The abortion option - A Values Clarification Guide for Health Care Professionals

the abortion option

      A Values Clarification Guide
     for Health Care Professionals
The National Abortion Federation (NAF) is the professional association of abortion providers
in the United States and Canada. We are grateful to Alix Hirabayashi and Lisa Butel who
revised, expanded, and updated this publication. We acknowledge Laureen Tews, MPH who
provided feedback and guidance, and who developed and wrote with Terry Beresford the 1998
publication on which this guide was based. We additionally acknowledge Annie Baker, Joan
Garrity, and Pat Anderson who provided expert feedback on the original 1998 publication and
Educational Foundation of America, The Richard and Rhoda Goldman Fund, The John Merck
Fund, Open Society Institute, and The David and Lucile Packard Foundation whose generous
support of NAF’s Access Initiative Project and programs to educate health care professionals
made this work possible.

                          © 2005 National Abortion Federation
                        1755 Massachusetts Avenue NW, Suite 600
                                Washington, DC 20036

Why this publication was developed                      abortion training is not incorporated into
The exercises in this publication are designed          many residency programs, most health care
to help you examine your beliefs about                  providers will need to decide for themselves
abortion so that you may be better able to              how important it is to learn about abortion
care for women considering this option.                 and/or to obtain abortion training.
Because one’s beliefs about abortion are
linked to one’s thoughts about sexuality,               The following exercises are designed to help
pregnancy prevention, parenting, and                    you critically examine the factors that might
adoption among other issues, some exercises             influence your beliefs about parenting,
examine these topics as well. While some                adoption, and abortion and, for some, your
exercises are geared specifically toward                choice to become trained and to provide
providers who are making decisions about                abortion services. They are also intended to
whether or not to obtain abortion training              illustrate the possible consequences of your
and ultimately to be involved in providing              choice to provide or not provide service. It is
abortion services to their patients, the                for these reasons that the National Abortion
majority of exercises are appropriate for the           Federation developed this publication.
wide range of health care professionals who
provide care to women. As a health care                 How to use this publication
provider, your responsibility to assess your            The legal and historical overviews in Part I
feelings about abortion and providing                   provide background information about the
abortion care is greater than that of people in         context in which abortion services are
other professions, because your decisions will          currently provided and the personal and
ultimately determine whether or not women               public health implications of restrictions on
receive accurate information about their                women’s access to abortion. This baseline
reproductive health care options, are                   information can help set the stage for health
empowered to make the health care decisions             care professionals as they proceed with the
that are best for them, and are able to obtain          values clarification exercises.
high quality, supportive, respectful abortion
services if they choose abortion. Further,              Many exercises that follow in Part II and Part
because information about abortion is not               III can be used either individually (Part II) or
included as a routine component of most                 in a group setting (Part III). Ideally, both
medical school or nursing curricula, and                formats will be used so that you will have an

The Abortion Option: A Values Clarification Guide for Health Care Professionals               © 2005 NAF   i
opportunity for personal reflection, free of         Why it is important for health care
     peer pressure, as well as the benefit of hearing     professionals to examine our values
     other people’s viewpoints and testing your           In spite of our efforts at objectivity, we all
     beliefs against possible challenges from others      hold personal values that can influence how
     in your group.                                       we respond to our clients. Sometimes these
                                                          values are very clear to us and are easily
     Further, each of the exercises is designed to        articulated. Others exist at a deeper level, so
     stand on its own and, thus, instructors or           that we don’t necessarily recognize the
     others using this publication, particularly in a     influence they have on our behavior and
     group setting, can choose to use only one or         judgments as health care providers. Further,
     two exercises that suit their particular             one’s values may change in response to life
     objectives. Certainly all the exercises have         experiences and your encounters with clients
     value, but given time constraints and other          and colleagues may influence your beliefs
     considerations, the publication is designed to       without your having much of a chance to
     give flexibility to those who use it.                reflect on these changes.

     We have arranged the exercises in sections to        The exercises presented here are intended to
     help guide users through the various sources         help you clarify for yourself your present
     of influence that affect one’s values. We have       personal values about pregnancy options,
     also included graphics in the upper corners of       abortion, and abortion training, and to help
     the pages that can serve to orient users to the      you think about those values in the context of
     broad categories addressed by the exercises in       professional judgments you may be called
     this publication.                                    upon to make.

ii   © 2005 NAF                 The Abortion Option: A Values Clarification Guide for Health Care Professionals
Table of Contents
Part I – Historical Overview of Laws, Regulations, and
         Consequences of Limited Access to Abortion Services...................................1

Legal Issues in the United States and Canada ............................................................................1
       Overview of Abortion Laws and Policies in the U.S.......................................................1
       Overview of Abortion Laws and Polices in Canada ........................................................2

Consequences of Limited Access to Abortion Services...............................................................4
      Examples in the U.S. during the 1950’s and 1960’s .........................................................4
      Examples in the U.S. after Roe v. Wade ...........................................................................5

Part II – Tools for Clarifying Our Values ..............................................................................7

Introduction – Individual Exercises for Values Clarification .......................................................7

Section A: The Role of External Influences in the Formation of Our Values............................7
       A.1 – Family and Social Group .......................................................................................7
       A.2 – Spiritual Beliefs......................................................................................................9
       A.3 – Life Stage .............................................................................................................10

Section B: The Influences of Our Personal Experiences in the Formation Our Values ...........10
       B.1 – Sexual Intimacy and Risk-Taking ........................................................................10
       B.2 – Parenting, Adoption, Abortion, and Pregnancy Prevention .................................12

Section C: Self-Evaluation of Our Objectivity When Considering a
           Woman’s Pregnancy Circumstances and Her Options ...........................................16
       C.1 – Examining Our Comfort Level with Gestational Age ........................................16
       C.2 – Examining Our Comfort Level with Circumstances...........................................17
             of Each Woman’s Abortion Decision
       C.3 – Individual Cases: Examining Our Potential Biases ............................................18
       C.4 – Pregnancy Options Decision Making ..................................................................20
       C.5 – Parenting and Adoption: Examining Our Potential Biases ................................22

Section D: Providing Abortion Care: Professional Values Clarification Exercises ..................24
       D.1 – Views about the Role of the Health Care Provider .............................................24
       D.2 – Personal Assessment of Professional Obligations ................................................24
       D.3 – The Decision to Provide Abortion Care:
             Motivations and Obstacles to Practice ................................................................25
       D.4 – Overcoming Obstacles to Providing Abortion Care: A Self Evaluation ............26

Part III – Additional Instructions for Using Selected
           Exercises from the Guide in a Group Setting ................................................31

The Abortion Option: A Values Clarification Guide for Health Care Professionals                                          © 2005 NAF       iii
Past and Present – Historical Overview of Laws, Regulations, and Consequences


Legal Issues in the United States                           means that the decision whether or not to
and Canada                                                  have an abortion is left to a woman and
Given that your professional judgments, and                 her physician.
perhaps your personal values as well, are
influenced in part by legal limits and                  (b) During the second third of pregnancy
regulations that govern the medical                         (about 14 to 24 weeks), state laws may
profession, it is appropriate to give a brief               regulate abortion procedures only in order
overview of the regulations and laws that                   to protect the woman’s health.
relate to abortion. These overviews are by no
means meant to serve as a comprehensive                 (c) During the later part of pregnancy (after
review, but will provide a basis for                        about 24 weeks), and after the fetus is
understanding where the law sets limits on                  viable, state laws may prohibit abortion
the provision of abortion as opposed to where               except when it is necessary to preserve the
individual practitioners or hospitals might set             life or health of the woman. Most states
personal or institutional limits.                           (40 states and the District of Columbia)
                                                            have passed laws to prohibit post-viability
An Overview of Abortion Laws and                            abortions under most circumstances and,
Policies in the United States                               in practice, there are only a small handful
                                                            of doctors nationwide who offer this care
Abortion laws differ, rather dramatically in                to women who need it.
some cases, from state to state. However, the
Supreme Court has issued some key                       For some time, the framework of Roe v. Wade
decisions, starting with Roe v. Wade in 1973,           served as the basis by which the
which today serve as the basic foundation for           constitutionality of state laws related to
state abortion laws.                                    abortion was determined. Subsequent Court
                                                        decisions, however, particularly Planned
In the Roe decision, the Court established that:        Parenthood v. Casey in 1992, have established
                                                        that states can restrict pre-viability abortions,
(a) In the first third of a pregnancy (about the        even in the first trimester and in ways that are
    first 13 weeks), state laws and regulations         medically unnecessary, as long as such
    may not interfere with a woman’s right to           restrictions do not place an “undue burden” on
    end a pregnancy through abortion. This              women seeking abortion services. Thus, state

The Abortion Option: A Values Clarification Guide for Health Care Professionals               © 2005 NAF    1
Past and Present – Historical Overview of Laws, Regulations, and Consequences

    laws requiring waiting periods before a woman        Medicaid recipients to refuse to cover
    can have an abortion, mandatory counseling           counseling or referral for services, such as
    which promotes childbearing, reporting               abortion, which the HMO objects to on
    requirements, and parental consent or                moral or religious grounds. As a result, even in
    notification have been implemented in many           states with expanded funding, women seeking
    states. (Note: Some state constitutions have         abortions may face obstacles to finding a
    stronger privacy protection than the federal         Medicaid provider that will cover services.
    constitution and thus in these states some of
    these restrictions would not be permitted.)          Since 1996, anti-choice forces in Congress
                                                         have maintained a statutory ban on even
    Additionally, in practice, individual hospitals      privately funded abortions at all Department of
    and practices can and do impose other                Defense facilities, including military bases.
    restrictions, such as gestational limits,            These facilities are restricted from performing
    anesthesia requirements, and so forth, on the        most abortions, except in cases of rape, life
    abortion services they provide. Thus even            endangerment, and incest. Further, medical
    though women in the U.S have a                       insurance for military personnel and their
    constitutionally protected right to obtain pre-      dependents only covers abortion in cases of life
    viability abortions, these medical services          endangerment. Although members of both the
    might not, in fact, be available or accessible.      House and Senate have repeatedly attempted
                                                         to remove these restrictions they have been
    A woman’s access to abortion services in the         unable to garner enough support to reverse it.
    U.S. is influenced in part by her ability to pay
    for that care, either out-of-pocket or through       An Overview Abortion Laws and
    her private or public health insurance program.      Policies in Canada
    The Hyde Amendment forbids the U.S.                  (Contributed By Joyce Arthur, Director & Spokesperson,
    Medicaid program from paying for abortions           Pro-Choice Action Network, Vancouver, British Columbia,
                                                         Canada) (April 2004)
    except in cases of rape or incest, as well as
    when a pregnant woman’s life is endangered by        Canada first liberalized its strict law against
    a physical disorder, physical injury, or physical    abortion in 1969. The new law allowed
    illness, including a life-endangering physical       abortions to be performed in hospitals with the
    condition caused by or arising from the              approval of a “therapeutic abortion committee.”
    pregnancy itself. States may use their own funds     A woman could get an abortion only if the
    to pay for abortions not covered by Medicaid.        committee decided her life or health was in
    However, only 23 states offer additional funding.    danger. But the law resulted in arbitrary
                                                         obstacles and unequal access for women. Dr.
    In addition, Congress permits health                 Henry Morgentaler, Canada’s pioneer abortion
    maintenance organizations (HMOs) serving             provider and pro-choice activist, fought various

2   © 2005 NAF                 The Abortion Option: A Values Clarification Guide for Health Care Professionals
Past and Present – Historical Overview of Laws, Regulations, and Consequences

court battles culminating in a 1988 Supreme             many provinces flout the law due to an anti-
Court decision that threw out the entire                choice political bias that dismisses abortion as
abortion law as unconstitutional. This ruling           an “elective” and abortion clinics as private
became known as the Morgentaler decision.               businesses operating outside of Canada’s
                                                        universal healthcare system.
The Supreme Court grounded the right to
abortion in women’s constitutional right to             Clinics became legal only in 1988, but there is
“security of the person.” One judge also found          not enough volume to support clinics except in
that the abortion law violated women’s rights to        the largest cities. About two-thirds of abortions
“freedom of conscience” and “liberty.” Unlike in        in Canada are still performed in public
the U.S., women’s equality rights are enshrined         hospitals. However, only about 20% of hospitals
in Canada’s constitution, so courts have been           perform abortions, which forces many women
very reluctant to confer any rights on fetuses –        to travel long distances from their communities.
to do so would interfere with women’s                   Hospitals often restrict access to abortion
established constitutional right to equality.           because of arbitrary or anti-choice policies. For
Various court rulings since 1988 have denied            example, many hospitals impose restrictions
fetuses any legal recognition in Canada and no          such as quotas, gestational limits, and general
abortion restrictions have ever been passed.            anesthesia requirements. Most hospitals require
                                                        physician referrals and many have long waiting
Although the Canadian legislature tried to re-          periods. A few hospitals require the approval of
criminalize abortion in 1990, the bill failed to        two doctors, or parental consent for any surgery
pass. Today, Canada’s governments, judicial             on minors with no exception for abortion.
system, and the mainstream media are largely            Anti-choice doctors and hospital employees
pro-choice.                                             often act as gatekeepers, preventing women
                                                        from accessing abortion services or even
Abortion is fully funded by Medicare in                 obtaining accurate information about them.
Canada, except for four provinces that refuse           Finally, the Canadian Medical Association
to fully fund abortions in private clinics, even        maintains an old policy that essentially curtails
though they have been ordered to do so under            abortions after 20 weeks, unless they’re for
a federal law, the Canada Health Act. This              compelling health or genetic reasons.
law says that provinces must provide all
Canadians with equal access to fully funded             Anti-choice protest activity is low in Canada,
healthcare according to five basic principles:          especially in recent years, although clinic
portability, accessibility, comprehensiveness,          protests are still routine at some clinics,
universality, and public administration.                particularly in British Columbia, Ontario, and
Abortion is probably the only medically                 New Brunswick. However, three Canadian
required treatment that doesn’t fully measure           doctors were shot between 1994 and 1997,
up to any of these ideals. That is because              with American James Kopp as the leading

The Abortion Option: A Values Clarification Guide for Health Care Professionals               © 2005 NAF    3
Past and Present – Historical Overview of Laws, Regulations, and Consequences

    suspect. A bomb destroyed a Toronto clinic in                 Examples in the United States during
    1992, and one of the shot doctors was also                    the 1950’s and 1960’s
    stabbed by an unknown assailant in 2000. A                    We have excerpted passages from Carole Joffe’s
    provincial bubble zone law in British                         Doctors of Conscience1 describing the experiences
    Columbia, the Access to Abortion Services                     of physicians who practiced when abortion was
    Act, protects two clinics and one hospital                    illegal in most states.
    from protesters. Clinics in Alberta and
    Ontario use court injunctions to keep                         A doctor who was a resident in a New York City
    protesters at bay.                                            hospital during the 1960’s describing what he
                                                                  called the “Monday morning abortion line-up”:
    As stated above, this overview should provide                 What would happen is that the women would get
    enough general legal information for                          their paychecks on Friday, Friday night they
    completing the exercises in this publication,                 would go to their abortionist and spend their
    because the exercises focus on personal values                money on the abortion. Saturday they would
    clarification. It is prudent, however, for all                start being sick and they would drift in on
    health care providers in practice to be as                    Sunday or Sunday evening, either hemorrhaging
    informed as possible about laws related to the                or septic, and they would be lined up outside the
    medical care that they provide and thus we                    operating room to be cleaned out Monday
    would recommend further study of abortion                     morning. There was a lineup of women on
    related regulations and legislation in your                   stretchers outside the operating room, so you
    state or province.                                            knew if you were an intern or resident, when you
                                                                  came in on Monday morning, that was the first
    Consequences of Limited Access to                             thing you were going to do. (Joffe, p.60)
    Abortion Services
    The negative impact on public health when                     Another doctor describing her residency
    abortion is illegal or otherwise inaccessible is              experience with illegal abortion in a county
    well documented. As a health care provider,                   hospital:
    your decision to provide women with                           There were two gyn wards. They were supposed to
    unbiased information and appropriate                          have thirty-two beds each, but they had to have
    referrals, or your decision to provide or not                 beds all up and down the hallways. They were
    provide abortion services has a direct                        always full [because of illegal abortions]. They
    influence, positive or negative, on the                       must have had one hundred and forty beds in those
    accessibility of abortion. The following                      wards...The residents would get duties of twenty-
    examples show possible consequences of                        four hour periods, and in that period, you’d get ten
    limited access to legal abortion and may help                 to twelve admissions. They walked into the
    you determine what role you might play in                     emergency room bleeding. The first thing the
    addressing decreasing access.

     Joffe C. Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. Wade. Boston:
    Beacon Press, 1995

4   © 2005 NAF                      The Abortion Option: A Values Clarification Guide for Health Care Professionals
Past and Present – Historical Overview of Laws, Regulations, and Consequences

doctor down there did was send them for an X-ray             she was not responsive. We finally figured the only
to see what was in their belly-to see if there were          chance we had was to do a hysterectomy. We took
knitting needles, hooks, catheters up their                  her to the O.R., but Anesthesia said, “We won’t
belly...Then when they got to the ward, the first            give her anesthesia, without getting blood pressure
thing you did besides examine them was to do a               or a pulse. We can’t monitor where we are, and so
culture for gas gangrene. It was a standard we               we might kill her with the anesthesia.” So I had to
had, whether they had a fever or not, to take this           do something I don’t recommend to anybody, which
culture, because if they had gas gangrene, you               is a hysterectomy under local anesthesia. We got the
really had to take drastic measures, like surgery,           uterus out – I still have a picture of it in my
heavy duty antibiotics, and all that kind of stuff.          teaching files – it was basically a bag of pus. We
Until the suction curettage came through, the                found a coiled up catheter in there. When we were
routine was that you accumulated all the women               all done, I was walking along beside her in the
until two o’clock in the morning when all the                corridor – they were taking her back to her bed.
major surgery was done, and the last gunshot                 And one of the tragedies of this septic shock is that
wound had been cleared out of the emergency room             people remain lucid until the end, and she was
– then the first-year residents dragged the patients         holding my hand, and saying, “Doctor, help me,
down to the operating room and started doing the             I’m dying.” And I knew she was, and I knew there
D. & C.’s at two o’clock in the morning. That’s              was not a blessed other thing we could do for her,
when the operating room was quiet...There would              and before she got to her bed, around midnight, she
be two or three operating rooms going at the same            died, and I have been haunted by that girl ever
time. Between 2:00 and 6:00 AM you could get a               since. (Joffe, p. 58).
certain number of D. & C.’s done and clean up the
women who weren’t septic, scrape their uteruses              Examples in the United States after
and get them back upstairs so they could be                  Roe v. Wade
discharged in a day or two. (Joffe, p. 61)                   While the scenarios described above occurred
                                                             before Roe v. Wade, on a smaller scale, similar
A chief obstetrical resident in a public hospital            situations sometimes still arise because safe,
in the 1950’s describing a twenty-two year old               legal abortion is still not accessible to many
patient whom he treated for septic shock                     women. A 2003 study2 found that 87% of
following an illegal abortion:                               counties in America do not have a single
What happens there, the infection is so                      abortion provider. Some women, particular
overwhelming, the bacteria produce toxins that               immigrant women, are unaware that abortion is
lead to a collapse of the cardiovascular system.             legal in the U.S. and turn to alternative
These patients have no blood pressure, no pulse-in           methods for self-abortion, for instance self-
some cases there is absolutely nothing you can do to         administered misoprostol which has been
reverse the situation. We gave the girl blood,               widely used by women in Latin American
cortisone, hydrocortisone – nothing was working,             countries for self-abortion and is documented

Finer LB, Henshaw SA. Abortion incidence and services in the United States in 2000. Perspectives on Sexual and
Reproductive Health 2003; 34(1): 6-15.

The Abortion Option: A Values Clarification Guide for Health Care Professionals                           © 2005 NAF   5
Past and Present – Historical Overview of Laws, Regulations, and Consequences

    to be quite widely available in some                            B) On March 27, 1994, Kawana Ashley, a
    communities and urban areas in the U.S.                            nineteen-year-old single mother with a
    Further, legislative restrictions, such as parental                three-year-old son, shot herself in the
    consent laws, mandatory biased counseling, and                     stomach during the 25th or 26th week of
    waiting periods, make it difficult for women,                      her pregnancy. She was hospitalized but
    particularly young, low-income, and rural                          ultimately survived her injuries. Doctors
    women, to obtain abortions. The following two                      delivered a female infant by emergency
    stories are examples of the consequences of                        caesarean who died 15 days later. Ms.
    access limited by financial constraints.                           Ashley was a Medicaid recipient, but since
                                                                       Florida’s Medicaid program funds abortion
    A) Rosie Jiminez, a 27-year-old woman living                       only in cases of rape, incest, or life
       in Texas, died on October 3, 1977 from                          endangerment, she needed to find a way to
       complications from an illegal abortion she                      pay for the surgery herself. Unfortunately,
       obtained in Mexico. Rosie was on Medicaid                       by the time she got enough money together,
       but, because the Hyde Amendment                                 she was into her second trimester, and the
       prohibits the use of federal Medicaid funds                     cost was higher. When she had raised the
       to pay for abortion except in cases of rape,                    extra money she needed, she was beyond 20
       incest, and life endangerment, she could                        weeks, the cutoff point at which the clinic
       not obtain a safe legal abortion using her                      stopped providing abortions. Out of
       health insurance. While some argued that                        desperation to end her unwanted pregnancy,
       Rosie went to Mexico for her abortion                           Ms. Ashley endangered her own life.
       because she was ashamed and wanted to
       protect her privacy, the fact that she had                   The World Health Organization has estimated
       twice before obtained a safe, legal abortion                 that worldwide approximately 80,000 women
       using her Medicaid coverage, before                          each year die as a result of illegal or unsafe
       Medicaid stopped funding abortion                            abortions.3 Additionally, hundreds of
       services, clearly connects the cutoff of                     thousands suffer wide-ranging and serious
       Medicaid funding with Rosie’s decision to                    health consequences. Clearly, limited or
       resort to a cheaper, although illegal,                       nonexistent access to safe abortion has
       abortion in Mexico. Rosie was a single                       monumental consequences for individual
       mother of a five-year-old daughter. She was                  women and their families. These figures make
       a scholarship university student supporting                  clear, however, the impact on public health
       herself and her child while in school with                   when access to safe, legal abortion is restricted.
       welfare payments and her income from a
       part-time job. She was six months away
       from obtaining her bachelor’s degree.

     Unsafe abortion: Global and regional estimates of incidence of a mortality due to unsafe abortion with a listing of
    available country data. Third edition. Geneva, Switzerland: World Health Organization, 1997. Available at

6   © 2005 NAF                       The Abortion Option: A Values Clarification Guide for Health Care Professionals
Tools for Clarifying Our Values


Individual Exercises for Values                         Section A: The Role of External Influences
Clarification                                           in the Formation of Our Values
Sometimes it is helpful in the course of                External influences on our thinking can
narrowing down our focus to look at both the            encompass many areas. As we grow up we
external and the personal influences on the             are introduced to values and ideas by everyone
development of our values. Life stage, social           around us while we simultaneously compare
culture, and our early spiritual environment            them to our personal experiences and
are examples of external influences on our              perceptions. We have chosen to focus on the
values. Individual experiences with sexual              influence of our culture (family/race/social
intimacy, parenting, adoption, abortion, and            groups), our spiritual/religious beliefs, and
birth control also have their places in the             life stage to connect them to our ideas about
shaping of our views. The following exercises           family and parenting, and consequently
are designed to help you identify the                   pregnancy options and abortion.
experiences that may contribute to your
present values about both the broad and                 Exercise A-1: Examining the Role of
specific aspects of abortion. Again, it is hoped        Family and Social Groups on Our
that understanding our personal beliefs about           Values
abortion will help us provide better care for           The family or social group (i.e. heritage, extended
women facing an unplanned pregnancy and                 family, adoptive family, socio-economic group)
considering the option of abortion. The                 that we grow up in provides us with our
exercises are divided into four categories:             customary beliefs and early social values. We use
external influences, personal experience                these as a backdrop when we interact with others
influences, and, with those in mind, a woman’s          and form opinions as we mature. Depending
life circumstances around her abortion. Finally,        upon our personal temperament we may integrate
we look at professional roles and responsibilities.     these values automatically or challenge them at
                                                        different points in our lives.
These exercises and questions can provide
you with insights as you work through them              The purpose of this exercise is to reflect on the
alone. Discussing your reactions to and                 source and influence these core beliefs have on
thoughts about them with others can also                your present ideas about parenting, abortion, and
expand your insights through shared and                 adoption.
different experiences.

The Abortion Option: A Values Clarification Guide for Health Care Professionals                © 2005 NAF     7
Tools for Clarifying Our Values

    1. a) Did the family you were brought up in            b) Does your present socio-economic group
       discuss specific values around parenting,           differ from that of the family you were
       adoption, or abortion? ____ Yes ____ No             brought up in? ____ Yes ____ No
       If yes, describe: _____________________             If yes, has this affected your views about
       __________________________________                  parenting, adoption, or abortion? _______
       __________________________________                  __________________________________
      b) Were there any family events that
      changed these views while you were living         4. Which social group would you consider has
      with the family? ____ Yes ____ No                    been the predominant influence on your
      If yes, describe: _____________________              values on parenting, adoption, and
      __________________________________                   abortion?
      __________________________________                   Heritage/race ____ Socio-economic ____
                                                           Family ____
      c) Describe any similarities or differences
      between the values you presently hold             5. a) Choose one of the options in each
      about parenting, adoption, or abortion and           category that would be the most
      your family’s values about parenting,                encouraged by your predominant social
      adoption, or abortion. ________________              group.
      __________________________________                 Number of          Family             Age of new
      __________________________________                  children          forms               parents
                                                        ❑ 0 child      ❑ single parent      ❑ Teenage parents
    2. Did your family’s values reflect your race/      ❑ 1 child      ❑ two-parent         ❑ Parents age 20-30
       heritage or nationality’s values?                ❑ 2 children   ❑ multigenerational ❑ Parents age 30-40
                                                                         in household
       ____ Yes ____ No
                                                        ❑ 3-4 children ❑ same-sex parents ❑ Parents age 40-50
       If no, how did they differ? ____________
                                                        ❑ 5+ children ❑ single gay parent
                                                           b) Does this represent your present life
                                                           experience? ________________________
    3. a) Did the socio-economic group you were
                                                           In what ways, if any, has this caused
       brought up in have any influence on your
                                                           conflicts with your family? ____________
       values about parenting, adoption, or
       abortion? ____ Yes ____ No
       If yes, describe its influence: ___________

8   © 2005 NAF                The Abortion Option: A Values Clarification Guide for Health Care Professionals
Tools for Clarifying Our Values

6. a) Do your current values differ from the                1. Have you held the same spiritual beliefs
   values you were brought up with in any of                   since childhood? ____________________
   the following areas? Check any that apply.                  __________________________________
❑ large families   ❑ small families   ❑ family on welfare
❑ role of women    ❑ role of men      ❑ mothers working
❑ birth control    ❑ adoption         ❑ abortion            2. How often, on average, during a day, do
❑ daycare          ❑ divorce          ❑ blended families       you consciously refer to your spiritual
❑ sex before       ❑ mixed race       ❑ marrying outside       beliefs before making a decision? After
  marriage           parents            of culture
                                                               making a decision? __________________
  b) If your values differ, what influenced the
  change? ___________________________
                                                            3. Have you been challenged by life
                                                               circumstances that called on actions not
                                                               supported by your religious or spiritual
7. What percentage of your current ideas
                                                               beliefs? Were you able to reconcile these
   about family is culturally (family/social
                                                               actions with your beliefs at a later date?
   group) influenced? ____ Influenced by
                                                               Did you do this on your own or with
   personal experience? ____ Other? ____
Exercise A-2: Examining the Role of
Spiritual Beliefs on the Formation of
Our Values
                                                            4. Do your beliefs about any of the following
Our spiritual or religious beliefs may be rooted in            topics that are influenced by your spiritual
our family or arrived at independently during                  values conflict with anyone in your life at
different points in our lives. Some people consider            present?
these private contemplations while others share these
                                                              Beliefs about family?        ___ Yes   ___ No
beliefs openly in their everyday interactions. The
                                                              Beliefs about social roles? ___ Yes    ___ No
merging of political and spiritual ideals in society
                                                              Beliefs about sex?           ___ Yes   ___ No
has historically been a difficult marriage. The
                                                              Beliefs about birth control? ___ Yes   ___ No
purpose of these questions is for you to reflect on the
                                                              Beliefs about abortion?      ___ Yes   ___ No
role of your spiritual beliefs in your everyday life.
                                                              If yes, how have you reconciled these
Take a moment to reflect on the following                     differences? ________________________
questions and take note if these raise any                    __________________________________
other issues for you.                                         __________________________________

The Abortion Option: A Values Clarification Guide for Health Care Professionals                  © 2005 NAF   9
Tools for Clarifying Our Values

     Exercise A-3: Examining the Role of                      when you were 18? Describe how your
     Life Stage on the Formation of Our                       views have changed since that time._____
     Current Views                                            __________________________________
     Our age influences our reactions to life and             __________________________________
     change. Youth provides us with optimism, easy            __________________________________
     access to childhood memories, and endless
     possibilities but it can also limit our broader       4. Have your views about the choice of not
     understanding of the impact of our decisions.            having or having children changed since
     Additional years bring us the perspective                you were 18? Describe: _______________
     provided by an accumulation of experiences but           __________________________________
     the depth of this perspective is dependent upon          __________________________________
     their range and the personal insights we have            __________________________________
     about these experiences. The purpose of these
     questions is to remind us to pay attention to the     5. How does your present age affect your
     influence of our age on our understanding of our         perspectives when discussing pregnancy
     clients’ dilemmas and the fluid nature of our            options with a patient? _______________
     perspectives throughout our lives.                       __________________________________
     1. How did you feel about romantic
        relationships when you were 16? 25? 35?            Section B: The Role of Our Personal
        45? Describe the differences: __________           Experiences in the Formation of Our Values
        __________________________________                 We have raised questions about the external
        __________________________________                 influence of family and social culture, age, and
        __________________________________                 spiritual values on the formation of our values. In
                                                           the following exercises we explore how our own
     2. What do you think would be the ideal age           experiences (and those of our intimate others)
        for a woman to have her first child? Have          with sexual intimacy, and our histories with
        your views changed about this since you            pregnancy, fertility, infertility, adoption, abortion,
        were 18? Since you were 30? 40? 50? What           and parenting can also influence our perspective.
        influenced these changes? _____________
        __________________________________                 Exercise B-1: Examining Our Own
        __________________________________                 Experiences with Sexual Intimacy and
        __________________________________                 Risk-Taking.
                                                           Because the need for an abortion always begins with
     3. What did you think of teenage pregnancy,           the act of sex, it is important to be aware of our
        adoption, single parenting, and abortion           underlying attitudes about this topic. Depending
                                                           upon our own personalities, our sexual identity and
                                                           experiences are often deeply personal and not often

10   © 2005 NAF                  The Abortion Option: A Values Clarification Guide for Health Care Professionals
Tools for Clarifying Our Values

discussed with others. We gather information through    4. Which of the following have had an
our own experiences, what we read and see in the           impact on your sexual or intimate
media and literature, and from stories gleaned from        relationships:
our social circle. Take a moment to reflect on the        Sexual abuse or sexual assault       _______
following questions and ask yourself if any of these      Coerced sex                          _______
experiences affect how you would consider a patient’s     Sexual infidelity                    _______
sexual history and its role in her pregnancy.              (yours, partner’s, parents’)
                                                          Infertility or fear of infertility   _______
1. Was your first sexual intimacy well planned            Sexually transmitted disease         _______
   or spontaneous? Was birth control an issue?            One night stand                      _______
   Given your present perspective, is there               Unplanned pregnancy                  _______
   anything you would change about that                   Abortion                             _______
   experience? If yes, describe. ___________              Drugs or alcohol                     _______
   __________________________________                   5. Which of the topics listed in #4 above
   __________________________________                      would you feel the most comfortable
                                                           discussing with a client having a similar
2. How healthy is your own sex life at                     experience in her own life? ______ The
   present? Is there anything you would like               least comfortable? ______
   to be different? If you are unable to make
   any changes, how has this affected your life         6. Describe how your experiences (or lack of )
   at present? Describe: _________________                 influence your discussions with clients in a
   __________________________________                      positive way. _______________________
   __________________________________                      __________________________________
   __________________________________                      __________________________________

3. Have you always had a sexual partner                 7. Describe how your experiences (or lack of )
   during your adult years? If not, what was               influence your discussions with clients in a
   the longest period of time you went                     negative way. ______________________
   without sexual intimacy? Describe any                   __________________________________
   effects it had on your life at the time. ___            __________________________________
   __________________________________                      __________________________________
   __________________________________                   8. What strategies would you use to improve
   __________________________________                      your comfort level with these topics if they
                                                           impacted the life of one of your clients?__

The Abortion Option: A Values Clarification Guide for Health Care Professionals                © 2005 NAF   11
Tools for Clarifying Our Values

     Exercise B-2: Examining Our Own                      Have any of these experiences complicated or
     Experiences with and Views about                     assisted in your ability to understand your
     Parenting, Adoption, Abortion, and                   clients’ choices? If yes, describe: __________
     Pregnancy Prevention                                 ____________________________________
     Not all of us become parents, but many of us have    ____________________________________
     had experiences and/or risks with pregnancy. Our
     experiences often affect how we see others in        2. Which, if any, of the following have you had
     similar situations. Think about your responses to       personal experience with in the role of child
     these questions and your present ideas about the        or family member? (check all that apply)
     challenges of parenting, adoption, abortion, and        Welfare                               _______
     pregnancy prevention.                                   Mental health problems                _______
                                                             Drugs and alcohol abuse               _______
     Parenting                                               Prenatal health risk by mother        _______
     Our experiences with parenting color the way we         Single parenting                      _______
     see it as an option for women. It is important to       Divorce/blended families              _______
     acknowledge our own experiences to help us be
     aware of our biases.                                 Was your experience as a parent or child
                                                          compromised in any way by these issues?
     1. If you do not have children, which of the         Describe: ____________________________
        following statements would apply to you?          ____________________________________
        (check all that apply)                            ____________________________________
       Do not want to have children      _______
       Not ready to have children        _______          How have you coped with these experiences?
       Infertility/difficulty conceiving _______          ____________________________________
       Lack of opportunity               _______          ____________________________________
       Do not want to be a single parent_______
       Financial reasons                 _______          Have any of these experiences complicated or
       Health reasons                    _______          assisted in your ability to understand your
       Career goals                      _______          clients’ choices? If yes, describe: __________
       Placed a child for adoption       _______          ____________________________________
       Loss of a child                   _______          ____________________________________
       Undecided                         _______
       Other                             _______          3. Would you or others view your parents/
                                                             family as the “perfect” family? ______
     If any of the above reasons have created stress         If yes, describe the impact on your present
     in your life, describe how you have coped.              views on parenting and family. _________
     ____________________________________                    __________________________________
     ____________________________________                    __________________________________

12   © 2005 NAF                 The Abortion Option: A Values Clarification Guide for Health Care Professionals
Tools for Clarifying Our Values

4. If you are a parent, have you experienced              Considered adoption when       _______
   any of the following with your child                    I or my partner became pregnant
   (children)? (check all that apply)                     Work(ed) in the adoption field _______
  Health challenges                     _______
                                                        How have these experiences affected your
  Mental health issues                  _______
                                                        personal life? _________________________
  Drug addictions                       _______
  Financial challenges                  _______
  Single parenting                      _______
                                                        Have any of these experiences challenged or
  Divorce                               _______
                                                        assisted in your objectivity as a health
  Death of a child                      _______
                                                        professional when counseling a woman about
                                                        pregnancy options? If yes, describe: _______
How have you coped with these experiences?

                                                        2. If you have no personal experience with
Have any of these experiences complicated or
                                                           adoption, has your objectivity been
assisted in your ability to understand your
                                                           challenged as a health professional when
clients’ choices? If yes, describe: __________
                                                           counseling a woman about pregnancy
                                                           options? If yes, describe: ______________
Fewer of us have personal experience with adoption
than we do with parenting. As with parenting, it is
                                                        Our experiences with abortion vary. It is
important to acknowledge how our experiences or
                                                        important to assess where our experiences are
lack thereof may influence our views of this option.
                                                        derived from and the influences they may have on
                                                        our objective understanding of other women’s
1. If you have a personal experience with
   adoption, which of the following apply?
   (check all that apply)
                                                        1. If you have experience with abortion,
  I am adopted                   _______                   which of the following apply? (check all
  Family member/friend is adopted_______                   that apply)
  Placed a child for adoption    _______
  Family/friend placed           _______                  My partner or I have had an abortion ____
    child for adoption                                    I have accompanied a family member ____
  Trying or tried to adopt       _______                  I have accompanied a friend           ____
  Family member/friend           _______                  I am aware that a family member and/
    adopted a child                                         or close friend has had an abortion ____

The Abortion Option: A Values Clarification Guide for Health Care Professionals              © 2005 NAF    13
Tools for Clarifying Our Values

       My partner or I have considered                    3. If you have no personal experience with
         abortion because of pregnancy         ____          abortion, has this had any effect on your role as
       I work in the abortion field            ____          a health care professional counseling a woman
       My family or I picket at                              about her pregnancy options? If yes, describe:
         abortion clinics                      ____          __________________________________
     Which of the above (if any) have had the
     most impact on your views on abortion?               Pregnancy Prevention
     ____________________________________                 Our attitudes about abortion sometimes have
     ____________________________________                 links to our views on the preventative side of
                                                          pregnancy. Birth control failure, absence, or
     Have any of these experiences challenged             misuse is a complex topic too often simplified if
     or assisted your objectivity as a health care        we do not address the complexity of individual
     professional when counseling a woman about           personalities, the power dynamics of relationships,
     her pregnancy options? If yes, describe:             cultural differences, and women’s experiences with
     ____________________________________                 the side effects of medications. Take a moment to
     ____________________________________                 reflect on your own experiences and evaluate
                                                          these in relation to your views on pregnancy
     2. If you or your partner has had an abortion,       prevention.
        describe the most difficult aspects of this
        decision. __________________________              1. Considering your own experiences with
        __________________________________                   birth control methods, have you
                                                             experienced any of the following? (check all
     Describe the positive aspects of this decision.         that apply)
                                                             Difficulty accessing birth control _______
                                                             Parental disapproval               _______
                                                             Partner conflict                   _______
     If you could, what would you have changed
                                                             Financial difficulties             _______
     about the experience? __________________
                                                             Misinformation                     _______
                                                             Compliance difficulties            _______
                                                             Lack of preparation                _______
     Have any of these experiences challenged or
                                                             Failure of method                  _______
     assisted your objectivity as a health care
                                                             Medical contraindication           _______
     professional when counseling a woman about
                                                             Use influenced by drugs or alcohol_______
     her pregnancy options? If yes, describe: ____
                                                             Assumed partner was using          _______
                                                             Cultural difference                _______

14   © 2005 NAF                 The Abortion Option: A Values Clarification Guide for Health Care Professionals
Tools for Clarifying Our Values

If yes, how did you solve these problems?               3. Would you describe yourself as a risk taker
____________________________________                       in general? ____ Yes ____ No
____________________________________                       Do you take risks with your health?
                                                           ___ Yes ___ No
If you have been pregnant, how many of your                Smoker?                          _______
pregnancies are the result of any of the above             Overweight?                      _______
difficulties with birth control? _______                   No exercise?                     _______
                                                           Seatbelts?                       _______
2. Have you or your partner experienced any                Sunscreen?                       _______
   of the following side effects from a birth              Drive too fast?                  _______
   control method? (check all that apply)                  Always practice safe sex?        _______
  Allergic reaction                     _______            Safe oral sex?                   _______
  Weight gain                           _______            Regular pap or other
  Mood changes                          _______             routine tests?                  _______
  Irregular bleeding                    _______            Ask potential partner about STD’s
  Nausea                                _______             before sex?                     _______
  Pain                                  _______         Have you taken risks with
  Change in sexual performance          _______          birth control? ____ Often?         _______
  Acne                                  _______         Have you discussed this with a health
  Change in sexual pleasure             _______          professional?                      _______
  Change in libido                      _______
                                                        Do you follow the same birth control advice you
If yes, how many times have you changed                 give to clients you counsel? ___ Yes ___ No
your method? _______                                    If no, why not? _______________________
Has this caused stress in your life? If yes,            ____________________________________
describe: ____________________________
____________________________________                    Have your experiences strained or assisted
____________________________________                    your objectivity when you discuss birth
                                                        control and pregnancies with clients? If yes,
                                                        describe: ____________________________

The Abortion Option: A Values Clarification Guide for Health Care Professionals             © 2005 NAF    15
Tools for Clarifying Our Values

     Section C: Self-Evaluation of Our                          At viability                        _____
     Objectivity When Considering a Woman’s                     At the end of the second trimester _____
     Pregnancy Circumstances and Her Options                    At some point in the third trimester_____
     When a woman presents with a pregnancy and                 It depends on the reason for
     is examining her options, her circumstances will             the abortion                      _____
     play a role in her decision. It is natural for a
     health care provider to be evaluating her choice         3. Now consider this list again as it relates to
     along with her in order to provide objective and            your comfort level with three varying
     respectful professional care. It is important to            degrees of your professional involvement in
     examine our own comfort level with her choice               abortion. At what point do you feel
     and consider our reactions when our neutrality              uncomfortable with:
     is challenged. We will begin by looking at the             a) making abortion referrals for patients
     option of abortion and our personal responses
                                                                b) assisting with the provision of abortion
     to issues such as gestational age, and then
     follow with the circumstances of the individual
     woman who is making this decision.                         c) providing abortions

     Exercise C-1: Examining Our Comfort                      Write your reasons for feeling this way about
     Level with Gestational Age                               gestational age. How long have you felt this
     For some people the acceptability of a patient’s         ____________________________________
     abortion decision is dependent on the stage of           ____________________________________
     pregnancy at which the abortion might take place.
     This exercise is designed to help you examine your       If you had different cutoff points depending
     own feelings about this very personal question           on the level of your involvement in providing
     and its possible influence on the exercises to follow.   services, what are the reasons for these
                                                              differences? If your feelings were consistent
     1. Does gestational age affect how you feel              across the different levels of involvement,
        about your patient’s abortion decision?               what are the reasons for this? ____________
        ____ Yes ____ No                                      ____________________________________
     2. If gestational age does affect your response,
        at what point do you feel uncomfortable
        with your patient’s abortion decision?
       At conception                              _____
       At implantation                            _____
       At the end of the first trimester          _____
       At quickening (i.e. point of
        fetal movement)                           _____

16   © 2005 NAF                    The Abortion Option: A Values Clarification Guide for Health Care Professionals
Tools for Clarifying Our Values

Exercise C-2: Examining Our Comfort                           ___ to end a pregnancy if the woman
Level with Circumstances of Each                                  does not want any more children
Woman’s Abortion Decision                                     ___ to end a pregnancy if the woman is
Sometimes we are comfortable with one woman’s                     not financially able to care for a
abortion decision, but are challenged by the                      child
circumstances surrounding another woman’s decision.           ___ to end a pregnancy if the woman
This exercise is designed for you to reflect on your              feels she is not ready for the
personal responses to the following situations. It also           responsibility of having a child
illustrates the wide range of circumstances that may          ___ to end a pregnancy if a child would
influence a woman to decide to have an abortion.                  interfere with educational or career
___ I can accept a woman’s abortion decision
                                                              ___ to end a pregnancy if the woman is
    in any circumstance when she has made
                                                                  unready for how a child could
    an informed and voluntary choice for
                                                                  change her life
                                                              ___ to end a pregnancy if the woman is
___ I can accept a woman’s abortion decision
                                                                  very young
    in certain circumstances including: (check
                                                              ___ to end a pregnancy if the woman has
    all that apply)
                                                                  not had a previous abortion
     ___ to end a pregnancy that threatened
                                                              ___ to end a pregnancy because of gender
         her life
                                                              ___ other(s): _____________________
     ___ to end a pregnancy that threatened
         her physical health
     ___ to end a pregnancy that threatened
         her mental health
                                                          ___ I find abortion unacceptable under
     ___ to end a pregnancy involving                         virtually any circumstances.
         significant fetal abnormality
     ___ to end a pregnancy resulting from                What are the reasons for your beliefs? How
         rape or incest                                   long have you held these beliefs? _________
     ___ to end a pregnancy resulting from                ____________________________________
         birth control failure                            ____________________________________
     ___ to end a pregnancy if the woman is               ____________________________________
         unmarried                                        ____________________________________

     ___ to end a pregnancy if the woman is
         in an unstable relationship or is not
         in a relationship

The Abortion Option: A Values Clarification Guide for Health Care Professionals              © 2005 NAF   17
Tools for Clarifying Our Values

     Exercise C-3: Individual Cases:                            ___ 22 year old carrying a fetus with
     Examining Our Potential Biases                                 severe deformity
     Parts 1 and 2 of this exercise individualize the           ___ 24 year old heroin addict who already
     circumstances of a woman’s abortion decision by                has three children in state custody
     providing more details to expose the complexity of         ___ 26 year old single mother who has a
     the decision. By putting yourself into the role of the         young child with leukemia
     health care professional responsible for providing         ___ 30 year old with 2 children whose
     access to abortion to only one of the following                husband died recently in a car crash
     women, you are challenged to examine your
     personal views and to experience the difficulties        What factors influenced your choice? How
     associated with limited access on the health             did it feel to have to make this choice?
     professional as well as the patient. This exercise       ____________________________________
     also illustrates the difficulty with comparing one       ____________________________________
     patient’s circumstance with another. Until we are
     put in this position we may assume that                  2. The six women described below have come
     determining a hierarchy of needs would be difficult         to you requesting a referral for abortion.
     but not impossible. Pay attention to your reactions         Due to circumstances beyond your control,
     to this challenge when putting yourself in the role         only one more abortion can be done and
     of the decision-maker. Part 3 helps us identify our         you must choose which one of your six
     personal discomfort, if any, when faced with the            patients is to receive the last abortion.
     circumstances of some women’s abortion decision.            Rank the cases from 1 (most want to refer
                                                                 for an abortion) to 6 (least want to refer).
     1. Before Roe v. Wade legalized all first
                                                                __ Gloria is 14 years old, unsure about
        trimester abortions in the U.S., some
                                                                   what to do. She has supportive parents.
        hospitals provided a very limited number of
        “special case” legal abortions. Hospital                __ Louise is 19 years old, has two children
        therapeutic abortion committees had the                    and has had two previous abortions.
        task of determining which cases were                    __ Selma is 24 years old, a student in
        worthy of being granted a safe, legal                      medical school and engaged to be
        abortion. You are on that committee and                    married. She wants to begin her career
        must determine which ONE of the                            before starting her family.
        following patients, all of whom are                     __ Eileen is 29 years old, single and
        requesting an abortion, will be granted the                pregnant with an IUD in place.
        one remaining legal abortion left in your               __ Margaret is 35 years old, divorced,
        yearly quota.                                              pregnant from a one-night encounter,
       ___ 12 year old incest victim                               her first sexual experience following her
       ___ 15 year old rape victim                                 divorce.

18   © 2005 NAF                    The Abortion Option: A Values Clarification Guide for Health Care Professionals
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