mardi 18 août 2015

Where Does Life Begin, And Other Tough Abortion Questions For Doctors In Training

Where Does Life Begin, And Other Tough Abortion Questions For Doctors In Training

Our recent post on how residents training to be ob-gyns think about providing abortions (or not providing them) went viral earlier this month and triggered a broader conversation among readers. The topic was also featured on Radio Boston and WBUR’s All Things Considered.

I asked Janet Singer, a nurse midwife on the faculty of Brown University’s obstetrics-gynecology residency program, and the person who organized the initial discussion among the residents, to follow up. She, in turn, ​asked Jennifer Villavicencio, a third-year resident​, to lead a discussion digging even more deeply into the topic.

Two of the residents ​in the discussion ​perform abortions, two have chosen not to do so. ​But they are colleagues and friends who have found a way to talk about this divisive issue in a respectful and productive way. ​Here, edited, is ​a transcript of ​their discussion, which gets to the heart of a particularly fraught question: When does life truly begin? ​Three of the residents have asked to not include their names for fear of hostility or violence aimed at abortion providers.

Jennifer Villavicencio (Resident 3): Let’s talk about a woman who comes in, has broken her water and is about 20-21 weeks pregnant and after counseling from both her obstetricians and the neonatologist [a special pediatrician who takes care of very sick newborns] has opted for an abortion. Let’s talk about how we each approach these patients.

Resident 2: As a non-abortion provider I will start just by saying that a patient of this nature in some ways is on one extreme of the spectrum. As an obstetrician, I view the loss of her pregnancy as an inevitability. I think we would all agree with that. So, taking part in the termination [another word for abortion] of her pregnancy is different to me than doing that for someone whose pregnancy, but for my involvement, would continue in a healthy and normal fashion.

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

Opponents and supporters of an abortion bill hold signs outside the Texas Capitol on July 9 in Austin. (Eric Gay/AP)

JV: Would your opinion change if she were 22 or 23 weeks and theoretically could make it to viability [the concept that a fetus could survive outside of the mother. Currently, in the U.S., the generally accepted definition of viability is 24 weeks gestation or approximately six months pregnant]?

Resident 2: Personally, it wouldn’t, because I feel there is a very slim chance of an intact survival [refers to an infant not having significant mental or disabilities] of an infant. If she were 22 or 23 weeks gestation and could potentially make it to the point of a survivable child, that likelihood is so rare. But for my involvement, she will still lose this pregnancy. My point is, if I help terminate this pregnancy, I am not playing an integral role in the loss of this pregnancy. I feel that supporting her in proceeding in the safest possible way, protecting her while accepting the loss of her pregnancy, is my job.

Future Health Of The Child

JV: … Does the future health of the child really play a role in it for you?

Resident 2: Yes it does, it absolutely does, and it’s kind of on a case-by-case scenario. Theoretically, the goal of every pregnancy is a healthy outcome for mom and baby, and if one of those is in jeopardy my perspective changes.

JV: What do you think Resident No. 4?

Resident 4: I think as you get closer to viability, it becomes a more complicated question.  We know from literature [the current known facts from research done in the area] involving breaking waters that the gestational age at which it happens is very important for the prognosis of the newborn. Unlike Resident No. 3, I think my involvement would weigh on me more greatly as the fetus approaches viability, because at 23 weeks our neonatal intensive care unit (NICU) would be resuscitating this baby if it was something that was important to the parents. We are in a very privileged position to work in a hospital with many doctors, so if you don’t actually do the termination yourself, chances are you have many other providers in the hospital who are able to do so. We have the luxury of opting out. I wonder how my answer to this question would be different had I not been working in this environment.

JV: So, what if you were in a place where you were the only person able to provide the termination?

Resident 4: I would have a hard time with that. I don’t know the answer to that question. Because I’ve not been there, I can say honestly, I don’t know what I would do.

JV: And how about you Resident No. 1?

Resident 1: In my opinion, that’s her decision. I feel very comfortable providing her with that healthcare service.

Two Patients At Once?

JV: Resident No. 1, it sounds like you are talking a lot about the woman, and Resident No. 4, you are talking about where the fetus would be if the fetus was delivered right at that point in time. So, how do we, as OB/GYN’s, who take care of two patients at the exact same time, reconcile that? I know for me in this particular situation I have no qualms whatsoever about providing this termination. Whatever the woman desires is what I am willing to do. I do not think that my personal feelings, ethics or politics should be involved in that. It’s hard as a provider who takes care of two patients in a situation in which one might not survive to reconcile that, but I almost always land on the side of the mother.

Resident No. 1: It is easier for me when I think about the poor outcomes that we see. I feel that a lot of people who are not in medicine do not see …[pause]

Resident 2: …what the alternative is.

Resident 1: Right … which is a severely premature delivery or a newborn with a serious infection being admitted into the NICU [intensive care unit for newborns] for months and months and months and the amount of emotional and financial strife that might bring upon the family. I think she can decide that that is not the choice that she wants.

JV: I think abortion is really an interesting place to discuss life – what life is – where it begins. Even in this scenario how much of a life is that 24-week fetus going to have in the NICU after it’s delivered versus not having a life if the pregnancy was terminated.

Resident 1: Even if it were to make it through the first six months to a year, what kind of life is that infant going to have. Especially in the patients we take care of; they do not have the resources to take care of a child like that, with so many medical issues.

JV: I think it is interesting too because in talking about this situation in which the outcomes are very, very likely, upwards of 95 percent, to be very, very poor, some of us are less certain of our positions on termination. But it seems to me like we, the four of us, (because we have talked about this before) are much clearer about an elective 16-week termination – two of us would do it and two of us wouldn’t. There seems to be a much more clean line, which is interesting, because ethically, I don’t know if it is a much more clear line when you think about the fetus.

One Patient Talking, One With No Voice

Resident 4: Well, I can speak to that. My central conflict in not providing terminations is that we are talking about two patients – one of whom is looking at you talking to you, interacting with you – the other one has no voice, is only seen by a black and white two-dimensional picture and who, I hesitate to say, doesn’t have anyone to advocate for them, because that makes me sound like a crazy person. But if you really accept the fact that we have two different patients whose needs are not one in the same, then you have to consider the possibility that [pause]… anyhow, my tension is that it is such an intellectual distinction to think about a fetus as its own entity, because you can’t do things like talk to it and consent it. That’s been a very big tension for me, not hearing from the fetus, but also wanting to respect it as something that I consider to be alive.

Resident 1: I don’t think that a pre-viable [before 24 weeks, the time a fetus can survive outside the womb] fetus has wants. And that may make me a different kind of person. I’m sure there are biological needs of a pre-viable fetus, but I don’t think of it as a human entity with a conscience and capable of making complex decisions.

Defining ‘Personhood’

Resident 2: I think that’s an interesting point, and one that I struggle with. I agree with you that a very early first trimester fetus likely doesn’t have a conscience, although I will never actually know if that’s true or not. It certainly isn’t capable of making complex decisions. But the same could be said for a 9-month-old, or even a 9-year-old. Clearly there is a difference between an in-utero fetus (in the womb) and an ex-utero (outside the womb) child, but I don’t totally know where that line crosses over into personhood. I have a hard time moving past the fact that 24 weeks is an arbitrary line created by medicine and technology; I think that personhood is a more mystical and innate quality than one that should or can be determined by technology.

Resident 3: I used to be pro-life, very much anti-abortion, and since I have grown and changed and studied science and become a provider of care to women, my opinion has changed a lot. A couple of different things come in to play. I agree with Resident 1 – a pre-viable fetus at 16 weeks is alive in name and heartbeat only. If it cannot survive outside the mother, then it is part of the mother. At that point I don’t have two patients. I have one patient who is pregnant. Even if I sit down and think about the potential life, I think that Mom, my patient, has still lived and learned and earned a lot more, as Resident 4 mentioned, respect than that potential baby has. My allegiance will always lie with the mother, because she is the one going through all of this.

Resident 4 – Would you perform an elective termination for a viable gestational age?

Pregnancy: A State Of ‘Caughtness’

JV: That’s a really good question. For me, if there is something wrong with the pregnancy, if the pregnancy is unlikely to survive, absolutely. Pregnancy scares me – a lot – I think it is a state of “caughtness” – women are, once they become pregnant, they are stuck – and they can perceive being stuck in a great way or a bad way. But, regardless of how they feel about the pregnancy, those women have no control over what’s going on. They are growing this pregnancy inside their body, and they can become extraordinarily ill, can lose their life. They can lose this child that they have dreamed about since they were themselves a child. They can lose that in an instant. That is a very scary thing to me. To make a woman be in that state of “caughtness,” to be trapped that way when she doesn’t want to be, seems very wrong to me. And that very much motivates how I think about these things.

Resident 1: Doesn’t that make you want to be able to prevent women from ever having to be in this state of being “caught”?

JV: Absolutely.

Resident 1: I think about abortion providers, there are certain ideas about them. I think one we can all, at least Resident 3 and I, agree on is that we work very hard to prevent women ever having to be in that situation.

Resident 4: And me too!

Resident 1: Yeah! Sorry, you too, you too. You know what I mean. All of us.

JV: For me, speaking for myself, I am not just pro-choice, I am pro-abortion. I think it is a medical procedure that should be a part of every woman’s care should she want it. If she was on birth control, if she wasn’t on birth control, if she got pregnant and didn’t want to be pregnant anymore. I don’t think it matters what the circumstance is. If a woman doesn’t want to be pregnant anymore, she shouldn’t have to be. I feel very, very strongly about that.

Resident 1: I think Resident 3, that both of us were raised very pro-life … I like the idea of what you said about “allegiance.” I feel the responsibility to defend a similar idea that you just described because of all the anti-abortion things we were taught.

Resident 2: … There are gray areas here for each of us; I think it’s so crucial to acknowledge that our opinions are far more complex than being just “pro-life” and “pro-choice.” I consider myself pro-choice in that I think it’s not my job to make decisions about other women’s bodies or lives. But supporting a woman’s right to make that decision and actually performing abortions are entirely different issues to me. I need to make peace with my own values and choices, and every pregnant woman in the world needs the ability to also make peace with hers, whatever that may mean.

Opting In, Opting Out

Resident 4: I’m caught between feeling like someone who really cares about women’s health, the empowerment of women, and was drawn to this field because of that and recognizing that not providing terminations has basically been cast as the opposite of empowering women. So, you know, so there’s that. I can tell you I feel I would lose sleep at night if I did terminations, and I do know that people who do terminations do sometimes lose sleep, and we have talked about it. I wonder if I am just one of the weaklings who can’t do it at the expense of everyone else who has to pick up my slack. That’s what I think in my moments of doubt.

JV: But don’t you lose sleep over other things too?

Resident 4: Well I lose sleep over lots of things, but with abortion we have a choice — we can either opt in or opt out. We can’t opt in or out of performing surgery for anything else. But I wonder if I’ve just overly intellectualized this question in the convenient setting of being able to opt out. That contrasts starkly with how I view myself as a physician, which is as an advocate for women.

JV: I think that you can be an advocate for women and not be an abortion provider.

Resident 1: I agree.

Resident 2: I have very similar feelings to Resident 4’s. I also consider it a luxury to work in a place where I know that women will have other options, that me not providing abortions is in no way a barrier to access to abortions. If I end up moving back home to some rural town in the West, I may end up changing my stance. It’s very different when I am someone with the appropriate training available to serve a population who are otherwise un-served with abortion services, and I choose not to do it. Now, back to the “but-for” rule, but for my provision of abortions, women are back to being “caught,” as you said before, and all of the sudden I’m standing in the way of their autonomy. That might be enough to tip the cost-benefit analysis I do in my head, when I think of my personal cost of violating my beliefs against the benefit of empowering women. It’s tough, and I don’t know for sure what I would do, but I know I would struggle with that choice.

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