I would remember that the last patient was, you know, just barely old enough to have this done, and did they really know what they were doing, and how would this affect them later? Should I have said something? ... I felt that I had betrayed who and what I believed. Who I was and what I believed in. (Cornelia)
And I just remember vividly the first, the first one I was in on. I was just watching what they were doing and I was standing in a place in the room where I couldn’t get out of it. And um, I was just horrified! Um, not, I mean, not with seeing blood. I wasn’t horrified from a squeamish point of view. Um, I was just horrified! And I, I, I couldn’t put, I didn’t understand it, you know? I just didn’t understand it at all. (Nora)
These quotes come from two nurses interviewed by Dr Debra Hanna for her academic study of moral distress experienced by nurses who assisted with elective abortions. In those interviews, Dr Hanna found that 10 out of 12 nurses experienced moral distress, even though nine of them had assisted willingly. They experienced this distress because they believed they had caused harm to “an objective good,” typically one they identified as the intentional destruction of another human.
Although the majority of nurses interviewed were healthy, they experienced consequences including “physical symptoms of moral distress such as sleeplessness, loss of appetite, nausea, diarrhea or other gastrointestinal upset, migraine or other type of headache”. Three of the nurses even underwent a tubal ligation, and the husband of a fourth had a vasectomy, so that “they would never have to make a choice for or against an abortion.”
The study is cited in Xavier Symon’s recent book, Why Conscience Matters: A defence of conscientious objection in healthcare. In it, he argues that health practitioners (and other professionals) who are forced to act contrary to their conscience suffer “moral injury”. This is because having to violate your deepest convictions about right and wrong is disorienting; it untethers you from the commitments that previously gave your life direction and meaning. It causes you to question who you really are—see, for example, the nurse quoted above who felt she had betrayed herself and her beliefs. This can prompt an existential crisis. A nurse who assists with an elective abortion may feel she can no longer say she is the kind of person who doesn’t intentionally take innocent human life.
The impact is most severe where someone finds themselves acting not against an isolated belief, but against “the very nexus of commitments that makes their life worthwhile”, like their religious faith. In this situation, Symons says, “To seriously violate conscience is, in a very meaningful sense of the word, to do violence to one’s self.” There’s a sense in which you’re coming apart as a person, in which you’re no longer a moral agent with a coherent outlook on the world. Instead, you’re internally fractured by contradictions and conflicts, and perhaps you have a sense that it’s no longer you who acts but someone else—a senior colleague, a patient’s demands, a legislature—that is overwhelming your will and acting through you.
As Dr Hanna’s study shows, this effect can be felt even by those who thought they were doing something worthwhile to start with. Once confronted with the reality of foetal body parts, initially willing nurses experienced the distress associated with having to act against what they came to see as an objective good. We might expect those who were unwilling from the outset—like conscientious objectors forced to act against their will and their identity-conferring beliefs—to suffer even greater distress.
Symons argues that conscience restrictions need to take account of this reality. Either their advocates must show they won’t lead to moral injury or, he says, they need to justify inflicting this moral injury on the practitioners involved. One thing they can’t do is trivialise conscience or pretend there’s no cost. The moral distress of nurses assisting with elective abortion makes that abundantly clear.
