AMA Journal of Ethics^®

Case

Amy sits in the waiting room by herself, bouncing her leg nervously. Four weeks ago she found out she was pregnant, and today she visits Dr. Robbins’ office to ask what her options are. She is strongly considering having an abortion. After 20 minutes pass, Kathy, a fourth-year medical student starting an externship, leads Amy to an examination room. Picking up on her anxiety, Kathy asks Amy if she is all right.

“I’ve always been uncomfortable with gynecologists,” Amy says, fidgeting on the examination table.

“I understand,” Kathy says, preparing the transvaginal probe as Amy stares wide-eyed.

“The first step in this process is to perform an ultrasound to determine how far along you are. According to our state law, I must show you the ultrasound and you must hear the fetal heartbeat, if there is one. I know this might be uncomfortable, and I apologize.”

“I don’t want to see the ultrasound,” Amy says. “What the baby looks like doesn’t make a difference to me—I am having this abortion because I’m not financially able to support a child right now. Having to see this ultrasound isn’t going to change my mind.”

“I understand your frustration. Although an ultrasound is often an important part of the process in abortion care, I don’t think women should have to view the ultrasound if they don’t want to. Unfortunately, this was a law that was passed last year and we can lose our license if we do not provide the ultrasound and have you view it. I can’t proceed with your visit until we have completed this part.”

Amy concedes to the ultrasound.

Later, Kathy talks with Dr. Robbins. “I think the patient made a valid point about the ultrasound. I’m really struggling to understand how forcing her to look at the ultrasound is acceptable. At my medical school, we don’t have to force the patient to look at the ultrasound. Some women want to look and some don’t. It doesn’t usually seem to change their decision.” Heat floods Kathy’s cheeks. “Amy’s already in a really vulnerable position. Why is the legislature allowed to dictate how we practice medicine?”

Commentary

This case brings up several clinical and ethical questions. Is there evidence suggesting that ultrasound viewing has an impact on patient decision making about abortion? Should there be legislation intended to influence women’s decisions about abortion? What role should legislation play in the patient-physician relationship? What role should legislation play in physician decision making?

Kathy struggles with a question that has become more frequent in the past decade, as those who oppose abortion advocate limitations on abortion care. Medical education prepares a medical student or a physician to counsel a patient on reproductive health care decisions, but sometimes clinicians must comply with legal obligations that directly contradict the findings of medical research.

Clinical Evidence: Ultrasound Viewing

Ultrasound, either abdominal or transvaginal, prior to an abortion procedure is common practice to assure appropriate dating of the pregnancy. However, it is not medically necessary and can add to the cost of the abortion procedure [1].

Do women undergoing abortion want to view the ultrasound? A recent study of patients at a large urban US abortion center found that 42.6 percent of women desired to view their ultrasounds [2]. The authors found that patients with low-to-moderate certainty about their decisions to have abortions were more likely to choose to view the ultrasound. No studies have examined the impact of mandated ultrasound viewing, but, given that 57 percent of patients in a recent large study did not want to view the ultrasound, one might conclude that required viewing interferes with the shared decision making model typical in the patient-physician relationship [2].

The literature on the impact of optional ultrasound viewing in abortion care is limited to a small pool of studies. Two small studies examine first-trimester ultrasound viewing [3, 4]. Both demonstrate that women appreciate having the option of ultrasound viewing. Women who viewed their ultrasounds before first-trimester abortions continued with abortion at the same rate as women who did not view the ultrasound. More recently, a large study found that women who are less certain of their decision to have an abortion might be more likely to continue their pregnancies after ultrasound, but that the majority of women opt to terminate after viewing the ultrasound [5]. Most of the literature on ultrasound viewing demonstrates that women would like to have a choice about whether to view the ultrasound and that ultrasound viewing is not conclusively linked to the decision to continue a pregnancy [5].

Legislation: Ultrasound Viewing

Kathy and Dr. Robbins resemble nearly half of all abortion providers in that the law regulates all or some aspects of their practices. The number of overall abortion restrictions has increased dramatically in recent years. According to the Guttmacher Institute, “205 abortion restrictions were enacted over the past three years (2011–2013), but just 189 were enacted during the entire previous decade (2001–2010)” [6]. And, despite the lack of evidence that ultrasound viewing influences abortion decision making, a number of laws require the practice. The Guttmacher Institute cites 22 states that regulate the provision of ultrasounds by abortion providers [1]. In 2013, two states, Wisconsin and Indiana, added laws mandating that a clinician perform and describe the ultrasound and offer the patient the opportunity to view it and listen to the fetal heartbeat [6]. Three states—Louisiana, Texas, and Wisconsin—require clinicians to show and describe the ultrasound to the patient [1]. In two other states, North Carolina and Oklahoma, laws requiring ultrasound viewing are on the books but not currently enforceable [1].

Legislative Interference

The American Congress of Obstetricians and Gynecologists (ACOG) recently addressed the role of government in the patient-physician relationship:

Absent a substantial public health justification, government should not interfere with individual patient-physician encounters…. Laws that require physicians to give, or withhold, specific information when counseling patients, or that mandate which tests, procedures, treatment alternatives or medicines physicians can perform, prescribe, or administer are ill-advised. Examples of such problematic legislation include laws that prohibit physicians from speaking to their patients about firearms and gun safety; laws that require medically unnecessary ultrasounds before abortion and force a patient to view the ultrasound image; laws that mandate an outdated treatment protocol for medical abortion; and laws that prescribe what must be communicated to patients about breast density and cancer risk, contrary to current evidence-based scientific data and medical consensus [7].

Kathy is legally required to tell Amy that she cannot decline an ultrasound if she wishes to proceed with her medical care in this setting [8]. Amy does not want to view her ultrasound but must. This legislation forces physicians to violate the ethical principle of respect for patient autonomy, which entails that patients be able to choose which treatments they receive and that they be able to make treatment decisions without coercion [9]. Laws requiring that a patient be offered an ultrasound and the opportunity to view the results might be consistent with both the medical evidence on ultrasound viewing in abortion care and ethical medical practice, but laws that require it are not. Furthermore, forcing patients to have unwanted procedures—especially invasive procedures—or to view results against their will may in fact cause harm, violating the ethical principle of nonmaleficence [8]. Moreover, while ultrasound may be beneficial in pregnancy, viewing the ultrasound has little proven effect as demonstrated in the current literature [3-5]. Therefore, requiring mandatory ultrasound violates the principle of beneficence, or performing only those procedures that have a benefit to the patient.

Abortion is a contentious area of medicine, but, as noted by ACOG above, this precedent of legislative interference in abortion care has important implications for other areas of medicine that may be less contentious but equally important to the trusting relationship between patient and physician.