Why the Principles of Bioethics Require Emergency Abortion Protections

Bioethics…is grounded in four key principles: respect for autonomy, beneficence, nonmaleficence, and justice.Since Roe v. Wade was overturned in 2022, women have had limited access to abortion care. States with the harshest and most stringent restrictions on abortion “have increased rates of maternal and infant mortality and morbidity, [and] greater anxiety and depression among women of childbearing age.” Consequently, the United States is currently grappling with a host of maternal health issues.

Bioethics, or the study of the ethical, social, and legal issues in biomedicine and biomedical research, is grounded in four key principles: respect for autonomy, beneficence, nonmaleficence, and justice. In this instance, as well as in other issues of healthcare access, bioethics can provide a profound conceptual framework for thinking through “what it means to be human, and a member of society, in relation to experiences of health, wellbeing, and flourishing.”

So, what are the bioethical implications of emergency abortion access despite legal challenges to its appropriateness and validity? And, accordingly, what are the ethical arguments for and against making abortion care available to all pregnant people experiencing a medical emergency?

The Need to Respect a Pregnant Person’s Autonomy    

The principle of autonomy refers to individuals’ rights to make informed choices about their own bodies. This principle supports the notion that patients have the right to receive necessary medical care, including emergency abortions, without facing barriers due to legal or institutional restrictions.

“What I needed was an abortion, a standard medical procedure. An abortion would have prevented the unnecessary harm and suffering that I endured.”

The principle of autonomy demands that patients have the right to “receive information and ask questions about recommended treatments” to “make well-considered decisions about care,” which must include emergency abortions, which are common. Data show that at least a third of pregnancies involve emergency room visits, and up to 15 percent involve potentially life-threatening conditions.

Additionally, an amicus brief filed on behalf of 17 women who experienced pregnancy emergencies in states with near-total abortion bans emphasizes that emergency abortions are vital for saving lives and underscores the importance of considering patient autonomy in such care.

Amanda Zurawski, one of the women featured, recounted having to delay terminating her pregnancy until she developed sepsis. Only then were her doctors able to proceed. She spent three days in the intensive care unit and is now unable to conceive future children due to the infection.

Zurawski, who was also the primary plaintiff in a lawsuit challenging Texas’s abortion ban, stated in a press conference: “What I needed was an abortion, a standard medical procedure. An abortion would have prevented the unnecessary harm and suffering that I endured. Not only the psychological trauma that came with three days of waiting, but the physical harm my body suffered, the extent of which is still being determined.”

The Need to Protect Pregnant People from Harm

From a bioethical perspective, forcing a patient to continue a pregnancy, risking potentially life-threatening complications and psychological trauma until they are near death before medical intervention is permitted, raises significant concerns. Healthcare providers have a duty to avoid causing harm. Being denied access to emergency abortions leads to significant harm for pregnant people: increased maternal mortality; medical complications; and long-term negative health effects, including loss of future fertility. To adhere to the principles of nonmaleficence and beneficence, medical professionals must be able to provide emergency abortion care to those experiencing complications.

The American Association of Pro-Life Obstetricians and Gynecologists argued in its brief to the Supreme Court that the claim “that federally mandated emergency room abortions are needed to reduce maternal mortality rates and shortages of women’s health providers…[is] driven by speculation and ideology, not fact.” However, research estimates that the closure of abortion clinics and early gestational age limits for abortion increase maternal mortality by 6 to 15 percent.

The association also claimed in its brief that the “argument that induced abortions are required for the stabilization and transfer of patients is medically insupportable.” But pregnant individuals frequently present to emergency rooms with severe complications, and may exhibit symptoms such as fever spikes, uterine cramping, chills, contractions, shortness of breath, or significant vaginal bleeding.

The association’s brief further argues against the logic of applying the Emergency Medical Treatment and Labor Act (EMTALA) to emergency abortions, claiming, “Proponents of EMTALA-mandated abortions identify a handful of medical conditions supposedly requiring an induced abortion. But in each case, they misstate the range of treatment options for these conditions, the risks to the mother, the legal implications of the pregnancy complication, or all of the above.”

[M]any critics believe that doctors are over-complying with abortion bans at the expense of the pregnant person.

However, the American College of Obstetricians and Gynecologists (ACOG) has stated that abortion can be medically necessary and “[t]he science of medicine is not subjective, and a strongly held personal belief should never outweigh scientific evidence, override standards of medical care, or drive policy that puts a person’s health and life at risk.”

Impeding Professional Responsibility

 The principle of beneficence highlights providers’ duty to act in the best interest of their patients. For instance, the American Medical Association (AMA) Code of Medical Ethics states that a physician’s primary ethical obligation is to promote the wellbeing of individual patients. However, doctors who provide emergency abortions in states with severe restrictions face criminalization and professional liability, which impedes their duty. If a provider is legally barred from offering necessary medical care, their ability to meet this obligation is severely compromised.

Take Idaho as an example, where abortion has been criminalized and the use of the EMTALA to provide emergency abortions has also come under fire. EMTALA would ideally provide a federal backstop in states that ban abortion, but healthcare providers remain reluctant to offer emergency abortion care due to concerns over potential criminal and civil liabilities, thus failing to meet their obligations because of state interference.

It’s important to note that, to date, there have been no documented prosecutions. In fact, many critics believe that doctors are over-complying with abortion bans at the expense of the pregnant person.

But declarations submitted by physicians in the District Court in Idaho warn of the state law’s, “serious and negative consequences for patients and healthcare workers alike.” These statements demonstrate that Idaho’s abortion ban hinders medical professionals from fulfilling their ethical duties. Due to the risks involved in providing emergency abortions, many doctors have left Idaho to practice in other states.

This finding supports earlier studies showing that many ob-gyns prefer to work in states with more supportive abortion policies. “The consequences of provider shortages are serious,” St. Luke’s Health System notes in its amicus brief in the Idaho case. “Without enough physicians and nurses to provide medical care to a community, the quality of care suffers, wait times for an appointment increase, and practitioners become overworked and stressed, causing burnout and—in a vicious cycle—deterring others from entering the medical field or practicing here, which only compounds the shortages going forward. Again, these consequences will be felt by far more than just the pregnant patients most directly affected by [the state’s abortion ban].”

Hindering Distributive Justice

The bioethical principle of justice calls for fairness and equity in healthcare access. Emergency abortion protections promote justice by ensuring that all patients, regardless of their location or circumstances, have access to necessary emergency medical services, including abortions, thereby addressing disparities in healthcare access. However, state abortion bans not only harm the state’s residents by forcing them to travel out of state to access needed care, but they also put financial pressure on abortion funds and providers in other states to provide care.

A study from the Guttmacher Institute found that nearly one in five patients now travel out of state for abortion care. In 2023, more than 171,000 people traveled out of state for abortion care, with some driving over 11 hours to access needed services. In 2023, around 37,000 people traveled to Illinois for abortion care, while 15,800 patients went to North Carolina and 14,900 to New Mexico.

Other states, such as Colorado, Washington, and Virginia, have also struggled to keep up with the need for services from out-of-state patients. The increased demand for services from out-of-state patients has made it challenging for pregnant people to secure appointments. In Colorado, some patients are facing waiting lists of several weeks for abortion care. The costs of providing support have risen due to increased expenses for travel, childcare, and housing associated with accessing care out of state. Abortion funds are sounding the alarm about financial shortfalls.

“This abortion fund was designed to help tide people over. It was not designed to compensate for half the states banning abortion after [former President Donald] Trump’s Supreme Court overturned Roe,” Karen Middleton, president of Colorado-based reproductive rights nonprofit Cobalt, told Colorado Newsline in August.

In January, the Abortion Fund of Ohio faced the “very difficult decision” to suspend operations until February 1, 2024. In 2023, they provided $1.5 million to assist nearly 4,400 patients in obtaining abortions, a significant increase from just 1,175 the previous year. However, this surge in demand proved to be unsustainable.

Last summer, the Utah Abortion Fund and Indigenous Women Rising also had to pause their operations for a month after exceeding their budgets, and many other organizations are now reassessing their funding policies.

In March, Oriaku Njoku, the executive director of the National Network of Abortion Funds, published a request in Inside Philanthropy highlighting “[t]he absence of a robust, committed community of philanthropic donors,” contributing to the funding shortfall. However, despite the growing need for financial support for abortion funds, national organizations like the National Abortion Federation and Planned Parenthood have reduced the amount of assistance they provide to eligible individuals in their financial aid programs, citing similar budget constraints.

Distributive justice demands that everyone has access to abortion services in their own communities. Abortion bans violate this principle, as they not only harm pregnant people in restrictive states—they strain the entire system, making it harder for everyone to access necessary care.

The Human Consequences of Denying Emergency Abortion Access 

While many state abortion bans include “exceptions” for life-threatening pregnancy complications, some hospitals have refused to provide emergency abortion care for fear of prosecution. Documents released to AP News in response to a Freedom of Information Act request from February 2023 revealed at least a dozen federal investigations into pregnancy-related complaints across 19 states in 2022. One such complaint involved an incident at Sacred Heart Emergency Center in Houston, where a woman facing pregnancy complications was turned away by front desk staff. She ultimately miscarried in a restroom toilet in the emergency room lobby while her husband called 911 for help.

In another case, staff at Person Memorial Hospital in Roxboro, NC, informed a pregnant woman experiencing stomach pain that they could not provide her with an ultrasound. As she traveled 45 minutes to another hospital, she unexpectedly gave birth in the car, and her baby did not survive.

Additionally, a recent investigation by ProPublica found that at least two women in Georgia have died because of the state’s abortion ban, according to an official state committee tasked with investigating their deaths.

These alarming incidents underscore a critical need for the principles of bioethics to be considered in policymaking. The current landscape not only endangers the lives of pregnant people but also violates these fundamental ethical standards in healthcare, which require that pregnant individuals be allowed access to emergency care, and that healthcare professionals have the legal authority to provide it.