The aim of this essay was to explore the many ethical dimensions of contemporary healthcare in terms of abortion. Abortion rates in the UK have been reported, as has abortion globally as an increased method of population control. The reasons for abortion, are varied, including abortion as a contraceptive, attitudes to human life, and disability and eugenics, all of which have been discussed. There is a clear need for the ethical implications of abortion to be addressed in relation to the thoughts, feelings and attitudes of healthcare professionals working with women either considering or opting for an abortion.
A medical abortion has been defined by the National Abortion Federation (Dudley and Mueller, 2008) as a termination “that is brought about by taking medications that will end a pregnancy” (p.1). The NAF further clarify that, “The alternative is surgical abortion, which ends a pregnancy by emptying the uterus (or womb) with special instruments” (p. 1). Abortions are permitted under the Abortion Act 1967 (UK Government, 1967) by a registered medical practitioner subject to certain conditions.
Research by the World Health Organization (WHO) suggests that abortion rates are steady, at 28 abortions per 1,000 women globally (Sedgh et al., 2008). A quarter of pregnant women in the world have either an unwanted birth or an abortion (Aguirre, 2007). In England and Wales, figures from the Department of Health (DH) show a slight rise of 0.3% in abortions, from 189,100 in 2009 to 189,574 in 2010 (DH, 2011). Almost half (49%) of the women opting for abortions in 2010 were in a partnership, while 26% were single, and 16% married (DH, 2011). The abortion rate in girls under 16-years of age was 4.0 in 2009, reducing to 3.9 in 2010 (DH, 2011). Rates for girls aged 15-19 years old were also lower in 2010 compared to 2009, although rates in women aged 30-37 years of age were higher.
With such a large percentage of the population being subject to an abortion, many health professionals are confronted with the moral and ethical issues surrounding abortions. For example, according to Brody (1972), a woman should not consider the option of having an abortion when the foetus has developed biologically and genetically, into what is classed as a human being as opposed to a collection of cells. He maintains that this life, albeit in the early stages, has the same value as any other human life and therefore should be afforded the same rights.
Whilst some pro-life groups or anti-abortion movements advocate that it is always inappropriate to have an abortion as it is ultimately not allowing the creation of a new human life (Harris, 1985, Schultz and Van Assendelft, 1999), a more open-minded view would be that a woman has the right to pursue an abortion (Warren, 2009). Indeed, it could be argued that each incidence and each woman should be measured on their own merit as to whether their actions contravened the foetus’ right to life and human rights. Another contrasting view would be to look at an abortion as a woman acting in self-defence in such instances whereby continuing with the pregnancy could or would damage health or even threaten the life of the woman (Warren, 2009; MacGuigan, 1994). Indeed, evidence supports the fact that where there is a “choice” between the continuation of a woman’s life or that of a foetus’, the woman’s body will instinctively act in self-preservation to the detriment and potential termination of the pregnancy. It is this type of incidence, in particular, that raises the need for the application of ethical theories.
2. ETHICAL ISSUES IN ABORTION
The relationship between abortion and contraception highlights its own ethical dilemma, which can shift the burden of responsibility from the pregnant woman to health professionals and those in authority. For example, studies conducted by Marston and Cleland (2003) reveal that abortion is not deliberately used as a method of contraception, but is more so used due to a lack of knowledge or understanding by the pregnant woman. Therefore, it is the obligation of policy-makers and healthcare professionals to ensure that information and contraception are readily available and easy to understand. This is essential in the empowerment of women, allowing them to take control of their lives and enabling them to take all possible measures against an unwanted pregnancy. Education is considered to be the easiest and most open non-invasive measure, which where necessary can be provided confidentially, obtained in private, and in some instances contact with a health centre or medical staff is not necessary. However, there will always be cases where an emergency or medical abortion is necessary, no matter how well informed or prepared a woman may be.
Thus, contraception focuses on the importance of starting with and prioritising women’s needs regarding abortion concerns. In order to improve medical services, healthcare professionals need to ask questions about the level of knowledge the woman has about abortion, in addition to considering relevant ethical issues (International Consortium for Medical Abortion, ICMA, 2012). They must ensure that the woman has all the information regarding potential risks and problems, that measures to reduce levels of pain are implemented, and that the women is aware of what to expect prior, during and after the procedure (ICMA, 2012). Additional staffing is also necessary for the provision of more efficient medical services, as well as more empathetic and highly trained staff. Furthermore, those women who are considering an abortion must have their concerns and the circumstances surrounding their own ethical dilemmas addressed (Tremayne, 2000; Karasahin and Keskin, 2011).
It has been argued by Rosenfeld (1992) that “healthy women who want to complete an unintended pregnancy in the first trimester have few significant or negative emotional consequences” (p. 137). Although a few women may have feelings of ambivalence or guilt, many also feel a sense of freedom and experience other positive reactions, including relief. However, the emotional response of a woman and her family to medical or therapeutic abortion is complicated. A number of factors may help address women at risk of emotional problems and depressive symptoms after abortion (Rosenfeld, 1992). Women who terminate their pregnancy during the second trimester, have a history of multiple abortions, have pre-existing psychiatric problems or have a lack of support at home are more likely to have emotional problems (Rosenfeld, 1992). By being aware of this, health professionals can implement the appropriate pre- and post-abortion care. This is also the case for women who have an abortion for medical or genetic reasons. These women are at increased risk of developing depressive symptoms and therefore health professionals are required to provide the appropriate psychological as well as medical support (Boss, 1994). Blumberg et al. (1975) explains, “Perhaps the role of decision making and the responsibility associated with selective abortion explains [sic] the more serious depression following [the abortion]” (p. 805).
Medical ethics related to abortion are most relevant when they focus on the individuals choosing to have an abortion, as opposed to just health professionals carrying out the abortion or treating the aftermath. To this end, a philosopher, focusing on medical ethics can play a vital role in exposing problems which exist within hospitals.There is an enormous demand for philosophers within the healthcare setting, suggesting a common ethical, moral and social viewpoint that could facilitate advice-giving to health professionals (Polaino Lorente, 2009).
2.1 International Ethical Codes
In the Hippocratic Oath, abortion is connected to medical ethics in both its actual form and contemporary reformulation such as stated in the World Medical Association’s 1948 Declaration of Geneva (Kivity, Borow and Shoenfeld, 2009). According to this oath, all members of the human race have a right to life and this is agreed globally in conventions such as:
1.The Universal Declaration of Human Rights (1949)
2.Declaration of the Rights of the Child, which clearly refers to such rights as applying to the unborn (1959)
3.International Covenant on Civil and Political Rights (1976).
However, the Society for the Protection of Unborn Children’s (SPUC’s) opposition to abortion is dependent on ethical principles which have masked universal acceptance (SPUC, 2012a). While the SPUC consists of members from many different religions, it is not an organisation based on religion. Nevertheless, this highlights the need of a focus on common acceptable (as opposed to religious-based) ethical dimensions in contemporary healthcare, especially in terms of considering the ethical implications of abortion.
2.2 Abortion in the United Kingdom
The main reason for legalising abortion inBritainwas the suspected number of illegal abortions being carried out. Pro-abortionists indicated that every year, there were 100,000 illegal abortions before legalisation (SPUC, 2012b). The committee of the Royal College of Obstetricians and Gynaecologists provides evidence that in England and Wales, there were 15,000 illegal abortions annually in 2007 (Event, 2008). Thus, in theUK, the application of ethical theories along with related approaches to practical dilemmas in healthcare focusing on abortion is particularly important and relevant.
2.2.1 Actual counts of legal abortions
The Abortion Act was agreed in 1967 and a year later it became effective as a statute inEngland,WalesandScotland. For the period of 30 years following the implementation of the Act, year on year the total number of abortions performed rose by 700% (SPUC, 2012b). InBritain, five million abortions were performed over this period. Yearly, 170,000 abortions occurred during the 15 years prior to 1997. It was over 187,000 in 1998, with more than 510 abortions a day, which was 87% higher than the pro-abortionists’ estimate of illegal abortions in the 1960s (Sedgh et al., 2012).
2.3 Reasons for abortion
Although more than 90% of abortions are authorised and performed to protect the mother’s physical or mental health, the majority of these abortions are performed for social reasons rather than medical reasons, and this has become widely accepted (Corkindale et al., 2009). Indeed, inBritainabortion is efficiently practised on demand (Ingham et al., 2008). This poses further ethical implications for healthcare professionals since abortion is no longer only considered for medical reasons, but is frequently a social choice and a method of solving an unexpected or unwanted pregnancy (Koyama et al., 2005).
2.3.1 Contraception and abortion
Although the pro-life movement is reluctant to make a connection between contraception and abortion, with some contraceptives there is both a link to abortion and identification with abortion (Smith, 1993). Indeed, some contraceptives are abortifacients and work by causing early term abortion. Furthermore, the number of abortions cannot be stopped primarily by contraception since pregnancy prevention also results in an anti-child state of mind; such unplanned babies are observed only as the unwanted result of contraceptive failure.
2.3.2 The eugenics movement
Eugenic ethics is protected as a religious belief, political philosophies, and judicial systems, and it is the reverse of the code that all human beings have equal value (Kasun, 1988). The mentality of the eugenic adjudicators is unusually narrow compared to physical, psychological or social situations (Connelly, 2008). This leads to disabled and unborn groups. Thus, issues of disability and eugenics are remarkably relevant to the application of ethical theories focusing on practical dilemmas in healthcare.
2.3.3 Foetal tissue in medical research
The major source for research into foetal tissue is from babies that are the result of induced abortion; such research consists of the human genome project. If permission is given, the dead bodies may well be used for research, but a mother aborting her child would not likely provide such support. In research, the use of foetal tissue seems to justify abortion because it can be used to assist in the health and life of other people. At the same time, it could be argued that such research is morally wrong because it neglects the unborn baby’s right to life (Nie, 2002).
2.4 Abortion and disability
Every abortion involves an assumption that the existence of unborn babies is of lesser value than an adult human’s life. It could be argued that abortion due to a disability diagnosed in the unborn child is not only an attack on the most vulnerable but on one who it is necessary to protect. It is also offensive to all disabled community members as it transmits to them the sense that they are inferior to, as well as of less worth than, the able-bodied (Sheldon and Wilkonson, 2010).
2.4.1 Pre-natal screening
In Britain, most pregnant women are offered regular pre-natal testing. It is a crucial activity, which has resulted in a greater number of women who may not have considered it before going on to have an abortion. Such tests are presented and if the results are positive for a disability, the immediate option given to parents is to make a choice between either continuing with the pregnancy or having an abortion. Britain offers pre-natal screening for disabilities only where a routine ultrasound has highlighted a potential problem, there is family medical history to suggest a child may inherit a condition, or the age of the mother puts her child at an increased risk of having, for example, Down’s syndrome.
In cases of artificial insemination, before implantation and hopefully fertilisation, the embryo is screened. Whilst still in the test tube embryos are monitored to determine their sex and genetic conditions, but can be superfluous. This approach prevents embryos from continuing to live (Hundt et al., 2011). Thus, medical and nursing professionals working in healthcare related to abortion must address the issues related to pre-natal screening adequately.
2.4.2 Gene technology
Genetic science is used to enhance the well-being of humanity, through exploration into gene therapy and to care for people with, for example, a genetic condition such as cystic fibrosis. However, this technology may be misused in order to limit human life. Genetic engineering attempts to engineer babies by manipulating their genes in the laboratory. However, the source from the genetic map position in the human genome program may be misused (Heinrichs, 2002).
The topic of abortion raises moral and ethical issues that need to be addressed by physicians, nurses, and clinic staff involved with conducting abortions. While abortions for medical reasons are legal in Britain, some staff may question the procedure for personal and religious reasons. Those staff who are pro-life (and see abortion as akin to murder) will likely seek work in other settings and thus alleviate their sense of guilt. Obstetricians, who often participate in the act of abortion, will need to have a professional view that sees the action as ethical, although some may hold private views of its morality, perhaps influenced by religious beliefs (Chervenak and McCullough ,1990). For example, health professionals might ask the question, “When is the foetus a patient?” The answer is when it is viable, regardless of age of gestation. Indeed, it could be argued that only the woman carrying the foetus can give a pre-viable foetus patient status. If the foetus is classified as a patient, it can be further argued that ending its life is almost never ethically justified.
The statistical data discussed within this essay indicate that few abortions are actually for medical reasons, but rather for personal, social and economic reasons. This has generated a great deal of discussion in terms of the ethics of abortion. Since the procedure is primarily used by the lower economic classes (who perhaps become pregnant because of lack of knowledge about birth control), abortion can be seen as a method to keep the future population of those likely to require government assistance in welfare and medicine somewhat reduced. As yet, there doesn’t appear to be any political or ethical writer ready to take this issue up. Some groups (such as African Americans) see this as an attack on their race. Feminists likely support the procedure if it is the wish of the pregnant woman. Many health workers would continue to support abortion on demand as it eliminates reliance on illegal abortions, which were often dangerous to a woman’s health, as was a huge problem in the past.
A few points should be made about the ethical issues posed by new technologies (such as embryos in stem cell research, sex selection and gene manipulation). In all of these cases, decisions are being made to limit viable life. Outka (2002) raised questions about the ethics of human stem cell research. Many good embryos are destroyed for the sake of research. This is seen as clearly unethical. Outka concludes that it is acceptable to conduct research on ‘excess’ embryos by appealing to the principal of “nothing is lost.”
Modern science has made it easy to determine the sex of the foetus at a very early stage. If the sex is female (and the parents already have a girl), will they seek an abortion Is the doctor or clinic likely to raise moral and ethical concerns In many cultures, a son is deemed necessary, so with new technologies many female foetuses inIndia andChina have been aborted. This raises the question of whether this cultural bias being seen in the large Indian population in theUK?
Ethical Issues in healthcare related to abortion are becoming increasingly relevant, as it provides an opportunity for discussion on various dimensions of contemporary healthcare. It also examines the application of ethical theories along with related approaches focusing on abortion. However, it is suggested that medical institutes and hospitals providing safe abortions should be aware of all ethical issues and the human rights implications involved. Their workers, including doctors and nurses, should be trained on the ethical issues of abortion so that they can provide comprehensive medical care to women who consider or opt for an abortion.
It is important to explore new opportunities for the in-depth study of ethical dimensions of modern healthcare, which examines the appropriate application of ethical theories and related approaches to effective dilemmas in healthcare focusing on abortion. There are many suitable applications of ethical theories and approaches to an ethical dilemma available, which mainly focus on the international and the population-control development, reasons for abortion, contraception and abortion, birth control and human life attitudes, disability and eugenics, abortion and disability, and other related ethical issues. Nevertheless, there remains a need to address each of these ethical issues specifically in terms of healthcare and the dilemmas experienced by healthcare professionals.
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