Moral distress in the wake of abortion restrictions in the USA

Moral distress in the wake of abortion restrictions in the USA

Dr Julie Chor presented the topic of moral distress at the FIGO World Congress 2023 in Paris. Alongside her colleagues Dr Jocelyn Wascher and Dr Katherine Rivlin, she delves into this concept and shares the far-reaching consequences of restrictive abortion laws in the US. 

“I’m not going home pregnant.” The patient sitting in front of us is determined, her composure masking the effort it took to overcome countless barriers to get here. We already know her story. We heard it from her doctor in another state, who was desperate to help this patient with a lethal foetal anomaly terminate her pregnancy. Meeting her, the injustice of the situation feels much more tangible—the added insult of the long drive to Illinois, the impersonal hotel, and the distance from her support network, the mounting costs, compounding her already heart-rending situation. We also imagine the frustration, guilt, and distress her doctor must feel, emailing and calling multiple hospitals and clinics to get her to the care that they were now forbidden to provide, despite years of training and skills.  

These kinds of clinic visits are now commonplace for us. Since the Supreme Court’s Dobbs versus Jackson Women’s Health Organization decision in June 2022,1 abortion is no longer federally protected in the United States, and many states have substantially limited or outright banned abortion. People in restrictive states can no longer access this previously common, safe, life-saving service. Furthermore, states that restrict abortion often have the highest rates of maternal morbidity.2 Health care professionals in restrictive states must withhold safe, desired medical care that they could previously offer, and instead, must turn patients away.  Helplessness to provide basic reproductive healthcare can be traumatic for the health care professional and can lead to moral distress. 

What is moral distress? 

Andrew Jameton first introduced the concept of moral distress in 1984, describing it as when an individual knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action.3 The concept emerged from discussions with nurses over care they were asked to provide with which they ethically disagreed. Such events that have the potential to negatively impact one’s personal integrity are referred to as moral dilemmas or potentially morally injurious events.  

While the initial definition of moral distress focused on negative claims of conscience —when an individual objects to the care being provided— the term has since broadened. 

Many healthcare professionals, including abortion providers facing new abortion bans, experience moral distress due to their inability to fulfill their positive claims of conscience – by not being able to provide care they feel morally compelled and profession bound to provide.4 

Stories of patients desperate to end pregnancies for medical, financial and social reasons pervade the media and increasingly become everyday occurrences for many clinicians. Abrupt legal changes can create an environment of instability and fear where one’s central identity as a health care professional can be upended overnight. In states where abortion remains protected, witnessing the seemingly insurmountable barriers that patients encounter in seeking care as well as knowing that not all patients are able to successfully reach this care and are forced to continue pregnancies can lead to significant distress as well.  

Outside the United States, health care professionals in other countries have been grappling with the consequences of restrictive abortion laws for years. The Supreme Court’s decision, however, comes at a time when many other countries, including our neighbouring country of Mexico, are liberalising abortion laws. In fact, in the past thirty years, the United States is one of only four countries that have increased abortion restrictions; meanwhile, more than 60 countries have moved towards more liberal abortion policies.5 Witnessing international progress while enduring our nation’s policy reversal deepens our frustrations.  

What are the consequences of moral distress? 

Psychological consequences of moral distress can have a lasting impact. While moral distress describes the short term reaction to a moral dilemma, prolonged exposure to moral dilemmas and distress can cause persistent, psychological damage known as moral injury.6 The symptoms of moral injury, including anxiety, helplessness, isolation, and burnout, can lead some to leave the workforce.6 Areas of the country already affected by reproductive healthcare professional shortages often have the strictest abortion bans. As more health care professionals encounter abortion ban-related moral dilemmas, experience moral distress, and go on to develop moral injuries and their sequelae, we expect to see increasing shortages of those willing to provide reproductive healthcare in these areas of the country. Such shortages will consequently compound already dismal maternal morbidity and mortality rates in many states with some of the most stringent abortion restriction.  

What can we do about it? 

Mitigating the consequences of moral distress in the face of abortion bans is not easy, and no approach will entirely alleviate the effects. Any proposed solution that falls short of changing state laws on abortion provision avoids the root cause. Yet while our current policies exist, finding ways to protect health care professionals against lasting psychological impacts is necessary. Potential areas to explore include validating experiences, promoting community, and engaging in advocacy efforts. 6 On an institutional level, allowing health care professionals time to seek mental health resources and to advocate for policy change may help decrease the sense of helplessness in the face of these bans. 6 Institutions in both restrictive and protective states can support these efforts by providing resources and compensation for those facilitating patient navigation. In states with protective laws, we can expand training opportunities and promote referral networks to increase access.  

We feel privileged to live in a state where abortion care is readily accessible without fear of legal consequence.

By providing life-saving abortion care, we are protecting individual reproductive autonomy which is central to our professional identities as health care professionals. We know that turning patients away from abortion care can have lasting psychological impacts for pregnant individuals, but now we are increasingly aware that the inability to act impacts the health care professional as well.  

The importance of support from OBGYN professional organisations such as FIGO cannot be overstated. As respected voices in reproductive health care, these organisations must use their voices to advocate on behalf of health care professionals and patients impacted by abortion restrictions. However, restrictions on the practice of reproductive health care also has important implications for and may portend future restrictions in other areas of medicine. Therefore, other medical specialties’ professional organisations also have a responsibility to act in solidarity with reproductive healthcare professionals impacted by these laws and advocate against legal intrusions into the practice of medicine.  

References

  1. Dobbs v. Jackson Women’s Health Organization, 597 US ___ (2022). 
  2. Addante AN, Eisenberg DL, Valentine MC, Leonard J, Maddox KEJ, Hoofnagle MH. The association between state-level abortion restrictions and maternal mortality in the United States, 1995-2017. Contraception. 2021;104(5):496-501. doi:10.1016/j.contraception.2021.03.018 
  3. Jameton A. Nursing Practice: The Ethical Issues. Englewood Cliffs N.J: Prentice-Hall; 1984. http://books.google.com/books?id=whFtAAAAMAAJ. Accessed November 19 2023. 
  4. Harris LH. Recognizing conscience in abortion provision. N Engl J Med. 2012;367(11):981-983. doi:10.1056/NEJMp1206253 
  5. Center for Reproductive Rights, The World’s Abortion Laws, 2022, http://worldabortionlaws.com/map/. 
  6. Rabin S, Kika N, Lamb D, Murphy D, Am Stevelink S, Williamson V, Wessely S, Greenberg N. Moral Injuries in Healthcare Workers: What Causes Them and What to Do About Them? Journal of Healthcare Leadership. 2023;15:153-160.