Abortion is healthcare! In what sense?
We have not written in a while. Brandon and I have both been pretty busy with some work-related obligations but we wanted to share something. What follows is not a typical Savage Collective piece, but in many ways, it is about the Machine. When I am not writing publicly against the Machine, I actually have an academic career. One academic hat that I wear is that of a bioethicist. I thought that some of the readers might be interested in this other part of my life. I wrote this little piece after the passage of Dobbs vs. Jackson. My co-authors on this piece are my friends Farr Curlin and Chris Tollefson. My primary academic appointment is in a nursing school, and I was struck by the fact that every professional nursing organization in the United States post-Dobbs issued a statement about why “Abortion is healthcare!” I wrote this little piece to explore the ways in which we need to understand the terms “health” and “care” that might render this phrase comprehensible or not. It is not a particularly sophisticated piece, but I was hoping that it would spur a discussion on my field. We’ll see. Maybe you’ll find it interesting. The paper was originally published in Nursing Outlook, the official journal of the American Academy of Nursing. You can find the original here.
In June 2022, the Supreme Court of the United States ruled in Dobbs v. Jackson Women's Health Organization that the U.S. Constitution does not, in fact, guarantee the right to abortion 1. Many professional nursing organizations, including the American Nurses Association and the American College of Nurse Midwives, promptly issued statements affirming that access to abortion is a right that must be protected 2,3. An important premise of these policy positions is that abortion is an essential part of reproductive healthcare. The American College of Nurse Midwives (ACNM) statement is typical in this respect: “ACNM’s position remains steadfast; abortion care is healthcare. Access to abortion is a key component of comprehensive reproductive healthcare.” 4.
Despite such unequivocal statements, the claim that abortion is healthcare depends on a particular and contested understanding of both “health” and “care”. These two terms are central to the nursing profession’s self-understanding, as the International Council of Nursing makes plain: “Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people” 5 Other formal definitions of nursing likewise advance some combination of these terms. How a nurse understands the terms "health" and "care" thus determines how they understand their obligations.
In this paper, we consider different ways to understand these terms to illustrate how at the heart of disagreements about abortion one finds disagreement about what healthcare entails. Importantly, to simplify the argument, we set aside the fetus to focus on what might constitute healthcare for the pregnant woman. We recognize that to ignore the fetus is to ignore what for many is central to the morality of abortion.
As we will illustrate, it matters whether one understands nursing “care” in terms of carrying out legal and professionally permitted technical interventions or whether one understands nursing care as a moral practice that pursues particular goods. Likewise, it makes a difference how one understands the internal goods of nursing as a moral practice. We conclude by discussing how differing understandings of the internal goods of nursing lead to incommensurable understandings of the place of abortion in nursing practice. These disparate approaches highlight the challenge of sustaining respect for conscience in the face of genuine moral pluralism among nurses.
Understanding nursing as a practice
To understand what care involves for nurses, we must start with what nursing is. Our argument holds that nursing is inherently a moral practice as opposed to a merely technical art. Strictly speaking, a technical art applies technology or technique (i.e., tools, methods, or strategies) toward some desired human purpose 6. The technician possesses expert knowledge in the application of the specific technology. However, there is no express moral end of a technical art. The primary concern of the technician is the effective use of the technology toward the achievement of a proximate goal, whatever longer range good might be sought. For example, a welder’s work is judged in relation to its effectiveness in joining pieces of metal in a desired fashion, not according to whether such pieces are being joined to modify a wheelchair or a missile. Accordingly, if nursing were merely a technical art, then one would assess a nurse’s practice only by assessing whether the nurse (i.e. the technician) is effectively applying relevant tools, methods, and strategies (i.e., technologies) without respect to what those technologies are being used for. Whether the nurse’s final goal was good or not would not bear on whether the nurse’s actions constitute good nursing.
Alternatively, nursing can be understood as a moral practice. A practice, philosopher Alasdair MacIntyre writes, is “any coherent and complex form of socially established cooperative human activity through which goods internal to that form of activity are realized in the course of trying to achieve those standards of excellence which are appropriate to, and partially definitive of, that form of activity …” 7. The “internal” good of a practice is what makes the practice what it is. For example, the internal good of baseball distinguishes baseball from other practices. It is that form of play specific to baseball (not merely throwing and hitting small objects expertly) that is realized when baseball players seek to achieve the standards of excellence that are appropriate to and partially definitive of baseball. Nursing-as-practice will involve activities very similar to nursing-as-technical art, but the former will be oriented toward a specific internal good, whereas the latter will not 7. Importantly, there are many goods that may result from a moral practice. We argue, however, that other goods are secondary to the primary internal good of the practice. This allows practitioners to set priorities when goods are in conflict.
On this understanding, nursing “care” includes all of those “socially established cooperative human activit[ies]” that nurses engage in as part of pursuing the internal good proper to nursing. Activities that pursue something other than the internal good of nursing are not, as such, nursing care, and activities that impede the internal good of nursing compromise the practice. Gastmans, Castile, and Schotsman 6, along with others, have drawn on MacIntyre’s understanding to argue that nursing care, being the activities of nursing practice, must be orientated toward some internal good. We agree. Our argument is premised on the claim that nursing is a moral practice not a technical art. But what is the good toward which nursing is properly oriented?
Health as the internal good of the practice of nursing
Health, we propose, is the central internal good of nursing—it is what gives point to the activities of nursing care. Indeed, health is arguably the internal good of all “healthcare” (including also pharmacy, medicine, surgery, etc.). It is the pursuit of health that distinguishes healthcare from other activities that involve acting on bodies (e.g. body-building, cosmesis, tattooing). Put differently, health gives healthcare its internal logic. Additional goods might be achieved in the practice of healthcare, including most obviously the money a practitioner earns. Unlike health, however, such goods are external to the practice—they have nothing to do intrinsically with healthcare. To give an obvious example, a healthcare practitioner’s activities do not cease to be healthcare just because the practitioner is working pro bono. Importantly, external goods like money can interfere with and compromise a practice. Almost everyone recognizes that healthcare professionals’ pursuit of money can distort their concern for patients’ health.
But what is health? Margaret Newman, one of the most significant theorists of health in nursing practice, highlights the simultaneous importance of health and ambiguities in how the concept of health is used in nursing practice. She writes, “Although nursing theorists recognize health as the goal of nursing, the terms used to define health are often broad and general and are subject to multiple interpretations” 8. Although theories of health within and outside of nursing are varied, three basic views emerge: one view understands health as an objective bodily norm—the well-working of the human organism; the second understands health as referring to well-being, subjectively defined; the third understands health as referring to liberation. These three views lead to very different appraisals of the claim “abortion is healthcare.”
View #1: Healthcare is for well-working of the human organism
This first view understands health as an objective characteristic of living bodies when they are functioning well—what Leon Kass defines as “the well-working of the organism as a whole” 9. Illness, by definition, involves a disruption of or deficit in this well-working. The role of healthcare practitioners, then, is to cooperate in restoring the bodily well-working of the human organisms under their care. To do this well, the healthcare practitioner must exercise sound clinical judgment to discern which care activities are conducive to the patient’s bodily well-working and which are not.
According to this first view, then, nurses should act, within the scope of their training and authority, in ways that enable people to maintain, improve, or recover the well-working (health) of the human body, and to help people cope with assaults to health so defined. To do this the nurse would decline to act in ways that intentionally damage or disrupt the well-working (health) of the human organism, even if such actions serve other worthy goals.
Patients may pursue diverse desirable states of affairs—many of them good—that are external to health so understood. Such states of affairs can be goals of nurses only insofar as pursuing them does not involve contradicting the nurse’s commitment to the well-working of the body. Importantly, some actions diminish the well-working of some aspect or part of the body in order to preserve the well-working of the body as a whole. Chemotherapy, for example, is used to destroy cancer cells, but as a side effect it damages other cells in the body. The concept of “double effect” helps to clarify when it is reasonable to accept such side effects that follow from one’s efforts to promote the well-working of the body as a whole 10.
For those guided by this first view, the phrase “abortion is healthcare” appears incoherent. Pregnancy seems to be both a sign and an instance of the well-working (health) of a female organism of reproductive age. That is not to say that pregnancy is necessary for health; clearly, women can be healthy without pregnancy. It is to say, however, that pregnancy is a sign of health; it is a sign that the reproductive system of a young woman is working properly. Indeed, if a woman of reproductive age has regular, unprotected sex with a male partner and does not get pregnant, healthcare practitioners might reasonably look for a deficiency in health (of the woman or the man) that might explain the absence of pregnancy.
Pregnancy is not merely a sign – an indication – of good health; a healthy pregnancy is itself an instance of good health, a well-working of the female organism. Successful reproduction, encompassing conception and gestation up to parturition is an instance of the successful performance of reproductive functions. Similarly, if pregnancy (that is not intentionally interrupted) does not result in delivery of an infant, one knows that something has “gone wrong.” As such, in this view, abortion appears to interfere with and interrupt the reproductive functions that partially constitute a woman’s health. Continuing a pregnancy until successful birth is what being healthy is for a pregnant woman, by contrast with, for example, miscarriage or stillbirth.
Of course, not everything that could be described as a “growth of cells in the female reproductive organ” is a pregnancy. Endometrial cancer, while involving the growth and development of human cells, is an illness that threatens the life of a woman. The uterine tumor and the developing embryo, despite superficial similarities, are radically different; the former involves disordered cellular multiplication and leads predictably to disintegration of overall health; the latter displays an extraordinarily ordered sequence of growth and development of which the embryo itself is the directive agent, as any textbook of developmental biology will attest. So again, despite the superficial similarity of a surgery to remove an endometrial tumor and a surgery to end a pregnancy, the two interventions are recognizably different: one is oriented towards healthy functioning, and one is not.
On this view, then, abortion is not healthcare, even if it is pursued to achieve other important goods such as education, career, money, or freedom. Abortion’s disruption of healthy reproductive functioning is contrary to the health of the mother.
Could some abortions be considered aimed at health so understood? We think so. Some procedures that are necessary to save the life of, or ward off grave threats to the health of, the pregnant woman are clearly parts of healthcare, even when such procedures result in the death of the fetus. In such cases, one might hold that abortion is healthcare just insofar as the intervention is intended to preserve the woman’s health and life from a grave threat and one has proportionate reason to accept the foreseen side effect of the death of the fetus. This consideration raises the issue of risk. One cannot know with certainty how a pregnancy will turn out, nor precisely quantify threats to maternal health. As such, there must be room for moral discernment and judgment, including by the pregnant woman and the healthcare team, regarding when risks to maternal health warrant ending a pregnancy.
We observe that those who believe abortion is healthcare often are concerned about downstream health implications of abortion not being available. If abortion procedures are not provided by healthcare professionals, some women may resort to unsafe abortions which pose serious risks to their health. Similarly, carrying an unwanted fetus to term may threaten a woman’s financial status, an important social determinant of health. Is abortion in such scenarios therefore healthcare? Although more can be said, to proponents of the view we are describing, it does not appear given this view that the abortion directly addresses a health need in such cases. Rather, such acts are directed against actual well-functioning of the body for the sake of possible future well-functioning. These seem incompatible with this first view of health and healthcare.
View #2: Healthcare is for “well-being”
On a second view, “health” is understood as subjective well-being, which ultimately is determined by what the patient believes is good for her. Well-being, so defined, is a state in which the patient’s goals are met. In this view the nurse should not let the purportedly objective well-functioning of the human body (View #1) stand in the way of achieving patients’ goals and a more expansive, patient-determined vision of “well-being.” The American College of Obstetrics and Gynecology, for example, holds practitioners accountable to pursue “well-being as the patient perceives it.” 11
When health is understood as well-being, subjectively defined, then it seems that the healthcare professional is obligated to provide services that the patient chooses in pursuit of his or her goals, whether or not doing so is required by or consistent with the well-functioning of the patient’s body. The services provided are guided primarily by what the patient autonomously chooses. Under such an orientation, “abortion is healthcare” makes sense, insofar as abortion can help a woman achieve her goals related to education, career, finances, or relationships, the most commonly cited reasons for seeking abortions 12,13. The ACNM makes this connection explicit, arguing that reproductive healthcare, including abortion, “elevates the level of education and economic growth for (women) and their families, benefiting entire communities.” The College ties abortion not to the well-working of patients’ bodies but to women’s successful participation in the educational system and economy. Abortion in this case would be considered “healthcare” because it employs the techniques and other resources of the healthcare industry to help patients achieve their goals. Because the patient autonomously chooses the abortion in light of what she values, then abortion is considered healthcare for her, even if the abortion interrupts an otherwise healthy pregnancy.
View #3: Healthcare is for liberation
The third view understands “health” as liberation. This view is largely articulated within the concept of reproductive justice which has emerged within the nursing and health services research literature related to abortion. The concept of reproductive justice draws primarily from “critical race theory” and “critical feminism” 14, both of which interpret history and culture through a focus on power and oppression. Namely, history and culture are marked by the dominance of powerful over the oppressed. The operative power may be the patriarchy (feminism) or white supremacy (critical race theory). Each represents a different form of oppression, and multiple systems of power and oppression can overlap, leading to the concept of intersectionality 15. For example, Black women can experience both race-based oppression and gender-based oppression. The intersection of these oppressions creates a unique experience of oppression that is different from what a Black man or an Asian woman experiences.
Importantly, then, within the tradition of reproductive justice (and health-as-liberation more generally) the internal good of health care is to liberate women and especially Black women from the oppression of White patriarchy that has often been operative through the American health care system. Reproductive justice focuses on securing full empowerment and agency for women to choose when, if, and how they have children. We might conclude then that within the reproductive justice discourse, abortion is health care to the extent that access to abortion liberates women, especially minority women, from domination. Notably, reproductive justice advocates recognize that abortion historically has been both a source of liberation and oppression. It has been used both to free women from domination and to oppress women in the context of forced abortions and eugenics 14.
There is significant overlap between Views #2 and #3. In fact, in some ways, “liberation” is the most important element in subjective “well-being” for some people. Likewise, both views share a specific commitment to patient autonomy and choice. However, the view of health as liberation relies on a unique intellectual foundation that warrants its specific treatment. Its approach to all health-related dynamics as power relations, and its narrowing of well-being to liberated autonomy, set it apart from View #2.
Dominant views of health within the abortion discourse in professional nursing
These three views of the internal goods of healthcare generate three different visions of the purposes of healthcare as a practice. In many situations, these three views can agree about how nurses are obliged to act. Actions that promote the well-functioning of the human body (View #1) often contribute to subjective well-being (View #2). As Daniel Callahan states, health as subjective well-being (View #2) speaks to the “intimate connection between the good of the body and the good of the self, not only in individual terms but the social community of selves.” 16 Likewise, some measure of bodily well-functioning seems necessary for human liberation (View #3). The incommensurable nature of these views is laid bare, however, whenever the objective well-functioning of the human body is seen as an impediment to subjective well-being or liberation.
Although we are not aware of empirical data on this point, it seems the dominant view in professional nursing is that healthcare is for more than well-functioning of the body. Many nursing theorists appear to endorse a concept of health that goes beyond the well-functioning of the body. For example, Callista Roy defines health as a “state or process of being or becoming an integrated or whole person,” which clearly includes goods that go beyond the well-functioning of the human body. Other theories rely on concepts such as forward moving of the personality (Peplau), independence (Henderson), self-care toward wholeness (Orem), capacities for daily living (King), and expanding consciousness (Newman) 17. In fact, although Gastmans, Castile, and Schotsman use a MacIntyrian account of practice, they appeal to well-being (in our view, subjectively defined) as the internal good of nursing care 6. Given that nursing theories tend to define health in these ways, it is not surprising that “abortion is healthcare” has become the dominant view in the profession, at least according to the statements of nursing organizations. More specifically, to the question “Is abortion healthcare?” professional nursing organizations tend to rely on some combination of View #2 and View #3. In fact, the most recent statement from the American Nurses Association (ANA) relies both on the idea of health as subjective well-being and health as liberation to construct their public statements about abortion. In official statements, ANA cites both the WHO’s well-being oriented view of health and also the concepts of reproductive justice to discuss the ethics of abortion 18.
Viewpoint diversity and the importance of conscience
This dominant view, however, can potentially lead to problematic implications for nurses who hold the seeming minority position that healthcare’s purpose is to maintain and restore well-functioning of the human body (View #1). The most problematic implication is that service to subjective well-being and liberation may require such nurses in certain circumstances to contradict their professional commitments by acting contrary to the well-functioning of the body. Abortion is one practice in which serving a patient’s subjective well-being and liberation appears to involve acting contrary to the patient’s bodily well-working. Within View #1, disrupting a healthy pregnancy directly violates the very good that makes the practice of healthcare what it is. Within View #1, asking nurses to participate in interventions that contradict the well-working of the human body asks them to alienate themselves from the good that inspires and defines their profession, and so alienates them from their work. Just as a legal profession that encouraged actions contrary to justice, or a teaching profession that encouraged ignorance over knowledge, would be in bad shape, so nurses who hold View #1 would suggest that the nursing nursing profession is in bad shape insofar as it cooperates in interventions that damage or disrupt the well-functioning of the body.
Likewise, those who hold View #1 may see this willingness to damage or disrupt the well-functioning of the body as a serious threat to the integrity of the profession. Some of the greatest harms in the history of healthcare have been committed when practitioners set aside the patient’s bodily health to pursue other desired goals, such as scientific knowledge (e.g., experimentations that assault health) or perceived social fitness (e.g., forced sterilizations as part of eugenics efforts). Less dramatic but more pervasive harms result whenever interventions with little health value are offered to enrich healthcare systems and their clinicians. When practitioners set aside the well-working of the patient’s body, gauzy appeals to autonomy can offer little protection from abuse. Nurses then go from healers to harmers, a situation those holding View #1 cannot countenance.
Understanding differences in these three views of health and their implication for nursing can open a door for dialogue between those who hold different views. We hope that mutual understanding will lead to tolerance of viewpoint diversity in professional nursing, especially with respect to minority positions. Such tolerance seems to be foundational in a pluralist, liberal democracy. However, a growing chorus of voices has called for professional associations to crack down on refusals to cooperate in practices like abortion. A recent high-profile essay argued that patients have a right to receive the services they believe will improve well-being, including abortion, and physicians have the duty to provide such services 19. Within nursing, Swedish laws allow clinics to refuse work to midwives who are unwilling to participate in abortions 20. Some readers may applaud these developments, but they are chilling to those who (View #1) believe intentionally damaging the well-working of the human body contradicts the practice of nursing.
All told, these concerns bring into focus the important issue of conscience related to participation in abortions. Conscience can be thought of as the “application of moral knowledge to situations that require moral decisions about how someone should act” 21. Nurses exercise conscience when they make judgments about how to promote the good of their patients. For those who are persuaded that health is the objective well-functioning of the body, asking them to participate in abortion would be asking them to violate their own consciences by acting contrary to what they consider to be their central professional commitments.
The nursing profession has long held that conscience should be protected. The American Nurses Association has a strongly worded policy defending nurses’ freedom of conscience, particularly with respect to abortion 18. Professional associations protect both conscientious participation in and conscientious refusal of abortions. The ANA states that “Nurses have the right to refuse to participate in [sexual and reproductive health] care based on ethical grounds, as long as patient safety is assured, and alternative sources of care have been arranged.” This is a strong statement in support of nurses’ right to follow conscience, a commitment of which nurses should be proud.
Conclusion
In the wake of the Supreme Court’s Dobbs decision, many professional nursing organizations affirmed their commitment to the idea that abortion is healthcare and access to it must be protected. Whether abortion is healthcare, however, depends on what the terms ‘health’ and ‘care’ mean. These terms are central to the nursing profession’s self-understanding, and how they are understood has important implications for the nature and scope of nursing practice, and for abortion within it. As such, those making claims about whether abortion is healthcare or not should present and explain their account of “health” and “care.” As nurses come to better understand competing accounts of these terms, that will make possible dialogue between advocates of different positions on abortion and other controversial issues in modern healthcare. Moreover, better understanding will contribute to the profession’s longstanding commitment to respect for conscience within nursing practice.
1. Dobbs v. Jackson Women's Health Organization, (United States Supreme Court 2022). https://www.supremecourt.gov/opinions/21pdf/19-1392_6j37.pdf
2. American College of Nurse Midwives. Position of The College. Accessed June 8, 2023. https://www.midwife.org/abortion-is-healthcare
3. American Nurses Association. US Supreme Court’s Decision to Overturn Roe vs. Wade: Is a Serious Setback for Reproductive Health and Human Rights Accessed June 8, 2023. https://www.nursingworld.org/news/news-releases/2022-news-releases/us-supreme-courts-decision-to-overturn-roe-vs.-wade----is-a-serious-setback-for-reproductive-health-and-human-rights/
4. American College of Nurse Midwives. Statement: ACNM Condemns SCOTUS Decision, Dobbs v. Jackson Women’s Health Organization. Accessed June 8, 2023. https://www.midwife.org/statement-acnm-condemns-scotus-decision-dobbs-v.-jackson-women-s-health-organization
5. International Council of Nurses. Nursing definitions Accessed July 17, 2024. https://www.icn.ch/resources/nursing-definitions
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20. BBC. Swedish anti-abortion midwife loses court case. Accessed November 29, 2023. https://www.bbc.com/news/world-europe-39587154
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Abortion should be made illegal - entirely. Full stop.
https://thequillandmusket.substack.com/p/your-body-your-choice-fetishizing?r=4xypjp