Abortion providers are motivated by conscience, too

Pro-lifers like to claim the moral high ground. But the tragic case of Savita Halappanavar, who died after allegedly being refused an abortion, highlights the ethical case for abortions, says obstetrician Lisa Harris

What are your thoughts on Savita Halappanavar, who died of septicaemia on 28 October in Ireland, after allegedly being refused an abortion?
What happened is very sad, and my heart goes out to Savita Halappanavar's family. Her death is made even sadder because it was likely preventable. As a physician myself, I have many questions about the clinical details of her case. In the reporting I've read, it is unclear to me if the serious threat that her pregnancy and infection posed went unrecognised, or if University Hospital Galway doctors felt that as long as the fetus had a heartbeat their hands were tied by Ireland's restrictive abortion law. Some, including me, would call that a problem of moral judgement.

What implications does the issue of fetal heartbeat have for clinical practice in this area?
It is contentious in the US as well. It is not uncommon for obstetrician-gynaecologists to be forced to delay appropriate care of patients having a miscarriage when a fetal heartbeat is present, putting patients at risk of haemorrhage or infection, according to research by Lori Freedman of the University of California, San Francisco, and her colleagues.

Not long ago I cared for a patient who was having a septic abortion [one in which the womb is infected]. An ambulance initially took her to a local religiously affiliated hospital that could not provide the emergency labour induction or dilation and evacuation procedure she needed because the fetus, as in Savita Halappanavar's case, was still alive. She was transferred to my institution and ultimately did well. I wondered, but don't know, if the doctors who initially saw her and transported her to my institution felt morally compromised by the policy of their hospital.

You feel that pro-lifers have claimed the moral high ground, and it is time to recognise that abortion providers act out of conscience too. How would you sum up your argument?
Conscience is not something that only healthcare providers who oppose abortion have. Conscience motivates abortion provision, just as it motivates refusals to offer or refer for abortion. This stance is not recognised, whether measured by law, institutional policies, most bioethical discourse or public discourse.

How does lack of recognition of that moral stance affect doctors who offer abortion?
When abortion work is thought to come from a place outside of conscience, abortion providers become stereotyped and stigmatised as immoral or acting without conscience. A second consequence is that abortion providers practise without the conscience protections that their colleagues who refuse to offer abortion have.

What are the main moral and conscientious arguments to support abortion?
That abortion is lifesaving; there is clear epidemiological evidence that in regions of the world in which safe abortion is unavailable ? because of the law, healthcare resources or intense stigma ? women die from or are harmed by unsafe abortion. That reproductive autonomy is the linchpin to full personhood in society. That compulsory birth is inhumane and unethical and is a cause of immense suffering. That imposing one's own personal moral or religious beliefs [against abortion] on another person is unethical.

There are likely many other moral reasons for offering abortion care. I would be eager to ask the many thousands of abortion providers in the US and around the world how providing abortion comes from their own sense of what is right or wrong.

What would you like to happen to redress this moral "asymmetry"?
Simply recognising that abortion work ? as well as a woman's decision to have an abortion ? can come from a moral place, from conscience, would be good for a start. Ultimately I would like to see institutional and legal protections for providers who wish to offer abortions out of conscientious commitment. And with respect to the other face of conscience, conscientious refusals, I would like to see a clinical standard of care for humane conscientious refusals, to which caregivers could be held accountable by patients, medical societies and the legal system when a refusal is done poorly.

What are the other situations in which taking action has sometimes been deemed less defensible, on grounds of conscience, than refusing to act?
Assisted suicide and stem-cell research are two. However in the US now, provision of contraception is probably the most important. Some religiously affiliated healthcare institutions are seeking exemptions from Affordable Care Act mandates that contraception be provided to women. I am concerned about how that will affect employees who feel that it would be immoral to withhold contraception from patients who request it ? and of course concerned about the patients that this will impact.

You wrote an article for the New England Journal of Medicine, entitled "Recognizing conscience in abortion provision". What was the response to it?
I heard from people across the US that they felt validated and relieved that someone was challenging the idea that only those who refuse to provide abortion or other contested services are moral actors. The article was also met with anger and utter disbelief by many, but not all, people who oppose abortion. This was not unexpected. Regardless, my goal was to start a conversation about conscience compelling abortion provision, and the article did that.

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