Later this month, the “Unplanned” movie will open in theatres in the U.S. This film tells the story of Abby Johnson, former Planned Parenthood director, now vocal pro-life advocate. The film, based on a book of the same name, tells how Abby’s first involvement in an actual abortion procedure caused her to quit her job and become an advocate for life.
Before reaching theaters, the film needed a rating, and the Motion Picture Association of America gave the film an “R” rating, meaning minors cannot go to the movie without parental consent.
Seem strange? An R-rating makes sense – abortion is deliberate, calculated violence, and surgical abortions are horrific to witness. We don’t want our young people exposed to the dismemberment of born children, so we shouldn’t want them exposed to the graphic dismemberment of pre-born children either.
But this rating reveals a double standard. This means that a 15-year-old girl can, without her parents’ consent, choose to have an abortion – but that same girl cannot see this film about abortion. On the one hand, we allow minors to have an abortion without parental consent, or even notification. On the other hand, we tell them they are too young to handle the reality of abortion. And then we add society telling them abortion is the answer because they are too young to be a mother. It’s no wonder they’re confused and overwhelmed when facing an unplanned pregnancy.
This should cause us to seriously question what kind of consent these young people are giving when they consent to abortion. Consent should be informed, but if young people are unready to see the reality of abortion, how are doctors ensuring they recognize what they are agreeing to? We continue to work on the idea of parental involvement laws because young people should not be left to make this choice uninformed and alone.
This film has the potential to open eyes to the reality of life in the womb, life that deserves protection regardless of outside circumstances. But many will not see it because abortion is horrific and graphic and ends a life – the very reason this story needs to be told.
]]>These concerns, including patient confidentiality, access to healthcare, and the possibility of abuse or broken family relationships, are serious issues that need to be considered.
So let us consider them, and see how all can be adequately addressed within the framework of legislation mandating parental involvement in a minor’s abortion.
Doctor-Patient Confidentiality
Confidentiality, first of all, has proven to be of crucial importance in getting adolescents to use health care, particularly with regards to reproductive issues [1]. We take this argument very seriously, and maintain the importance of confidentiality. Confidentiality is not broken, however, by a well-designed parental consent law: parents are not notified without the adolescent’s awareness. The adolescent is made aware of the need for consent, and given the option of obtaining judicial consent (from a court) instead of parental consent. This gives the option to circumvent parental involvement in cases of abuse, lack of a legal guardian, or other legitimate concerns. The safety and well-being of the adolescent is at the forefront, alongside the safety and protection of pre-born children. The majority of teens will benefit from the involvement of their parents in this major decision. A parental consent law is a step forward in protecting teens against coercion, peer pressure, abuse, future uncertainty, and other potential reasons they may choose abortion.
While confidentiality is a priority for patients, it is also important to point out that it is not an absolute right. In cases where others could be affected by our choice (in this case a pre-born child), there is precedent for setting limits on confidentiality. For example, counsellors need to report child abuse if it is reported to them, and lawyers are required to report a client’s plan to commit a specific crime. This is an example of an appropriate balance between protection of privacy, but also the rights of others, including parents, society, and pre-born children.
Access to Health Care
Access to health care is another consideration when it comes to minors seeking an abortion. Such access can actually be improved by a parental consent law. It can be very difficult for adolescents to navigate the health care system on their own, from making appointments to transportation to appointments to accessing the follow-up care they may need. Absences from school or home will need to be explained, and the stress of dealing with pregnancy alone is significant.
Studies show that adolescents often know later in their pregnancy that they have conceived, or do not seek medical attention until they are “beyond facilities’ gestational age limits”. [2] While Canada has no laws restricting abortion, most facilities will only perform abortions before the 20-week mark. If the adolescent does present early enough for a drug-induced medical abortion, the complication and failure rates are higher than for surgically-induced abortion, so parental involvement and care are very valuable [3].
An adolescent who gets an abortion in secret is more likely to hide pain and complications following the procedure, putting her health at risk, and her parents will not know to watch for signs of physical or psychological struggling. This can have dramatic consequences. Studies have found a significantly higher rate of suicide in 15-24 year olds following induced abortions, compared to those who are not pregnant or who chose childbirth. Post-abortive teens also indicated feelings of guilt, fear and confusion over what occurred [4-7].
A review of the literature from 1995-2011 found that pregnancy loss, including through abortion, carries a higher risk of subsequent mental disorder than childbirth. Thirteen studies showed a clearly higher risk for the abortion group versus those who chose childbirth, while only 5 studies found no difference [8]. It is evident, then, that a teenager should not be expected to face this decision and/or procedure alone, with all the potential ramifications.
The Canadian Medical Association, in its official policy on induced abortion, stresses the need for full and immediate counselling services for patients in the case of an unwanted pregnancy, something easier to ensure and maintain with parental consent requirements in place [9]. Not only are adolescents likely to make their pregnancy-related decisions in a state of stress, emotion, and exhaustion, they are also doing so with a less-developed prefrontal cortex than an adult, one of the “key ways the brain doesn’t look like that of an adult until the early 20s” [10]. Adolescent brains show marked differences in areas of impulse control and planning for the future, both critical to making an informed decision on parenthood, and capacities that are similarly unavailable in the peers they may turn to for help and advice.
In addition to the incomplete brain development of adolescents, there are marked hormonal shifts occurring in adolescence. These shifts affect the intensity with which emotion is felt as well as stress levels. Add to that the hormonal shifts that come with pregnancy and you have a dangerous decision-making cocktail which, like many cocktails, will lead to regretted decisions.
Helping or encouraging adolescents to keep their pregnancies and abortions secret is helping them isolate themselves at a particularly vulnerable time, at an age where their coping mechanisms are not yet well-developed.
The Canadian Medical Association Code of Ethics states that physicians must “balance the developing competency of minors and the role of families in medical decision-making”[11]. It recognizes that, while minors should be heard and their participation in their healthcare encouraged, minors cannot always make medical decisions unassisted. Abortion is also unique in that another life is involved besides that of the patient, deepening the impact of the decision.
Parental consent does not equal parental control – it is about responsibility and care. It is still necessary to obtain the pregnant woman’s consent, meaning that the decision belongs to the adolescent. Her parents can share their reasoning and attempt to influence her decision, but the main goal is to provide support for pregnant adolescents regardless of the outcome of their pregnancy. The parents’ duty is to act in the best interests of their child. They cannot fulfill that duty if they are missing relevant information regarding the life and medical history of their teenage daughter. Whether the adolescent chooses abortion, adoption, or active motherhood, support is crucial to their success and well-being. A parental consent law makes it clear that the government supports young women as well as the lives they may carry, and is working to enhance their well-being now and across their lifespan.
Sources:
1 English, A. & Ford, C. (2004). The HIPAA privacy rule and adolescents: Legal questions and clinical challenges. Perspectives on Sexual & Reproductive Health, 36 (2)
2 Dobkin, L., Perucci A. & Dehlendorf, C. (2013). Pregnancy options counseling for adolescents: Overcoming barriers to care and preserving preference. Adolescent Pregnancy, 43 (4), 96-102.
3 Lanfranch, A., Gentles, I. & Ring-Cassidy, E. (2013). Complications: Abortion’s Impact on Women. The deVeber Institute for Bioethics and Social Research, ON, Canada.
4 Ely, G., Flaherty, C. & Cuddeback, G. (2010). The relationship between depression and other psychosocial problems in a sample of adolescent pregnancy termination patients. Child & Adolescent Social Work Journal, 27 (4) 269-282.
5 Gissler, M., Hemminki, E., Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987–94: register linkage study. BMJ 313: 1431.
6 Curley, M. & Johnston, C. (2013). The characteristics and severity of psychological distress after abortion among university students. Journal of Behavioral Services & Research, 40 (3), 279-293.
7 Humphrey, M., Colditz, P., Flenady, V. & Whelan, N. (2013) Maternal and Perinatal Mortality and Morbidity in Queensland Queensland Maternal and Perinatal Quality Council Report 2013. State of Queensland (Department of Health). Retrieved from http://www.health.qld.gov.au/caru/networks/docs/qmoqc-report-2013-full.pdf
8 Bellieni, C. & Buonocore, G. (2013). Abortion and subsequent mental health: Review of the literature. Psychiatry & Clinical Neurosciences, 67 (5), 301-310.
9 CMA Policy: Induced Abortion. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD88-06.pdf
10 The teen brain: Still under construction. http://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml
11 Canadian Medical Association, Code of Ethics, 2004.
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A story out of New Zealand tells of a school nurse booking a student for an abortion, driving her there during school hours, bringing her home late, and lying about why they were late. A year later, as the girl deteriorated emotionally and physically, it came out to her parents that she had received an abortion. The surgery damaged her uterus and she will now never be able to have a baby.
Any parent reading this story will feel outrage at having a school employee go behind your back to encourage your 15-year-old daughter to get life-changing surgery in secret. But legally, just as in Canada, the school did not have to notify the parents. There was no requirement of parental consent for a minor to have an abortion.
The fact that underage girls in Canada can get an abortion without parental consent or notification means stories like this can happen here too. Parents need to stand up for their right to protect and guide their children. No one should encourage your children to make major life decisions in isolation, or counsel them to hide things from you. As this story shows, parents can be left wondering why their child is struggling, and be unable to provide the best care and support.
We believe parental notification should be ensured before performing an abortion for a minor. Parents are involved in virtually all other medical decisions, and may have valuable information about a child’s medical history. Doctors, school nurses, or private abortion clinic employees should not play counselor and parent to teens in crisis.
A legal opinion prepared on the topic on parental consent for abortion stresses that parents are ultimately responsible for the care and guidance of their children. Under the United Nations Convention on the Rights of the Child parents have primary responsibility for the upbringing and development of their children, with the best interests of the child being their primary concern. Article 18 indicates that this “best interests” measure includes taking into account a child’s maturity and capacity for decision-making; it does not, however, preclude parental involvement with mature minors.
The fact that a school needs permission to take your child on a field trip, but not for surgery, is beyond ridiculous. That same teen needs parental consent before getting a tattoo or using a tanning salon, and needs legal consent before being allowed to drink, smoke, or drive a car. Has abortion really become such a taboo subject that we are willing to just ignore legal oversights rather than face the wrath of abortion advocates?
Undermining parental authority undermines the best interests of children. It tells parents they don’t need to be involved in their children’s lives, and tells teens not trust their parents for support. If someone can take my child for surgery and I only find out about it later, they can expect to hear from me. I expect they’d hear from you too.
It is important to consider what this argument says in relation to minors. “Her choice” may sound supportive, but is it really? Should a young teen want to be left to make such a choice alone? If she fully realized the long term impact of this choice, would she choose to carry such a secret, choose to have no one to turn to for support? Is her choice really a choice if she felt there was only one option?
We all want what is in a minor’s best interests. Yet some argue a parent or guardian should not be involved when their daughter has an unplanned pregnancy. Why is it, at a time when a young teen has to make an irreversible decision, we think that anyone but the parents should be deciding what is in her best interests? Who, if not parents or guardians, can genuinely protect the best interests of our children? Doctors? Governments or courts? The teens themselves?
Doctors are well educated in the physical realities of abortion. In this way, they are well-positioned to inform girls about the procedure, as well as other options. They are not, however, in a position to offer counselling and emotional support to anxious girls, nor should we ask them to be. The reality is, for a teen in a vulnerable position, doctors can be intimidating and their opinions overwhelming.
Perhaps the government could objectively determine the benefits of an abortion for a particular individual. Even in the unlikely event that they could, this would take away a long-recognized legal right to parental authority. Parents would be deemed secondary authorities, while the government usurped their responsibility. If this was acceptable when deciding who should have an abortion, why not in deciding who should be allowed to have kids at all? Why not in deciding where your children should be educated? State control over the nation’s children can never be the answer.
Finally, and perhaps most importantly, what about the teen herself? Many teens are as mature emotionally as they are physically. Should these young women not have a voice? Indeed, they should. However, their voice should not be the only one they hear. Science is clear that the teenage brain is still developing, particularly the pre-frontal cortex, the area of the brain which allows for future planning and decision-making. The adult brain has a deeper capacity for this kind of thought, making adults a better choice than peers when grappling with such an impactful decision as abortion.
In addition, adults can offer resources. These resources are not only financial, but also include resources such as a driver’s license and vehicle to get to doctor appointments, time they are willing to give to babysit a child that could be born, support they are willing to give to their new grandchild, and access to follow-up care post-abortion or post-partum. A parental consent law in Canada would recognize the value of adult support and involvement in a teen’s pregnancy, as well as recognizing parental authority and responsibility.
Parents and guardians, then, are really the only option when it comes to consent for minors to have an abortion, just as parents are the ones who need to consent to a teen getting a tattoo, using a tanning salon, or even going on a field trip from school.
What about parents who are incapable of making good decisions, you ask, or whose relationship with their children is strained, or worse, abusive? This is a legitimate concern when requiring parental consent. But does that mean we should strip all parents of their rights for the sake of those few who may be inept? Certainly not. What it means is that we build safeguards into the law, where teens have the option of bypassing parental consent with good reason. In these cases, be it of abuse, incest, or fear of reprisal, we can allow doctors, government, or courts to step in and assist an adolescent in making a good medical decision. Parental consent should be the standard to which exceptions are made, not the exception itself.
“What are we teaching our adolescents when they find persons in authority willing to help them deceive their parents? What does it teach these adolescents with regard to the respect owed to any adult, least of all a deceitful doctor or a duped parent?”
Intentionally removing a teen’s parent(s) from the decision-making process misleads the teen toward the false notion that parents are nonessential, simply obstructive to the process, and that the teen is completely capable of making mature, wise decisions without the parent’s advice.”
The College of Pediatricians makes it clear that the special secrecy given for abortion needs to end.
“Medical care of children and adolescents uniformly requires written and verbal parental consent for any procedure – inside or outside of a medical office. For example, written parental consent is required for minor children to receive over-the-counter medications when in day care or at school. This is because appropriate medical care can only be provided within the context of the patient’s family and medical history.”
Ignoring medical history and family relationships to accommodate abortion does no one any favours. Recognizing the ongoing development happening in an adolescent’s brain, the paper concludes:
“Legislation mandating or encouraging parental involvement in decisions related to a minor’s pregnancy protects adolescents during a very vulnerable time in their lives. Society recognizes this need, and often requires and encourages parents to be a positive resource for their adolescents in matters of health, and other issues of consequence. Therefore, excluding them from a minor’s decision about abortion cannot be justified.”
You can read the full statement, with supporting sources, here.
It’s time for us to bring our laws in line with decades of common law, and common sense. Parental notification and consent should be mandatory for girls under the age of 16 seeking an abortion. Parents need to be informed so they can counsel their daughters, as well as get them the medical care that may be needed during and after the pregnancy. Abortion potentially has both physical and psychological side effects, and parents are best positioned to act in the best interest of their daughters (and potential grandchildren). Keeping parents out of the picture isolates young teens at a particularly vulnerable time, leaving them open to pressure from virtually anyone attempting to influence their decision.
Consent and notification laws are one way to show that families are valuable, protecting both parental rights and the best interests of children.
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Confidentiality, first of all has proven to be of crucial importance in getting adolescents to use health care, particularly with regards to reproductive issues [1]. This is obviously not, however, a fact unique to adolescents, though it is certainly portrayed that way. Interestingly, the Abortion Rights Coalition of Canada references an American privacy law (HIPAA) as an example of why confidentiality is crucial and parents should not be informed if their daughter chooses an abortion. That law, however, specifically mentions abortion in the context that an adolescent minor (under 18) may only maintain confidentiality in cases “when a minor has requested and received court approval to have an abortion without parental consent or notification” (emphasis added) [1]. It is grouped with HIV/AIDS and sexually transmitted infections in that patient confidentiality may be maintained following court consent, but treatment or action cannot occur without adult consent. Further, confidentiality is not broken in that parents are told in secret. Adolescents are made aware of the requirement and informed of the need for parental consent before contact is made, and given the knowledge that they have the opportunity to seek court consent instead if necessary.
Access to health care, then, is the other major consideration. Such access can actually be improved by a parental consent law. It can be very difficult for adolescents to navigate the health care system on their own, from making appointments to transportation to appointments to accessing the follow-up care they may need. Absences from school or home will need to be explained, and the stress of dealing with pregnancy alone is obviously significant for an adolescent. Studies show that adolescents often know later in their pregnancy that they have conceived, or at least do not seek medical attention until they are “beyond facilities’ gestational age limits”. [2] While Canada has no laws restricting abortion, most doctors will only perform abortions before the 20 week mark, as after this point the fetus is considered viable. If the adolescent does present early enough for a drug-induced medical abortion, the complication and failure rates are higher than for surgically-induced abortion, so parental involvement and care can be very valuable [3].
An adolescent who gets an abortion in secret is more likely to hide her pain and complications following the procedure, putting her health at risk, and parents will not know to watch for signs of physical or psychological struggling. Studies have found a significantly higher rate (3-6x) of suicide in 15-24 year olds following induced abortions when compared to those who are not pregnant or who chose childbirth when pregnant, as well as decreased self-esteem and feelings of guilt, fear and confusion over what occurred [4-7]. A review of the literature from 1995-2011 found that pregnancy loss, including through abortion, carries a higher risk of subsequent mental disorder than childbirth. Thirteen studies showed a clearly higher risk for the abortion group versus those who chose childbirth, while only 5 studies found no difference [8].
The Canadian Medical Association, in its official policy on induced abortion, stresses the need for full and immediate counselling services for patients in the case of an unwanted pregnancy. This is much easier to ensure and maintain with parental consent requirements in place [9]. Helping or encouraging adolescents to keep their pregnancies and abortions secret is helping them isolate themselves at a particularly vulnerable time, at an age where their coping mechanisms are not yet well-developed. That doesn’t sound like a consideration of best interests at all.
We must briefly consider the concern that is sure to be raised in dramatic fashion almost immediately. Is there the possibility that parental consent requirements will drive some adolescents to self-harm or illegal means of obtaining abortions in an effort to avoid telling their parents, or the now-infamous “coat hanger argument”? This common rhetoric has always held true for a small, sensationalized minority of cases, and will continue to do so. Desperate young women, like desperate older women, will take desperate measures. This does not, however, negate the need for a parental consent law with all its potential benefits for the majority. Rather than abandon parental consent, we should instead focus on alternate front-line support for these women who feel their situation is so dire they cannot possibly share the news of a pregnancy with a parent or guardian.
In terms of decision-making and consent, the terms mature or immature are not meant as a comment on an adolescents’ character or intellect, but rather as a scientific reality in terms of brain development. Not only are adolescents likely to make their pregnancy-related decisions in a state of stress, emotion, and exhaustion, they are also doing so with a less-developed prefrontal cortex than an adult, one of the “key ways the brain doesn’t look like that of an adult until the early 20s” [10]. Adolescent brains show marked differences not in intellectual ability compared to adults, but in areas of impulse control and planning for the future. Those last-to-develop capacities are critical to making an informed decision on parenthood. These abilities are accessible in their parents, who can assist them in reasoning through a decision beyond the emotional basis, and beyond what peers are capable of.
In addition to the incomplete brain development of adolescents, there are marked hormonal shifts occurring in adolescence. These shifts affect the intensity with which emotion is felt as well as stress levels. Add to that the hormonal shifts that come with pregnancy and you have a dangerous decision-making cocktail which, like many cocktails, will lead to regretted decisions.
The argument put forward regarding adolescents needing consent to continue with a pregnancy should be dismissed without further consideration. Just as parental consent is needed for any surgery, so it should be needed for abortion at any stage of pregnancy – we do not ask for parental consent for an adolescent to get appendicitis or cancer, we simply involve them in helping their child cope with the consequences. As stated in R. v. Morgentaler, abortion is not a right, and should not be treated as such [12].
Parental consent does not equal parental control – it is about responsibility and care. Parents can share their reasoning and attempt to influence the decision, but the main goal is to provide support for pregnant adolescents regardless of the outcome of their pregnancy.
Sources:
1 English, A. & Ford, C. (2004). The HIPAA privacy rule and adolescents: Legal questions and clinical challenges. Perspectives on Sexual & Reproductive Health, 36 (2)
2 Dobkin, L., Perucci A. & Dehlendorf, C. (2013). Pregnancy options counseling for adolescents: Overcoming barriers to care and preserving preference. Adolescent Pregnancy, 43 (4), 96-102.
3 Lanfranch, A., Gentles, I. & Ring-Cassidy, E. (2013). Complications: Abortion’s Impact on Women. The deVeber Institute for Bioethics and Social Research, ON, Canada.
4 Ely, G., Flaherty, C. & Cuddeback, G. (2010). The relationship between depression and other psychosocial problems in a sample of adolescent pregnancy termination patients. Child & Adolescent Social Work Journal, 27 (4) 269-282.
5 Gissler, M., Hemminki, E., Lonnqvist, J. (1996). Suicides after pregnancy in Finland, 1987–94: register linkage study. BMJ 313: 1431.
6 Curley, M. & Johnston, C. (2013). The characteristics and severity of psychological distress after abortion among university students. Journal of Behavioral Services & Research, 40 (3), 279-293.
7 Humphrey, M., Colditz, P., Flenady, V. & Whelan, N. (2013) Maternal and Perinatal Mortality and Morbidity in Queensland Queensland Maternal and Perinatal Quality Council Report 2013. State of Queensland (Department of Health). Retrieved from http://www.health.qld.gov.au/caru/networks/docs/qmoqc-report-2013-full.pdf
8 Bellieni, C. & Buonocore, G. (2013). Abortion and subsequent mental health: Review of the literature. Psychiatry & Clinical Neurosciences, 67 (5), 301-310.
9 CMA Policy: Induced Abortion. http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD88-06.pdf
10 The teen brain: Still under construction. http://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml
11 Canadian Medical Association, Code of Ethics, 2004. https://www.cma.ca/Assets/assets-library/document/en/advocacy/policy-research/CMA_Policy_Code_of_ethics_of_the_Canadian_Medical_Association_Update_2004_PD04-06-e.pdf
12 R. v. Morgentaler (1988) 1 SCR 30, 1988 CanLII 90 (SCC). Retrieved from https://www.canlii.org/en/ca/scc/doc/1988/1988canlii90/1988canlii90.html?searchUrlHash=AAAAAQAZcGFyZW50YWwgY29uc2VudCBhYm9ydGlvbgAAAAAB&resultIndex=1
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