Abortion counselling and the informed consent dilemma

Bioethics

Volumn 25, Issue 9, 2011, Pages 495-504

  Woodcock, Scott ^a  

^a UNIVERSITY OF VICTORIA   (Canada)

Author keywords

Abortion; Informed consent; Reproductive autonomy

Indexed keywords

ABORTION; ARTICLE; COUNSELING; FEMALE; HUMAN; HUMAN RELATION; INDUCED ABORTION; INFORMED CONSENT; PATIENT EDUCATION; PREGNANCY; PSYCHOLOGICAL ASPECT;

ABORTION APPLICANTS; ABORTION, INDUCED; COUNSELING; FEMALE; HUMANS; INFORMED CONSENT; PATIENT EDUCATION AS TOPIC; PREGNANCY; PROFESSIONAL-PATIENT RELATIONS;

EID: 80054047446     PISSN: 02699702     EISSN: 14678519     Source Type: Journal    
DOI: 10.1111/j.1467-8519.2009.01798.x     Document Type: Article

References (45)

1. For a prominent example, see: R. Veatch. Abandoning Informed Consent. Hastings Cent Rep 1995; 25: 5-12.
2. In its relatively short history, the concept of informed consent was originally developed to protect patients from coercion and only later co-opted to facilitate fully autonomous choices. Thus, due charity ought to be applied to its untapped potential. For a well respected history, see R.R. Faden & T.L. Beauchamp. 1986. A History and Theory of Informed Consent. New York: Oxford University Press.
3. See N.C. Manson & O. O'Neill. 2007. Rethinking Informed Consent in Bioethics. Cambridge: Cambridge University Press. The precursor to this book can be found in O. O'Neill. 2002. Autonomy and Trust in Bioethics. Cambridge: Cambridge University Press.
4. R. Wachbroit and D. Wasserman. Patient Autonomy and Value-Neutrality in Nondirective Genetic Counselling. Stanford Law Pol Rev 1994; 103: 103-112.
5. J. Savulescu. Rational Non-Interventional Paternalism: Why Doctors Ought to Make Judgments of What Is Best For Their Patients. J Med Ethics 1995; 21: 327.
6. C. McLeod. 2002. Self-Trust and Reproductive Autonomy. Cambridge, MA: MIT Press.
7. Note that I use the term 'counselling' broadly so as to include all cases in which health care workers offer patients information about their options regarding pregnancy; I do not restrict the word to only those cases in which patients are provided services that are formally acknowledged as counselling.
8. L. Cannold. Understanding and Responding to Anti-Choice Women-Centred Strategies. Reproductive Health Matters 2002; 10: 171-179
9. For a candid defense of the anti-abortionist strategy to focus efforts on counselling to protect women from their own decisions to abort, see David Reardon. 1996. Making Abortion Rare: A Healing Strategy for a Divided Nation. Springfield, Ill.: Acorn Books. Admirably impartial reports on abortion counselling and the existence of alleged post-abortion depression can be found in N. Gibbs. The Abortion Campaign You Never Hear About. Time 2007; February 26; 14-23
10. E. Bazelon. Is There a Post-Abortion Syndrome? The New York Times Magazine 2007; January 21: 40-70. 1992. 505 US: 833, 882-883.
11. Ibid: 882. The 'truthful and not misleading' clause is widely understood as a necessary condition for the information required before abortion can be performed, though the ruling seems to confuse 'if' with 'only if' when it states that 'If the information the State requires to be made available to the woman is truthful and not misleading, the requirement may be permissible.'
12. See Z. Lazzarini. South Dakota's Abortion Script - Threatening the Physician-Patient Relationship. N Engl J Med 2008; 359: 2189-2191.
13. See: J. Benshoof. The Chastity Act: Government Manipulation of Abortion Information and the First Amendment. Harv Law Rev 1988; 101: 1916-1937
14. C.E. Wells. Abortion Counseling as Vice Activity: The Free Speech Implications of Rust V. Sullivan and Planned Parenthood V. Casey. Columbia Law Rev 1995; 95: 1724-1764
15. R. Post. Informed Consent to Abortion: A First Amendment Analysis of Compelled Physician Speech. Univ Ill Law Review 2007: 939-990
16. H.J. Tobin. Confronting Misinformation on Abortion: Informed Consent, Deference, and Fetal Pain Laws. Columbia J Gend Law 2008; 17: 1-42.
17. See C. Turner Richardson and E. Nash. Misinformed Consent: The Medical Accuracy of State-Developed Abortion Counseling Materials. Guttmacher Policy Review 2006; 9: 6-11.
18. See: Regarding Abortion: Informed Consent or Selective Disclosure? Nurs Forum 2004; 39: 31-32.
19. One now finds this referred to as the 'Juno syndrome' after the controversy that followed the popular film in 2007. Setting aside whether or not one thinks that the film glorifies teen pregnancy, it is a realistic feature of the film that a young woman's decision could be influenced by the mere fact that the fetus 'has fingernails' while she remains unable to justify to herself why this ought to make a difference. Moreover, the realism at stake here is heightened by, but not dependent on, the fact that Juno is a teenager rather than a more mature adult.
20. In this respect, the prospect of offering less than maximal information to patients considering abortion is not equivalent to what is commonly referred to as therapeutic privilege, for the latter is normally thought to involve bypassing informed consent for the sake of avoiding some separate loss of welfare. (For example, see C. H. M. Da Silva et al. Not Telling the Truth in the Patient-Physician Relationship. Bioethics, In the case of abortion, the harm to be avoided involves the disruption of a patient's ability to make autonomous decisions. Thus, it is a problem located within the scope of informed consent, whereas therapeutic privilege involves a trade-off between informed consent and patient welfare. 2003; 17: 417-24
21. Required reading for this discussion would include: S. Sherwin. 1992. No Longer Patient: Feminist Ethics and Health Care. Philadelphia: Temple University Press
22. A. Jaggar. 1994. Abortion and a Woman's Right to Decide. In Living with Contradictions: Controversies in Feminist Social Ethics. Boulder, CO: Westview Press: 281-286
23. L.M. Purdy. 1996. Reproducing Persons: Issues in Feminist Bioethics. Ithaca, NY: Cornell University Press
24. R. Tong. 1997. Feminist Approaches to Bioethics: Theoretical Reflections and Practical Applications. Boulder, CO: Westview Press.
25. For an early defence of the view that patients can autonomously request limited disclosure, see: J. Childress. 1982. Who Should Decide?: Paternalism in Health Care. Oxford: Oxford University Press.
26. See J. Elster. 1979. Ulysses and the Sirens: Studies in Rationality and Irrationality. Cambridge: Cambridge University Press.
27. Note that this potential impact on a patient's personal decision need not represent a reversal of support for the political right to terminate a pregnancy. See: L. Cannold. 2000. The Abortion Myth: Feminism, Morality, and the Hard Choices Women Make. Hanover, NE: University Press of New England.
28. Virtue Theory and Abortion. Philos Public Aff 1991; 20: 223-246.
29. For those sceptical that details like those related to fetal development could be genuinely significant for patients' decision-making, as opposed to being purely prejudicial, consider the following variation on an example from Hursthouse: if a friend laments that she is especially disturbed by the fact that a miscarriage resulted in a fetus with fingers and toes, it is highly inappropriate to respond, 'It's not as if it was a person just because it had toes.' It would not just be a social faux pas; it would be indicative of an inability to see that the friend considers the details to be salient features of her loss. Similarly, health care professionals counselling women for abortion ought to allow for the possibility that patients view anatomical details of a fetus as salient to their decision to abort or continue with a pregnancy. See ibid: 238.
30. Note that this observation need not lead to a view as drastic as that of Anne Maloney, who combines the facts of oppression with the work of difference-based feminists like Nel Noddings to arrive at a curiously pro-life position regarding abortion. See: 1994. Women and Children First. In Living with Contradictions: Controversies in Feminist Social Ethics A.M. Jaggar, ed. Boulder, CO: Westview Press: 273-275. (For a less severe view of the application of difference-based feminism to abortion, see: C. Wolf-Devine. Abortion and the 'Feminine' Voice. Public Aff Q 1989; 3: 81-97.)
31. Indeed, the commonplace nature of inadequate social resources and other oppressive factors that pressure women to abort ought to lead to mixed feelings among those witnessing the recent trend for anti-abortion 'counselling' centres to focus on providing much needed resources for women contemplating abortion as a way of mitigating conditions of poverty or abuse. It is disconcerting to see misleading information being combined with an aim as commendable as providing aid (short-term as it is) to vulnerable women.
32. This is also true, of course, for fixed policies requiring that physicians offer, rather than exclude, certain kinds of details that are not medically imperative. See Lazzarini, op. cit. note 9.
33. For a concise introduction to standpoint theory, see S.G. Harding. 2004. The Feminist Standpoint Theory Reader: Intellectual and Political Controversies. New York: Routledge.
34. Nancy Felipe Russo. 2008. Foreword. In Rachel Needle and Lenore E.A. Walker Abortion Counseling: A Clinician's Guide to Psychology, Legislation, Politics and Competency. New York: Springer: xiii-xxi, xx.
35. See, for example: Leslie Cannold. 'There Is No Evidence to Suggest.': Changing the Way We Judge Information for Disclosure in the Informed Consent Process. Hypatia 1997; 12: 165-184
36. M. Evans, V. Bergum, S. Bamforth, and S. MacPhail. Relational Ethics and Genetic Counselling. Nurs Ethics 2004; 11: 459-471.
37. It is worth noting, though, that uniformity at the basic level of what is medically essential is particularly important in situations like abortion counselling, where patients may be particularly vulnerable and subject to emotional manipulation. I thank an anonymous referee for pointing this out.
38. Admirable references for abortion counselling can be found in: A. Baker. 1995. Abortion and Options Counselling: A Comprehensive Reference. Granite City. Hope Clinic for Women
39. J. Brien & I. Fairbairn 1996. Pregnancy and Abortion Counselling. New York. Routledge. Chap. 5-6; Emmy Surman. Challenges and Dilemmas in Counselling Young Women on Pregnancy Options. Reproductive Health Matters 2001; 9: 153-159
40. K.E. Simmonds & F.E. Likis. Providing Options Counseling for Women with Unintended Pregnancies. JOGN Nurs 2005; 34: 373-379
41. R. Needle & L.E. Walker. 2007. Abortion Counselling: A Clinician's Guide to Psychology, Legislation, Politics, and Competency. New York: Springer: ch. 5.
42. H. Madder. Existential Autonomy: Why Patients Should Make Their Own Choices. J Med Ethics 1997; 23: 221-225
43. Mary Terrell White. Decision-Making through Dialogue: Reconfiguring Autonomy in Genetic Counselling. Theor Med Bioeth 1998; 19: 5-19.
44. The potential for this kind of excessive deference will be heightened in cases where the patient's sense of what can be rightfully demanded of physicians has been conditioned by oppressive power dynamics related to factors like age, race, gender and income level. Imagine how the offer of additional information might come across differently for a white, wealthy, thirty-five year old woman speaking with a female physician, as compared to a black, economically challenged, seventeen year old woman speaking with a white male physician. Awareness of such considerations is critical for the practical judgment of healthcare workers.
45. As mentioned earlier (op. cit. note 4), Carolyn Macleod has persuasively argued that cultivating self-trust is also crucially important for promoting the reproductive autonomy of women. Patients must be offered the opportunity to trust health care workers, but they must also be given the support necessary to trust their own decision-making capacities in order to be in a position to make fully autonomous decisions. Macleod is primarily concerned with examples from new reproductive technology like IVF, but her arguments aptly apply to the context of abortion as well.