The ethics of direct and indirect referral for termination of pregnancy

doi:10.1016/j.ajog.2008.06.007

American Journal of Obstetrics and Gynecology

Volume 199, Issue 3, September 2008, Pages 232.e1-232.e3

https://doi.org/10.1016/j.ajog.2008.06.007 Get rights and content

Referral of pregnant patients for termination of pregnancy by physicians morally opposed to the procedure is ethically controversial, with polarized positions taken by physician organizations. Based on the ethical principles of beneficence and respect for autonomy, we establish the distinction between direct and indirect referral. Direct referral is beneficence based and requires the referring physician to ensure that the referral occurs. Indirect referral is autonomy based, with a beneficence-based component that requires that the physician provide information to the patient about health care organizations that will provide competent medical care. We show that only indirect referral is ethically required in healthy women for termination of an unwanted pregnancy or a pregnancy complicated by fetal anomalies because the indications for this procedure are solely autonomy based. Direct referral for termination of pregnancy is not ethically required but is permissible. Conscience-based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral do not.

Section snippets

Two ethical indications for referral

In the language of medical ethics, referral has both beneficence-based and autonomy-based indications. Beneficence is the ethical principle that takes an evidence-based, clinical perspective on the patient's health-related and other interests and creates the obligation to act in such a way as to result in the greater balance of clinical benefits over clinical harms for the patient.5, 9 Beneficence, we will argue, requires direct referral of patients for medically indicated intervention. Respect

Beneficence-based direct referral

As the patient's fiduciary, every physician has a beneficence-based ethical obligation to see to it that every patient receives the diagnostic and therapeutic services that are required in evidence-based clinical judgment.5, 9, 10 In practice, this beneficence-based obligation is implemented in 1 of 2 ways. The physician is competent and willing to perform the service in question and offers or recommends it to the patient. The alternative is that the physician is not competent or willing to

Autonomy-based indirect referral

Sometimes, patients request medical intervention that is not beneficence based but is clinically safe and effective in achieving the patient's goal. These procedures have only autonomy-based indications. This is by definition the case for cosmetic procedures to improve appearance. The indications for termination of pregnancy in a healthy woman are also autonomy-based because beneficence-based clinical judgment provides physicians with no professional competence to make decisions about either

Polarized positions are unnecessary

Our ethical analysis of direct and indirect referral has important implications for the current, politicized polarization between advocates for conscience-based exceptions to make referral for termination of pregnancy and advocates for an obligation to make unconditional referral for termination of pregnancy.1, 2, 11 This polarization becomes unnecessary when one acknowledges the ethical distinction between direct and indirect referral and the fact that ethical analysis of indirect referral

Conclusion

The ethics of referral for termination of pregnancy is not sui generis. The ethics of such referral is autonomy-based, with a beneficence-based component of the physician's fiduciary obligation to protect the woman's health and life, similar to referral for cosmetic procedures. When referral is autonomy-based, only indirect referral, providing referral information but not ensuring that referral occurs, should be the clinical ethical standard of care. Direct referral is a matter of individual

References (11)

F.A. Chervenak et al.
Does obstetric ethics have any role in the obstetrician's response to the abortion controversy?
Am J Obstet Gynecol
(1990)
Committee opinion number 385The limits of conscientious refusal in reproductive medicine
Obstet Gynecol
(2007)
AAPLOG response to the ACOG Ethics Committee opinion #385: “The limits of conscientious refusal in reproductive medicine.”
R.R. Faden et al.
A history and theory of informed consent
(1986)
L.B. McCullough et al.
Ethics in obstetrics and gynecology
(1994)

There are more references available in the full text version of this article.

Cited by (29)

A simulated patient study to assess referrals to abortion care by student health centers in Pennsylvania
2020, Contraception
Citation Excerpt :
The American College Health Association also states in its ethical guidelines that providers must consider referral “to avoid abandonment” in situations where their personal values conflict [26]. While some physicians still argue against the obligation to provide abortion referrals [27,28], most physicians surveyed agree with the duty to refer [29]. Yet actual referral behavior in our study and prior literature does not reflect this consensus [30,31].
To determine college health centers’ referral patterns for students seeking induced abortion.
We conducted a cross-sectional simulated patient study at 4-year colleges in Pennsylvania between June 2017 and May 2018. A researcher posing as a student seeking abortion referral contacted student health centers twice during the course of the study using a structured script, once as a minor (under 18 years), and once as an adult. The primary outcome was “direct referral”, defined as a referral to an abortion provider. We measured proportions of student health centers who provided no referral, “indirect referral” (referral to a non-specific provider), and “inappropriate referral” (referral to a non-abortion provider). We analyzed the relationship between the proportion of direct referrals and minor status of the caller as well as college characteristics (religious affiliation, location, student body mean income, and size). We included variables found to be significant as covariates in a generalized linear model that accounted for the cluster of multiple calls to each institution.
We attempted contact with 115 institutions, once as a minor and once as an adult, resulting in 202 successful contacts. Direct referral was the most common outcome (49.5%), followed by inappropriate referral (33.7%) and no referral (21.8%). The proportion of direct referrals given to minors was similar when compared to adults (48.0% vs 52.0%, OR 0.82, 95% CI 0.47–1.42). Religiously affiliated institutions were less likely to provide a direct referral than non-religiously affiliated schools (aOR 0.47, 95% CI 0.30–0.75). With each increase in students’ household income tertile, health centers were more likely to provide a direct referral (aOR 1.22, 95% CI 1.05–1.42).
Half of college student health centers in Pennsylvania do not provide direct abortion referrals, and many provide inappropriate referrals. Student health centers at religiously affiliated institutions and those with poorer students are less likely to provide direct abortion referrals.
Student health providers should inform themselves about fake health clinics and local abortion providers. Colleges should train staff, create accurate resources and define clear policies around referral. Professional and policymaking organizations should affirm the duty of all college health centers, regardless of religious affiliation, to provide abortion referrals.
Abortion referral-making in the United States: findings and recommendations from the abortion referrals learning community
2019, Contraception
In recent years, reproductive health researchers and practitioners have increased their focus on abortion referrals as an overlooked component of access. March 2019 proposed changes to the regulation of publicly funded family planning services that severely restrict abortion referrals have heightened public attention. In October 2017, Provide, Inc. convened researchers and practitioners to assess our knowledge of abortion referral and make recommendations for future research. We found that existing literature on abortion referral is limited and may overlook important outcomes as well as variations in patient experiences by age, race, income, and other attributes. Recommendations include more robust attention to patient experiences and research that assesses a broad range of referral-making practices and outcomes, with specific attention to vulnerable populations and to referral quality and the distinction between appropriate and inappropriate referral.
Ethical dimensions of fetal neurology
2012, Seminars in Fetal and Neonatal Medicine
Citation Excerpt :
To achieve this goal, the woman should be given the choice between continuing her pregnancy to viability and thus to term or termination of pregnancy. If the woman elects an induced abortion, it should be performed or an appropriate referral made.15 If the woman elects to continue her pregnancy she should be apprised about decisions that will need to be made later.1
Ethics is an essential dimension of the management of counseling a pregnant woman when a neurologic anomaly is diagnosed. This paper provides an overview of obstetric ethics, with a central focus on the ethical concept of the fetus as a patient. On this basis, the authors analyze the ethical and clinical dimensions of the obstetric management options for pregnancies complicated by a neurologic anomaly. These management options include aggressive management, induced abortion, termination of pregnancy during the third trimester, non-aggressive obstetric management, and cephalocentesis.
Obstetrician-gynecologist experiences with abortion training: physician insights from a qualitative study
2010, Contraception
Citation Excerpt :
Given that abortion remains one of the most common surgical procedures for women in the United States, the hope is that even physicians who do not want to provide abortion (for any reason) will be able to support their patients through the referral process in a patient-centered manner. Because ob-gyns are often the primary provider of care for women, it is their professional responsibility to be surgically competent to perform the procedure and/or to be ready to make a safe referral, as ACOG now requires [15] and medical ethicists advocate [16]. Thus, physicians should be encouraged to treat patients who choose abortion respectfully.
Abortion is one of the most contested, yet common surgical procedures in the United States and a required component of obstetrics and gynecology resident education. Approaches to abortion training are variable.
We conducted in-depth interviews with 30 physicians who had graduated 5–10 years prior from four US residency programs with routine abortion training. Interviews focused on their experiences with abortion during training and in practice.
Graduates' positive and negative experiences demonstrated that many valued teaching about the social issues surrounding abortion as well as training in surgical skills. Respondents found training rewarding when attending physicians openly discussed their personal commitment to abortion practice, respected differences of opinions about abortion and demonstrated high regard for abortion training. Some residents who opted out of surgical training for abortion valued partially participating in the rotation.
Many physicians-in-training consider didactics related to the social context of care and respect for moral boundaries important components of abortion training.
An ethically justified practical approach to offering, recommending, performing, and referring for induced abortion and feticide
2009, American Journal of Obstetrics and Gynecology
Citation Excerpt :
The ethics of referral for induced abortion or feticide is straightforward for physicians who do not have conscience-based objections to induced abortion. If they do not perform induced abortion themselves, they can make what we call direct referrals.31 The referring physician sees to it that the patient will be seen by a colleague competent and willing to perform the procedure.
We provide comprehensive, practical guidance for physicians on when to offer, recommend, perform, and refer patients for induced abortion and feticide. We precisely define terminology and articulate an ethical framework based on respecting the autonomy of the pregnant woman, the fetus as a patient, and the individual conscience of the physician. We elucidate autonomy-based and beneficence-based obligations and distinguish professional conscience from individual conscience. The obstetrician's role should be based primarily on professional conscience, which is shaped by autonomy-based and beneficence-based obligations of the obstetrician to the pregnant and fetal patients, with important but limited constraints originating in individual conscience.
Reply
2009, American Journal of Obstetrics and Gynecology

View all citing articles on Scopus

: Cite this article as: Chervenak FA, McCullough LB. The ethics of direct and indirect referral for termination of pregnancy. Am J Obstet Gynecol 2008;199:232.e1-232.e3.

: Reprints not available from the authors.

View full text

Clinical opinionGeneral gynecologyThe ethics of direct and indirect referral for termination of pregnancy

Section snippets

Two ethical indications for referral

Beneficence-based direct referral

Autonomy-based indirect referral

Polarized positions are unnecessary

Conclusion

Am J Obstet Gynecol

Committee opinion number 385The limits of conscientious refusal in reproductive medicine

Obstet Gynecol

AAPLOG response to the ACOG Ethics Committee opinion #385: “The limits of conscientious refusal in reproductive medicine.”

A history and theory of informed consent

Ethics in obstetrics and gynecology

Clinical opinion
General gynecology
The ethics of direct and indirect referral for termination of pregnancy