If You Don’t Want to Provide Abortions, Don’t Go Into Healthcare

Last week, the Department of Health and Human Services defended a registered nurse who claimed that the hospital she worked for violated her conscience by forcing her to assist with an abortion. The complaint, filed in May 2018, alleged that the nurse was a self-identified Catholic, and cites violations of the Church Amendment that protects healthcare workers “from impositions of certain requirements contrary to religious beliefs or moral convictions”—in this case, abortion.

Rule changes in the Department of Health and Human Services and new leadership at the HHS Office of Civil Rights have created a fundamental shift of these agencies from protecting patients to protecting providers. Unfortunately, this shift from patient-centered care to protecting providers is required for institutions that want to retain federal funding such as Medicare and Medicaid for essential health services. The University of Vermont Medical Center (UVMMC), where the nurse worked, stands to lose $1.6 million if it does not bring its policies into compliance with federal requirements.

The Trump administration's decision to issue a violation against the hospital is both wrong and dangerous. As a nurse, clinician-scientist, and researcher whose work is centrally grounded in reproductive health, rights, and justice, I wish I could explain a few things to that Vermont nurse. Namely that nurses hold the tension of opposites—life, death, navigating transitions, advocacy, working with physician and family needs, communities, and policymakers. The American Nurses Association Code of Ethics and statement on reproductive health has clear instructions and guidelines about the conduct of professional nurses—“clients have the right to make reproductive health decisions based on full information and without coercion”—and nursing professionals must be prepared to discuss “all relevant information about health choices that are legal.” It is the guiding document of our service to the public.

I’d also like to remind her that this situation perpetuates a myth: that the only conscience claims that can be made are negative, framed as objection, rather than positive, as in the conscience-driven imperative to deliver care.

I can attest that healthcare workers provide abortion and other reproductive health services because of their moral beliefs, not in spite of them. I have spent the last 28 years of my nursing career providing direct clinical care to people needing and seeking abortions. My work and the work of my colleagues in abortion care is consistent with core nursing values, including human dignity, privacy, justice, autonomy in decision-making, precision and accuracy in caring, sympathy, and honesty.

To be clear, I respect people's desires not to do things that go against their moral or religious beliefs. I know that professional nursing in the United States was established in religiously affiliated institutions. However, people shouldn’t go into healthcare if they don’t want to provide healthcare.

There’s a larger issue here that isn't being discussed: Who is worthy to serve the public with comprehensive reproductive services, and what are the standards of care that should be provided?

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Ever since Roe v. Wade decriminalized abortion in U.S., there has never been an honest reckoning about abortion within healthcare services, education, training, and research. Patients have always needed and sought abortions, healthcare providers haven't always chosen to help patients who need or seek them, and despite the fact that the public has clear support for abortion, it remains a politically charged issue framed as a false dichotomy of opposite camps, when the truth is that it's more complicated. The majority of pregnancies that end in abortion in the U.S. happen under medical supervision, which by definition is healthcare. The fact that, in most cases, you can't just get an abortion from your regular provider or gynecologist has contributed to this incomplete conversation.

Even more disturbing, privileging the healthcare workforce over the needs of the public runs counter to our commitment to patient-centered care. People of color, and Black people in particular, are disproportionately more likely to receive care from public and religiously affiliated institutions that are affected by these conscience rules. What that amounts to is the fact that those who don’t have good insurance (or any insurance at all) have a lower standard of care forced on them. This is why the accommodations for conscience need to be re-examined as unethical and incompatible with the social contract to which members of the health professions commit.

These rules aside, we also need to more closely scrutinize the reasons students want to earn the right—yes, the right—to serve the public as a member of the health professions. It is a life of service that people shouldn't enter simply because of consistent employment, decent wages, or the social capital afforded to those of us who do this work. Committing your life to the health professions is a path that's both intellectually challenging and emotionally rewarding path. Part of my work as a faculty member is to determine who is worthy to serve the public—a duty I do not take lightly.

I recently had to ask this question of my fellow faculty and university administration as part of a now-defunct proposal to the Regents of the University of California, San Francisco, to merge with the Dignity Health System, a Catholic hospital. This partnership could have led to patients being denied gender-affirming care, abortion, and more. I asked the Regents to carefully consider all of the implications of the proposal, specifically what it means for a publicly funded university that serves as an anchor institution for the San Francisco community to merge with a religiously affiliated hospital with wildly different perspectives on human rights. Following public outcry, the school dropped its proposal.

Most of all, I would have asked this nurse to wrestle with why her discomfort with abortion kept her from empathizing with the person who needed it. My research has shown that nurses wrestle with ethically challenging care in real time, because there are few places in their educational preparation and on-the-job training to do so. Once afforded the opportunity to critically dissect their views and clarify their values, nurses are able to understand that the people we serve are experts by experience and know best what they need—more so than we do.

This is why service needs to be centered in how conscience claims—positive or negative—are accommodated.

Monica R. McLemore, PhD, MPH, RN, is an associate professor in the Family Health Care Nursing Department and a clinician-scientist at Advancing New Standards in Reproductive Health, a program of the Bixby Center for Global Reproductive Health, all at the University of California, San Francisco.

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