By Cushla Hassan, RN & Joseph Hassan, MBchB
A year ago, Kai Tiaki Nursing New Zealand published Rose Stewart’s challenging article, “Conscience ‘not always a force for good’,” giving her perspective on conscience and health care.1
In the article, Stewart expressed her concern that health professionals who invoke their conscientious objection to abortion or contraception risk infringing the rights of women to reproductive health care. She argued “conscience is not always a force for good.”
In this article, we suggest freedom of conscience is essential for a health-care worker and protects the rights of the patient, the health-care worker and society as a whole.
As health-care workers, we bring ourselves as whole persons to our important role. We are present as real people, not robots. Our background, culture, beliefs, and especially conscience, will and should, affect how we care for our patients.
A Healthcare Worker’s Privileged Role
Care, empathy, altruism and conscientiousness all stem from the values we have developed during life. They are influenced by our beliefs, culture and background. Many of us have chosen to enter health care as a calling. We see our role as a privileged one, where we have the opportunity to work in partnership to help ease the suffering of our fellow human beings. For many of us who are Christians, this calling is an extension of our belief in Jesus, who calls us to serve all with dignity — especially the disadvantaged, the poor and the marginalized.
We believe God is the source of all life and that human life is particularly sacred. These beliefs are part of us, give our lives purpose, allow hope, encourage our deepest being and inform our conscience. Our beliefs encourage us to seek to care for others through our work in the health-care professions. They drive us to keep serving even when our work is difficult and unrewarding. Christians do not hold these views uniquely, however. Health-care workers from other religious traditions also share the same belief that human life is sacred.
Our conscience necessarily guides our actions inside and outside our workplace. It guides the choices we make daily between right and wrong — whether this relates to stealing from the corner store or lying to a fellow worker. Our conscience also informs our choices in health care — whether to be fully honest with a patient about a mistake we have made, whether to allow a patient his or her full autonomy, whether to spend a little longer with a distressed patient, thereby encroaching on our paperwork time. Our conscience also guides our actions with regard to abortion and contraception.
There is no reason to suggest that human life begins at any other time than at the point of conception. At this time, a new individual is formed, with their unique genetic code, characteristics and future. Given the necessities of life, this person will grow to become a mother, a musician, a health-care worker. Many of us believe we do not have the right to end a person’s life, even at this early time.
Our conscience and our professional ethics do not allow us to take part in what we regard as the killing of this person.
How can we respond as health professionals, if we had these views about life?
Conscience Requires Understanding Pressures Women Face
When Joseph began practising as a GP, he initially felt he needed to ignore his beliefs and practise in a way which was “unbiased.” He met many women requesting abortion. In a large number of these cases, he saw these women as making a decision for abortion based on fear, lack of support, threatened relationships and other pressures. Often the decisions were hurried, and the woman would not seek support from those closest to her, out of shame.
In some cases where women requested abortion, there was a repeated pattern of unexpected pregnancy where little had changed to improve choices and decision-making. In some cases, Joseph saw women who experienced grief and trauma as a result of abortion. He referred several patients to secondary care, despite having misgivings about how the choice was being made. He hoped they would receive pre-decision counseling to address their social issues and that abortion procedures would only occur once all other avenues had been explored with the women.
In every case referred, however, the women had their pregnancies terminated with what seemed like little further opportunity to discuss alternatives to abortion. The dominant opinion seemed to be that the best way to reduce trauma to a distressed pregnant woman was to offer a rapid termination service, rather than to provide a window of time to explore the complexities of her situation and to ensure an authentic informed choice.
Joseph recognized that he could not continue to practise medicine in this way. He was not being fully present to the patient, nor fully himself in his practice of medicine. Nor did he consider he was offering the standard of care necessary for these women in crisis and nor was he fully considering the life they carried within them. This lead to intense personal reflection and inter-professional discussion. It resulted, finally, in a collaboration between GP, practice nurse and midwife to address this important area of practice and plan a new service.
A Higher Standard of Care Requires Looking Deeper & Helping More
We felt there was a need for a primary health-care response to unplanned pregnancy, rather than simply referring all women to secondary-care abortion providers.
Thirteen years ago, in 2001, we set up Crisis Pregnancy Support/Hapai Taumaha Haputanga. This is a service based within a general practice in Nelson. We engage volunteer health professionals as “acute response care coordinators” who meet with pregnant women. Most of these volunteers are nurses, who receive specific training and attend regular peer review. They become expert in accessing community support for these women. We also have a larger group of community-based volunteers who provide some practical support.
If a woman presents with a crisis pregnancy, we recognize that our responsibility is to two patients, not only the mother (whose dignity and autonomy we give the utmost respect) but also her unborn child.
Our role is simply to offer hope and support in the midst of her crisis. She will be given space and time to reach an autonomous decision and she is assured that our support remains constant.
Unfortunately, there is no easy solution to an unplanned pregnancy. An abortion does not make the problem disappear. A woman goes from being unexpectedly pregnant, to living a new journey that may include unexpected feelings of loss and trauma as the result of an abortion.
We assess a woman’s level of support and then together build a more robust network where required. We link in with existing support services and provide community-based support. The goal is always to empower. At times, we seek funds to help with one-off expenses such as driver’s license fees or rental accommodation bonds. At other times, we help with emergency accommodation, accessing ongoing education, advice regarding restraining orders or information about work and income assistance. We try to remain “present” with the woman and encourage her as she undergoes multiple transitions in this emotionally challenging time.
Empowering Women to Avoid Unwanted Abortions
In our work with pregnant women, we see that without this kind of service, many actually accept an “unwanted abortion.” In many cases, the woman is not opting for abortion as a “free decision based on her conscience,” but due to coercion, threats of an ended relationship, financial pressures, worries about education or other similar outside pressures. If these factors are addressed and practical help provided, then many women choose to continue their pregnancy.
The outcomes of our work have been very encouraging and reinforce our conviction that this type of primary care service is essential if we are to offer our patients real choice. We also care for many women for whom abortion has had severe and long-term adverse effects. These can include depression, drug/alcohol abuse and anxiety-related conditions, among others. The fact that these adverse outcomes are more common in those who have had abortions has been clearly demonstrated in work carried out by New Zealand researcher David Fergusson, at Otago University (see summary below).2
Health-care workers must be allowed to practise within their professional ethics and according to conscience, independent of outside pressure (including pressure from oppressive ideologies, unjust government or legislation). History has given us examples of the terrible consequences for health-care workers and patients where this does not occur. For good reasons, the Hippocratic tradition was reinforced in the 1948 Declaration of Geneva, as the appropriate ethical framework for medical practice, following the atrocities committed against patients during the Holocaust.
For those involved in health care, working according to one’s conscience is not only a “force for good” but also an essential safeguard against corrupt or oppressive influences on the privileged role we have with our patients.
Summary of Fergusson’s Longitudinal Study
Research which found links between abortion and mental illness arose out of an influential ongoing longitudinal study of 1265 people born in the Christchurch region in 1977.
Data from the Christchurch Health and Development Study, founded and led by Otago University psychology professor David Fergusson, has spawned more than 400 academic articles and books over a range of disciplines. It has influenced public policy on a variety of social and health issues, from the need to fence swimming pools, to the dangers of passive smoking, to the link between low socioeconomic background and poor access to preventive health care.3
In a study from the Christchurch data, published in 2009, Fergusson found major mental illness was 30 percent higher in women who had had an abortion compared to those who hadn’t. Substance abuse was the most common problem linked with having undergone an abortion. The higher level of mental illness was not present in women who had carried an unwanted pregnancy to term. He concluded abortion was “an adverse life event” associated with a “modest increase” in risk of mental disorder, which supported a “middle of the road” attitude to abortion.4
Investigating the impact of abortion on mental health had been the most controversial aspect of his research, he said. “There have been lots of attempts to discredit our research, but it has stood up to intense scrutiny.”1
Last year, 14,073 abortions were performed, the lowest annual figure since 1995, when 13,653 women had abortions, Statistics New Zealand said.
Women aged 20-24 had the highest abortion rate, 27 abortions per 1000 women, compared to the overall rate of 15.4 abortions per 1000 women aged 1544 years. The median age of women having an abortion was 26, and 64 percent of abortions were the woman’s first.
(This article, and the summary below, are reprinted with permission and were originally published in Kai Tiaki Nursing New Zealand, Vol 20, No 7, August 2014.)
Cushla Hassan, RN, is a practice nurse at St Luke’s Health Centre, Nelson, and manager of Crisis Pregnancy Support.
Joseph Hassan, MBchB, is a GP at St Luke’s Health Centre, Nelson, and medical adviser to Crisis Pregnancy Support.
More about Crisis Pregnancy Support can be found at www.CrisisPregnancySupport.co.nz
1) Stewart, R. (2013) Conscience “not always a force for good.” Kai Tiaki Nursing New Zealand; 19: 7, pp30-31.
2) Fergusson, D.M.; Horwood, L.J.; Boden, J.M. (2008) Abortion and mental health disorders: evidence from a 30-year longitudinal study. British Journal of Psychiatry; 193: 6, pp444-451 doi: 10.1192/bjp.bp.108.056499.
3) University of Otago. (n.d.) 2010 Distinguished Research Medal: Prof David Fergusson. www.otago.ac.nz/profiles/otago015738.html. Retrieved 19/7/14.
4) Health Research Council. (2009) Abortion and mental health. http://www.hrc.govt.nz/sites/default/files/Professor%20David%20Fergusson%202.pdf. Retrieved 20/7/14.