The following is a letter Care Net authored to the editors of the AMA Journal of Ethics and The Journal of the American Medical Association in response to articles they published making a variety of false and misleading claims about pregnancy centers. Versions of this letter were submitted to the journals but were never published.
The article “Why Crisis Pregnancy Centers Are Legal But Unethical,” [i] published in the March 2018 AMA Journal of Ethics, and the companion piece, “At “Crisis Pregnancy Centers,” Critics Say, Ideology Trumps Evidence,”[ii] which appeared August 7, 2018 in The Journal of the American Medical Association (JAMA), are biased representations of pregnancy centers which, at best, fail to provide reliable evidence for the claims that are made, and, at worst, are thinly veiled partisan attempts to discredit and cast aspersions on the moral character of non-profit organizations that have served their communities for decades, many that engage physicians who are members of the AMA and ACOG.
The basic premise of the article, which has been argued by various politically-motivated abortion rights groups over the last several years, is that pregnancy centers appear to be medical in nature but do not comply with the same medical standards as other medical practices, such as abortion clinics. Furthermore – and this is also a claim that has been made by abortion rights groups repeatedly – pregnancy centers provide misleading and incomplete information to women and are therefore unethical.
However, a review of the article’s arguments and sources reveals that its claims are based upon highly biased and/or anecdotal material, with minimal to no scientific validity.
Beginning in the article’s abstract, the authors claim that pregnancy centers “”¦.are exempt from regulatory, licensure, and credentialing oversight that apply to health care facilities”¦.” But the truth is that pregnancy centers comply with the same laws, statutes, and regulations that apply to physician’s offices and other similar facilities, which includes abortion clinics.[iii],[iv] Affiliates are trained to follow best practices similar to the those found in the AMA’s Legal and Operational Guide for Free Medical Clinics.[v],[vi]
Next, the abstract states, “Because the religious ideology of these centers’ owners and employees takes priority over the health and well-being of the women seeking care at these centers, women do not receive comprehensive, accurate, evidence-based clinical information about all available options.”
First, pregnancy centers model charity, integrity, and compassion and all clients are treated with the same respect and caring. Manifesting these qualities is a priority, as it should be in every place where medicine is practiced. Affiliates are required to adhere to a code of ethics that includes providing permission-based, non-coercive care, that protects client privacy and autonomy.[vii]
Next, pregnancy centers do not claim to provide “comprehensive reproductive services,” in that it is made clear that we do not dispense birth control, nor perform or refer for abortions.[viii] However, pregnancy centers do approach clients holistically, attending to their physical, emotional, and spiritual needs.
Further, centers provide detailed, medically accurate information about abortion procedures and the risks associated with them.[ix] On the other hand, abortion clinics rarely offer parenting support, childbirth education, or material assistance to women who choose to carry to term.[x]
It is also worth addressing in detail a number of other false or misleading claims made throughout the body of the article.
The article also falls short in providing clear evidence of its claims that pregnancy centers are not really medical and do not comply with medical standards. The article claims that pregnancy centers “purport to provide medical advice”¦” Care Net’s training materials are explicit on the difference between medical advice and medical information, and unequivocally train non-medical personnel to only provide information.[xi] Further, they are instructed to use medical information derived from the same reliable medical sources that any other medical practice relies upon.[xii]
The article also states, “Despite looking like legitimate clinics, most CPCs are not licensed, and their staff are not licensed medical professionals.” Approximately 30-40% of Care Net affiliates do not provide any medical services and therefore have no reason to engage medical personnel nor carry a license. Over 60-70% of Care Net affiliates do offer medical services, and thus utilize medical personnel. All medical pregnancy center clinics adhere to existing laws that govern the practice of medicine and are subject to the same licensing regulations as most physician offices, retail clinics and abortion clinics.[xiii],[xiv],[xv],[xvi] In most states, a physician’s license fulfills the requirement for a facility to provide basic medical services.[xvii] In a handful of states, additional requirements are necessary to function as a medical facility.[xviii] Medical pregnancy centers in those states comply with all legal requirements.
The article attempts to scare its readers by claiming that pregnancy centers’ non-compliance with HIPAA provisions could lead to “violations of client privacy.” The authors state, “For example, client information might not be kept confidential”¦.” This is an entirely hypothetical statement, with no basis in fact. Most centers do not meet the legal definition of a covered entity under the HIPAA regulation because they do not furnish, bill, or are paid for health care in the normal course of business and do not transmit health information in electronic form in connection with a transaction for which a HIPAA standard has been adopted by HHS. (e.g., billing)[xix]
However, centers readily comply with all applicable confidentiality and HIPAA regulations that apply to many abortion clinics, retail clinics, and other physician’s offices.[xx],[xxi]
Care Net pregnancy centers agree to respect client/patient privacy, and medical centers adhere to and distribute a notice of privacy practices modeled on HIPAA. And despite the article’s claim that “adoption of these guidelines is optional and adherence is not regulated or enforced,” adoption of these guidelines is mandatory for Care Net affiliates and adherence to them is enforced.[xxii] Care Net will disaffiliate any center that persists in violating or is unwilling to comply with our standards of affiliation. It is evidence of our commitment to functioning according to ethical principles.
Next, the authors claim that “”¦CPCs engage in counseling that is misleading or false.” Not true. All Care Net affiliates commit to providing accurate information about abortion.[xxiii],[xxiv] The medical information disseminated to clients is derived from reliable medical resources.[xxv] The content found in Care Net’s Before You Decide magazine is based upon textbooks, peer-reviewed scientific journal articles, and authoritative websites (for example, cdc.gov) with over 300 citations. All Care Net-provided patient education information is carefully researched, written and reviewed by a panel of physicians and other medical experts.
Then, the article states, “”¦CPCs often suggest a link between abortion and subsequent serious mental health problems, while multiple studies have invalidated this assertion.” In reality, the worldwide scientific literature found in peer-reviewed journals contains sufficient evidence that induced abortion is a risk factor for a number of health problems, including depression, substance abuse, and preterm labor.[xxvi]
Next, the authors state that “”¦most of these centers do not provide comprehensive women’s reproductive health care, abortion care, or referrals for abortion.” Clever use of semantics and outright misrepresentation do not make a good argument. In truth, “comprehensive women’s reproductive care” is doublespeak for abortion and contraception, and nothing else. On the other hand, pregnancy centers approach clients holistically, providing far more comprehensive services including medical, parent support, childbirth education, material assistance, referrals for medical care, mental health, legal, food, shelter, and spiritual support. Furthermore, centers do not claim to provide “all options,” such as the abortion option, but rather that they provide information about all options. To that point, pregnancy centers provide disclaimers to clients that they do not provide, perform, or refer for abortion. This disclaimer appears on their websites, their “request for services” intake forms, and is given verbally when women call the centers.[xxvii]
The example the article gives to support its claim about the lack of comprehensive health care is that “”¦CPCs tend to avoid discussion of contraception and dismiss the role of condoms in preventing sexually transmitted infections.” This is false. Care Net affiliates provide accurate information about contraception and sexual risk avoidance that neither overstates nor understates the role of condoms in reducing the risk of STIs, in line with the Centers for Disease Control condom information which states that: consistent and correct use of male latex condoms can reduce (though not eliminate) the risk of STD transmission. “¦The most reliable ways to avoid transmission of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), are to abstain from sexual activity or to be in a long-term mutually monogamous relationship with an uninfected partner.[xxviii]
It is disheartening that the authors chose to ignore the readily available information about pregnancy centers and publish erroneous claims.
Next, the article then attempts to suggest that pregnancy centers may not be “legal,” claiming that it is “complicated.” They begin by stating, “Centers lack regulatory oversight as they are not medical practices and do not charge for services.” This is confusing and deceptive to the reader. Medical pregnancy centers provide legitimate medical services, which constitute the practice of medicine. Accordingly, they are subject to, and comply with, the same regulations that apply to most physician’s offices.[xxix] Further, providing free services is a time-honored practice among charitable and non-profit organizations. This is a blatant attempt to vilify organizations who exist to provide compassionate care with integrity. An organization that provides free services is no less legitimate than its fee-for-service counterpart, as evidenced by AMA’s own publication: Legal and Operational Guide for Free Medical Clinics.[xxx] Sadly, the article attempts to justify this argument by saying that pregnancy centers do these things in order to hide behind free speech laws, making themselves “much harder to regulate.” It is offensive to suggest and false in accuracy that pregnancy centers are seeking loopholes to avoid scrutiny.
The article also deceptively uses the word “noncompliance” to refer to pregnancy centers’ treatment of regulations such as HIPAA. It is inaccurate to say that medical pregnancy centers are “noncompliant” with HIPAA; they simply do not meet the legal definition of a covered entity.[xxxi] However, the Commitment of Care and Competence requires that pregnancy centers protect the confidentiality of clients and patients.[xxxii]
Moreover, the legality of pregnancy centers was upheld by the Supreme Court of the United States in the NIFLA v. Becerra case that the article cites. The Supreme Court’s ruling in favor of NIFLA in June of 2018 indicates that California’s Reproductive FACT Act likely violates pregnancy centers’ freedom of speech, as it places burdensome requirements on centers that appear to target their religious beliefs.[xxxiii]
The authors continue their article with a section asking if pregnancy centers are unethical. The section starts with the statement, “Because CPCs purport to offer medical advice and care, it seems reasonable to expect them to abide by medical ethical principles.” We agree. That is why Care Net has and enforces its Standards of Affiliation.[xxxiv]
Then, the authors attempt to argue that pregnancy centers are unethical because they fail to govern themselves by the four “fundamental principles” that are “widely regarded as guides to practice: beneficence, nonmaleficence, respect for autonomy, and justice.”
The authors of the article allege that centers violate principles of ethics. Beneficence is purportedly violated by “providing inaccurate and misleading information “¦ because it is not patient-centered and does not fully consider the patient’s well-being.” Centers maintain that reliable medical data exist about the harms that may be associated with abortion that directly affect a woman’s well-being and thus must be included in informed consent.[xxxv] The authors’ claim focuses upon maternal safety alone, failing to recognize another patient. Herein lies the disagreement. What is the unborn child? Does it deserve human rights? A provider’s opinion on this matter sets clinicians on parallel courses of morality, which will never converge.
In arguing that pregnancy centers violate the beneficence principles, the article states that, “Anti-abortion ideology thus supersedes the needs, values, and preferences of the woman seeking care.” Upon what are the authors basing this commentary? Whose values? Do they claim to speak for all women? What evidence do they provide to support this claim? Moreover, the “anti-abortion ideology” produces pregnancy centers that are equipped to educate woman on all of their options, not just abortion. In contrast, the pro-abortion ideology governing abortion clinics produces entities that focus on one option: abortion.
The authors further cite the relative safety of abortion in contradistinction to childbirth. There are numerous and complicated methodological factors that make a valid scientific assessment of abortion mortality extremely difficult. Among the many factors responsible are incomplete reporting, definitional incompatibilities, voluntary data collection, and research bias, reliance upon estimations, ideological motivations, inaccurate and/or incomplete death certificate completion, and failing to include other causes of death such as suicides.[xxxvi]
Autonomy, say the authors, requires informed consent free of coercion. MPCs argue that medical data exist to suggest that abortion providers minimize the risks of abortion in the interest of ideology, and that this data should be presented to patients.[xxxvii] Such differences in opinion regarding the interpretation of a body of evidence surrounding various diagnoses and procedures is common in medicine, and should not be suppressed, being indispensable to the pursuit of science. Clinicians are licensed independent practitioners who are free to practice medicine according to their conscience and reading of the literature. Thus, again, a difference in opinion exists among clinicians regarding what constitutes complete informed consent in regard to abortion.
Similarly, the accusation of coercion is not well referenced in the paper, and is arguably a matter of opinion. In fact, within the article’s own references from Care Net, NIFLA, and Heartbeat International on their code of conduct, the Commitment of Care and Competence, specifically decries the practice of coercion.[xxxviii]
Using inflammatory language without substantiation (“misinterpreting and misrepresenting medical evidence”), the authors claim that pregnancy centers violate “respect for autonomy.” In truth, Care Net requires affiliates to use medically accurate information for patient education that is derived from reliable medical sources.[xxxix] For example, Care Net’s primary tool for options education in centers contains over 300 citations from reliable medical sources, including peer-reviewed journals, government websites (NIH, CDC, FDA, OSHA, HHS, etc.), and medical textbooks.[xl]
The article continues to make the claim that pregnancy centers “”¦violate respect for a woman’s autonomy by failing to give her the tools necessary to make the decision that is best for her life and circumstances.” Care Net’s training and client education approach is specifically designed to respect patient autonomy, especially providing accurate information about abortion risks. We do not refer for abortion, all of our care is permission-based and non-coercive, as codified in our Standards of Affiliation.[xli] The authors would have better served the women whose autonomy they claim to want to protect by asking, instead, “Do abortion providers violate a woman’s autonomy when they don’t give her resources to carry out a life-affirming decision?” What this article fails to recognize is that women are smart and know how to find abortion services. Women are not hindered in obtaining abortions because they did not receive a referral at a pregnancy center. A simple Google search will reveal options where an abortion can be obtained in the U.S..[xlii]
Non-maleficence is allegedly violated by a sexual risk avoidance emphasis, which may cause patients to fail to use measures to protect against STI and pregnancy. This point is conjecture at best, and not cited in a standard expected of a published journal. The authors are encouraged to review the Centers for Disease Control’s stance on condom use and abstinence.[xliii]
The authors then attempt to argue that pregnancy centers violate the nonmaleficence principle by claiming that pregnancy centers intentionally delay women from obtaining abortions. Again, Care Net training materials explicitly teach respecting patient autonomy, avoiding coercion in any form, and prohibit any attempt to delay a woman’s pregnancy decision. Moreover, the average woman spends less than an hour at a pregnancy center and her decision is usually made over a 24-hr period, with or without the involvement of a pregnancy center. Research indicates that by the time a woman who chooses abortion confirms her pregnancy, she has already made her decision.[xliv]
Justice, the article maintains, is said to be violated when access to abortion services is obstructed. The article states that, “In the setting of CPCs, justice is violated when women are not apprised of the availability of abortion services and access to abortion is consequently obstructed.” Centers offer free support for all women who are making a pregnancy decision and do not interfere if they choose abortion. Center personnel complete comprehensive training and instruction on administering permission based care.[xlv] Women who enter a center may leave at any time, should they no longer wish to receive the offered services. Lastly, to state that centers obstruct access to abortion in a nation with legal access to the procedure for any reason, throughout the entire course of gestation, is hyperbolic.[xlvi]
The authors correctly concede centers right to function in accordance with the First Amendment yet claim that pregnancy centers violate ethical standards that guide medical professionals. We agree that pregnancy centers should abide by professional ethical standards. The authors fail to recognize that laws exist to protect healthcare professionals from being forced to recommend a medical intervention that they feel is harmful for their patients and/or is contrary to the professional’s moral code. The Supreme Court’s ruling in NIFLA v. Becerra, affirmed pregnancy centers’ freedom of speech.[xlvii] Refusal to provide a referral for abortion does NOT constitute an ethical violation, which appears to be the crux of the authors’ complaints against pregnancy centers.
Further, patient autonomy doesn’t supersede the physician’s duty to “first do no harm.” In the vast majority of cases, induced abortion is an optional, or elective procedure, that is not medically necessary.[xlviii] To employ lofty expressions as “distributive justice” and to claim “obstruction” would be laughable if it wasn’t so reprehensible.
The authors make several more attempts to demonstrate that pregnancy centers impede justice. They claim that pregnancy centers “”¦target low-income women and women of color, adolescents, and women with less formal education.” Pregnancy centers market to women who are making pregnancy decisions and serve each without discrimination. This is expressly stated in the Commitment of Care and Competence. In fact, pregnancy centers seek to provide services to women and men who are most in need of our services. Minority people groups are targeted by abortion clinics in that they undergo a disproportionate percentage of abortions compared to majority groups.[xlix] Individuals in these populations are in need of options when confronted with a difficult pregnancy decision, not pressure to abort, which is the primary objective of abortion clinics placed in these areas.
Bryant and Swartz’ article should have been published as an opinion piece and expression of free speech, and not as a medical review.
The authors conclude the article by suggesting ways in which pregnancy centers can become more ethical. For example, the article says, regarding abortion, “For no other medical procedure would someone who is not a health care professional seek to give detailed counseling on the risks of the procedure.” In this day of web-based medical information, this is a patently false assertion. Many healthcare organizations utilize lay volunteers and/or staff in providing patient education. Care Net trains nonmedical personnel to provide disclaimers that they are not a medical professional, they are only giving medical information (not advice), and they are using reliable, sourced material.[l]
The authors conclude with an extremely biased recommendation that physicians should “”¦educate themselves about where women can obtain comprehensive reproductive health care locally to avoid referrals to CPCs for women considering abortion”¦ and alert to the harms they can cause.” This egregious “advice” is given without substantiation from evidence-based research, and is founded on highly partisan information.[li] For example- a quote from the second citation used Bryant’s article, (Rosen’s 2012 “The Public Health Risks of Crisis Pregnancy Centers” found in Perspectives on Sexual & Reproductive Health)
sums up with problem with the “evidence:”[lii]
“While centers have not been subject to systematic evaluation by nonpartisan investigators, the prochoice investigations have consistently found practices common among crisis pregnancy centers “¦.”
What evidence is there that patients have been “harmed” by receiving services from a pregnancy center?
The authors of the article say that, “As obstetrician-gynecologists, we have had several disgruntled patients come to us who were disappointed and felt deceived by the care that they had received at CPCs.” This type of anecdotal comment is not evidence-based and cannot be verified; therefore should not be the basis of claims of unethical behavior. One cannot practice medicine without encountering the occasional disgruntled patient. The “harms” the authors claim are unsubstantiated and an affront to pregnancy center physicians. Pregnancy center affiliate data collected over the last four years tell a different story and revealed a 98% client satisfaction rate among individuals who completed exit surveys.[liii]
What is documented about the real work of pregnancy centers? The following is excerpted from the Charlotte Lozier Institute A Half Century of Hope, A Legacy of Life and Love Pregnancy Center Service Report, Third Edition:[liv]
In 2017, pregnancy centers provided nearly 2,000,000 people, primarily women and youth, in the United States with free services, with estimated community cost savings of at least $161 million annually. Women, youth, and men received services including pregnancy tests, life-affirming options consultation, sexual risk avoidance education, parenting and prenatal education, ultrasound and medical services, community referrals, and material support. Community-based pregnancy centers through their service accomplishments contribute to positive outcomes in maternal and child health, women’s health, and family well-being. They are increasingly being recognized for their impact and standing in communities across the country. As providers of alternatives to abortion, pregnancy centers have sought to accomplish their objectives and mission in ways that have made them models of community- and faith-based action. Affiliates of the three largest national networks (Care Net, Heartbeat International, and the National Institute of Family and Life Advocates)”¦ provide training, resources and/or services subject to a national code of ethics instituted in 2009, “Our Commitment of Care and Competence.” Volunteers who interact with clients “¦ are required to complete specialized training which focuses on integrity and quality of care, where honesty, compassion, and empathy towards clients are paramount.
Given the misleading statements and outright falsehoods published by the AMA Journal of Ethics in the article, “Why Crisis Pregnancy Centers Are Legal but Unethical” by Amy G. Bryant, MD, MSCR and Jonas J. Swartz, MD, MPH, and the companion piece, “At “Crisis Pregnancy Centers,” Critics Say, Ideology Trumps Evidence, which appeared August 7, 2018 in The Journal of the American Medical Association (JAMA), we call on the editors of the AMA Journal of Ethics and the editors of JAMA to print a retraction of the article, correcting the falsehoods presented therein and ceasing from publishing or posting the original contents of the article.
[i] Bryant, A. G., & Swartz, J. J. (2018). Why crisis pregnancy centers are legal but unethical. AMA Journal of Ethics, 20(3), 269-277. doi:10.1001/journalofethics.2018.20.3.pfor1-1803
[ii] Rubin, R. (2018). At “Crisis Pregnancy Centers,” Critics Say, Ideology Trumps Evidence. JAMA, 320(5), 425. doi:10.1001/jama.2018.8661
[iii] Excerpt from Standards of Affiliation: All pregnancy centers operating medical services shall: a. Function under the authority and direction of a licensed physician who is in good standing with the physician’s state
licensing board; b. Only utilize trained and licensed medical professionals to perform medical procedures, including ultrasounds; c. Carry sufficient medical liability coverage for the center and all medical personnel (unless they have their own coverage).
[iv] https://www.acponline.org/practice-resources/regulatory-resources/regulatory-compliance
[v] Care Net. (2017). Compassion, hope, and help. Retrieved from https://store.care-net.org/compassion-hope-and-help-trainers-guide/
[vi] American Medical Association Foundation. (2015). Legal and operational guide for free medical clinics. Retrieved from American Health Lawyers Association website: https://www.ama-assn.org/sites/default/files/media-browser/public/ama-foundation/legal-operational-guide-free-medical-clinics.pdf
; Legal Solutions; Medical Perspectives, NIFLA Medical Manual, etc.
[vii] Excerpted from Care Net’s Code of Ethics: Our Commitment of Care & Competence: Clients are served without regard to age, race, income, nationality, religious affiliation, disability or other arbitrary circumstances; Clients are treated with kindness, compassion and in a caring manner; Clients always receive honest and open answers.
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