. Attorneys-general such as Robert Casey of Pennsylvania and Dallas DA Henry Wade were being sued by pro-abortion forces because they represented the states, not the United States.
Speaking of the United States, it is doubtful that any sort of national legislation will ever be passed by Congress. If any legislation regarding birth will even be considered, chances are it would be something to do with genetic engineering (cloning) of humans, rather than the far more volatile issue of abortion.
A look at some recent decisions indicate that the pendulum may be swinging in favor of the pro-abortion advocates. A federal judge in Columbia, SC struck down South Carolina’s 1996 abortion clinic regulations, calling them an unconstitutional infringement on a woman’s right to an abortion. And within the last several weeks, a court awarded $107 million to be paid by an Internet web link which listed the names, addresses, and usual routes to work of abortion doctors throughout this country, and was seen as a rallying point for the anti-abortion radicals who have already caused more than 2,500 bombings, arsons, blockades, and episodes of vandalism in the last twenty years. Thus, from a legal standpoint, as we near the 21st Century, to quote Justice Harry A. Blackmun in his comments on Thornburgh vs. American College of Obstetricians & Gynecologists: “few decisions are more personal and intimate, more properly private, or more basic to individual dignity and autonomy, than a woman’s decision whether to end her pregnancy. A woman’s right to make that choice freely is fundamental.”
This brings me to my own statement of conscience and responsibility: Legally, the nursing profession and the entire medical establishment may counsel a woman about her decision, but not prevent her from carrying out an abortion, if she so chooses. For the nursing profession, it is not a crisis of conscience, but a responsibility concerning health and care-giving. Legally, as a nurse I would be bound to follow the wishes and instructions of a woman and her doctor. I must withhold certain moral doubts. It is my duty to safeguard health, to provide proper conscientious care. My personal stand, therefore, is to support a woman’s right to choose, whether I agree with her particular choice or not. Assisting in performing an abortion, even counseling and after-care are not matters of conscience to many. However, the American Nurses Association does have a code for nurses which upholds the nurses’ rights to refuse assignments that conflict with their personal ethics.
The ANA Position statement on reproductive health has historically advocated for the health care needs of all patients, including services related to reproductive health. While granting nurses an ethical “way out”, at the same time the ANA believes that health care clients have the right to privacy and the right to make decisions about personal health care, without coercion.
It is interesting to note that the ANA believes that abortion is largely a social failure. As long as abortion is a ” legal reproductive alternative”, the provider should discuss objectively the pro’s and con’s of abortion. The ANA feels that some states, with restrictive legislation, are hampering good counseling efforts.
There are a good many nursing and health provider associations and groups which very specifically set up their positions in order to uphold the ethical, legal, and moral requirements in this very difficult area.
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) advocates, among others, that nurses have the professional responsibility to provide nursing care to all patients and not impose their personal beliefs on patients or other personnel. AWHONN agrees with the ANA that a nurse can refuse to assist in abortions without risk of losing her job. However, they also recommend that the nurses should inform their employers about their beliefs, at the same time assuring that all abortion and other medical practices are performed in a safe environment by skilled surgeons and doctors.
It is clear that every organization of professional nurses and care-givers leaves it up to the individual to take his or her own stand. As stated above, I am pro-choice, and as a nurse would respect a patient’s right to abort, whatever her private reason may be. I would be responsible for her health and safety, even her state of mind. My job would be more than technically assisting a surgeon, were I an operating room nurse. It would be to provide a sense of well-being and confidence in the patient, as well as her family and/or friends.
The New York State Nurses Association agrees with the principles and standards as set forth by the ANA, but published its own take on Abortion. Here the NYSNA wants to make certain that its members respect the privacy of any and all patients, and that they cannot and should not subject the patients to any personal prejudicial attitudes or undue pressure regarding the abortion position. Interestingly enough, from a moral viewpoint, the NYSNA also states that caring for the patient before or after an abortion, is NOT regarded as participating in an abortion. The NYSNA also recommends, in its position statement, that no individual patient or group of patients, should be left unattended or uncared for in any stage of an abortion procedure. All efforts are to be made that the patients receive the services of a REGISTERED NURSE who does not object to the concept of abortion.
What is only casually referred to, and what I find more important than other standards is the need for education. The very idea of Abortion is so fraught with controversy, that not every institution dares to provide education for nurses and care-givers. The NYSNA does point out that the nurse has a right to an educational preparation which will enable one to meet the emotional, physical and psychological needs of women who are considering having, or have had a voluntary termination of pregnancy. NYSNA believes the nurse has a responsibility to obtain this education. Nevertheless, the question remains whether it is the nurse’s responsibility to be a counselor, and not merely a care-giver or doctor’s right hand.
Even those in favor of the pro-choice position fear the dangers of passing through a gauntlet or cursing, placard-waving, demeaning crowds on their way to work. They face the daunting task of lonely women, afraid and often deserted by friends, family, and the father. Nurses also face the unenviable task of taking a stand on whether illegitimacy is reason enough to terminate a pregnancy. How should the nurse react when asked that final, awful question by the patient: “Should I go ahead with this?” Some Nurses’ Associations suggest referring the patient to someone in authority who could provide a comforting answer to that question, thus relieving the nurse of responsibility for the final go-ahead.
Registered nurses also face a problem in some clinics, where women are literally persuaded by marketers to terminate their pregnancies. They are considered, therefore, not like patients in need, but rather as implementation to the bottom line. Perhaps the easiest position to take, ethically, is one proposed by the California Nurses for Ethical Standards, which states that “we believe, as Florence Nightingale did, that health care must be for the ‘good of the patient.” Yet, this same group pledges NOT to assist in the taking of human life in the course of their professional duties nor to advocate any philosophy that would accomplish that end. In other words, this is a pro-life organization of professional nurses.
No real statistics have been developed with provide insight into the percentage of registered nurses who approve, and those who disapprove of terminating a pregnancy. From some unofficial overviews, the majority or nurses, even (as I do) feel that it may not be ethically or morally correct, it is still a task that must be performed, and performed capably.
The fact that thousands of nurses are involved in abortions annually, is proven by studies conducted by the American Medical Association, and printed in their Journal of the American Medical Association. Their figures for 1995, for example, show that a total of 1,210,883 legal abortions were reported to Centers for Disease Control. Approximately half these abortion were performed at about 8 weeks’ gestation, and 88% were performed prior to 13 weeks. It is interesting to note that these terminations were reported. Are appendectomies or liposuction procedures reported as well, or are abortions a legal anomaly.
These figures, of course, do not include abortions performed outside clinics and hospitals, or any other health provider which keeps (or is legally mandated to keep) records.
One additional legal, moral, as well as ethical area must be added: that there is likely to be an increasing number of hard decisions as artificial placentas, or test tube babies, are developed, and as doctors learn more about keeping the critically ill alive. With in vitro fertilization, among other techniques one author entitles his article: “When is an Abortion Not an Abortion?”
Another ethical and moral conundrum comes with the increasing use of ultra-sound and other devices to check on the health and status of the fetus. As more and more of these techniques are put into use, finding malformed or “incomplete” fetus, or the discovery of a hereditary gene that puts the baby at risk of health or even survival, may cause women to opt for therapeutic abortions. While it may be logical (if heartbreaking) for parents to wish to spare themselves the impossible task of trying to nourish and nurture such a baby, religious leaders seldom separate the healthy from the sick when fostering the belief that ALL life is precious.
Another ethical and moral decision to be made in the area of Abortion is that of the low-income or poverty mothers. There are now family planning clinics, as authorized by the federal government under Title X. These so-called Title X clinics are a critical source of reproductive health care. For Medicaid recipients and other low-income women. These clinics have also come under attack by the Pro-Life right wing groups for seemingly encouraging abortions with federal funds (not true). Nurses working in such clinics have the responsibility to present all sides of a pregnancy termination problem. Obviously, a federally-funded institution cannot encourage a termination or counsel otherwise. Still nurses ion duty often become frustrated by their clientele, so often teenagers and single-parent mothers, perhaps already burdened by children, and unable to care for the ones alive, without thinking about the unborn. The dilemma is a rational one: should the nurse act as an impartial counselor only, or provide the sort of “push” some women may need in order to make a decision.
A serious problem occurring in the ranks of the medical personnel in abortion clinics and health providers that perform terminations of pregnancy is “burn out”. A number of studies, begun as early as the mid-1970s, show that hospital and clinic staffs may suffer negative reactions, some may demand transfers, or refuse to do any more abortions. In fact, doctors and nurses may perceive a conflict between their commitment to save life and their role in relieving a patient of her unwanted pregnancy. While statistics show that very few nurses report such negative feelings, anxiety, depression, and feelings of guilt and deep depression are often found in training and role-play seminars. Even in an era where no maternal deaths occurred, as in the case of Dr. Bernard Nathanson, who played a prominent role in the legalization of abortion in the U.S., after a year and a half, he resigned his clinic post because he ws deeply troubled by 60,000 mothers living and 60,000 fetuses dead.
It is also interesting to note that in a recent survey taken of medical students, the male students were far more anti-abortion than the females. However, a survey taken by the Gallup Poll showed just the opposite, women are far more likely to approve legalizing abortions than men.
In another survey of compensation in abortion clinics, the physicians; pay was far higher than for comparable physicians in hospitals, and nurses were also paid at a higher rate than their peers in “regular” hospitals, while counselors in clinics barely average minimum wage levels.
One other seldom-mentioned fact should be mentioned: the fact that more and more registered nurses are minorities. While this certainly does not interfere with their abilities, it may cause some friction with the patients, who have a racial or even a gender bias. There have been reported prejudice cases where white patients refused the counseling or assistance of Afro-American, Filipino,.Hispanic or Oriental nurses and care givers. Also, there have been a few problems of females objecting to male nurses during this very traumatic decision-making time.
With my pro-choice stance, how can I summarize the ethical, moral, and legal situations concerning abortion: First of all, a need for more definitive and thorough education of nurses and other care-givers about their responsibilities, their personal and professional choices and options, as well as turning counselors into true counselors and not into marketers for abortion services.
Second, while the total number of reported abortions have declined slightly over the past three years, the threats of pro-life extremists is still a fearsome worry. Recently, a doctor who performed abortions in upstate New York was shot to death by a sniper while seated in the living room of his home. There are still bombings, and one doctor reported that his monthly bill for protection is as high as $1,500, not to mention the cost of security personnel, bullet-proof windows, etc. Whether some sort of common ground can ever be firmly established is still, at best, a vague possibility. Some nurses and physicians think of themselves as operating in an ever-changing war-zone. The states, as well as the Federal government simply must pass legislation providing privacy in the making of a choice for terminating a pregnancy. As much as religious leaders, especially the Roman Catholic church and some right-wing conservative Protestant denominations denounce abortions, they remain a legal right. There should be no fear for care-givers to assist in the counseling, care, and after-care of women who freely chose to terminate their pregnancies.
Third, as new scientific and technological opportunities exist for contraception which might well obviate the need for abortions, nurses, physicians, and care givers need to become familiar with, and educated, in these alternatives.
Next, the wide gulf that separates the middle-class and well-to-do from the indigent need not be an obstacle in the care provided when the need for terminating a pregnancy exists.
Prejudice because of the gender, ethnicity, national origin of the nurses and other care-givers needs to be eliminated.
Finally, we cannot escape the fact that, for a good many people, abortion is not a medical affair, but a cultural and social and religious one. It seems strange to see pro-life physicians refer to themselves as “Christian doctors” as if Christianity were the only concept that believes in the sanctity of life. It is a very narrow-minded, truly anti-religious stance.
Pro-choice does not mean I favor abortions on demand. It DOES mean I respect a woman’s right to choose. I would not, and could not, act as a spiritual adviser to sway her choice. That, as a nurse, would not be my job: I would be concerned with providing the optimum medical, emotional, and loving care to assure her well-being before, during, and after the procedure.
Abortion may continue to be controversial, but not forbidden when a woman makes her choice.
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