Friday, July 8, 2011

Guest post: Telling my patients "No"

Happy Friday! Please warmly welcome Candid Cannula, a fellow abortioneer who's graciously joined us for a guest post this morning. I loved reading about her counseling dilemma -- one that we all grapple with, I think -- and hope you will too.


“I hope this is the right thing to do,” my patient – let’s call her Nicole – said right off the bat, instantly setting off warning bells. I asked her to elaborate, and her next sentence did nothing to alleviate my concerns: “Well, I’m basically being forced to do this.”

Those two sentences told me all I thought I needed to know, and I was sure that Nicole was not going to be seen today. But I pressed further, asking her all the standard questions to get a better picture of her situation. How had she felt when she first found out she was pregnant? Who had she told? Who was forcing her to be there, and in what way? Had she talked to anyone who was supportive? Had she considered continuing the pregnancy? How did she think she would feel after an abortion?

My role as an abortion counselor has two distinct parts: providing informed consent for abortion procedures, risks, aftercare instructions and contraceptive options; and discussing patients’ decisions to terminate their pregnancies, ensuring that they are confident it is the right choice for them and that they are not being coerced. I have the awe-inspiring right to turn patients away if I feel the latter criteria are unfulfilled, and it is that right that I struggle with when faced with patients like Nicole.

Her story came out in bits and pieces as we continued to talk: like so many of my patients, she had always considered herself to be against abortion and never imagined that she would wind up across from me in this counseling room. She did not think she would cope well after the procedure and she was struggling with whether it was the “right” thing for her to do. At twenty-one, she was a few years removed from legal childhood yet still dependent on her parents, and she said that they were the ones making her terminate the pregnancy. “My parents will kick me out if I have a baby,” she told me. “I’ll be homeless. I won’t have anywhere to go.”

What would you do if your parents were supportive of you either way?

“Honestly,” she said wearily, “I wouldn’t be sitting here right now.”

Nicole was not going to have a procedure that day. I was sure of it. But when I brought up the idea of her leaving, her tune changed.

“No,” she said urgently. “I have to do this.”

You told me you’re being forced. You told me you don’t want to have an abortion. We can’t see you when you’ve told me those things.

“I’m being forced, but I have to do this. I don’t WANT to do this, but I HAVE to. You don’t understand! It’s my decision too. I came here for an abortion, and I have to have an abortion.”

Nicole, what you’ve told me worries me. We find that women cope best after an abortion when they’ve been able to come to terms with it as their decision. Take some more time. The procedure, the cost won’t change between now and next week. Come back next week if you decide this is the right thing for you. We’ll still be here.

“NO!” she exclaimed. “I planned for this today. I can’t come back next week. Nothing’s going to change! You don’t understand, I don’t HAVE a choice. Yeah, I’m going to feel awful afterwards, and yeah, I’ll probably regret it in a way, but it’ll be worse otherwise – I have to have an abortion today!”

I spent a very long time with Nicole gathering the pieces of her story, asking the same questions, asking different questions, offering her resources to be able to continue the pregnancy, alternately trying to convince her to reschedule her appointment and feeling terribly conflicted about whether that was the right thing to do. I had little doubt that she would end up having an abortion, but maybe she could be in a better place with more time to own the decision. Or maybe another week would only create additional obstacles and difficulty, needlessly complicating her life further.

Where does the patient’s constitutional right to choose an abortion intersect with the counselor’s responsibility to screen and refuse service due to perceived ambivalence or coercion? What do ambivalence and coercion mean for women who lack the emotional or financial support to continue a pregnancy they may otherwise have welcomed? I came to feel that Nicole’s claim of being forced to be there was her way of coping with needing an abortion so that she didn’t lose her family and her home. She may have made a different decision if her family supported her either way, but the reality was that they didn’t, and she wanted to keep them in her life more than she wanted to continue the pregnancy. Many women are “forced” to have an abortion by various life circumstances; does it matter whether those circumstances are other people or faceless considerations like financial constraints, age, or health problems?

I’ve turned abortion patients away who have returned a week or two later, grateful for the extra time to think about the decision and better equipped to cope afterwards. I know that sometimes, it truly is better to wait when ambivalence is detected; patients can’t change their mind after the procedure. But I struggle with exercising my right to turn patients away when they protest. How do I know which patients will truly benefit from it? Doesn’t the patient ultimately know what’s best for her? Why should it be my right to deny a patient the service she insists on accessing?

Nicole had her procedure that day. Like many of my patients, I imagine no pregnancy outcome would have been positive for her. Many patients will never feel 100% confident or at peace with the decision to have an abortion. But no one would have subjected her to an assessment of ambivalence or coercion in order to continue the pregnancy, and that’s one thing that makes abortioneering such a uniquely challenging kind of work. In the counseling room, it’s often a delicate balancing act: trusting the patient to know what’s best for her, and stepping in when I judge that she is simply not ready to take the step that day.


  1. Poor Nicole :( It has to be so crappy between a rock and a hard place. But I really appreciate your perspective; regardless of who is "forcing" her to have an abortion, a decision is a decision and it's not always possible for clinic staff - or even friends and family - to drill deep enough to get at a patient's true feelings.

  2. I've never been comfortable with the entire idea of the counseling. I felt like it was invasive and as much as the staff at the clinic care, you are not in the end going to take my affairs in your hands and see to it my life is not made more difficult by your decisions- so in the end who are you to decide at all? If this were a root canal no such counseling would be needed, I'd have to convince no one of my preparedness or "mental readiness." As much as you may care, I don't know you and don't see you as a friend but rather the clinic staffer standing between me and the procedure I need. You are just one more hoop, one more person who has more power than I do in a decision that should boil to no one besides me. Life circumstances "force" people to do things all the time. Of course you feel forced when you have an abortion, it's expensive, it's usually a multi- appointment situation, it's got a time limit- everything about it is forced. But it's still the best option out of a bunch of shitty ones sometimes but having to point that out to the clinic staffer isn't really as much counseling as me smoothing your guilt for letting me have something my right to should not be questioned. I know that's not how you may feel or your intention on the other side of the desk, but it's what I'm thinking as I look at you.

  3. Jenni, thanks so much for sharing your experience with it. I know what you're saying and have always felt torn between CC's perspective and yours.

    I do have one quibble: I don't think it's about the counselor wanting to assuage her own "guilt." I don't know any abortioneers who feel guilty about "letting" patients have an abortion! But it's important to me that we do what we can to set patients up for a healthy experience during and after. Especially seeing as there are still too few places to turn for people who do have a hard time coping with their abortion decision (the Exhale and Connect & Breathe hotlines are great, but a lot of online and in-person resources are anti-choice places that tend to manipulate women's stories and sometimes make them feel worse). And having heard from some women who had little or no counseling and a hard time later, I tend to err on the side of, I'd rather offer counseling that most people don't need, than skip counseling that a few people could have seriously used.

    But I realize that can seem paternalistic, especially in light of the fact that, yes, hysterectomies and lobotomies involve fewer informed consent procedures than abortion does. And recent research has shown that US abortion patients often feel the way you do: that "coping with it" is their own business, that they see the counselor as a hurdle or someone to whom they have to justify themselves, or are worried if they say the wrong thing it could jeopardize their access to the procedure. I'd like to cite the presentation I saw on this, but the researchers said their article hasn't been published yet.

    On the other hand, in some countries where counseling doesn't go beyond informed consent and education about the procedure, research finds patients would rather have it address emotional and decision-making aspects as well. So I'm not sure where the best balance is.

    Sorry this comment is so long. It's just that this is an arguably complex dilemma, as this excellent post and your excellent response make very clear.

  4. Hi Jenni - thanks for commenting. I completely get where you're coming from and I know that plenty of patients I see feel the same way you do. I do my best to be sensitive and cater to each patient’s needs, whether she needs emotional support or just informed consent to get through.

    As I hopefully conveyed, I feel very conflicted about the whole matter because I do trust patients to ultimately know what's best for them and I never want to be someone who makes their life harder. But I also believe that abortion providers need the right to refuse patients - whether due to a medical condition that would make an abortion unsafe, or whether we judge that she's not sure of her decision (and while I get your point, a root canal is just not the same type of medical choice for most people). In a way, turning an ambivalent patient away is just as much a decision in favor of her health and safety as turning her away due to medical reasons. In either case we are trying to avoid a bad outcome as much as that’s possible (which it is, much of the time) and help the patient get what she needs.

    Of course it's disempowering to have someone else make that decision for you, and that's true no matter why someone gets refused. I saw a patient recently whose iron levels were WAY too low to even consider doing a surgical procedure argue, and argue, and argue, saying that she accepted the risk of having the abortion while severely anemic, it was her choice and why wouldn't we just do it? But obviously the doctor can and should refuse in that case. And if I tell the doctor that I’m just not sure about this patient because she seems really ambivalent, the doctor is going to be grateful I said something and will probably refuse to see her, because she can delay the abortion until her iron levels are up or until she’s really sure it’s the right choice. It’s not really about me and my guilt. I agree with everything placenta sandwich said, and also want to add that abortion doctors are a threatened class who deserve our protection and support too, and they rely on the counselor to ensure they don’t perform an abortion on someone who should not have an abortion. Yes, there’s an aspect of paternalism there, and I do struggle with this issue. But ultimately abortion providers have rights too, and we should not be forced to provide services for anyone if we have legitimate reason to think we shouldn’t.

  5. Whoops - guess that didn't work right - that was me, candid cannula, above...


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