Pregnancy Centers: A Clear Purpose of Medicine with Coherent Ethics

Abstract

What is the purpose of medicine? This fundamental question is at the heart of the criticisms faced by pregnancy centers (PCs) and accusations that they are unethical. PCs maintain that the purpose of medicine is to treat and prevent disease. Because pregnancy is not a disease, PCs do not advocate for elective abortion or contraceptives. PCs view the function of values (e.g., autonomy) as constraints upon physicians that prevent physical and ethical harms. Their critics either embrace an ill-defined purpose of medicine such as promoting well-being or conflate the value of autonomy with medicine’s purpose. This leads to a subjective view of medicine and changes the relationship from physician–patient to vendor–customer. This subjective nature along with its attendant vendor–customer relationship cannot solve for current or future ethical problems such as sex-selective abortion and its fatal discrimination against females.

Summary:

Pregnancy Centers embrace a traditional “treat and prevent disease” purpose of medicine.  This clear and objective purpose logically leads to not advocating for abortion or contraceptives.  The authors outline a coherent ethical structure outlining the role values play in regards to this purpose. This is contrasted with the current ill-defined purpose within medicine today that has led to an inconsistent change of the physician-patient relationship to a vendor-customer one, ethical incoherence, and several attendant harms, most notably sex-selective abortion.

Pregnancy centers (PCs; formerly crisis pregnancy centers) provide an alternative to women who are considering abortion through a compassionate care model that embraces a holistic approach providing practical, emotional, and spiritual support to women and men making difficult pregnancy decisions. In 2017, there were an estimated 2,750 PCs in the United States that provided over $161 million worth of resources and medical services free of charge and largely without taxpayer funding to over 888,000 women, youth, and men (Gaul and Bean 2018). These centers performed over 400,000 free ultrasounds, and one-fourth of the locations offered sexually transmitted infection testing. Additionally, 295,900 men and women attended parenting courses, and 24,100 clients received emotional and spiritual recovery support after abortion.

In spite of this tremendous charitable effort, PCs have come under sustained criticism from the media, legislatures, academic journals, and even professional medical societies (Rubin 2018; Bryant and Swartz 2018). The legal zenith occurred in 2018 when the Supreme Court of the United States decided the case of National Institute of Family Life Associates v. Becerra. The case centered on a California state law mandating PCs to post state-sponsored abortion services information. The Supreme Court in a narrow 5–4 decision stated that PCs were not required to post that information. Medical societies also have criticized PCs. In 2014, a committee opinion of the American College of Obstetricians and Gynecologists (ACOG) on “Increasing Access to Abortion” cites PCs as obstacles to abortion care (ACOG 2014). Most recently, a joint position statement of the Society for Adolescent Health and Medicine and the North American Society for Pediatric and Adolescent Gynecology accused PCs in the United States of not adhering to medical and ethical practice standards (Swartzendruber et al. 2019).

PCs have been criticized in several areas; however, the ethical critique is the most foundational. If PCs are truly unethical, that challenges their legitimacy and forms a basis for increasing regulation or censorship. The crux of the ethical argument against PCs centers on a woman’s “right to choose” either abortion or any legal contraceptive. Critics claim that those who do not provide these are unprofessional, practice “dishonorable disobedience,” or breach the standards of care or ethics (Fiala and Arthur 2014; Cantor 2009).

The critics assume this “right” is essential to the purpose of medicine. But is it? We contend that the root of the disagreement stems from differing views of the purpose of medicine and the function that values play. PCs adhere to a traditional purpose of medicine with well-established ethical principles, while their critics and much of medicine embrace an ill-defined purpose that lacks firm ethical boundaries or structure. This has resulted in ethical dilemmas and multiple harms.

Ethical Framework

Any purpose should be carried out by means that have a reasonable chance of upholding the intended purpose. However, the ends cannot justify the means. We maintain that the means in medicine have traditionally been limited or constrained by the values of autonomy, nonmaleficence, beneficence, justice, veracity, and fidelity. Physicians who practice with these values in mind minimize their chances of being unethical. It bears emphasis that these values are not the purpose of medicine but the boundaries that define the limits of the ethical practice of medicine. For instance, a medicine may be beneficial, but we cannot force the patient to take it due to the limiting value of autonomy. We cannot lie to convince them of a beneficial therapy due to the limiting value of veracity. Likewise, the beneficial results should outweigh the harms of any treatment. Thus our means are limited by the values of beneficence and nonmaleficence. The means must always be subjugated to the overarching ethical principles. How we arrive at the desired goals matters.

What Is the Purpose of Medicine?

We should not assume all medical interventions automatically cohere with the purpose of medicine. We must first clearly define the purpose of medicine and then assess whether the means align with the purpose. Presently, the purpose of medicine is not universally agreed upon nor understood (Kass 1975; Pellegrino 2008, p. 89). This has profound implications because violating the purpose of medicine would challenge a health professional’s integrity and may be considered unethical conduct (ACOG 2007b).

The purpose of medicine for thousands of years was to “benefit the sick” as embodied by the Hippocratic Oath (Antoniou et al. 2010). With the advent of immunizations and preventive health, this was expanded to include preventing disease with an emphasis on healthy living habits. We use the phrase “treat and prevent disease” as an updated version of the traditional purpose of medicine. However, in a noble attempt toward a holistic approach, authors have expanded the purpose of medicine to include improve “health, health care and quality of life,” “betterment of public health,” or “well-being” (Calman 1994; American Medical Association n.d.; Centers for Disease Control and Surveillance n.d.).

The difficulty with well-being is that it is not adequately understood and has an expansive definition that includes physical, emotional, psychological, and economic components; development and activity; life satisfaction; domain-specific activities; and engaging activities at work (Centers for Disease Control and Surveillance n.d.). Purposes should be measurable; however, do we know whether our patients have more or less well-being? Solid purposes or mission statements for organizations should be specific to that organization or enterprise. However, well-being can also include access to clean water and nutritious food, safe neighborhoods and working environments, and orderly society with social services; however, none of these areas are predominantly within the scope of medicine. This broad understanding of well-being has led to increased subjectivity and the goal of “making the patient happy.” Giving patients what they want results in satisfied customers but may or may not improve their health or contribute to lasting happiness (Kass 1975).

Implications of Well-Being as a Purpose

Well-being and its attendant subjectivity have now expanded beyond abortion and contraceptives to other aspects of medicine and thus are transforming medicine. Instead of treating an objective disease with medical therapies, we instead ask the patient (customer) what outcome he or she wants a medical therapy (means) to produce, sometimes treating a disease and sometimes not. Pregnancy is not a disease but a normal part of human physiology, and most contraceptives are given to healthy women. Nearly all abortions and most contraceptives do not treat a disease; thus, these therapies are elective ones that the patients requests, not ones that they medically require. This expansion of the enterprise of medicine moves the traditional physician–patient relationship to a vendor–customer relationship. Instead of a trusted counselor and advisor, the physician has become a “scalpel for hire, selling his services upon demand” or “…mere purveyors of medical technology…” (Kass 1975, p. 12; Charo 2005, p. 2472). All medical techniques then become permissible if legal for those who want it and most importantly can afford it. The vendor–customer relationship echoes through the actual words used: “right to choose,” “abortion on demand,” and “elective abortion.” Additionally, ACOG’s own choice of words when they state “…provide the standard reproductive services that patients request” underscores the vendor–customer relationship by using the word “request” (ACOG 2007b, p. 1203). Conversely, another ACOG opinion states “The physician is not ethically obligated to perform every test a patient requests…” apparently supporting a physician–patient relationship (ACOG 2007c, p. 1022). This highlights the inconsistent relational view where they may have a physician–patient relationship while at other times a vendor–customer one.

This has also negatively impacted the relationship between medicine and the state. Who could practice medicine was historically controlled by the state, but the actual practice of medicine was not. The reason for this was that medicine had such a solid ethical framework that the state had no reason to regulate it in the name of policy and/or ethics. This changed with abortion as nearly every state that allows it also regulates it (Baglini 2014). The state now increasingly views medicine as a vendor–customer relationship that must be regulated.

Medicine has traditionally been based upon objective diagnostic criteria that physicians agreed upon. Well-being largely eliminates objectivity and replaces it with a dominant subjective view. ACOG further argues for a commitment to scientific practice but then advocates for abortion not for objective purposes, but for “…a patient’s conception of well-being” (ACOG 2007b, p. 1205). This delinks science and objectivity from medicine in exchange for a subjective consumer perspective with its resultant inconsistencies.

Effects on Values

Critics of PCs mistake values that limit the means of medicine for the purpose of medicine. Because well-being is as the patient defines it, it is now the physician’s duty and goal to give as much medical autonomy to the patient as possible (Fiala and Arthur 2014). Autonomy as a new purpose of medicine has its own problems. How much autonomy in medicine should physicians give patients? Autonomy evidenced through abortion on demand has negative externalities such as the discrimination against female children or the “missing girls” problem that exists in several nations. In 2006, Hesketh and Xing estimated 80 million “missing girls” in China and India alone almost exclusively due to sex-selective abortion. This practice has been documented in many countries including Georgia, Azerbaijan, Armenia, Nepal, and Vietnam to name a few (Guilmoto, Hoang, and Van 2009; Frost, Puri, and Hinde 2013). The United Nations Population Fund website in 2019 estimates that there are 126 million fewer women in the world due to sex-selection. Sex-selective abortion is firmly based on socioeconomic reasons that are similar to the reasons that most abortions are performed throughout the world (Guilmoto, Hoang, and Van 2009; Frost, Puri, and Hinde 2013; Hesketh and Xing 2006; Biggs, Gould, and Foster 2013). If abortions were only performed for the objective health of the mother, then this discrimination would not exist. Sex-selective abortion also has adverse social effects with reports of sexual violence and trafficking related to it (United Nations Population Fund n.d.). There are no current ethical constraints in medicine to solve this problem; thus, we again see the state intervening but with little success (Hesketh and Xing 2006; Junhong 2001; Frost, Puri, and Hinde 2013; Jha et al. 2011).

Additionally, PCs and others who promote the sanctity of life are criticized for being unjust. The value of justice is broad and multifaceted but can be approached by analyzing the actors (physician, woman, and unborn) and whether they perform or do not perform an action. Performing an action that causes harm is a clear-cut source of injustice. This source of injustice is absent in the case of a physician who does not perform the action of abortion. A duty to perform an action lies in an oath, a legal agreement or in the very nature or purpose of the profession. The current criticism focuses on the duty of the physician to perform or support the woman’s “right to choose.” Critics cite that medicine is required to provide abortion as an essential service similar to a public utility such as water or electricity. However, almost all abortions are elective or not required; thus, it is an antonym of essential or required. Critics must either redefine the word “essential” that bears no semblance to the English word or place the meaning of “essential” entirely on the woman with its highly subjective nature. If this approach was broadly applied to medicine, it would result in medical catastrophes, a furtherance of the vendor–customer relationship, and delinking medicine from science.

Conversely, if physicians are required to support elective abortion, then there is injustice against the physician for coercing them to act contrary to their view of the purpose of medicine. Lastly, there is injustice to the unborn as they bear a disproportionate burden in the woman’s “right to choose.” Critics address this problem by relegating the unborn as nonpersons, but this results in difficulties countering “after-birth abortion” (infanticide) arguments (Giubilini and Minerva 2013). Again, the force of law by the state, and not the ethics within medicine, appears the only way forward within this view.

The discriminatory effects of the “missing girls” problem and the common practice of aborting Down syndrome children due to their “deficiencies” strike some as unjust (Das Gupta, Chung, and Shuzhuo 2009; Benn and Chapman 2010; Dixon 2008; Reynolds 2003). But if justice is crying out for this general and predictable effect of abortion, then why is justice not crying out against every individual abortion decision? These disturbing trends are reversing in some countries. Public campaigns valuing girls and education that Down syndrome children live very happy and fulfilling lives while enriching their family’s lives have improved these problems somewhat (Das Gupta, Chung, and Shuzhuo 2009; Skotko, Levine, and Goldstein 2011a, 2011b, 2011c). However, the current ethic provides no firm boundaries to eliminate this discrimination. Additionally, newer noninvasive prenatal testing (NIPT) may easily expand discrimination to nonmedical traits or less significant genetic combinations (Benn and Chapman 2010; Skotko 2009; ACOG 2008). With merely a blood test of the mother beginning at nine to ten weeks of gestational age, NIPT can currently screen for Patau, Edwards, and Down Syndrome in addition to several other chromosomal and genetic abnormalities of varying effects (Gregg et al. 2016). Additionally, NIPT routinely determines the sex of the unborn child (Dondorp et al. 2015). In light of the complete mapping of the human genome combined with this advancing technology, physical characteristics beyond sex may be detected in the future such as hair or eye color, physical stature, or mental ability providing more opportunities to discriminate against or for nonmedical traits (Nuffield Council on Bioethics 2017; Benn and Chapman 2010).

The current confusion and inconsistency in medicine regarding these issues is demonstrated by ACOG. ACOG opposed sex-selective abortion in 2007, having made no similar statement for Down syndrome (ACOG 2007a). This cast ACOG in the position of picking the winners (girls) and the losers (Down syndrome) in the genetic lottery. ACOG later rescinded their sex-selective abortion opinion without explanation. ACOG’s inconsistent and changing view of human life is likely a manifestation of a poorly grounded ethical framework regarding the value of life.

Critics of PCs view nonmaleficence and beneficence pertaining only to the woman while ignoring the unborn. This is inconsistent with the obvious fact that medicine makes vast efforts to protect the unborn and refrains from administering some tests, medications, or surgical procedures due to their presence. This special consideration for the unborn is the standard of care and grounded in ethical principles. The unborn are live human beings, and medicine is focused entirely on human beings. They are more vulnerable to harms that could result in death or unnecessary deformity. They are unseen and perhaps unknown, which is why each woman is asked whether she could be pregnant before an X-ray or computed tomography is performed, medicines prescribed (e.g., several classes of antibiotics, many cholesterol-lowering medications, and nonsteroidal anti-inflammatory medications are contraindicated in pregnancy), or an elective surgical procedure performed. Physicians will refrain from possible beneficence for the woman in deference to her unborn child. Thus, medicine at least highly values nonmaleficence for the unborn and by inference takes into consideration more than just the desires of the woman who is seeking therapy. However, all this work to protect the unborn is at odds with elective abortion. This places medicine in the role of the guardian of a product that a customer can choose either to keep or discard. This current view within medicine is inconsistent and altogether incoherent with the broader practice of medicine.

“Treat and Prevent Disease” Purpose

The rights of conscience debate is not a whim of ethical preferences but is fundamentally a question of what the purpose of medicine is. If the purpose of medicine is to “treat and prevent disease,” then the traditional physician–patient relationship is preserved, and physicians do what is best for the patient’s health rather than giving patients what they request as in a vendor–customer relationship. Abortion would be constrained to times to “treat and prevent disease” when the mother’s life is at risk rather than abortion for any reason. This ethic solves the current and future ethical problems while eliminating the current discriminatory and unjust practices against girls and individuals with Down syndrome.

PCs adhere to this purpose of medicine with its strong ethical framework as well as the universal understanding of the unborn’s special status. PCs view pregnancy as a physiologic condition to be managed and not a disease to be eradicated consistent with a treat and prevent disease purpose of medicine. PCs educate women and men about pregnancy, sexual health, abortion procedures and risks, and alternatives to abortion and recommend actions that promote health. They counsel the woman against actions that could result in death or unnecessary deformity of their unborn child, just like medicine does. PCs do not promote most contraceptives as they tend to fall outside of the “treat or prevent disease” purpose of medicine. This approach places the ethics of contraception upon the woman while removing the medical professional from enabling morally questionable sexual behavior.

Some accuse PCs of being “dishonest” in relating information regarding abortion and contraceptives. These accusations generally stem from different interpretations of conflicting literature in these areas. Although a detailed response is well outside the scope of our article, two important observations are in order. First, different interpretations of the literature with attendant modifications of practice patterns are common in medicine. Thus, any accusations should be used sparingly and with moderate tones both of which are lacking in these very controversial topics. Lastly, PCs’ view of the purpose of medicine is quite clear; however, they also promote stable and functional relationships while encouraging women to develop their inner virtues and strengths to live in a meaningful way ultimately holding out a pathway to lasting joy and happiness.

Conclusion

Fundamentally different views of the purpose of medicine lie at the root of the charges of unethical behavior of PCs and by extension to all health professionals who do not promote the practice of elective abortion or comprehensive contraceptives. Critics of PCs erroneously exchange a limiting value for the purpose of medicine or embrace an overly broad purpose such as well-being. This highly subjective purpose combined with the elective nature of abortion results in a vendor–customer relationship replacing a physician–patient one. Additionally, these critics have no firm ethical framework or a solution for multiple current and future ethical difficulties. This combination has discriminatory effects costing millions of unborn lives. On the other hand, PCs adhere to a traditional purpose of medicine with a robust medical ethic that provides clear ethical pathways that eliminate current problems and address future ones. The onus lies squarely on the critics of PCs to develop a purpose and ethic in medicine that is as robust as the one the PCs embrace.

Biographical Notes

Christopher Lisanti, MD, FACR, is an assistant professor of radiology at the Uniformed Services University of the Health Sciences, assistant program director for research in radiology at Brooke Army Medical Center, and medical director for the Pregnancy Care Center in San Antonio. His research interests are in abdominopelvic imaging, ethics, and medicine’s purpose.

Sandy Christiansen, MD, FACOG, is an adjunct professor at Mount St. Mary’s University in the Division of Graduate, Continuing, and Professional Education, national medical director for Care Net, and medical director for the Care Net Pregnancy Center in Frederick, Maryland. Her areas of interest include women’s health, pregnancy education, abortion complications, sexual health, and the Hippocratic practice of medicine.