By Carmel Shachar
Since June 24, 2022, I have spent a lot of time thinking through the post-Roe legal and ethical landscape, both publicly and privately. Very often, the discussion is centered about the impact that Dobbs v. Jackson Women’s Health Organization will have on patients whose health or lives are threatened by their pregnancies — such as people with ectopic pregnancies, missed miscarriages with a high risk of sepsis, and preeclampsia — and the physicians who care for them.
These cases are, no doubt, important. But I am writing this piece to provide a counterpoint to this public discussion: abortion should be safe, legal, and accessible not only when the patient’s life or health is in danger. When we focus on the “blameless” abortions, such as the underage victims of incest, or the woman who wanted to be a mother but found out she has cancer that needs to be treated, we cede ground on this issue, by playing into the notion (whether knowingly or not) that some abortions are more justified or acceptable than others.
It is a common trope that many anti-abortion advocates justify their own abortions by framing it as “the only moral abortion is my abortion.” Most pro-choice advocates instinctively reject this framing of some abortions as permissible and most as problematic. But we need to be careful not to draw upon this framework in our public discourse. As tempting as it may be to use examples of “moral abortions,” such as treatment to save the life of the pregnant person, we need to make it clear that bodily autonomy and a right to access care make all abortions moral.
The Association of Bioethics Program Directors’ (ABPD) Bioethics Guidance for the Post Dobbs-Landscape helped crystalize my position on this matter. In its position statement, the ABPD “affirms a commitment to reproductive health care services in accordance with core healthcare ethics principles.” In other words, abortion is health care. And providing access to quality medical care for people when it is needed should be one of the guiding ethical principles of our health care system, the ABPD argues. Thus, banning abortion is directly opposed to creating an ethical and just health care system. We know banning abortion pushes people to pursue unsafe abortions, to the point where 47,000 people a year die needlessly because they cannot access the quality medical care they need.
Access to care is about respecting the needs of the patient, rather than judging how those needs came about. I’m reminded of my work on access to HIV and HCV medications. There is a reason the program designed to support access to HIV medications is named after Ryan White — a child who contacted HIV through a blood transfusion. In 1990, we needed that “moral” victim of HIV to secure public funding to combat the HIV epidemic. But today we would find it ethically repugnant to deny access to HIV antiretrovirals to patients because of how they became HIV positive. And we don’t ration HCV medications, even when they were prohibitively expensive, on the basis of why people became HCV positive.
We also avoid judging why people need care when it comes to other infectious diseases. Even at the height of the pandemic, when our health care system was overwhelmed, we were reluctant to ration care on the basis of people’s vaccination status. When cases of Zika and Ebola emerged in the United States, we did not tell patients, “you chose to travel to risky locations, so we will not help you with the consequences of your actions.”
If abortion truly is health care, part of the spectrum of reproductive care services, then it should not be the exception. We should respect the need of the person to no longer be pregnant, and not concern ourselves with why that person no longer wants to be pregnant.
I sympathize with the emergency room physicians who find themselves dealing with ectopic pregnancies. The woman who shared her experience of miscarrying twice in a pre- and post-SB 8 Texas in the New York Times Daily told an important story. As someone who thinks a lot about how we provide better access to care and how we support providers in delivering that access, I’ll continue to write about and engage with reporters on these issues. But I want to make it clear that I’m not interested in supporting only the “justifiable” abortions. Access to care is a core bioethical consideration and it means supporting legal abortion broadly.
Abortion need not be justified in terms of edge cases, in terms of horror stories or life-or-death circumstances. Respecting autonomy means allowing patients to make their own choices about their bodies — full stop. And ensuring access to care means ensuring access to abortion.
