More than semantics: Abortion access and equity

Watson begins with two questions: “Should the need for abortion care be considered a health disparity? and, “If yes, would framing it this way increase the ability of poor women and women of color to get the medical care they need?” (Watson 2022). Our answers are yes, and no. According to the CDC (2020), health disparities are “…preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.” Based on this definition, the inequitable distribution of access to reproductive health services encompasses a health disparity. By extension, we agree with Watson that inequitable access to abortion among marginalized populations is a health disparity. But we disagree that framing abortion access as a health disparity helps lead to an increase in access to abortion services. We argue that the language of health disparities, while a vital descriptive tool, does not provide a robust analytic framework for taking action. Moreover, no matter what conceptual framing we use in our scholarship, bioethicists can 1) elevate reproductive narratives and 2) advance political and practical strategies to help secure abortion access for those who most lack it.

Watson rightly underscores that disparities in abortion access, the current “clinical and social realities” that persist in the U.S., ought to be central to our ethics analysis in order to emphasize the experiences of women (Watson 2022). However, it is unclear how an acknowledgement of uneven abortion access, inarguably a disparity along socioeconomic, racial, ethnic, and even geographic lines, meaningfully centers pregnant people more than other frameworks. Indeed, other approaches can uplift and highlight the diverse experiences among those seeking abortion. For example, Powers and Faden’s (2008) social justice framework for public health and health policy requires that we aim to not further disadvantage populations that are already disadvantaged when weighing health policy options. This framework involves not only the description of health disparities (among other social determinants of health) but provides an analytic component that takes us beyond description. Applying this social justice lens to abortion highlights how women who are poor, living in rural areas, and/or who are Black, Latinx, or Indigenous are underserved and have borne the burden of reproductive injustices, such as forced sterilization (Ross 1992). Centering the narratives of women and their lack of access to reproductive health care including abortion is not a strength unique to the health disparities framework. Instead, we have at our disposal a range of rhetorical approaches to draw upon when working against abortion exceptionalism in our scholarship.

Beyond a useful theoretical reframing, Watson speculates that adopting the health disparities lens may pose our best chance at convincing medical and policy leaders to acknowledge lack of access to abortion as a lack of access to health care because many of them know and accept the health disparities framework. While we cannot prove or refute this claim from an empirical perspective, this move is not particularly convincing given that the awareness of health disparities does not necessarily mobilize sustainable action to address them. Take the persistence of racial disparities in maternal health outcomes as an example. Despite more attention paid to the specific ways that Black women and other women of color face greater rates of maternal mortality, this disparity has continued to widen during the spread of Covid-19 (Ahn et al 2020; Rabin 2022). As noted recently by Thomas (2022), the perpetuation of this difference is in part due to a longstanding decentering of Black women, and the contexts in which they face systemic restraints, in our examination of health disparities. We are therefore not optimistic that adopting the language of health disparities in efforts to advance abortion access will result in tangible change without a robust effort to also listen to women facing access barriers.

Naming and pointing out a health disparity is a crucial step in taking action to address an unjust statistical difference. Likewise, conceptualizing abortion access as a health disparity may very well help shed more light on existing inequities. But describing a health disparity is only a first step in addressing the gap. Though Watson endorses the Reproductive Justice (RJ) framework, it ultimately seems that she does not go far enough in identifying how it is more than an “intellectually superior” alternative to the health disparities lens. At its core, the RJ framework aims to deeply affirm the full humanity of Black women and other women of color beyond an experience of setbacks imposed by our healthcare system. It seems equally appropriate then in the spirit of RJ to emphasize how, in a time of understandable panic surrounding reproductive rights, that healthcare providers, advocates, and other allies have fearlessly maintained access to abortion, and that part of our role as bioethicists is to learn from and facilitate this work. No matter how we frame the problem, the solution lies (for at least some of us) in a commitment to maintaining a woman’s right to a safe and effective abortion as a component of larger efforts to improve the material realities of women in our communities who are systematically neglected or ignored. Like Watson, we agree that one way to do this is to advocate for overturning the Hyde Amendment that bars abortion from being covered by Medicaid and other Federally sponsored programs. Removing tangible barriers like cost will continue to be critical as legal protections are undermined at the state and federal level.