Problem Patients: I think Abortion is Murder, but I Still Need One

20 Aug

Sometimes working in abortion care is not so different from other parts of the medical field. There are patients you love to work with, who appreciate your expertise and compassionate care, and others who are more frustrating, who require more of your time, energy, and patience. One particular brand of complicated abortion patients is the woman who says some variation of, “I think abortion is murder, but I want to have one anyway” or “I think you should be in jail for working here, but I need a procedure done.” How do you interact with this patient in a way that is healthy and preserves both your rights as a care provider and her rights as a woman?

I recently finished reading Dr. Susan Wicklund’s book This Common Secret: My Journey as an Abortion Doctor. One of the many powerful stories she tells is about her interaction with a patient like the one I described above. Dr. Wicklund had a detailed conversation with the patient about the patient’s view on abortion, and ultimately Dr. Wicklund decides not perform the abortion. This is both for her sanity as well as the emotional health of the patient. Dr. Wicklund explains her decision by saying that the patient has the right to her own opinion on abortion, just as Dr. Wicklund has the right to refuse to see patients who she doesn’t think are making a healthy medical decision, patients who thinks she is a murderer, yet want her to perform the procedure anyway. “I have rights too,” she powerfully declares.

When I read that, I had to put the book down. I never thought about it that way. Does this woman have the right to have an abortion? Absolutely. Does she have the right to violate an abortion provider’s emotional security and moral center? Hell no. I had this conversation with women time and again and was always torn — yes, they deserve to decide what medical care they receive. But do they have the right to tear down my profession in the process, calling us murderers and then demanding services? It’s not exactly something they go over in basic training, is it?

What do you think? I’d love to hear from other abortion land workers as well as pro-choice activists about this one.

20 Responses to “Problem Patients: I think Abortion is Murder, but I Still Need One”

  1. Serena August 20, 2010 at 12:55 pm #

    I have had similar experiences as a clinic escort. One time a woman came in with an entourage of friends – as I opened the door for them, one of the friends felt it was necessary to tell me that she was “pro-life.” I told her that was fine and encouraged her to have a nice. What else can you say?

    I think that Dr. Wicklund’s book had so many powerful stories in it – I think that it’s really important to make sure that patients feel 100% confident about their decision to have an abortion – because if they’re not, they might regret their decision later. And if a patient comes in and is hassling the doctor or the clinic staff, they should be invited to leave.

  2. Heather Freeman August 20, 2010 at 1:06 pm #

    I, too, see her point, and am horrified by people so hypocritical as to demand a service they would have denied to everyone else – but here’s what concerns me. How is this doctor’s decision more defensible than that of a pharmacist who refuses to dispense emergency contraception or birth control? In both cases, their job entails doing something with which they morally disagree. In both cases, the service being denied is one that can be difficult to access with another provider, depending on the patient’s location, class, and privileges.

    I certainly think the provider has the right to not be emotionally abused or attacked by the patient, and maybe that’s where the distinction is. If the woman in question requested the procedure with no more than a statement of “I don’t like abortion, but I need to do this” – that’s one thing. If the woman rather went on a tirade, calling the doctor a murderer, that’s quite another. What you describe – a “detailed conversation” – could be anywhere in between. Does granting the doctor that discretion open the door to patient abuse?

  3. ProChoiceGal August 20, 2010 at 1:12 pm #

    I honestly can’t be bothered to find it now, but I think Dr. Hern told a similar story, where he turned down a young patient who said to him, without apology, that he’s a murderer who deserves to be killed.

    It’s a tricky situation, I imagine. I have some guesses, but I can’t say for sure what I would do in that situation.

  4. catnmus August 20, 2010 at 5:10 pm #

    I agree with others that Wicklund’s denial to the patient is kind of like a pharmacist refusing to dispense birth control. Refusing to perform abortions at all is one thing. Refusing it to one patient but not to another is different, though. More like refusing to dispense birth control to an unmarried woman vs. a married one.

    What might be a better (though more time-consuming) solution would be to require all such patients to undergo counseling and a 24-hour waiting period first. “If you feel this is murder, then why do you want this abortion? What makes your case more special than other women’s cases? Convince me that you deserve this abortion. Write a 500 word essay on the subject in your own handwriting and sign it, so that you can’t say later that I talked you into anything.” Something along these lines, but maybe less confrontational than I’ve said here, might do more to change these patients to more pro-choice stances.

  5. NYCprochoiceMD August 20, 2010 at 5:34 pm #

    @catnmus, I know your intentions in writing that such “patients should be forced to undergo counseling and a 24-hour waiting period first,” but that is no less coercive than forcing women who are confident of their decisions to wait 24 hours. I respect Dr Wicklund’s decision not to treat that patient, but it should be a very rare occurrence.

    Women who are anti-choice and who think abortion providers are murderers have as much right to have an abortion as women who believe abortion providers are saints. Access to abortion is a human right and we can’t deny such access to someone just because they’re mean to us or they don’t like us. Women do not need to justify their decisions to anyone. They don’t need to write an essay.

    The line is where someone is outright abusive to staff or presents physical danger; such patients would need to be referred elsewhere. Beyond that, witholding abortion services is as coercive as the many policies anti-abortion activists enact to attempt to influence women to think the way they do. For a pro-choice person to try to make an anti-choice person somehow become pro-choice in order to allow access to a medical procedure is as bad as an anti-choice person trying to force a pro-choice person to not have access to a procedure.

  6. KushielsMoon August 20, 2010 at 8:29 pm #

    I think there is a huge difference between refusing an abortion for a woman who thinks it’s murder, and a pharmacist refusing to dispense birth control.

    In the first situation, it is the PATIENT who believes abortion is murder/wrong, and the doctor is refusing to provide service not based upon the doctor’s morals, but in the patient’s best interest. A pharmacist is pushing his or her personal beliefs onto other people when they refuse to provide service, regardless of what’s in the patient’s best interest.

    If I told someone I was about to do something I thought was wrong, I’d probably want them to stop me. From what I’ve seen, most of the women who regret their abortions either were coerced, or believed that abortion was wrong and had one anyway.

    Doctors are only allowed to obtain consent from mentally stable patients. I have to wonder, is someone mentally stable if they’re requesting that a doctor “murder their baby,” as they would see it?

  7. Steph L. August 20, 2010 at 8:43 pm #

    Reminds me of the excellent article: “The Only Moral Abortion is My Abortion: When the Anti-Choice Choose.”

    Link: http://www.dailykos.com/storyonly/2007/7/22/9334/83825 (I can never post that enough!)

    I don’t know what I’d do if I were a provider. One one hand I can’t stand the thought of denying a woman an abortion, on the other hand I’d be worried about potential lawsuits stopping me from practicing and her becoming one of those vocal “I regret my abortion” antis.

  8. Cassie August 21, 2010 at 12:04 am #

    It brings up an interesting question; what rights do providers have to moral beliefs about medical care given? Are we allowed to continue CPR on a patient who unexpectedly ceased respirations but whose wife thinks he didn’t want resuscitation? How can we preserve the life of someone hemorrhaging during a procedure that doesn’t believe in blood transfusions? How can we fight for a preterm infant struggling for life who was born to a mother who doesn’t have custody of her other 5 kids, doesn’t want this child and abandons him after delivery when 3 blocks away someone who didn’t go in to preterm labor at the same gestation is choosing to end her child’s life, or the mother down the hall is having seizures because she didn’t want to lose her child of the same gestation?

    There are principles of beneficience, nonmaleficience, and autonomy which govern medical ethics but the ethics of the providers are not permitted to play in to medical practice. Providers choose this field to help people and differ on their opinions of what that might be. Mental and emotional health can be as important as physical health, so we must constantly balance care of all facets of the patient with the normal expected reactions of someone else in the same situation. But we must never forget those values on which our forefathers built this profession. Check out the hippocratic oath and tell me what it says about abortion: http://www.medterms.com/script/main/art.asp?articlekey=20909

  9. NYCprochoiceMD August 21, 2010 at 6:30 am #

    @Steph L, thank you for the link. One quote stood out for me:

    “Early in my career, I thought I was obligated to provide an abortion for every woman who arrived at my doorstep requesting an abortion. My experience in general medicine, surgery, and abortion has led me to believe differently. Not inadvertently, women give either me or my staff an uneasy feeling about their ambivalence or their anxiety about the abortion process. Since I have never been sued for an abortion I did not perform, my policy is to acknowledge my gut feeling, which is more often right than wrong.”

    Perhaps my feelings are related to my inexperience. I certainly wouldn’t want to be in a position where a woman thought I coerced her into a decision that wasn’t right for her. I certainly have had people go home to think about it and come back a few days later when they have seemed ambivalent, and someone telling me I’m a murderer is probably a sign of ambivalence.

    I definitely would say that there is only one quality in a patient seeking an abortion that really bothers me, and that is when she insists that she’s different from everyone else there because she has a “good” reason and nobody else does.

  10. NewsCat_in_DC August 21, 2010 at 9:51 am #

    I think the example in Dr. Hern’s case was a 15 year old, or at least I remember a case where I doctor asked a young patient about abortion and she said they were all murders and he (the doctor) would go to hell.

    I understand the right of doctor’s not to be abused by their own patients. That’s a very different right than what is being expressed by pharmacists. But I wonder how loud or how abusive the patient has to be in expressing her views before it becomes truly unworkable?

    I guess what I’m saying (particularly in the situation of a younger patient) is that they may be going through a lot of cognitive denial at the moment. But LATER, when they think back on the wonderful care they get from the doctor who performed their abortion they may start to think differently. But if a doctor, feeling abused, outright refuses, they later have the baby, you bet they will go on to become a gold-star anti-choice activist who will tell stories about “horrible abortion doctors.”

    By all means, make sure the patient really wants an abortion, but I’m not sure it’s right to turn them away because they still feel bad about abortions. Especially if YOU asked first “am I going to hell?”

  11. Steph L. August 21, 2010 at 10:11 pm #

    @Cassie
    The original Hippocratic Oath, as translated into Enlgish, says this:
    “I will not give a woman a PESSARY to cause an abortion.”

    http://www.nlm.nih.gov/hmd/greek/greek_oath.html

    Hippocrates deemed pessaries and suppositories as too dangerous for the woman.
    However, Hippocrates reccomended oral abortifacents as well as physical excertion instead. There’s a well recorded story of a young dancer who came to him seeking an abortion – he had her do some strenous excercises, which succeded in terminating the pregnancy.

    Sorianus, another Greek physician, agreed with Hippocrates, stating that “one should choose those which are not too pungent, and may not cause too great a sympathetic reaction and heat.” Sorianus, in fact, wrote the text “Gynecology,” detailed an abortifacent regime that inlcuded herbs, baths, excersise, fasting and bloodletting while discouraging sharp instruments as they could perforate the uterus.

    The Hippocratic oath would also supposedly ban euthenasia and physician-assisted suicide. And it “bans the knife” which would arguably ban surgery – this however was due to limited knowledge at the time on how infections happened and succesful surgery techniques.

  12. NYCprochoiceMD August 22, 2010 at 7:15 am #

    Many doctors take the Oath of Maimonides (http://www.fordham.edu/halsall/source/rambam-oath.html) instead of the Oath of Hippocrates. Interestingly, the Oath of Maimonides is rumored to have been born out of a conflict Maimonides (a 12th century rabbi) himself had with a patient whose pregnancy threatened her life; Maimonides thought the life of the woman took precedence over the life of the fetus. (Some people think the oath was written much later in the 18th century by someone else). The oath of Maimonides requires the physician to watch over the life and death of his patients, allowing end-of-life comfort measures.

    The line which to me is the most relevant to this conversation is as follows:

    “May I never see in the patient anything but a fellow creature in pain.”

    Someone who is pregnant, doesn’t want to be, and finds abortion in conflict with her personal beliefs is in a lot of pain. I think this is the person who needs to be cared for with the most empathy we have available to us.

  13. Kore August 22, 2010 at 8:00 am #

    No one has a right to anyone else’s work. I believe that a doctor has the right to refuse services unless she has contracted with her employer (e.g., a hospital or company like Kaiser) to go forward with care no matter what. We ask doctors to trust us, we should extend the same to them.

  14. EAMD August 22, 2010 at 4:37 pm #

    I am totally with KushielsMoon on this one, and frankly think the comparison to pharmacists who refuse to provide birth control pills is insulting.

    As stated in the previously linked Arthur piece, many docs believe anti-abortionism to be a psychological contraindication for an abortion procedure. This means the patient’s beliefs make an abortion more dangerous for her, emotionally and physically (since, anti-choice patients may be less likely to adhere to appropriate follow-up procedures). Refusing to provide an abortion based in this info is a far cry from deciding not to serve a patient based on moral disapproval of her actions (as is the case with pharmacists).

    Additionally, there’s a key difference between being self-serving and self-protecting. As far as I’m aware, pharmacists don’t deny birth control because they’re concerned the patient will turn around and sue them for providing birth control pills. I am obligated to treat to the best of my ability even those patients I do not like; I do not have an obligation to risk my professional license in order to do so.

    I do agree having a blanket rule of denying abortions to anti women would be unethical. But that is hardly what Dr. Wicklund is describing.

  15. Heather Freeman August 22, 2010 at 9:18 pm #

    @Kushiels_Moon and @EAMD: it was certainly not my intention to insult anyone, and if I did I apologize. However, many antis will say that the denial of EC or BC is in the patient’s best interest, just as they say it is in the woman’s best interest to stay home and have lots of babies. Just because we find that reasoning twisted and wrong does not mean that it is not sincere. Any time one person sits in judgement of another, no matter how solidly righteous zie may feel, there is the potential for abuse.

    I find it even more alarming that there is talk of anti-choice views being a sign of mental instability, and therefore a reason to deny healthcare! There is a long history of women being denied basic rights due to mental instability, hysteria, insanity, which boiled down to nothing more than “I don’t understand the way you think, therefore you must be insane and bad and wrong.” This is what the other side does to us already: can’t we be better than this?

    That’s why I, in my original comment, find the distinction in the patient’s actual behavior towards the provider, not her beliefs. Behavior is a reliable indicator of future problems; beliefs are not. Perhaps the anti seeking an abortion will have a change of heart after she has one. Perhaps she is in a situation such that she can neither be pregnant nor change her pro-life stance, due to community or family pressures. Perhaps she will regret it, and blame the provider. Perhaps she is simply a hypocrite, and sees no problem with doing what she preaches against. How is it our job to judge her? How does that trust women?

  16. Not Guilty August 23, 2010 at 11:47 am #

    If I were an abortion doctor and I had a patient say that they thought I was a murderer, I would deny them service. I definitely think that is very different from a woman seeking birth control and a pharmacist “refusing” on moral grounds. There is a different morality involved in denying service to a person who calls you a murderer and a right-religious nut pharmacist who is being high and mighty. I would also take a comment about being a murderer as a threat from that patient, so denying them service is perfectly legitimate, IMO.

  17. pomegrenade August 23, 2010 at 3:36 pm #

    I fully understand Wicklund’s decision to refuse that woman an abortion. She was sparing herself, her staff, and possibly even other patients a great deal of potential agony should the woman have decided to cause a ruckus. And she in no way violated the woman’s right to an abortion. She didn’t tell her she couldn’t have one. Just that she couldn’t have one at that particular facility.

    Were I to find myself in a similar situation, I’d probably do the same thing. I wouldn’t have the nerve to deal with someone like that if they decided to cause serious problems.

  18. NYCprochoiceMD August 24, 2010 at 4:54 am #

    @Heather, I agree with you, but looks like on this topic we’ll all have to agree to disagree. I think it’s a slippery slope from denying an anti a legal medical procedure to denying someone else a legal medical procedure. I do wonder what providers can do in this situation to protect themselves from future frivolous lawsuits.

  19. EAMD August 25, 2010 at 12:23 am #

    Heather, I appreciate the clarification and I see your point about the sincerity of the antis’ logic. I guess my understanding is that so-called “conscience clauses” are in place so a pharmacist can protect hirself, and not hir patients. The pills aren’t usually denied because of a woman’s best interests (in the eyes of the pharmacist); they’re denied because the pharmacist doesn’t want to facilitate or participate in the “murder” of a “child”. I suppose judgment/concern about what the woman “should” be doing (wow, how many times can I use scare quotes in this comment?) may play a secondary role, but it still seems to me that the comparison between a self-important pharmacist and hesitant provider doesn’t quite work.

Trackbacks/Pingbacks

  1. Tweets that mention Problem Patients: I think Abortion is Murder, but I Still Need One | Abortion Gang -- Topsy.com - August 20, 2010

    [...] This post was mentioned on Twitter by Sharon and Mary Maxfield Brave, The Abortion Gang. The Abortion Gang said: new post:: Problem Patients: I think Abortion is Murder, but I Still Need One http://j.mp/daviA1 #prochoice [...]

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