Women’s Health Care after Dobbs

In the debates following the Dobbs decision, many have expressed concerns that state laws restricting abortion might create setbacks for maternal health. If a pregnant woman’s health or life is at risk, will she still receive the care she needs in states where abortion is restricted? Alternatively, if the fetus has a severe or life-limiting condition, is it cruel and traumatic to the mother to guide her in continuing the pregnancy to term?

Discussions surrounding these questions require the utmost clarity regarding what is meant by abortion. Abortion in the popular lexicon often amounts to any procedure that ends a pregnancy. In the medical community, it has a different definition; and in ethical conversations, its definition differs still. Shortly, I will explore the various uses of the word in more detail, explain why I think it’s important to be precise, and defend a narrower meaning that involves directness and intentionality.

But even when a clear definition of abortion is established, amid the heat of the debate and the fear over the future of women’s health, what’s often overlooked are alternatives to abortion that are both ethical and safe for the mother. And if Dobbs helps medicine move away from viewing abortion as standard care, clinicians and researchers will have new opportunities to develop treatments aimed at both the mother’s and baby’s well-being. As someone thoroughly trained in internal medicine, I am familiar with the ambiguities that often complicate real-time treatment; but as a student of ethics, I also think it’s important to consider ways medical practice can respect the dignity of both the mother and the unborn child.

Abortion’s Definitions

Abortion often means different things to different people and in different contexts. For example, medical students learn in their introduction to obstetrics and gynecology that abortion is a rather complex and technical term. Whereas in common usage it typically refers to the deliberate termination of a pregnancy, in medicine, abortion encompasses the former meaning as well as any failure of a pregnancy to progress to the point of viability. In medicine, the emphasis is on the end result, rather than how it occurred.

Abortion in the healthcare community typically falls under three categories: spontaneous abortion, which refers to miscarriage; elective abortion, which refers to the termination of pregnancy for non-medical reasons; and therapeutic abortion, which refers to the termination of pregnancy for any medical reason pertaining to the mother or her unborn child.

Spontaneous abortion, or miscarriage, obviously doesn’t raise any moral concerns because it involves no free human act. But the other terms raise a number of ethical questions. Whereas elective abortion clearly indicates the lack of medical rationale, does the term suggest that every abortion outside that category is non-elective? For instance, among therapeutic abortions, certain situations would seem more dire than others—perhaps the woman is in danger of dying; but perhaps a therapeutic abortion is recommended because her unborn child has genetic abnormalities. If the doctor recommends an abortion for any “medical” reason, it doesn’t follow that the mother should accept the recommendation without hesitation; it’s often not quite clear how “therapeutic” that abortion really is.

Since abortion as a medical term comprises a spectrum of acts or events of varying ethical qualities, it tends to obscure considerations of what ought to be done. When a woman is in danger of dying, does it not seem reasonable enough—even necessary—to perform a standard medical procedure that could save her life? Of course it does. But a pregnant woman in need of medical attention means that there are two people who require care, and so using abortion as standard of care overlooks the dignity of the unborn child.

In contrast to the standard medical usage, pro-life advocates such as the Catholic Church tend to define the term more narrowly, with a view toward ethical clarity: simply stated, all the acts that fall under abortion are morally impermissible. The Catechism of the Catholic Church refers to abortion precisely as direct abortion—defined as “abortion willed either as an end or a means”—and teaches that it is “gravely contrary to the moral law” (CCC, 2270). This is based on the principle that innocent human life is never to be directly harmed.

John Paul II, in Evangelium vitae, conveys a similar teaching with the term procured abortion, defined as “the deliberate and direct killing, by whatever means it is carried out, of a human being . . . extending from conception to birth.” These two documents suggest that the directness and intentionality of the act of abortion are closely related and critical to both its identity and its moral evaluation. For the remainder of this essay, I will use the term abortion to refer to the direct and intentional killing of an unborn human life. And more generally, our debates about abortion will be much better served if we pause and explain what we mean by abortion.

Double Effect

While abortion (defined as a direct and intentional killing of unborn life) is never morally sound, sometimes the death of the baby can be an acceptable consequence of medical treatment. The framework used to describe these situations is called double effect. The first known description of the principle of double effect comes from Thomas Aquinas (STh II-II, 64.7), in his justification of killing in self-defense. The basic idea is that sometimes it is permissible to cause harm as a foreseen but unintended side effect—or “second” effect—of an act intended for good. At its core, the principle of double effect rejects “the-end-justifies-the means” reasoning, also called consequentialism.

In various subsequent formulations, the principle has enjoyed longstanding use in ethics, including in a number of medical applications. One representative account of double-effect reasoning, as articulated by F. J. Connell, involves four required conditions that I summarize as follows: 1) the act must be morally good or neutral; 2) the agent must not intend the bad effect, but may permit it if unavoidable; 3) the bad effect cannot be the means to the good effect; and 4) the good effect must be proportionate to the bad effect.

A typical application of double-effect reasoning in pregnancy is the use of chemotherapy to treat cancer in the mother, foreseeing but not intending the additional effect of harm to the child. In contrast, abortion can never be justified since the death of the child is the direct effect of the abortion procedure, the bad effect is willed by the one performing it (second criterion), and the bad effect is caught up and identified in the means to the good end (third criterion).

Overlooked Alternatives

Now that we have seen why the principle of double effect does not apply in cases of abortion, we can look at what viable alternatives are available to doctors whose patients have complications with their pregnancies.

One highly discussed challenge in pregnancy is pulmonary hypertension, which involves abnormally high pressure in the blood vessels between the lungs and heart. Depending on its severity, this condition can lead to worsening heart failure and death; accordingly, a standard medical recommendation for pregnant women with pulmonary hypertension has been abortion. A Catholic hospital in Phoenix encountered a case like this in 2009 and lost its affiliation with the Church for performing an abortion in an effort to save the mother’s life. Since then, new classes of medications and multidisciplinary approaches tailored to the patient have significantly improved chances of survival of both mother and baby—changing the tone of the debate and opening new possibilities for women with pulmonary hypertension to pursue pregnancy.

More broadly, exciting developments in the fields of maternal-fetal medicine and fetal surgery have led to unprecedented abilities to protect the lives of mother and baby, to surgically correct severe defects prior to birth, and to lower the age of fetal viability. Extremely premature babies are now surviving at 21 weeks’ gestation—a little past the halfway mark of the standard length of pregnancy—and survival for babies at 22 and 23 weeks is higher in hospitals with maternal-fetal medicine programs.

Finally, the emergence of perinatal palliative care has enabled women to benefit from continued support and coordinated care throughout pregnancy when their baby has a life-limiting condition. This patient-centered approach allows for the possibility of alleviating suffering and pursuing life-prolonging treatments at the same time. Additionally, studies have shown that perinatal palliative care may help parents grieve appropriately, and the majority of those who choose this option are glad “to meet their baby” after delivery.

Furthermore, with abortion no longer being a default treatment in many places, the medical community will have opportunities to continue to develop care for both mother and child.

Steps Forward

In sum, more precise, consistent use of the term abortion—defined as the direct and intentional killing of an unborn human life—will be a helpful step in the right direction, not just for medical professionals, but for lawmakers, ethicists, and the general public as well. Defined in this way, and with newer therapeutic developments, it becomes easier to understand how abortion may never be necessary to save a woman’s life—a position officially supported by hundreds of obstetrician/gynecologists around the globe.

Following the Dobbs decision, as the debates and controversies continue, we can expect significant developments in ethics, medicine, and law. As the field of medicine is being forced by law to consider viable alternatives to abortion, the widespread use of more ethically nuanced approaches will go a long way in revitalizing medicine.