I recently came up against some jumbo-sized legal and ethical issues during a shift at work, and I very much want to discuss them, but a fair amount of backstory is required. So, presto: here it is.
There’s a special kind of camaraderie that naturally bubbles up when you work in a hospital. It’s all about teamwork, and every member of the team is essential: nurses, doctors, nurse’s aides, housekeeping staff, clerks. It is much like being in the military, or perhaps more like playing on a sports team…or at least like working in a restaurant. Yes, most like a restaurant. The clerk is the hostess, the aides are the bussers, the nurses are the waiters, the MDs are the cooks, and the patients are the customers. It’s everyone’s job to make sure that the customers leave happier and better off than when they arrived. Sort of like a hospital. I worked in restaurants for years: you don’t get to choose your customers. However, if a waiter says “I don’t want to serve table five because they ordered the steak tartare and I’m a vegan“, perhaps someone else would be kind enough to switch tables with them. Or, more likely, their manager would instruct them to go get a job at Zen Palate and show them the door.
Not so with hospitals, believe it or not.
Labor & Delivery — the name says it all. It’s where women labor and deliver. Babies. That’s why we’re all there, that’s what we all signed up for. At many large hospitals there are whole floors devoted to women’s health with an L&D unit, a postpartum wing, and antepartum wing and even a few GYN beds. But at my hospital (and I’ll often refer to it as “My Hospital” because it’s easier, but it’s not like I own the joint) we have only L&D and postpartum departments. So as long as they don’t have chicken pox or anything contagious, antenatal cases have no choice but to stay on one of these two units. GYN cases get scattered on various med/surg floors. Seems like that covers everybody, right? All patients with stuff going on in their ladyplumbing have an appropriate place to convalesce, right?
Wrong.
When my hospital closed its GYN unit several years ago it became instantly clear that there was nowhere to admit patients undergoing terminations, so they started showing up on labor & delivery which was generally regarded as inappropriate but unavoidable. Let me back up a little: we have two women’s health clinics where all straightforward abortions are performed (by “straightforward” I mean medically uncomplicated and gestationaly early; there’s really nothing straightforward about abortion, is there?) which means that when a medical or surgical termination patient makes their way to the unit, something is quite amiss. Examples:
- a woman with a cornual pregnancy that somehow made it to 17.4 weeks gestation
- a woman with a complete placenta previa that was brought in by ambulance because she was hemorrhaging on the subway while on her way to an elective 19 week termination that very day elsewhere. This was lucky on her part because she was unaware of her dangerous condition. Danger, danger.
- a woman who developed HELLP syndrome at 18 weeks.
- a woman who had started the procedure in the clinic (laminaria placement for cervical dilation) and then did not return for the completion due to pressure from her family. Several days and a high fever later, she was hospitalized.
My point is this: your average elective terminations rarely, rarely rarely end up on our labor unit. If they do, it means someone missed their Friday appointment and now it’s Saturday and the clinic is closed, or they’re a transfer from another hospital or clinic or some other paperwork screw-up. I think I’ve seen two in three years. We only do medical terminations on the unit–all surgical cases get transfered to the main OR– so really the role we nurses play is minimal. We admit the patient, we take their vital signs, we manage induction medications. That’s pretty much it. It’s not like we’re turning on the suction for a D&C and we’re not present for KCl injections. We get emergency cases, and we get cases where Mothers make agonizing decisions to end wanted pregnancies due to major fetal anomalies. That being said, if you are a woman in either of these difficult situations, good luck getting a nurse at my hospital, because our nurses have Letters. Lots and lots of Letters.
Back when the GYN unit closed years and years ago and L&D started admitting termination cases, the nurses balked, and in my opinion rightly so: abortions have no place on labor and delivery for countless reasons; and since the nurses had never been expected to “participate” in terminations before, they were unwilling to start now. In other words: it’s not what they signed up for. In response, hospital administration allowed those nurses who felt morally compromised to write “conscience letters” expressing their decision to opt-out of being assigned these cases–forever–thus opening a giant can of worms. Just how big is that worm can? Zeppelin-sized.
First of all, just like at a restaurant you don’t get to choose your customer. This is bullshit of the highest order. Personal politics should not enter into patient care ever. It is not our place as nurses to judge, it is our job to care for women in need. To only take certain assignments is the very definition of judgmental. If I tried to submit a letter stating that I didn’t want to care for any laboring women from Mali because they have a funny tendency to bite I’d be cited for discrimination.
Secondly, I work in a public hospital and therefore we accept any patient who walks in the door. Let me say this again: a Public Hospital with a capital ‘P’. We are funded with public monies. Whether you like it or not, these patients are exercising their rights under the law. Last time I checked, abortion was still legal. I have no interest in debating the moral morass surrounding abortion. I do not care of you think life begins at the point of conception. I do not care if it goes against your faith. I do not care if you believe abortion is murder. I do not care if it simply gives you the heebie-jeebies. The law is the law. Still don’t want to care for these patients? That’s no problem because guess what: there are many, many, many private and religiously based hospitals that don’t terminate pregnancies at all, and they are always hiring. Go work there.
Then there are problems with the letters themselves: you do not have to specify where you draw the line and the hospital does not ask you to. Do you have a problem with all abortions for all reasons in all circumstances or only elective terminations of healthy fetuses? How about healthy fetuses after 10 weeks? 15 weeks? Do you differentiate between 15.6 weeks and 16.1? Maybe only if the mother’s life is threatened. Or maybe only rape cases. Maybe only rape cases involving a family member. Perhaps fetal anomalies are sufficient rationale…quick, name which ones! Anencephaly? Trisomy 13? Trisomy 21? I think you get my point. These letters can be as vague as the writer wants them to be, and this administrative loophole results in nurses changing their moral attitudes on a shift-by-shift basis, and a case-by-case basis. I have seen nurses refuse cases of induced labors of non-viable fetuses or those that are clearly IUFDs and not terminations in the first place. It’s inexcusable. No one wants to be assigned a sad case, obviously, but it is unfair that the few without letters get these cases dumped on them simply because the rest of the staff have flexible morals or are just plain lazy or both. I have a friend on the unit who was called in and blatantly lied to: she was told it was busy and they needed extra help on the floor but when she arrived she found there was simply a termination case no one else would take. These vague “conscience letters” are ridiculous. Nothing is clearly outlined in them, and even if there were, we don’t have access to the letters on the unit anyway. I am convinced that half the time a nurse claims to have a letter filed, she actually does not.
Patients can and do suffer. These women can languish in triage having not been seen by a nurse for hours while the staff bickers and hems and haws in the hallway within earshot about what to do. Nursing administration gets involved, doctors fume and patients wait. And wait. And wait. Take the case of a woman who was devastated when she learned in clinic that her baby had trisomy 13 and made the difficult decision to terminate. She was sent to the unit by the clinic and the MDs tried to admit her and get her to an OR but no nurse would take the assignment. It was a Friday, and this poor woman was sent home after sitting in triage for 6 hours. She had to wait all weekend. Those who do get admitted may still suffer. Call bells go unanswered, they overhear gossip about themselves, they see eyes roll. They know– even when they don’t understand English, they know. It’s very fucked-up.
I do not have a conscience letter in my personnel file. During my interview it was made clear to me that these cases can end up on L&D, so I knew from the start that this was going to be a part of my job. Actually, since I knew nothing abut how clinics and hospitals function, I assumed that it would be. I was raised pro-choice in New York, a state that passed one of the most liberal abortion laws in the US back in 1970. These “conscience letters” are anathema to me. Do I want to circulate on D&Cs in the main OR all day? No, I want to work in L&D. I want to be part of a team, and usually I feel like I am…until one of these cases rolls through the door and it becomes every-nurse-for-themselves.
And that bring us to that shift I mentioned. Remember those legal and ethical issues I encountered recently? This is all just exposition.
On a completely different note, I changed the theme because I like a wider text area…easier to read. trouble is, with this theme the hyperlinks are veeerrrrrry lightly shaded in light brown. NOT easier to read. This post has a zillion links in it, if you have trouble seeing them, let me know and I’ll switch to yet another theme. Other than the link issue, I really like this one.
