Two fifths of all female teenagers in America will have conceived by age 19 and half of these will deliver. ' Adolescent pregnancy has great health, economic, and sociopolitical implications, relating to issues such as prematurity, low birthweight, infant mortality, learning problems, delinquency, poverty, and dependency. 2 Every year there are about one million adolescent pregnancies in the United States, and approximately 350,000 teenagers chose to have an abortion. ' This article will highlight ethical and legal issues relating to abortion in adolescence. It is germane, however, to first review some medical characteristics of abortion in adolescence.
The physician who diagnoses pregnancy in an adolescent will often be amazed by how late the patient may come for care. Indeed, minors are overrepresented among those who develop complications relating to late or absent prenatal care, i and teenagers are major contributors to the statistics of second trimester abortions.4 Yet, teenage pregnancy carried to term still results in a higher mortality than interruption of pregnancy through legal abortion.5 Moreover, the abortion mortality rate for adolescents is lower than that of their adult counterparts.0 In addition, there is a much higher death rate with illegal abortions than with legal abortions.7 Although long term gynecological consequences of abortions during early adolescence have been reported, the study has not been replicated, M and current research has not been able to show increased rates of infertility or fetal loss among women who aborted in adolescence.4
From a mental health point of view adolescents are quite troubled and ambivalent about the abortion decision. They are less likely than older women to approve of abortion.9 Many adolescent girls who choose abortion will suffer transient behavioral difficulties. The procedure itself is considered stressful and may be followed by feelings of guilt and depression.10 Predisposed teenagers with prior emotional problems may experience a psychiatric breakdown after an abortion or delivery.11 These are worrisome facts, yet the majority of teenagers who have undergone abortions agree that the decision had a painful but maturing influence on their lives.11,12
Adolescent Stages of Moral Development
In considering the issue of abortion in teenagers it is important to telate it to the particular characteristics of adolescents:
* They are going through a developmental process (this includes cognitive and moral development);
* They exhibit varying degrees of maturity;
* They need to develop their autonomy.
In adolescence, there is an intensified emotionality that differs qualitatively from that of the child in that the emotions are experienced as a result of states of the self rather than as direct correlates of external events. Associated with this heightening of subjective feelings is the discovery of conflicts between different feelings. This happens around the same time that the capacity for formal operational reasoning emerges.
To understand an adolescent's ethical thinking, one needs to be aware of the stages of cognition and moral reasoning. This has been done by social psychologists who have stratified moral development in six stages. lî For the sake of conceptual clarity, they may be divided into three major categories: preconventional, conventional, and postconventional (Table 1).
The preconventional adolescent is frequently a deprived or moderately retarded youngster. These adolescents are often "well behaved" and are responsive to their culture's label of "good" and "bad. " They interpret "good" or "bad" in terms of physical power of those who enunciate the rules, ie, "I have to abort. My father told me that if I became pregnant he is going to kick me out of the house."
The conventional stage is most common in early adolescence. Maintaining the expectations and rules of the family, group, or nation is perceived as valuable in its own right. There is concern not only to conform but also to maintain and justify the social order, ie, "I have decided against an abortion. I'm a Catholic and that would go against the teaching of my church."
The postconventional level is sometimes noticed around mid-adolescence but it usually appears (if at all) in late adolescence. It is characterized by a strong impulse toward autonomous moral principles that carry their weight apart from the authority of the group or persons that follow them, ie, "I have decided to have this abortion because I'm not ready yet to be a mother. I think it is my duty to be well myself before I take care of a baby."
From the above it may be understood that the types of moral development represent a developmental sequence. Cognitive maturity is a necessary but not a sufficient condition to reach moral judgment maturation. Another important consideration is that in addition to the personal decision of the moment, the decision taken may also have an impact on the adolescent's future moral development.
Finally, it helps to recognize a peculiarity of adolescent pregnancy. In spite of its many potential adverse consequences, pregnancy is a landmark in a girl's life which (especially if carried to term) differentiates her from her nonpregnant peers. It means that she has crossed a biological threshold. No matter how negative the circumstances surrounding this experience, it remains phenomenologically a most significant (though often thwarted) event.14
The "mature minor doctrine" represents societal recognition of the adolescent's increasing maturity and autonomy. Historically, the era of the rights of minors started in 1967 when the Supreme Court recognized that a juvenile had a right to a just trial before any sentencing could take place. 15 This decision (in re Gault) has been considered an antecedent to the extension to adolescents of the legal rights described in laws dealing with contraception and abortion.16 The rulings related to abortion in adolescence are summarized in Table 2.
In 1976, Planned Parenthood of Central Missouri v Danforth stated that parents or guardians could not prevent an abortion on a consenting minor. ,7 In 1979 the Supreme Court ruled against a Massachusetts law requiring parental consent for the abortion of an unmarried minor (Be/lot ti ? Baird). However, in that ruling the court allowed certain measures for the "immature minor" encouraging parental consent or notification in those cases. As a safeguard the same decision allowed for the prerequisite of parental consent for abortion in the case of immature minors to be overruled by an appearance in the court. iS Variants on this theme were involved in 1981 (Supreme Court in HLV Matheson) and 1983 (City of Akron v Akron Center for Reproductive Health, Ine, and Planned Parenthood Association of Kansas City, Mo, Inc. v Ashcroft). Since legal issues relating to abortion remain under scrutiny and have the potential to change, specific state rules need to be consulted periodically, and in particularly difficult cases the aid of competent legal advice is recommended. IS>Z2 In everyday practice the situation may be further complicated by limitations of access imposed by the federal government (denial of Medicaid payment for abortions) that affect many teenagers. 23
The abortion debate has divided the medical community as much as the general population. Professionals holding honest positions, grounded in the best intentions, are nevertheless often engaged in angry battles and militating in bitterly opposing camps. This is often unrelated to the official position of their specialty, subspecialty, hospital, or institution. Those who invoke adolescent rights will argue strongly for adolescent autonomy in decision making regarding abortion. They are primarily concerned with the serious risk of increased adolescent morbidity and mortality (late diagnosis of pregnancy, late abortions, and complications of criminal abortion).24 Those who favor parental responsibility in decision making will support the concept of family autonomy and the special rights of parents to counsel and advise their children (attempting to "protect vulnerable, immature minors from the unforeseen consequences of their potentially irrational acts").25 A position relating to adolescent abortion is often also intertwined with an underlying view about the abortion decision in general.
THE MORAL DEBATE
A host of complex philosophical concepts have been advanced to analyze the moral significance of abortion. They center mostly, but not exclusively, on the personhood status of the fetus (Table 3).14
For the purpose of this article, a variety of opposing ethical thoughts most frequently expressed in relationship to the morality of abortion are summarized as follows:
1. Abortion is the equivalent of infanticide, hence the whole procedure is morally wrong.26
2. A fetus is not a person and has no moral claims: abortion presents no moral problems.27
Legal Status of Adolescent Abortion
Ethical Themes in Adolescent Abortion
3. Personhood is conferred neither at conception nor at birth, but is part of a process developing over time. An abortion following a late diagnosis would therefore be a vety serious decision, an early abortion would not. A fetus acquires moral status the closer it comes to the newborn status.28
4. A fetus has a moral claim to development and birth but it is not an absolute claim against all other considerations.29
Certainly these reflections do not exhaust the number of possible interpretations of the significance of abortion, yet they certainly suffice to illustrate the complexity of the issue and the often irreconcilable nature of the differences. Moreover, recent technological advances will continue to add new dimensions to this old dilemma.30
ADOLESCENT ABORTION COUNSELING
The debate surrounding abortion in adolescence can be approached from the vantage point of a multitude of diverse philosophical positions. When we are confronted with a pregnant teenage patient (as opposed to a speculation), the issue becomes even more urgent and difficult. Perhaps two cases will illustrate this point.
Jean, 17 years old, had been dating her boyfriend for a year. She had a strong conviction that she would be a virgin as long as she remained unmarried and that he would "respect her." She was the only daughter of elderly parents, raised in a fundamentalist tradition. She believed that only "bad girls" would anticipate sexual encounters and use contraceptives. When Jean saw me about her pregnancy, she was suffering deeply over the idea that she had betrayed her parents' trust and that she was "no good." She was torn by the conflict between sacrificing her pregnancy for the sake of her parents' happiness and the desire to "have Jim's baby. " In our counseling sessions she became aware of how she was considering different alternatives and contradictory values. Her first step was to discover what her genuine values were, as opposed to impulsive decisions that were arising in her mind (marriage, abortion). Ultimately, she decided to continue her pregnancy, motivated by the conviction that this was a responsibility she had to assume.
Joan, 15 years old, had been promiscuous and depressed tor a long time. After a suicidal gesture she finally accepted my suggestion for a psychiatric consultation. In her sixth month of therapy, shortly after deciding to initiate a sexual moratorium, she found herself two months pregnant. Her mother, an alcoholic in a recovery phase who was taking care of her three younger siblings, encouraged her to continue the pregnancy because "she didn't believe in abortion." Joan was not sure who the father-to-be was. She was torn between her perception of the fetus as a defenseless person in need of protection and love (like herselr) and her new understanding that she was not ready for maternity; that under the present circumstances her baby's future would be as bleak as her mother's and her own. In her second counseling session she decided to have an abortion. She cried bitterly, "I need to grow first!"
Whenever an adolescent chooses an abortion, the question may be raised: What is the moral significance of the act? It may have been variously described to the teenager as morally indifferent, as murder, as wrongdoing, as the lesser evil. These ethical questions are usually a major source of conflict for the developing adolescent.14 To be effective, counselors therefore need to be familiar with ethical reasoning, the stages of adolescent moral development, and an understanding of their own personal reactions and feelings toward both the patient and abortion. " Doing the utmost to be objective, guiding the patient with questions, and showing respect for the patient's autonomy while at the same time attempting to provide protection (whenever possible with family participation) may not only help the patient in crisis but also provide the opportunity for preventive and reparative counseling.
An overview of the medical significance of abortion in adolescence coupled with information relating to the corresponding legal, ethical, and ideological issues is especially helpful when analyzed from a developmental perspective. The debate surrounding counseling for the pregnant adolescent, sex education, adolescent contraception, and abortion should also be seen in the context of a larger developmental struggle in moral philosophy, political ideology, and socioculturel change. Currently, our society stands at a crossroads at which a number of different ethical systems are converging. Each is a carrier of a highly particulat kind of moral tradition. When such moral traditions encounter each other, they are, to some large degree, hurt and fragmented in the process. i2 Thus, it is no surprise that the confusion inherent to pluralism is highlighted in issues dealing with the status of adolescents.
In discussions on teenage morality, abortion, and birth control, it is often the case that the farther away a theorist is from clinical reality the more clear cut and tigid will be the viewpoint. Fortunately, professionals from the various disciplines involved in the care of pregnant adolescents have repeatedly offered thoughtful advice. Thus in 1983 a hastily proposed and researched solution to teenage pregnancy, the "squeal rule," was opposed by the vast majority of the medical community.33-35 Recently, the National Academy of Sciences addressed the issue of adolescent pregnancy prevention.36 The Academy Panel on Adolescent Pregnancy and Childbearing called for "aggressive public education" and, among other measures, supported a widespread availability of oral contraceptives as "the safest and most effective means of birth control for sexually active adolescents." It also advocated a greater distribution of condoms to teenagers and the need for sex education programs to include information on how to obtain these birth control products. Although the panel found "little available evidence" that programs to discourage teenagers from having sex are successful, it endorsed further study of such programs. In brief, it outlined a proactive program that requires greater support for low cost, convenient, and confidential birth control services to teenagers, including public and private clinics, as well as additional effort to develop comprehensive school based clinics. Finally, it proposed that, should prevention efforts fail, abortion should be available as an option to adolescents without mandatory parental consent. Adoption should also be a viable option. This is a bold step that needs to be followed by an approach to the important societal, familial, and educational issues that underlie adolescent "problem behaviors."37
Controversy about abortion in adolescence will continue in the broader society and within the profession. It therefore becomes part of our task to learn and update our medical knowledge and improve our ethical reasoning so as to help maintain the debate on a level of mutual respect and scientific accuracy.
Ultimately, our work and knowledge will bring aid and compassion to the teenagers (and their families) under our care.
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2. Baldwin WH: Adolescent presrtancv and childhearing: Growing concern for Americans, ftipiil Bull 1976: 31:1.
3. McAnamey ER. Greydanus ITE <edsi: Adolescent pregnancy: A risk condition.' Srmm Rmnul.il 1981; 5:1-103.
4. Cates W: Adolescent abortions in the United States. } Aduksc HeuWi Core 1980; 1:18-21.
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6. Cates W; The HvJe Amendment in action: How did the restriction of federal funds lor abortion ¿freer km income »«men.' JAMA 1981; 2*6.1109-1112.
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13. Ki>hlherg L. Gilligsn C: TIu Adi desceñí us u Phdtisnpher. American Academy of Arts and Sciences. Boston. Daedalus. 1971.
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18. Belimi v Borni 78-329 (US Supreme Court. 1979).
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20. Paul EW. Schaap R: Legal rights and responsibilities of pregnant Teenagers and their children, in Wells CF. Stuart IR (eds): Pregnanes in Adolescence. Needs, PruWems and Management. New York, Van Nostrand Reinhold Co, 1982.
21. Holder AR: Legal Issues m Pediatrics and Adolescent Medicine. New Haven, CT. Yale University Pr«s&. 1986.
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23. Berger LR: Abortions in America: The effects of restrictive funding. N Enal) Med 1978: 298:1474-1477.
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29. Thomson J): In defense of abortion. PhAe ftiHic Avoirs 1971: 1:47-66.
30. Callahan D: How technology is refraining the abortion debate. Hastings Cent Rep 1986: 16:13-42.
31. Silber TJ: Approaching the adolescent patient: Pitfalls and solutions. J AiLJesc HeoiA Cow 1986: 7:31S-40S.
32. Mclntyre A: A Brief History of Ernies. New York. McMillan Pub Q.. 1966.
33. Committee on Adolescence. American Academy of Pediatrics: Pregnancy and abortion counseling. Atfcurrics 1979:63:920-921.
34. Kreutner AK. Langhorst DM: Abortion ami abortion counseling, in fCreutner AK. Holinworth DR (eds): Adolescent Obstetrics ana Gynecology. Chicago. Year Bixik, 1978. fr 79-119.
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37. Jessor R. Jcssor SL: ProWem Rehavuir and Psychosocial Development. A Limgttudmul Study of Youth. New York. Academic Press. 1977.
Adolescent Stages of Moral Development
Legal Status of Adolescent Abortion
Ethical Themes in Adolescent Abortion