A Clinical Ethicist’s Perspective on Creating a New Abortion Statement

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Published:
October 2, 2019

Like many others who live and breathe the ethics of modern-day healthcare, I am unsettled by the recent efforts of some within Adventism to modify our “guidelines” on abortion. As I understand the present effort, it is to produce a “statement” on abortion. Neither guidelines nor statements amount to Fundamental Beliefs in our Church. Guidelines, Statements, and Documents[1] amount to a separate, lessor category, of expression of Adventist understanding of life.

My post congregational, professional life for the Church has focused on healthcare ethics for over 20 years. And just so you know, like the guidelines themselves, I am not pro-abortion. As the document expresses, “Abortion is one of the tragic dilemmas of human fallenness” and it is “never an action of little moral consequence.” To be clear, our document does not support abortion: “Abortions for reasons of birth control, gender selection, or convenience are not condoned by the Church.”

As an ordained minister within the Church working for a non-Adventist, faith-based healthcare system as a hospital-based clinical ethicist, I am involved when “maternal-fetal conflict” imposes immense tragedy upon the lives of expectant mothers and their loved ones. I am routinely involved in such tragic cases as a help for the moral decision making necessary to resolution of the conflict.

In reading the recent reports and having been engaged in discussions surrounding the issue, I do not have the impression that those wishing to change the Church’s position fully understand the reality of clinical decision making in these difficult cases. Secondly, I am doubtful that those who wish to change the document fully understand or appreciate what it actually says. Finally, I wonder if those pressing for change realize what they would be getting into should we adopt a “ban” on abortion in “our” hospitals. Let me take these issues one at a time.

1. Clinical Realities

Labor and delivery units all over the world routinely deal with complications in the course of women’s pregnancies. Let me note a few of the more common and difficult maternal-fetal conflict cases and what a ban on abortion would dictate in real cases of tragedy. Let’s please not forget that none of us is discussing elective abortions for convenience because the topic is irrelevant to us; our guidelines dismiss them as morally inappropriate and our hospitals do not allow them. So, what might the typical complications in maternal-fetal cases look like and what would a ban impose upon the outcomes of these types of cases?

Miscarriage management or illicit induction of delivery?

Question: A 32-year-old woman carrying twins at 17 weeks gestation suffers the loss of one of them at home. She checks into the hospital at the urgent request of her physician only to get the grave diagnosis that her other twin (whom she desperately wants) has a 5% chance of survival to viability (around 23 weeks). She is dilated to 7 centimeters, her placenta is ruptured, and she is having contractions. Medications are able to stop her active labor. If the baby does survive to viability it will have underdeveloped lungs resulting in an anticipated six-month fight for life in the Neonatal Intensive Care Unit. Should the baby survive the NICU (this is not a given), it will likely have four to eight life-long medical conditions associated with having survived the NICU as a premature baby. Does the hospital support her difficult decision to allow the fetus to die a more natural death? Or must we insist upon her continuing her pregnancy? Some involved with clinical interpretation of a ban on abortion would not allow her that choice in our hospital.

Question: The mother of eight has just received a C-section in the hospital. She has a heart condition associated with pregnancy and to protect her own health she is told she should never get pregnant again. She chooses to have an Inter-Uterine Device (IUD) placed. Her doctor informs her that he is not allowed to provide an IUD unless it has built-in, time released hormones embedded in it. Not understanding why and having to consent for placement she asks the physician to explain. He describes the fact that the hospital has imposed a ban on any IUD that does not have hormones because to allow a non-hormonal IUD placement risks the IUD becoming an abortifacient when the conceptus is developing for the 2-3 days of travel toward implantation in the uterine wall.

Exactly when is a woman pregnant? Upon fertilization? Upon implantation in the uterine wall? A ban on abortion would require we have a very clear position about when life begins which the Church is clearly not ready to state. By definition, you cannot have an abortion until you have a pregnancy and hence the debate commences. When is a woman pregnant, at fertilization of the egg by the sperm or at implantation in the uterine wall? If you want to protect fetal life at all costs and at every stage, you better be prepared to protect the conceptus as it travels to implantation. And this doesn’t account for protecting the approximately 50% of all fertilized eggs that fail to establish a pregnancy. What is their moral status?

I could go on:

Can a couple decide against rescue cerclage? Or are they morally obliged to do everything possible to maintain their pregnancy?

Can a woman in the ICU with pulmonary emboli decide to end her pregnancy in order to increase her own chance of living? 

Can a couple request and receive approval for induction of a pregnancy when the fetus (not an unborn child) has a condition inconsistent with life? The fetus will die. It may die at any point during pregnancy, delivery, or after within a short time. Hoping for some few minutes or hours with their baby after delivery and before it dies, the couple request induction so as to enjoy such time. If there is a ban on abortion our answer to them must be “no” because inducing a deliver prior to viability is considered an abortion by many.

Can a pregnant woman whose fetus has implanted on a C-section scar in the uterus obtain an abortion in your hospital? The placenta, hungry for enough blood to sustain the growing fetus reaches out beyond the uterine wall to surrounding vessels. Should the thin wall of her scarred uterus rupture as the placenta develops, she could die from internal bleeding before even getting to a hospital. When diagnosed, should a woman with this condition be allowed to terminate her pregnancy in an Adventist hospital?

2. What does the document actually say?  

As my colleague David Larson notes, too few people in our Church know anything about the existing abortion guidelines. I have polled hundreds perhaps thousands of my students and Church audience members regarding the guidelines. No better than 5% of our membership know anything about it. Additionally, those who critique the Church for the content of the guidelines rarely if ever actually offer an analysis of it. They seem somehow embarrassed that they can’t be counted among strict Evangelicals or Catholics in the vitriolic pro-choice pro-life culture war debates here in the United States.  

The reasons for the present movement to change the guidelines may be authentically driven by moral and biblical concerns; concerns I share even if my positions may be different. A recent article highlights the historical reality of some more powerful sources of American Christianity’s shifting biblical interpretation of when life begins and thus when a moral concern is legitimately at stake. Protecting nascent human life in-utero at all costs hasn’t always been authentic to American Protestant faith traditions.[2]

More specifically, the existing document explicitly notes that the Church does not and should not serve as the conscience for its membership (see point number 4). On one occasion when speaking with an Adventist physician about abortion practices, I mentioned the fact that our Church has guidelines that might provide guidance for his practice. He kept talking. Later, however, he came back round to my point and said: “Just so you know, I don’t care if the Church has a guideline. My practice is my practice and the Church has no right to impinge upon it.” Fair enough, I thought. We are, after all, a Protestant church.

Let that sink in for a bit. We are a Protestant church.

Finally, on this point about using the document, I haven’t heard a word from the women of our Church who may be tired of being manipulated by Churchmen. The existing document places the moral onus of making the excruciating decision to terminate a pregnancy on the pregnant woman. But it does so within a context that no one is talking about and I can’t help but wonder why? The guideline says:

“3. In practical, tangible ways the Church as a supportive community should express its commitment to the value of human life. These ways should include:

1. strengthening family relationships

2. educating both genders concerning Christian principles of human sexuality

3. emphasizing responsibility of both male and female for family planning

4. calling both to be responsible for the consequences of behaviors that are inconsistent with Christian principles

5. creating a safe climate for ongoing discussion of the moral questions associated with abortion

6. offering support and assistance to women who choose to complete crisis pregnancies

7. encouraging and assisting fathers to participate responsibly in the parenting of their children.

The Church also should commit itself to assist in alleviating the unfortunate social, economic, and psychological factors that add to abortion and to care redemptively for those suffering the consequences of individual decisions on this issue.

4. The final decision whether to terminate the pregnancy or not should be made by the pregnant woman after appropriate consultation. She should be aided in her decision by accurate information, biblical principles, and the guidance of the Holy Spirit. Moreover, these decisions are best made within the context of healthy family relationships….

5. Therefore, any attempts to coerce women either to remain pregnant or to terminate pregnancy should be rejected as infringements of personal freedom.”

In the document, there is more text dedicated to upbuilding and uplifting our lives surrounding such issues than there is text focused on explicit justifications for terminating a pregnancy. Where has the Church been on conducting this work? Where are the passionate voices doing their best to change Church culture along these lines?

3. What a ban might look like on a day-by-day basis:

One thing abundantly clear to me is that the majority of lay Adventists (and likely a majority of Church Administrators) believe that the General Conference of the Seventh-day Adventist Church (GC) actually owns “our” Healthcare Systems. Not so. They are not legal entities of the Church. Our denominational ties to the American Adventist healthcare corporations are emotional, theological, and mission-oriented. The Church does not own “our” hospitals. What the hospital systems do is up to them, not the GC. There are abundant articles on this topic from across the entirety of Church-owned and independent journals. The fact that the relationship between our healthcare systems and the GC is a good one is a testament to the commitment of both to remain united in identity and mission. This is exceedingly difficult. One is hard pressed to find anywhere in the world a faith-based healthcare system where tensions with the administrative branch of the faith are not stressed and strained over the past, present, and likely the future. We have every reason to be very proud of the present, good relationship we enjoy.

Unlike some of my colleagues, I happen to think the Church would serve itself well to have a robust conversation on the question of when life begins. Among other things, it could clarify what counts as an “abortion” in our hospitals. Right now, there is no clarity across the denomination and our various guidelines and statements reveal a leaning toward a developmental view on the question of when life begins (see my article “Just What is the Seventh-day Adventist Position on When Life Begins?” in Spectrum, vol. 38, #4, Fall 2010, pp. 70-80). If such a study can form a consensus that includes those passionately offering healthcare ministry in the name of the Church all across the world, then perhaps we could learn to live with each other.

In the absence of such conversation and in the wake of a new statement that “bans” abortion, what might life look like in “our” hospitals, at least here in the United States? Let’s play this out:

• The GC passes this new statement amounting to a ban on all abortions in our hospitals.

• The Adventist Healthcare Systems based here in the States come together and in good spirit agree to do all they can to live up to the statement.

• Word inevitably comes from some watchdog group that Hospital X in Midtown, USA is flaunting the new statement. How does the GC respond?

A GC officer reaches out to a North American Division officer who reaches out to a Conference officer who reaches out to a pastor who is assigned to vet all abortion requests that the hospital receives. Of course, the CEO of said hospital would have to approve of and create systems for such clinical oversight.

Okay, instead, let’s make a best case scenario:

• The GC creates another bureaucracy under the existing Health Department to audit each healthcare system and hospital on a yearly basis to make sure none of them are performing abortions and thus out of compliance (with or without the purported “Compliance Committees”) on yet another matter of dictate from above.

Go back to those cases I noted above. Imagine being in the midst of one of those tragic cases. You and your supportive family and friends have struggled for days, maybe weeks, finally being forced due to your health to go to a hospital for help. As all the options for the best way forward are explored and as the tragedy unfolds you choose to focus attention on saving your own life while remaining hopeful that again someday you may be able to carry another fetus to term. But just as you are settling into the difficult choice of losing your baby you overhear a nurse tell your physician, “You definitely need to check with Ethics to make sure we can do that.”

Please understand, I’m not making this up, it happens thousands of times a year all across the country. I’m the person on the other end of that phone call. These clinical ethics consultations happen thousands of times every year in faith-based hospitals who have “banned” any procedure that looks like an abortion. Such persons — these mothers who want so much to have their child survive to birth — are forced to find treatment elsewhere. As the country and Adventism clamp down on our moral high horses, women caught in this vice have fewer and fewer options for good quality care for a troubled pregnancy.

Perhaps I should take heart by this effort to change the document and enforce a particular view and practice upon our people and healthcare ministry. Make no mistake, those behind this push to change the document will not stop at the production of a new document. Enforcement and compliance will follow. Who will manage that compliance, whether or not the “Committees” actually exist? Will the healthcare systems be forced to report to the GC each year on the number of therapeutic abortions performed in their facilities? Would detailed case studies be included in that report to show how and why a breach of the ban was ethically justified? And if so, what of private, protected health information and the American laws that protect it?

Similarly, I might find a silver lining for my line of work. Such a move by the Church would surely result in the need for more clinical ethicists, well-informed of the Church’s theology. But who will bear the cost of this new workforce? Maybe the Church should bear the clinical and theological cost with new coursework required in the Seminary and undergrad ministerial programs? More likely, the GC will impose its evaluation upon those healthcare systems who want to be allowed to have “Seventh-day Adventist” in their name and on their buildings. Comply or face a lawsuit from the GC to strip them of the name.

Like many of my colleagues I am of the opinion that the existing guidelines can be improved. But to imagine that we can improve it by including a ban on abortion and that doing so can be accomplished in the few months remaining before Indianapolis strikes me as absurd.

 

Notes & References:

 

Mark F. Carr, Phd., MDiv. is the Alaska Region Director of Ethics for Providence St. Joseph Health in Anchorage, Alaska. He is an ordained SDA minister with a history of pastoral and academic ministry for the Church. 

Photo by Richard Catabay on Unsplash

 

Further Reading:

"Abortion Rates and Ratios Continue Dropping in the United States" by David Larson, September 27, 2019

Our Abortion Guidelines Are Too Good to Replace” by David Larson, September 16, 2019

Abortion Law: Adventist Leaders Active Behind the Scenes” by Kent Kingston, September 18, 2019

Amidst Growing Criticism Adventist Church is Revisiting Abortion Position” by Michael Peabody, September 23, 2019

The Seventh-day Adventist Church’s Official Guidelines on Abortion, approved and voted by the General Conference of Seventh-day Adventists Executive Committee at the Annual Council session in Silver Spring, Maryland, October 12, 1992.

The current Spectrum print journal, volume 47, issue 3, includes additional articles on abortion.

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