CMDFA NSW Conference on Moral Injury
9 MINUTE READ
There are few examples more vexing for the Christian Health practitioner (CHP) confronted with a request or situation that conflicts with their convictions, than abortion.
With advancing gestation, there is increasing desperation in the mother who wishes to terminate her pregnancy and it is increasingly difficult for the Doctor or Nurse/Midwife to object to participate. The law to terminate a pregnancy for any reason up to 22 weeks has been passed in NSW and other States in Australia.1 The law has included a conscience clause to allow those to abstain from involvement electively in some states.2
While the term “moral injury” was originally coined regarding returning military personnel from conflict zones3, the same term can apply to some degree for CHP managing early pregnancy. When a person’s conviction is compromised, moral injury may be suffered. The difference between a conviction and a mere opinion is that the latter may change without much consequence while the former is a line one draws in the sand of the soul and is guided by faith, and a certitude of what is right and wrong in a specific situation. It is deeply held and guides decision making. Convictions are mostly, but not always, formed by faith and reliance on revealed Divine instruction. For example the conviction, “first, do no harm” (primum non nocere) is threatened if you are instructed by a soldier to pull a trigger to kill another human. Your refusal to obey may result in your own execution. Similarly, the law may allow for a procedure that your convictions prohibit, but there may be significant cost to stand by these convictions. Indeed, many a Christian martyr has faced the lions for such. How can we approach these clashes of conscience as CHPs in early obstetric practise?
Consider Scenario 1
You are a busy GP and a couple come to see you and open the consultation with the news they are pregnant. They have two girls and ask if they can do a NIPT test to check the gender because they do not want another girl and will abort if they find out this fetus is female.
Moral challenge: By all accounts, this is a healthy 8-week pregnancy, there are no risk factors other than the fetus being female. You are affronted with the callous choice to destroy this pregnancy because of her unwanted gender. This couple may terminate the pregnancy anyway if they can’t get a test but you feel that complying with their demand for a test may make you an accomplice. They ask you to do the test anyway. Can you refuse a test where you know the outcome may make you complicit in an abortion?
Moral injury: While legal, their request is unethical and gender discriminatory. In India, this is illegal but in Australia, abortion for any reason is allowed in some states up to term.
Principle being violated: thou shalt not murder4 – intentionally take innocent human life. No one would argue against the innocence, humanity or vitality of this fetus.
Threat: potential loss of relationship with patients and their community. Possible complaint to HCCC / AHPRA, possible departmental discipline. Personal hypocrisy if you compromise.
Primary: be prepared for these scenarios. Establish the principle and always be ready with an answer for the hope you have within you, given with gentleness and respect.5 You may divulge the root of your convictions if asked but it should not be forced without request from the parents. Role play with colleagues to practise what and how to approach this question. Pray daily for your practise and patients, that you would be ready for these events.
Secondary: at the time. Politely let them know of your conviction to protect and nurture innocent life from conception to natural death. Let them know that diagnostic tests merely reveal what is reality, is diagnostic for gender, and violates no principle of your conviction. Let them know what they do with the result is their decision and you would be delighted to assist them in any way to preserve the pregnancy but you would not be comfortable referring to another practitioner for the intent to destroy it. You may let them know that there is a NSW hotline for further advice which is on public notice. Also ensure that you will offer any ongoing physical, mental and social care should complications arising from a termination occur (if they proceed with one), and that you would be there for them if they change their minds.
Tertiary: reflect on the interaction. Pray for the couple in your quiet times, speak to friends, confidantes about the injury you have experienced and revisit your convictions reading the Word of God and authors who have pioneered these difficult paths. (CMDFA resources library).
Consider Scenario 2
A 17 year-old young woman finds out she was date raped and is 14 weeks pregnant and has been admitted for a termination of pregnancy. She is scared but has signed the forms to have it done. You come on duty as a nurse and she seems ambivalent to having the procedure. You escalate your concerns but the doctor and senior nurse on shift insist you oversee her taking the abortifacient the pharmacy has dispensed. Your manager suggests your ongoing employment depends on compliance with departmental policy.
Moral injury: patient is questioning, superiors deny and coerce you to follow orders. Your personal convictions are being violated.
Principle violated: Thou shalt not murder – take innocent life. Even while recognising the wrong done in the conception, should the innocent life pay for the sins of the parent/s?
Threat: loss of job, career, references, future employment, complaints, demotion, discipline and deregistration. Disrupted personal working relationships, fear, ridicule and anger.
Primary: Recognise the objective value of life in the womb. If this was a wanted baby, the value of the fetus would be radically different and the approach to the mother would be entirely supportive. Prepare beforehand with colleagues and role play. Recognise the injury done to a woman violated. Set up alternative options for the woman exploring the requirements for a pregnancy, support, protection from and prosecution for the assailant, delivery of the baby, adoption options, post-partum care and ongoing protection strategies to prevent it happening again. Pray for such a time as this (Esther 4:14).
Secondary: establish the facts of the pregnancy: alive, in utero, any other medical issues to be addressed. Determine to inform senior or manager about moral convictions and note the law supports conscientious objection to participating in abortion.2 Inform a sympathetic support person of your situation maintaining confidentiality.
Ask for wisdom and prayer.
Tertiary: debrief: with colleagues, write down details of conflicts, pray for the woman, her baby and those around her. Resolve to advocate for the unborn, crisis pregnancies, and practically help with volunteering, supporting financially or materially a local crisis pregnancy clinic or support group.
Consider Scenario 3
A 30-year-old woman with a previous abnormal pregnancy resulting in a stillbirth with lethal multiple congenital abnormalities, is pregnant again and at the 20 weeks scan there are signs that this abnormality is representing. She asks you as the doctor to stop the pregnancy before viability and let them grieve. The husband is heartbroken but does not wish to terminate and would rather let nature take its course.
Moral injury: you feel coerced to participate in fetocide. You grieve at the couple conflict.
Principle violated: taking of innocent life, peacemaking mandate as a CHP.
Consequences: estrangement from mother, loss of trust, family disruption, demotion or career destruction, risk of complaint to AHPRA/HCCC. RANZCOG position on mother’s primacy in opinions and decisions about her pregnancy may result in complaints/dismissal.
Primary response: prepare for scenarios by careful thought before crisis. Prayerful study on valuing human life in all ages and forms. Pledge to protect all innocent life with dignity even if unsustainable in the near future. Consider providing practical support and resource development for women to offer viable alternatives to abortion. Inform senior staff of your position on pregnancy management of lethal malformations. Write out what you would say, read up on advice given by professionals, ask colleagues how they would react.
Secondary response: present your personal conviction and acknowledge the legal right of the woman to pursue termination. Offer the opportunity to discuss the course of action with another specialist. Inform the couple of potential ongoing conflict, offer referral for conflict resolution.
Tertiary: Consider future scenarios with lethal conditions and ask what can be done to ease a life shortened by major structural defects and metabolic errors of metabolism.
Principles: the 3 simple rules
A pastor from the Hebrides at a 1983 CMF student’s conference in Perth, Scotland once gave us three rules to conduct life-affirming practice in medicine. They have never failed me yet.
- Do not take active steps to shorten life – This is premeditated murder. Nature may be allowed to take its course. This is unless the ongoing pregnancy will result with predictable certainty in the untimely death of them both (ectopic, Eisenmenger’s syndrome, renal failure?). Withholding futile treatment in good faith that the intervention has little to no chance of extending life is not intentional killing.
- Do not withhold nutrition or hydration unless impossible to support.
- Provide symptomatic relief as far as is medically and psychologically possible. Develop protocols such as those developed by Dame Cicely Saunders for palliative care.
In early obstetric practice, they have served me well, thus far.
A video of this talk is available to members of CMDFA. If you are not a member and would like more information please call the CMDFA Office on 02 9680 1233.
A/Prof Harvey Ward A/Prof Harvey Ward is a busy OBGYN on the Coffs Coast, active in his local church as a musician and apologist. He is a CMDFA NSW committee member and is training as a Saline Process trainer. He is happily married to Kathy and has 3 married children. He is passionate about teaching and making birthdays. His dreams of being a rock star are fading, but he has recorded 2 albums, published poetry and is writing a book.
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- Abortion Law reform Act 2019 no 11, NSW Parliament
- Abortion Law Reform Act 2019 Section 9, NSW Parliament
- Koenig H (2020) Journal of religion and Health 59 (2323-2340) Identifying moral injury in Health care Professionals – the Moral Injury Symptom Scale – HP
- Exodus 20:13
- 1 Peter 3.5