In a world where informed consent is a cornerstone of medical practice; we examine if there is such a thing as too much information when consenting to a procedure, and if so, does forcing women to have ultrasounds prior to obtaining an abortion cross this line?
Informed consent is a key principle that lies at the heart of modern clinical practice. The seminal Nuremberg Code established in the aftermath of the Second World War brought global attention to the importance of obtaining informed consent from subjects participating in medical research. As we have moved from a paternalistic ‘doctor-knows-best’ approach to patient care and towards a patient centred approach, this notion of informed consent has become ubiquitous across all ethical medical procedures in much of the world.
The definition of consent given by the NHS, and shared by many healthcare services worldwide, is that ‘For consent to be valid, it must be voluntary and informed, and the person consenting must have the capacity to make the decision.’ Crucially we must recognise that a decision can still be valid if it is not the one that a medical professional would recommend. This point is reinforced by the mental health act, which stipulates that ‘If patients are competent, they are entitled to refuse consent, no matter how illogical this seems’.
Upholding these values is a fundamental part of enabling patients to retain their autonomy, and on a wider scale, is vital in respecting an individual’s right to exert freedom of choice when it comes to their own wellbeing.
Forced ultrasounds- taking the notion of informed consent too far?
In light of the above, it seems somewhat ironic that this same notion of informed consent is currently used in ten states across the United States to enforce laws that opponents argue are used to manipulate patient choice. The law in question is that which makes it mandatory for women considering an abortion to undergo an ultrasound prior to the procedure – regardless of whether it is against the patients’ wishes or serves no medical purpose.
Opponents of these regulations suggest that these laws toy with the emotions of women facing the life changing decisions associated with an unexpected pregnancy, and were established with the aim of coercing such women to adopt the ‘anti-abortion’ sentiments of those who designed them.
Recent data from the Guttmacher Institute shows that the law in 3 of these states – Louisiana, Texas and Wisconsin – require that the medical provider give a detailed description of the foetus throughout the ultrasound procedure. This audio commentary is supplemented by hearing the sound of the foetal heartbeat and although women are given the choice to look away from the screen, the description of the foetus, from the chambers of the heart to fingers and toes, is a mandatory requirement for any abortion provider.
In order for these detailed descriptions to be made, it is in some cases necessary for a trans-vaginal examination to be carried out, instead of the less invasive abdominal ultrasound procedure with which we are more familiar. In some exceptions, including sexual assault and incest, these regulations may not apply.
Whilst it is common for an ultrasound to be carried out prior to a termination, including here in the United Kingdom where they are used to date the pregnancy, it is clear from the invasive and excessive requirements made in these laws that such medical motives were not the priority when these regulations were enacted.
However the apparent rise in the popularity of abortion restrictions is not going unchallenged. In North Carolina earlier this year judge Catherine Eagles ruled that forced ultrasounds are illegal. In her ruling she criticises the use of health care providers to deliver anti-abortion messages on behalf of the state, saying that ‘…it compels a health care provider to act as the state’s courier and to disseminate the state’s message discouraging abortion”.
Evidence suggests that viewing an ultrasound prior to an abortion rarely changes a woman’s decision to terminate her pregnancy
Justifications given for the regulations i.e. the need to have as much information as possible to make an informed decision do not appear to be supported by a strong scientific basis. A study recently published in the Journal of Obstetrics & Gynaecology using data from nearly 16,000 women showed that nearly all pregnancies were terminated regardless of whether women had elected to view an ultrasound scan or not (98.4% of women who viewed the scan and 99.0% of women who did not choose to view proceeded to terminate their pregnancy). The study concludes by saying that ‘…viewing does not alter decisions of the large majority of women who are certain that abortion is the right decision’.
These results should come as no surprise when one considers that the many barriers to abortion already in place mean that it is a choice that few people are likely to take lightly.
Whilst the advantages of adopting such strict and invasive regulations are clouded in doubt, the disadvantages are much easier to see. Many argue that these regulations are just the latest step in a ‘pro-life’ led attempt to restrict a woman’s access to abortion; the ‘Ask your boss bill’ and laws demanding admitting privileges are also thought to be aimed at limiting availability. The resulting decrease in access to abortion clinics with 4 states in the US having only one abortion provider each, gives rise to concerns of a loss in the degree of autonomy that a woman has in controlling her own fertility, and deciding if and when she would like to start a family.
Furthermore it is likely the additional cost, perceived stigma and invasion of privacy that these regulations cause will lead to a rise in the number of women who either turn to the black market for pills for an early medical abortion, or seek out unlicensed abortion practitioners to have their termination. This results in effectively criminalising abortion for these women, in addition to the health risks associated with undergoing any medical procedure carried out under unregulated conditions.
The need to respect patient autonomy should never be overlooked.
Of course, some women may welcome the opportunity to have an ultrasound, and if they feel that it helps them to make the best decision for themselves then offering the procedure is not something any reasonable individual can find fault with.
However, for the overwhelming majority of women who for reasons only they can understand have already made their decision to have an abortion, forcing them to endure ultrasounds against their will is to disregard respect for patient autonomy completely.
Ultimately, it seems not only insensitive, but also unethical and profoundly wrong to force women in this situation to endure further invasive procedures and distress, simply because they have chosen to exert their freedom of choice.