AMA Journal of Ethics^®

Abstract

In abortion care, the term "elective" is often used as a moral judgment that determines which patients are entitled to care. Secular health care organizations that attempt to avoid controversy by allowing “therapeutic” but not “elective” abortions are using medical terminology to reinforce regressive social norms concerning motherhood and women’s sexuality because what distinguishes pregnant women with medical indications for abortion is that they originally wanted to become mothers or, in cases of rape, that they did not consent to sex. Secular health care organizations should stop denying the moral agency of patients and physicians who conclude abortion is morally acceptable and should only use the word elective when billing codes require it. Regardless of reason, the proper label for all abortion is health care.

The Term "Elective" as a Label

My stepfather recently had elective surgery—a classic case of knee replacement on demand. Tom wanted to reverse the perfectly natural physical change of eroded cartilage (exacerbated by his choice to play squash for pleasure), so he went to a physician who agreed with his value-laden rejection of how using a wheelchair would change his life. Insurance paid for this elective procedure because his physician recommended it, but that recommendation was simply confirmation that a safe medical procedure could return Tom’s body and life to what he previously experienced as his baseline state.

The phrase "knee surgery on demand" is as silly as the phrase "abortion on demand," yet the latter phrase appears in political rhetoric and judicial opinions.¹ Medicine designates all but the most emergent procedures as elective, which means they are all done on request of the patient. Yet the way in which abortion is categorized as elective or medically indicated is quite different than the way in which other medical procedures are so categorized, and it both reflects and feeds the politics of abortion. This dynamic has bad consequences for patients, which should motivate serious examination of how clinicians, health care organizations, and insurers have used—and misused—the term elective abortion.

Williams Obstetrics, a classic textbook in the field, provides one example of how the term elective abortion is defined in medicine. The content of its chapter on abortion suggests that the authors support legality and access, but the 2018 edition of the chapter contains a subsection called “Classification” that’s dedicated to distinguishing “elective” and “therapeutic” abortions:

Therapeutic abortion refers to termination of pregnancy for medical indications. Inclusive medical and surgical disorders are diverse and discussed throughout this text. In cases of rape or incest, many consider termination. The most frequent indication currently is to prevent birth of a fetus with a significant anatomical, metabolic, or mental deformity. The term elective abortion or voluntary abortion describes the interruption of pregnancy before viability at the request of the woman, but not for medical reasons. Most abortions done today are elective, and thus, it is one of the most frequently performed medical procedures.²

Yet Williams Obstetrics does not explain why abortions are classified. What purpose does this classification serve? What goal does it accomplish?

Some private and public insurance plans will not pay for "elective" abortions, and one could argue that clinicians and health care facilities are simply using terminology that reflects this coding issue. But whether the patient or her insurer will be billed for the procedure is not the primary significance of the term. Many secular hospitals and private practice groups attempt to avoid internal and external controversy by prohibiting their physicians from performing elective abortions.^3,4 As a result, women with medical indications can often receive therapeutic abortions within their current health care delivery systems, and those whose abortions are labeled elective must go elsewhere. For some patients, getting to a clinic requires significant travel, added expense, and braving a picket line. For all patients, being rejected by the organization that provides all their other health care sends a stigmatizing message: “We won’t perform this simple, safe, life-altering procedure for you because of your reasons.”

The Term "Elective Abortion" Is Moral Judgment Masquerading as Medical Terminology

Every abortion is elective. No pregnant woman with health problems is required to terminate her pregnancy—she can choose to deliver a baby with a disability or a terminal condition, risk her own health to deliver a baby, or decide the risks outweigh the benefits and choose abortion.⁵ But like women considering nonmedical risks and benefits of pregnancy and parenthood, every woman analyzing medical indications for abortion also has a choice.

Alternatively, perhaps no abortion is elective. Pregnancy is a radical bodily change, and the risk of death from childbirth is 14 times higher than from abortion.⁶ Deciding whether to bring a new child into the world is a serious moral commitment, and doing so can cause some women economic or interpersonal harm that could result in deeper or more sustained suffering than many medical conditions. Several physicians who perform abortions have told me that many of their patients do not perceive themselves as having any choice at all—dire social circumstances lead them to see abortion as their only option.

Social abortion is another term that is occasionally used to describe abortions that are not chosen in response to disease or anomaly.⁷ However, the decision to become a parent and the decision to not become a parent are equally "social." Both are lifestyle choices that revolve around women’s or couple’s visions of their most happy and meaningful lives, yet women with planned pregnancies are never described as pursuing social childbearing.

The term medical indication can falsely suggest the kind of medical complexity that typically justifies hospital care, implying a logic to some hospitals’ willingness to do therapeutic abortions while referring elective abortions to clinics. Yet abortion for the medical reason of an embryonic genetic anomaly discovered at 8 weeks does not require hospital-level abortion care, and abortion for the social reason of a partner’s abandonment at 20 weeks might be more safely done at a hospital in some communities. With the exception of some maternal health conditions, the reason for the abortion rarely changes the procedure. Instead, it is advancing gestational age that increases the procedure’s complexity and risks. Labeling an abortion therapeutic usually signifies whether it will be done, not how.

Ultimately, the term elective abortion is moral judgment dressed up as medical judgment. Medical versus elective is code for morally justified versus morally unjustified,⁸ as decided by someone other than the patient and her physician. Yet the patients’ rights and medical ethics revolutions of the 1970s were premised on the idea that ordinary people were serious moral thinkers entitled to request or refuse medical care according to their own values, and patients’ expressions of values and priorities in this area of medicine are as worthy of respect as in any other. When you learn a woman’s or a couple’s reason for an abortion, you also learn what moral status that woman or couple assigned to their embryo or fetus. When a woman does not want to have a child, and she has concluded that her embryo or fetus does not have moral status that outweighs her own, she is entitled to decide the risk of childbirth is not outweighed by its benefits. However, instead of treating a patient who has decided she needs an abortion as a moral decision maker and allowing her physician to respond to her as a medical professional, secular hospitals and practice groups that prohibit their willing physicians from performing "elective" abortions are using their institutional power to unjustly impose the judgment of strangers on her instead. As a result, this misappropriated medical terminology allows politics to rob patients of access to legal medical care.

The Term "Elective Abortion" Reflects and Reinforces Institutionalized Sexism

The distinction between elective and medically indicated abortions is a regressive, destructive conceit. What really distinguishes abortion patients with medical indications is that these pregnant women are presumed to have initially wanted a child—they would not have asked for an abortion if it weren’t for this health problem—or, in cases of rape and incest, that they did not consent to sex. The allowance hospitals, private practice groups, and insurers make for medically necessary abortions is not a medical line, it is a sex-discriminatory social line: We will only care for women who accept the social norms that women are meant to be mothers and that women cannot have sex solely for pleasure instead of for procreation. Mainstream medicine will cast out all others.

Women’s ability to control their fertility, which medicine can now safely and effectively provide, is a prerequisite to their full citizenship. By labeling the vast majority of abortions women request as elective, the medical profession labels women’s equality optional. In 2014, abortion rates were the lowest they’d been since abortion became legal nationwide in 1973.⁹ Still, 2.8 million US women confronted unintended pregnancy in 2011, and 42% of them chose to terminate those pregnancies.¹⁰ If the low 2014 abortion rate holds steady, 1 in 4 American women will have an abortion before menopause.¹¹ Calling the vast majority of these procedures elective is a cavalier way to dismiss the aspirations and disparage the judgment of the almost 1 million American women who ask for this procedure every year.⁹

Who is a candidate for care? If my stepfather had only sprained his knee and had requested knee replacement surgery, his request would have been refused—his physician would have told him that was not the appropriate medical solution for his condition, and therefore he would not have been a candidate for surgery. The way the term "elective" is used in abortion means this is what the vast majority of women confronting unwanted pregnancies are told by their health care practitioners—pregnancy termination is not the appropriate medical solution for your condition. That is a moral judgment, in many cases colored by a gender judgment, not a medical judgment.

Electing to Drop the Term "Elective Abortion"

For these reasons, I’ve discarded the term "elective abortion." Instead, my scholarship focuses on what I think of as "ordinary abortion." I use this term to describe the vast majority of abortions, which are done at early gestational ages for the most common reasons—eg, “Not ready for another child/timing is wrong,” “Can’t afford a baby now,” or “Have completed my childbearing/have other people depending on me/children are grown.”¹² Ordinary abortion is in contrast to extraordinary abortion, which describes the minority of abortion cases that have a variety of distinctive features but often include increased medical complexity and later gestational age.⁴ For the same reasons, secular health care organizations should stop discriminating among pregnant patients who want to end their pregnancy. Only use the word "elective" when billing codes require it, and otherwise resist the urge to categorize abortions when it’s not relevant to the medicine.

Most women can’t exercise their right to abortion without the help of a medical professional. As a result, regardless of reason, the proper label for all abortion is health care. The term "elective abortion" obscures the fact that abortion restrictions and bans are government policies of forced childbearing. Instead of categorizing abortions, the medical profession should continue working to make the word "elective" an accurate descriptor of every woman’s childbearing.