Ethics: Pro You, Pro Me: Abortion and Culture

Abortion has long been a contentious and polarizing subject made worse by politics. Strong opinions exist on the moral, ethical, and religious implications of abortion. Societal pressures to pick one side over the other has resulted in emotional decision-making for many. A fetus' right to personhood and life versus the woman’s right to privacy and choice has been debated (Davis, 2022). Hasty classifications into left versus right has lessened the application of evidence and increased the desire for one side to win over the other. In the United States, Supreme Court rulings on Roe v. Wade have provided legal guidance on abortion since the 1970s (Jozkowski et al., 2019). The June 2022 ruling by the Supreme Court of the United States (SCOTUS) inDobbs v. Jackson has intensified the abortion debate.

Sowhat are human rights? Though a seemingly simple question, the answer requires a deep introspection into a myriad of factors that make life worth living. Morality and religion are at the core of culture and many ethical practices and norms are deeply rooted in cultural beliefs (Saroglou, 2019). The application of one set of cultural beliefs to all is an affront to autonomy and justice. The primary duty of the professional nurse is the patient and their needs should supersede personal beliefs. The only acceptable side is “pro-evidence and pro-neutral” in which health promotion and humanity are on the same side. Imposition of a healer’s will and cultural beliefs on a patient is bullying and culturally insensitive.

This column briefly describes the cultural make-up of the United States and the vulnerability that exists in certain populations. A historical case example is included to illustrate one instance where medical decisions were hijacked by the government. The nurse’s role and ethical obligations following the Supreme Court of the United States (SCOTUS) decision to overturn Roe v. Wade is explored.

Diverse Cultures in the United States

The United States Census Bureau (2021) reports that there are 44 million immigrants in the United States representing 14% of the population. Approximately half of this number are women who are within the World Health Organization definition of reproductive age (15-49) (WHO, 2021). Immigrants come from all over the world, per the U. S. Census Bureau, (Budiman, 2020, p. 1) “…immigrants from Asia combined accounted for 28% of all immigrants, close to the share of immigrants from Mexico (25%). Other regions make up smaller shares: Europe, Canada, and other North America (13%), the Caribbean (10%), Central America (8%), South America (7%), the Middle East and North Africa (4%) and sub-Saharan Africa (5%).” Particularly at risk for poor health outcomes are immigrant women of reproductive age due to their vulnerability (Alarcao et al., 2021).

Vulnerable populations are those groups of people who, for various reasons, are in danger of experiencing health issues and inadequate healthcare access. The immigrant population may face additional barriers including feelings of displacement, and difficulties with language, transportation, and healthcare cost. Many have come to the United States from patriarchal cultures that believe women exist solely for childbirth purposes (Guillaume & Rossier, 2018). Patriarchal power dynamics may influence women’s decisions to use methods to control fertility, in addition to the number and spacing of pregnancies (Donnelly et al, 2023). The notion that abortion regulates fertility and that women rely on abortion solely to avoid having a child no longer holds true (Guillaume & Rossier, 2018). These women may seek equitable contraceptive and reproductive health services, including abortion, from providers whose own belief systems should not influence their care of the patient.

Compared to native-born women, research indicates that immigrants and refugees encounter significant obstacles, particularly when accessing contraceptive and reproductive health services in the United States (Hasstedt et al., 2018; Kirkendall & Dutt, 2023, Tapales et al., 2018). For example, information dissemination, such as use of contraceptives, may not be equal between native-born American women and immigrant women. Tapales et al. (2018) found in their study on this issue that foreign-born black women were less likely to use a more effective contraceptive compared to native-born black women. Access to abortion and utilization of preventive care services such as pap smears, mammograms, screenings for sexually transmitted infections (STIs), etc. is less among immigrant women in the United States than native-born women (Davidson et al., 2022; Hasstedt et al., 2018). These differences may be the result of several factors including provider bias, restrictions to enrollment in public health insurance programs, and fear of deportation, among other factors (Arvallo et al., 2023).

Medical versus Political: Historical Reminders

Fine (2005) provides an in-depth analysis of what happens when a family’s private pain is exploited for political gains. According to Fine (2005), 26-year-old Terri Schiavo fell into a persistent vegetative state after suffering cardiac arrest. Even though no doctor who examined Terri believed she had any chance of living, a fierce highly public battle took place between her parents, Robert and Mary Schindler, and her husband, Michael Schiavo. Since Terri could not speak, her husband argued that his wife would not have wanted her life artificially prolonged with no hope of recovery. Terri’s parents argued otherwise.

In the months that followed, Terri’s case ignited heated and rancorous debate both nationwide and internationally over quality of life, right-to-die and end-of-life issues as human rights issues. Although the courts sided with Michael Schiavo, the state legislature passed a bill, known as Terri's law, that gave Jeb Bush, the Florida governor at that time, authority to prevent the removal of Terri’s feeding tube (District Court of Appeal, Second District, 2001). This law was later ruled unconstitutional by the Florida Supreme Court. After numerous debates and acrimonious negotiations involving state and federal courts, Terri's feeding tube was eventually removed, ending the long legal struggle over her fate as she died at the age of 41 on March 31, 2005.

Fine (2005) observed that justice includes a fair and equitable distribution of limited medical resources. Families may experience bankruptcy caring for someone in a persistent vegetative state at which point Medicaid assistance is sought. The very lawmakers who fought in Terri’s case were the same ones who voted to cut the Medicaid spending bill. For many politicians it may never be about the patient but rather be everything to do with winning. This is a pertinent reminder that medical decisions should remain between the medical team, the individual and families. The government or public should not have an opinion on anyone’s private health issue.

Professional Organization Statements

The WHO reported that there are approximately seventy-three million induced abortions annually. More than half of these abortions were considered unsafe with one-third performed under the least safe conditions by untrained individuals using dangerous methods. Due to strict abortion laws, ninety seven percent of all unsafe abortions occurred in developing countries (WHO, 2021). In their report, the WHO concluded that, the fewer restrictions there are to abortion, the fewer deaths from unsafe abortions occur. The Centers for Disease Control and Prevention (CDC) reported 629,898 legal abortions in the United States alone in 2019 (CDC, 2021). More than fifty percent of those abortions were for women under age thirty with approximately 92.7% occurring under thirteen weeks gestation (CDC, 2021). According to Berer (2017) countries with flexible abortion laws share these common reasons: 1) risk to life, 2) rape or sexual abuse, 3) mental/physical health risks, 4) economic or social reasons 5) serious fetal anomaly and 6) per the woman’s request.

In a joint statement to the Supreme Court that included the participation of the American College of Nurse Midwives (ACNM) and The National Association of Nurse Practitioners in Women’s Health (NPWH) among other organizations, the American College of Obstetricians and Gynecologists (ACOG) stated” that “abortion restriction legislation is not grounded in evidence and impedes the clinicians’ ethics by forcing them to choose between what is right for their patients and adherence to an unscientific, harmful law” (ACOG, 2022). The NPWH also observed that “laws that criminalize a clinician’s duty to care will only harm patients” and, “The patients who will be most harmed by this ruling are those already suffering from the social and systemic impacts of marginalization” (2022). Similarly, in a position statement on reproductive health, the American Nurses Association (ANA, 2022) noted that “Nurses are obligated to share with their patients in an unbiased manner all relevant information about sexual and reproductive health choices” and “Abortion is a reproductive health alternative that nurses and other providers can discuss when counseling patients.” ANA also affirmed that the nurse has the right to refuse to participate in sexual and reproductive care based on ethics grounds if patient safety is assured and alternative sources of care have been arranged (ANA, 2022; 2023).

Human Rights and Reproductive Justice

According to the United Nations (U.N), “Human rights are rights inherent to all human beings, regardless of race, sex, nationality, ethnicity, language, religion, or any other status. Human rights include the right to life and liberty, freedom from slavery and torture, freedom of opinion and expression, the right to work and education, and many more. Everyone is entitled to these rights, without discrimination” United Nations, n.d., para. 1). On December 10, 1948, the United Nations General Assembly in Paris drafted General Assembly resolution 217 A (III) – the Universal Declaration of Human Rights (UDHR) as a common standard of achievements for all peoples and all nations. It sets out, for the first time, fundamental human rights to be universally protected. Since its adoption in 1948, the UDHR has been translated into more than 500 languages - the most translated document in the world - and has inspired the constitutions of many newly independent States and many new democracies. The United States Constitution also protects the rights, freedom, and pursuit of happiness for everyone in the United States. Since its codification, many amendments have been made to the constitution to grant more rights to all people.

The Bill of Rights is the first 10 amendments to the constitution. It protects freedom of speech, the press, assembly, and the right to petition the Government for a redress of grievances. All these incremental amendments were meant to ensure that as the country continues to grow into a beautiful tapestry of races, creeds, religions, and sexual orientations, everyone is able to live a free life. Free from government interference, and from fear of prosecution for no other reason than making life choices for themselves and their families. Free from a culture of vigilantism which turns neighbors against neighbors resulting in states banning abortion and allowing civilians to sue those suspected of conducting, helping, seeking, or being associated with abortion. All human rights are equal and therefore laws or regulations that attempt to curtail those rights are unethical as they violate principles of autonomy, equality, and justice, among others (Human Rights Watch, 2023).

Reproductive justice is a term originating from the work of twelve Black women with backgrounds in reproductive health. It is the human right to maintain bodily autonomy and plan a family according to personal wishes and ability. It is also the right to parent in a safe and sustainable environment free from oppressive laws (Ross & Solinger, 2017; Shankar et al., 2021). Equitable reproductive justice mandates a true analysis of existing power systems, oppressive legislations, de-marginalization of the vulnerable and recognition of intersectional identities that can result in societal oppression (Shankar et al., 2021). Identities can include sex, gender identity, education level, socioeconomic position, immigration status, and race, among others. Globally, systemic racism drastically undermines sexual and reproductive justice (McGovern et al. 2022). Nurses and other healthcare providers should consider the multiple identities that can influence patients’ decisions to seek reproductive care that may include abortion (Corpuz & Simmonds, 2022), Cultural humility, a cornerstone of reproductive justice, complemented by cultural competence, have been proposed as approaches to develop a deeper understanding of patients’ perspectives and choices (Greene-Moton & Minkler, 2021; Shankar et al. 2021).

Practice Implications: Cultural Competence and Cultural Humility

TheCode of Ethics for Nurses with Interpretive Statements (ANA, 2015), compels nurses to “collaborate to create a moral milieu that is sensitive to diverse cultural differences and practices “ (p. 32). Developing cultural competence, having the knowledge, attitudes, and skills to effectively respond to sociocultural issues arising in the clinical encounter, is widely acknowledged as essential to establishing this milieu and decreasing health disparities (Campina-Bacote, 2018). Cultural competence is the ability to center care in the client’s cultural context and may prevent inequities in the way we practice and care for patients from different cultures and backgrounds. It is needed for mindful practice and quality care. Dr Campinha-Bacote has provided a useful pneumonic to understand the components of cultural competence “A-S-K-E-D.” “A-S-K-E-D” stands for Awareness (A) of one’s own biases and prejudices and the exploration of cultural backgrounds without imposing beliefs on others. Skill (S) refers to the ability to perform an assessment and acquire data that is both culturally relevant and essential. Knowledge (K) requires self-assessment and attaining factual knowledge of other cultures and of the populations being served; Encounters (E) represents our active engagement in the care of culturally diverse patients, while Desire (D) represents our sincere ambition to care for and respect those with different beliefs, experiences, and backgrounds. (Campinha-Bacote, 2011; Ingram, 2011).

Cultural humility involves addressing our positionality and privilege, acknowledging the patient’s expertise in their own lived experiences, and creating an inclusive and safe clinical setting, among other practices. It is described as central to reproductive justice and to achieving equitable health outcomes (Bachorik et al., 2023; Julian et al., 2021; Ruud, 2022). Foronda (2020) has developed a rainbow model of cultural humility that provides a visual support to understand various approaches that can be used by individual nurses who endeavor to practice cultural humility. Foronda et al. (2022) have also created a cultural humility toolkit for nurse educators with several strategies to teach cultural humility and incorporate core concepts in the curriculum,

Recognizing the influence and necessity of formal nursing leaders in sustaining an ethical environment that promotes health equity, Murray-Garcia et al. (2021) described the development of the Anti-Racism and Cultural Humility (ARC) Nurse Leader training program. The co-founder of the concept of cultural humility with Melanie Tervalon (1998), Murray-Garcia et al. sought to develop “equity leaders”. These individuals would engage in discussions of antiracism and contribute to an ongoing individual and institutional process that incorporates the tenets of cultural humility: nurturing a lifelong commitment to self-evaluation and critique, redressing power imbalances, and developing mutually beneficial, non-paternalistic partnerships with the community.

Conclusion

Providing equitable sexual and reproductive healthcare, including counseling on abortion, to immigrants and other frequently oppressed and minoritized groups is a global mandate requiring cultural competence and cultural humility. Together with an understanding of systemic and structural determinants and our ethical obligations as patient advocates and allies when faced with restrictive federal and state legislation, reproductive justice and health equity may be realized. (ANA, 2022; Robichaux & Sauerland, 2021; WHO, 2023).

Authors

Christine Robinson, DNP, CRNP, AGPCNP-BC
Email: chrisberg703@gmail.com

Christine Robinson is Assistant Professor of Medicine at Penn State Health. Christine is a nurse practitioner who specializes in internal medicine. For years, she has been dedicated to providing comprehensive and personalized care, with a strong focus on women's health. Her goal is to empower every woman to take charge of her well-being.

Frank Owusu-Ansah, MBA, CPA, CGMA
Email: polimess@gmail.com

Frank Owusu-Ansah is SEC Reporting Director at Alto Pharmacy. Frank is an avid human rights advocate who served as the Student Council President and on several sub-committees during his time at the University of Ghana and currently serves as a human rights advocate in the greater Harrisburg area.

Catherine Robichaux, PhD, RN
Email: robichaux@uthscsa.edu
ORCID ID: 0000-0002-0220-8003

Catherine Robichaux teaches ethics in several nursing programs. She has conducted and published research on ethics issues including ethics education for nurses, ethical care of the IDD population, and structural competency and the social determinants of health. Dr. Robichaux has been a member of the ANA Ethics Advisory and chair of the Ethics Education Subcommittee. She currently serves on the expert panel revising the Code of Ethics for 2025.