Autonomy and Pregnancy

A comic humorously depicting pregnant women as zombies; by Jen Sorensen

Often when people think about issues of autonomy (the right to make decisions for one’s self) for pregnant women, they think about access to abortion. Other than having the decision to keep or terminate a pregnancy constrained by lack of abortion access, there are other ways that pregnant women lose decision-making rights.

In most of the USA people are allowed to make “living wills” or issue “advance directives” in order to indicate what medical treatment they would like to receive (or not receive) under particular circumstances. The point of the advance directives is to allow people to retain decision-making rights (that is, autonomy) even in the event that they are unconscious when they encounter the medical system. These “advance directives” can be very specific, or they can be very general, such as simply appointing someone to make decisions on one’s behalf in the event that one is unconscious or otherwise incompetent to make one’s own decisions.

Well, most people are allowed that right. But in 35 states pregnant women are not allowed that right. A partial list of these states can be found here. In these states if a woman is pregnant her living will is no longer considered valid and her advance directives for how she would like to receive (or refuse) care are ignored. If she has named someone to make decisions on her behalf, this too is ignored. Instead the doctors are required to make decisions about her treatment in the “best interests of the fetus.”

This is just one more example of how women’s autonomy is precarious. It is only respected if women are not pregnant, but if a woman becomes pregnant her rights to autonomy seem to become limited. Doctors will actually administer pregnancy tests to women (of childbearing age) before honouring (or ignoring, depending on the results) their living wills.

What Could be Done?

I have been trying to think of ways that a pregnant woman could retain the right to have her advance directives followed. One idea I had was that perhaps women should include a “no pregnancy test” clause in their advance directives. Alternatively, women could also include detailed instructions about which treatments they would accept or refuse if they were pregnant and unconscious or otherwise incompetent. This might not mean that the directive would be honoured, but I think it might provide the basis for legal action if the directive were ignored.

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Abortion Access in Canada

I recently found the article, “Who Decides?” by Scott Lemieux via a post on Figleaf’s blog (I left a comment there and this post is a modified version of that comment).

Lemieux muses about abortion access in Canada:

In Canada, late-term abortions are not legally restricted, and Canada also doesn’t have the other kinds of restrictions found in many American states and doesn’t exclude abortion from guarantees of health care. As far as I can tell, there’s no evidence that Canadian women get late-term abortions at significantly higher rates (and historically overall abortion rates in Canada have actually been lower). Essentially, absent evidence to the contrary, I think the presumption in favor of a woman’s decision-making capacity is justified, and further restrictions are likely to do more harm than good.

I find Lemieux’s musings on what abortion and abortion access might be like in Canada to be highly misleading. Canada does not have the kind of easy access to abortion that Lemieux implies.

Lemieux is right when he says that there are no laws restricting abortion in Canada. But that does not mean there are no restrictions. Most abortions in Canada are done in hospitals (rather than clinics) and hospitals are left to make their own policy regarding abortion. Most hospitals do have policies that restrict late-term abortion access. Hospitals used to set a cut-off of 21 weeks (with exceptions made for mother’s health or foetal health), but recently with advances in prenatal testing (especially prenatal genetic testing) many hospitals have increased this limit to 24 weeks (again with health-based exceptions). In these cases hospital policy does not seem to reflect a commitment to women’s decision-making (after the early period of the pregnancy), instead the policies reflect changes in medical technologies and the dates at which reliable test results become available. Some clinics also place limits on when they will perform abortions.

Second, even though abortions are legal, no hospital or doctor is required to perform them. So Canada also has issues with access when women cannot find a doctor in their area willing to perform an abortion. In some cases this effectively means there is no access. One province (PEI) has no abortion providers at all; and a second (New Brunswick) has virtually no abortion providers. Canada is also a large country with a small population so even in the provinces that do have abortion providers, women in the northern or rural areas of those provinces might not be able to access abortions.

Third, while it is true that abortions are covered under most provincial insurance plans (so they are a part of our guaranteed health coverage, as Lemieux states), abortion is one of the few services that are excluded from reciprocal billing (PDF).  Part of the guarantees made in the Canadian Health Act is that insurance coverage is portable from province to province. This means that if I live in Ontario, I am covered by the Ontario Health Insurance Plan (OHIP), but if I go on vacation to BC and have an accident I can still use my insurance in the BC hospitals. One of the few exceptions to this promise is abortion coverage. Most provincial insurance plans will cover abortion within that province, but will not cover abortions if you travel to another province. Obviously this can cause significant access problems for women in PEI and New Brunswick who cannot find access in their own province. It also limits access to abortion for college and university aged women who go to school outside of their home province. Most students remain covered under their home province, and if they find they need an abortion while in another province they will have to pay out of pocket.

Canada might not have any laws restricting abortion access, but this does not mean that access to abortion in Canada is unrestricted.

I include some links for further reading after the fold.

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Palin’s Response to AZ shootings

So Sarah Palin finally responded to the criticisms of her “cross-hairs map.” But I find her response really odd for two reasons.

First, according to the New York Times she said:

“Acts of monstrous criminality stand on their own,” Ms. Palin said in a video posted to her Facebook page. “Especially within hours of a tragedy unfolding, journalists and pundits should not manufacture a blood libel that serves only to incite the very hatred and violence that they purport to condemn. That is reprehensible.”

So when she says something it cannot be interpreted as an incitement to violence, because acts of violence “stand on their own” and should be considered the “acts of a single evil man” (in video about 0:59 ETA: She made the video password-protected but it is now on YouTube here).  But when journalists and pundits accuse her of saying those things then those accusations have the ability to incite violence. When someone other than Palin speaks, suddenly any ensuing acts of violence no longer  “begin and end with the criminals who commit them” (video about 2:05 the video is now on YouTube here), but can be at least partly attributed to the journalists who incite violence.

Second, the accusations against her amount to “blood libel,” which might sound good but could be read as anti-Semitic (if it makes any sense at all):

By using the term “blood libel” to describe the criticism about political rhetoric after the shootings, Ms. Palin was inventing a new definition for an emotionally laden phrase. Blood libel is typically used to describe the false accusation that Jews murder Christian children to use their blood in religious rituals, in particular the baking of matzos for passover. The term has been used for centuries as the pretext for anti-Semitism and violent pogroms against Jews.

A full transcript of the video is available at Shakesville.

A description of why the use of the term “blood libel” is anti-Semitic at Religion Dispatches Magazine.

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