Abortion and the Stewardship Testimony
A pro-choice friend of mine once remarked that she thought of abortion as a necessary evil. Of course we should seek to minimize the number of abortions which occur, she said, but at the end of the day, access to safe, legal family planning care saves women’s lives, so it has to exist. I, too, am pro-choice. While I agree with my friend that reducing the number of undesired pregnancies is a good goal, and while I know that access to safe abortions unquestionably saves women’s lives, the words “necessary evil” always give me pause. Quakerism is rarely a dogmatic faith, but at the same time, Friends’ emphasis on faithfully living our testimonies does not seem to leave room for condoning any evil, whatever the apparent benefit. Even in the most wrenching situations, we have to find ways to discern how God is leading us.
I initially confronted this challenge as a first-year medical student. As I began to provide clinical care, I saw patients and their families struggle mightily in the face of unintended pregnancies. I met women who had to choose between finishing college and raising a child. I heard about the extra work shifts it took to provide for a new baby. I saw the pain in patients’ eyes when they told me they had no one who would support them if they decided to have an abortion. As a new physician, how would I counsel these patients? What treatments would I offer? Generations of people before me had wrestled with these same questions and had come up with myriad answers. It would be easy to simply make a choice and justify it by appealing to precedent, but I knew that in the long-run, if I did not have some way of seasoning my decisions in light of my faith, I would always have some doubt about them. The question naturally followed: could abortion ever be consistent with Quaker values?
Abortion has long been a challenging issue for Friends. It has been the subject of written works, vocal ministry and personal debates. Often, I hear the Quaker anti-abortion argument expressed in terms of the peace testimony. We have a witness of nonviolence out of respect for the Inward Light in all people. The argument goes that even a fetus must be imbued with the Light and so abortion is a form of violence, an act in contradiction to Friends’ testimonies.
Elegant though this argument is, it seems rigid and even a bit doctrinaire: it seems a bit of an overreach to presume to know when and how God brings Light into a new person. I think the most honest thing we can say about this process is that we don’t know exactly how it happens. I would venture that most Quakers (though perhaps not all) would agree that sometime between conception and birth, the Inward Light becomes part of the developing fetus. When, precisely, that happens is unknowable. Some would argue that it occurs at the exact moment of conception, while others would say, just as convincingly, that it doesn’t take place until the baby comes out into the world. In the face of such uncertainty, the fetus becomes a special case of the peace testimony. To understand our obligations to her, we need to clarify what we really mean by violence.
Violence can be physical, but it can also be emotional or economic. The central characteristic of a violent act is that it causes suffering. To deprive someone of food is certainly a form of violence, even though it may not produce physical injury unless the person is starved for days or weeks. Conversely, an act which might under other circumstances seem violent may not be if it is intended to alleviate suffering. A surgery to set a broken bone comes to mind: the procedure itself involves cutting and suturing, drilling and casting, all of which would be barbaric if performed on an awake patient for no good reason. In the setting of a traumatic injury, however, performing such a reconstructive surgery is the antithesis of violence.
If abortion is likely to cause fetal suffering, then, it seems reasonable to argue that it is an act of violence and therefore contrary to the peace testimony. Scientific consensus, however, is that the central nervous system structures necessary for the fetus to experience subjective pain and the suffering associated with it are not developed until the third trimester of pregnancy (Susan J. Lee, et al. “Fetal Pain: A Systematic Multidisciplinary Review of the Evidence”). The vast majority of abortions performed in the United States take place in the first trimester and so are extremely unlikely to cause fetal suffering. Moreover, it is worth considering that preventing a woman from accessing a needed abortion may well cause her to suffer physically, emotionally and economically, making this impediment an act of violence toward the woman. Bearing all of this in mind, I would argue that abortion is not in and of itself, violence.
But even if the peace testimony does not necessarily proscribe abortion, we are still in need of a Quaker ethical framework in which to weigh both personal reproductive health decisions and policy issues. To develop such a schema, I think it is helpful first to frame the abortion issue in the context of the secular practice of clinical medical ethics and then to ask how the Quaker faith can further inform this system.
Contemporary medical ethics is founded on the principles of non-maleficence, beneficence, justice, and autonomy. When faced with two or more treatment options, we are meant to compare them in light of these four key concepts and choose the one which has the least potential for harm and the greatest potential for benefit, the one which most fairly distributes resources and which is most consistent with the patient’s wishes. When balancing these four principles does not yield a clear answer, the modern medical system privileges patient autonomy above the other three factors. This rubric, simple though it is, is very helpful for clarifying an ethical dilemma. Often, by distilling the question down to its most basic terms, an answer presents itself.
The problem becomes a bit more challenging in the case of a pregnant patient, but the same guidelines still apply. As one of my mentors explains it, when we treat a pregnant woman, we really have two patients: the woman and the fetus. We have to respect the interests of both patients in all our medical decisions. Applying the four-category approach, we have obligations of beneficence and non-maleficence toward both woman and fetus. However, while we have an additional obligation to respect the woman’s autonomy, we have no such duty toward the fetus, who has no autonomy: in the case of a conflict between the interests of the woman and the fetus, we ultimately must respect the woman’s decision (Laura DiGiovanni. “Ethical Issues in Obstetrics”).
Helpful though this system is, there is always the risk of oversimplification. An appeal to autonomy could easily become an excuse for an impoverished decision-making process. “There’s a tough choice to be made,” we can hear the provider saying to the patient. “Here are your options. Let us know when you’ve picked one.” Such an approach minimizes the important role which a thoughtful counselor can play in helping a patient come to clearness about a challenging decision and fails to adequately support the patient as she makes her choice.
In the face of this counseling problem, the principle of stewardship becomes particularly relevant. This testimony has a beautiful way of enriching the concept of autonomy. We often talk about stewardship in terms of environmental or economic concerns—we ask ourselves, for example, how best to care for the physical part of Creation so that we pass on a better world to our children—but there is a broader theme to the stewardship testimony. As John Woolman writes:
As Christians, all we possess are the gifts of God. Now in distributing it to others we act as His steward, and it becomes our Station to act agreeable to that Divine Wisdom which he Graciously gives to his servants…. If the Steward of a great Family, from a selfish attachment to particulars, takes that with which he is entrusted and bestows it lavishly on some, to the injury of others, and to the damage of him who employs him, he disunites himself, and becomes unworthy of that office. (John Woolman. Quoted in Faith and Practice of New England Yearly Meeting)
“All we possess” includes our bodies. This physical part of us, perhaps even more clearly than the natural world around us, has been placed directly under our care. We have a responsibility to use it wisely, to treat it well, to nurture it when it is broken and yet also to avoid selfish attachment to it. In short, while we have the freedom as autonomous people to do as we please, we also have a responsibility to “act agreeable to that divine wisdom” in the use of our bodies and in our reproductive decisions just as we do in the use of natural resources and in our monetary decisions.
Recasting the issue of autonomy in light of the stewardship testimony provides needed guidance for both clinician and patient. The testimony serves as a place to center down in contemplation and as an important source of queries to steer discernment. The patient considering abortion may find herself asking, How can I best put my physical self to God’s purpose under these circumstances? What are the most just uses of my physical, emotional and monetary resources? How can I best serve myself, my family, my friends and my neighbors? The provider may ask, How can I help my patient identify those of her own values which are most relevant in this case? What additional information does she need to come to clearness in this situation?
Of course, the way one person answers these queries may be very different from the way another does. I have known patients facing unintended pregnancies who, after much meditation about whether to have an abortion, decide that the most just use of their resources is to end the pregnancy so they can focus on adequately caring for the children they already have. I have known others who decided that while they were not intending to get pregnant, at that moment, God’s plan for them was to have a child. In the face of challenging circumstances, even such divergent decisions may be equally faithful.
Abortion itself is not evil, though it is often necessary. In my experience, a woman’s decision to end a pregnancy represents a profound act of stewardship and is uniformly reached after a thoughtful process of discernment. Such decisions are more common than many of us realize. Walk through any hospital ward, and you are bound to find someone who has made a choice she did not want to have to make, but which life has thrust upon her. It may be a decision about whether to withdraw or prolong care, about which treatment to accept and which to decline, or it may be about ending or continuing a pregnancy. Trying though these choices are, the consideration which they require is an opportunity to strengthen our spiritual practice. Modern health care may be fraught with imperfections, but it is also fertile ground for deep discernment and ultimately for radical acceptance of God’s plan for us, whatever that may entail.