1. TEACHING POINTS: ORIENTATION

The values clarification exercise can be challenging, satisfying, and thought provoking. Consider the origin of your beliefs. How could your feelings affect the interactions you have with a patient? How could recognizing these feelings prior to the interaction have a positive impact upon patient care? How do you anticipate your feelings could change with this training experience?

Consider the following key points:

  • There are no right or wrong answers.
  • Patients have the right to make decisions for themselves and to receive legally available medical services supporting these decisions.
  • As the healthcare provider, you serve patients best by providing active listening and accurate information. Strong negative reactions to patient behavior may harm the provider-patient relationship.
  • Each of us is shaped by our personal life experiences, which in turn may affect our judgments. It is important for health care providers to identify and understand those influences. Self-exploration and understanding help us to promote a non-judgmental climate for patient interaction and care.
  • We cannot know what the best decision for each patient is without walking in their shoes. Imagine what is going on in their life to explain their decisions and behavior.
  • Family planning and contraceptive recommendations by health care providers have been found to vary by patient race/ethnicity and socioeconomic status and may contribute to healthcare disparities, suggesting that providers should be particularly aware of subconscious bias (Dehlendorf 2010).
  • Family planning decisions are well served by a shared decision making approach that takes into account the best scientific evidence, as well as the patient’s values.

EXERCISE 1.1: General Feelings about Pregnancy Options

Purpose: This exercise is designed to illustrate the range of beliefs about the acceptability of pregnancy options and to help you clarify your personal views about your patients choosing abortion, adoption, or parenthood.

  1. In general, how do you feel about your patients choosing abortion, adoption, or parenting in each of these situations? Are you challenged to accept a patient’s decision in the following circumstances?
    • There are no right or wrong answers to this exercise.
    • If you feel ambivalence about one of these scenarios, consider what patient situation would change your view.
  2. Were you surprised by any of your reactions? How have your life experiences contributed to these feelings?

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EXERCISE 1.2: Gestational Age and Abortion

Purpose: This exercise is designed to help you clarify whether your beliefs are influenced by the gestational age of a pregnancy.

  1. At what gestational age do you start feeling uncomfortable about your patient choosing to have an abortion? Check all that apply.
    • Consider what happens between the gestational age that feels all right and the one that doesn’t.
    • Does your response have to do with your understanding of fetal development, concerns about fetal pain, physical risk to the patient, what it feels like doing the procedure as a provider, or other perceived ethical concerns?
    • When (if ever) you first saw a gestational sac or fetal parts, how did you feel about it? Were there any factors that influenced how you felt?
  2. Do you feel different about the gestational age if you are making a referral vs. performing an abortion? If so, why?
    • If you are struggling with the idea of making referrals, consider if the situation differs from other medical circumstances where we value accurate, evidence-based information and patient autonomy.
    • Are there ways to respect the moral autonomy of the patient, without undermining your own?
    • What if no other alternative abortion services were accessible? What kind of patient hardship would motivate you to offer services?
    • Each provider is different and needs to find their own comfort level.

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EXERCISE 1.3: Your Feelings about Patient’s Reasons

Purpose: This exercise will help you clarify your feelings about some potentially challenging situations than may arise in abortion care.

  1. How would you feel about referring or providing an abortion for a patient who:
    1. is ambivalent about having an abortion but whose partner wants them to terminate the pregnancy.
      • While this decision is important for both partners, it is the pregnant patient who has the legal right to make the final choice. In addition, they are the one bearing the risks of pregnancy and ultimate responsibility for the child.
    2. wishes to obtain an abortion because they are carrying a female fetus
      • Sex selection brings up complicated ethical and cultural issues. It might be helpful to ask if there are medical or cultural reasons that support their preference (i.e. sex-linked genetic conditions or family pressure to have a male child). Discussing these with the patient may help you better understand their position and decide your comfort level or need to refer.
    3. has had many previous abortions
      • Over half (54%) of patients obtaining abortions used a contraceptive method during the month they became pregnant (Jones 2002).
      • Patients have multiple abortions for many reasons. Discussion may help you better understand their personal barriers to avoiding unintended pregnancy.
      • Comprehensive contraceptive counseling, including long-acting methods and emergency contraception, may help them find a method that meets their reproductive goals
    4. indicates that they do not want any birth control method to use in the future
      • Patients often wish to avoid sex after abortion. Help the patient assess their situation and whether abstinence is a likely reality. You may tell them you have heard this perspective from patients you have seen back later with unintended pregnancy. Proactive planning is an important form of self-care; however, it is also important to avoid pressuring a patient into choosing a method they don’t want, as many patients will not desire more information about contraception on the day of abortion (Mattulich 2014). Discuss birth control options, and what has or has not worked in the past. At a minimum, give condoms and emergency contraception, and recommend they return if their situation changes or offer a scheduled follow-up visit to discuss it further.
  2. What factors influenced your choices? How might you handle your discomfort when caring for patients under these circumstances?
    • Recognizing personal discomfort with a situation is an important step towards providing unbiased care. Remember there may be more to the situation than the patient communicates directly.
    • Sometimes talking with colleagues may be helpful. Sometimes referral will be the best option for your patient. Consider how best to provide appropriate support for them.

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EXERCISE 2: Feelings about Providing Abortions

Purpose: This exercise will help you clarify your feeling about abortion provision.

  1. As you embark on this experience, consider how you might disclose this training to others. Do you think there are any parallels between the stigma that patients and providers experience?
    • As you explore your level of involvement with options counseling and abortion care, consider the implications this may have on disclosure to family, friends, or acquaintances.
    • A “prevalence paradox” is a phenomenon that can affect patients and providers alike (Kumar 2009). The less something is talked about, the more stigmatized and rare it seems when in fact it is very common. In other words, silence creates a vicious cycle that often distorts the true nature of things. Research supports that having a safe space to discuss the stigma around abortion may alleviate the burdens on staff and providers (Harris 2012).
    • Utilize faculty support during this rotation to discuss whether you experience a sense of burden or stigma.
  2. Consider the following quotation on the role of “conscience” in abortion provision, and not just the historical focus on the refusal to participate. What are your thoughts on how this view affects stigma?
    • “[Providers] continue to offer abortion care because deeply held, core ethical beliefs compel them to do so. They see women’s reproductive autonomy as the linchpin of full personhood and self-determination, or they believe that women themselves best understand the life contexts in which childbearing decisions are made.. among other reasons” (Harris, “Recognizing Conscience in Abortion Provision,” NEJM 2012).
      • It is important to recognize the “conscience” in abortion provision, and not just in the refusal to participate. The goal of this exercise is to teach learners how provision can address stigma, and impact clinical practice, law, and bioethics.
      • Some learners find it helpful to read or hear about other providers and their path to abortion care. For examples, see Physicians.
      • Consider how your role as a healthcare provider places you in the position of not just having an opinion on comprehensive reproductive health care, but being in a position to provide it.

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EXERCISE 3: Abortion access (Optional)

Purpose: The negative public health impact of restrictive abortion laws is well documented. The following exercise is designed to help you think through the consequences of limited access. How might your decision to offer options counseling, referrals, or services influence the accessibility of abortion where you may practice?

  1. What is your reaction to the following account?

It is estimated that for every 99 U.S. patients receiving abortion, 1 presents for care beyond the capabilities of a particular clinic to receive one. Many factors delay patients seeking care. Here two patient’s explanations of what caused a delay in access to care from the ANSIRH Turnaway Study:

Still trying to get Medicaid and arrangements to stay for the procedure since it was out of town. Trying to get insurance.” 23-year old Hispanic patient from New Mexico, at 22 weeks

“I didn’t find out until I was 22 weeks and getting the funding. I was determined but there was so much preventing me from getting up there.” 24-year old white patient from Minnesota, at 24 weeks

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