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Keywords: pregnant persons, uterine infections, emotional resiliency

The changes in abortion laws in the United States since Dobbs have resulted in extraordinary changes for pregnant persons since, under the prior five decades, they had different and additional options. According to one source, in the recent past, fourteen states have banned abortion, eight states were considering this, and six states have reduced their gestational threshold for abortion to 20 weeks or less.¹ Of greatest importance to what I will discuss here, in some states, minors may pursue obtaining an abortion without involving their parents through the means of a judicially granted bypass.² This is, however, often an emotionally draining and time-consuming process. It may be highly traumatic for these adolescents, much less any pregnant persons, to discuss this personal information in court to a judge they don’t know and who lacks special expertise in both obstetrics and adolescent psychology.³,⁴

I recall when in this country, prior to Roe vs. Wade, abortions were unlawful. Pregnant persons then, if they could, asked others they trusted if they knew of a doctor who could illegally give them the abortion they wanted. At this same time, hospital personnel grieved, knowing that many persons who could not get abortions would try to perform them on their own. The results were frequently tragic. These people would end up with uterine infections and no longer be able to have children or would even die.

We are, some data suggests, now reencountering these same risks. Since Dobbs, the number of people having abortions has decreased by several, tens of thousands of persons.⁵ The decisions now posed may be particularly difficult for teenagers. They face, for example, greater financial barriers, among many other obstacles.⁶ A recent survey of these patients found, for instance, that among 15-to-17-year-olds, 40% said they would consider doing a self-managed abortion (SMA), whereas among those 20-to- 24-year-old, 28% would consider a SMA if and when they could not get an abortion in any other way.⁷ Adolescents even just living in states in which getting an abortion would be difficult feel increased stress.⁸ Further, research have shown that people concerned about their physical or mental health are more likely to consider SMA. Thus, these changes may pose for this more vulnerable group somewhat of a vicious cycle.

Those teenagers who live in states in which they can get a judicial bypass and not have to tell their parents will be the group whose needs I will address here. A core question looming for them, of course, is how they should decide whether or not to tell their parents and then get an abortion if they can get it through a bypass. For some, this lying by omission may be ever after most painful. They may see their doing this as betraying their parents. Yet, they may have more difficulty obtaining an abortion if they seek to pursue this in any other way.

We can ask then and should ask how providers of every sort should best support theses teenagers, regardless of whichever way, in the end they will decide. The main single issue I will discuss in his piece is therefore how providers can best help them decide whether or not to inform their parents. This may be the most difficult decision they must make. For most children, their feelings for their parents run especially deep. Thus, if they lie to them, the consequences for both their parents and them may be great and long lasting. They may have negative health effects and negative social consequences that persist then throughout their lives.⁹

Their deciding whether or not to tell their parents may tax these patients’ emotional resiliency, requiring them to imagine conflicting outcomes that they may not be able to predict. Adolescents are likely to have the developmental capacity to independently make most health decisions, but in this case, they must also imagine as best they can both their own and their parents’ eventual outcomes. Providers may best then ask these patients then what they might most want to do in regard to their parents, so long as, of course, these patients indicate they would want to discuss this. This may be their only opportunity to discuss their dilemma with another person. Having done this, they may then not feel and be so alone.

Topics that providers may particularly consider raising are the degree to which they see their parents as being absolutely devoted to their religious and/or secular ethical beliefs, their conviction that they should be able to still make decisions for their children even when as at this time they are now in their late teens, and, looking into their future, what they see as most likely to cause them to feel regret. All these questions may most stem from their keeping their abortion a secret. Thus, providers should ask them whether, ever before, they have kept secrets from their parents, and if they have, how then they have fared. Their being able to share just this with their provider may though relieve some of the angst they may have about this.

We all, perhaps, like to believe and tend to believe that we can most objectively rely on our logic. Our capacities for reasoning and analysis certainly do help us see solutions we seek all the time. They may, though, too, entirely fail. This is especially the case when we have strong feelings. Then, our search for reasons may be most biased. We then particularly may come up with arguments that support what we feel but ignore those that go against us. We end up convinced more strongly, wrongly, that we are right.

After providers inform these patients of this, these patients may find it easier to imagine that their parents’ reasoning may be biased. Having recognized this generally, they can then ask themselves in more detail regarding the nature of their parents’ beliefs. Are their parents mostly absolute and inflexible or more open to accepting beliefs that contrast with theirs and are held by others?

A first more specific area then about which providers can inquire involves their parents’ religious beliefs. A paradigmatic example of another context in which parents’ religious views and those of their teenage children may clash may occur when these parents are Jehovah’s Witnesses.¹⁰ These parents may come into a hospital with a teenage child needing blood, but based on their religion, they may not consent to this. Legally, in the U.S., the outcome then, as it pertains to mature minors, may like abortions, vary, depending on the state.¹¹ Although this holding is not recognized by the US Supreme Court, some states have a ‘‘mature minor’’ doctrine that allows minors to consent to medical treatment including blood under these circumstances without parental consent.¹² Hospital staff in this situation sometimes fear that a teenager is refusing to receive blood even though this might be life-saving and this patient may want it. The patient may be refusing, they reason, for the sake of their parents who may believe that if they refuse, this may affect their after-life. Thus, the staff may consider telling the parents that they must, for a short time, leave, so that they may ask these teens privately and outside of their parents’ influence what they most want, or the staff may wait until night to ask these teenagers what they want after their parents have left, if, of course, they do.

A question that these patients’ providers might next ask these patients is how taking especially into account their parents’ religious beliefs, they believe their parents would respond if they have or even just indicate that they want to have an abortion. An important contribution that providers may make to these patients’ awareness at this time is to indicate to them that their parents, like all of us, may not respond to logic, as just discussed. Some parents’ religious views, like some parents who are Jehovah’s Witnesses, may not be views they feel they can alter.¹³ Providers then can give these patients an opportunity to discuss what they anticipate would be the most likely effect of what they choose on themselves and on their relationship with their parents and what weight, relative to other considerations, they might then want to give these possible outcomes.

If they have then shared and discussed this, again, regardless of what they decide, their having done this may benefit them substantially. This may help enable them to better live with whatever they decide. They will know that they have not only pre-considered this, themselves, but have done this with a provider whom they trust.

They may, too, after a similar discussion, be better able to anticipate whether their parents have secular ethical views more unyielding.¹⁴ Here a paradigmatic example is parents who are certain that their way of raising children is right and their adult childrens’ way of raising their grandchildren is wrong. They may, for example, feel that their adult children are too strict or too lax.¹⁵ Moreover, and of all-over-riding significance here, these grandparents may believe this to an extent that when they are with their adult children, they constantly berate them for this reason and continue to do this until these parents, their children, literally, won’t invite them back into the house.

These grandparents may place what they believe is right in these cases wholly above their relationship with their adult children. In a similar way, teens thinking of pursuing an abortion outside their parents’ knowledge may face this same risk if they instead tell them. This may sour or even destroy their relationship. Thus, providers may discuss their parents’ commitment to ethics with them just like they discussed their parents’ religious beliefs, as I have described above with these same ends in mind.

Providers, finally, may want to remind these patients that regardless of what they decide, they should take care not to judge themselves harshly afterwards. Here, as in all instances, they can only do the best they can with what they can see at this time. If, in retrospect, they would choose differently, this new insight should not be a source of self- blame or shame. They may have some regrets regardless of what they choose. Each choice has, of course, gains and losses. If these patients regret some aspect of having had the abortion, for instance, they may regret the parenting opportunity they have missed. If they instead go on to have their child, they again may not wholly escape a life of regret. They may regret aspects of their being a parent, but at this same time not regret having given birth.¹⁶ Trying to avoid feeling regret to the degree that they can is the goal they should strive for.¹⁷ If providers can help these adolescents see this and accept this before they decide what to do, this may better prepare them to accept what they choose, for better or worse, and then to go on and fare the best they can with their life.

¹Ralph L, Hasselbacher L. Adolescents and Abortion restrictions: disproportionate burdens and critical warnings. J Adolesc Health. 2023;73(2):221–223.

²Coleman-Minahan K, Stevenson AJ, Obront E, et al. Young women’s experiences obtaining judicial bypass for abortion in Texas. J Adolesc Health. 2019;64(1):20–25.

³Braverman PK, Adelman WP, Alderman EM, et al. The adolescent’s right to confidential care when considering abortion. Pediatrics. 2017;139(2).

⁴Hoopes AJ, Maslowsky J, Baca MA, et al. Elevating the needs of minor adolescents in a landscape of reduced abortion access in the United States. J Adolesc Health. 2022;71(5):530–532.

⁵Ralph, note 1.

⁶Allison BA, Vear K, Hoopes AJ, et al. Adolescent awareness of the changing legal landscape of abortion in the United States and its implications. J Adolesc Health. 2023;73(2):230–236.

⁷ Ralph, note 1.

⁸Liu SY, Benny C, Grinshteyn E, et al. The association between reproductive rights and access to abortion services and mental health among US women. SSM Popul Health. 2023;23:101428.

⁹ Hoopes. Note 4.

¹⁰Woolley S. Children of Jehovah's Witnesses and adolescent Jehovah's Witnesses: what are their rights? Arch Dis Child. 2005;90(7):71571–9.

¹¹Id

¹²Id.

¹³Maguire D. Roe v. Wade. Catholic wisdom. Conscience. 1998;18(4):29.

¹⁴Kaczor C. Moral absolutism and ectopic pregnancy. J Med Philos. 2001;26(1):61–74.

¹⁵Merz EC, Maskus EA, Melvin SA, et al. Parental punitive discipline and children's depressive symptoms: Associations with striatal volume. Dev Psychobiol. 2019;61(6):953–961.

¹⁶McCarthy A. Childbearing, abortion and regret: a response to Kate Greasley. Theor Med Bioeth. 2023;44(3):259–274.

¹⁷Id., at 273.

None.

The Author declared that there is no conflict of interest.