Hollenberger, J. & Pooler, D. (2023). Equipoise: Ethical Considerations for Pregnancy Options Counseling. International Journal of Social Work Values and Ethics, 20(1), 129-141. https://doi.org/10.55521/10-020-111
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Pregnancy options counseling is an intervention that supports individuals who are struggling with making decisions related to an unintended pregnancy and typically occurs within medical and social service agencies across the United States. This intervention is important, as nearly 50% of pregnancies in the United States are unplanned or unintended. While little information is presently available on how pregnancy options counseling is practiced across settings, there are likely many opportunities where ethical dilemmas arise for the counselor. This paper will introduce pregnancy options counseling within medical and social service settings and identify ethical considerations for social workers and other helping professionals. The paper ends with a focus specifically on equipoise as a state of being.
Keywords: Pregnancy options counseling; unplanned pregnancy; social work ethics; social work in health care; clinical social work; reproductive decision making
Pregnancy options counseling is an intervention that is often used to reduce anxiety and assist with concerns and decision-making that may arise with individuals experiencing an unintended pregnancy. Presently, pregnancy options counseling is utilized in multiple types of settings, including medical clinics, human service organizations, adoption agencies, and faith-based pregnancy resource centers (Berglas et al., 2018; O’Donnell et al., 2018). A woman who experiences an unplanned pregnancy, likely, will take a pregnancy test at one of the agencies listed above and then have the option to receive pregnancy options education or counseling pending a positive result. In other instances, she may take a home pregnancy test, receive a positive result, and then seek organizations where they are able discuss her options and provide support and resources. This intervention is important as almost half of pregnancies in the United States are unintended (Finer & Zolna, 2016).
Pregnancy options counseling offers a unique opportunity for social workers, mental health, and other health care providers to engage and assist women during an unplanned pregnancy situation. Ideally, pregnancy options counseling provides ethical, unbiased, and non-directive, patient-led counseling to pregnant patients, and their partners and/or families, who need support processing and discussing their ideas and emotions related to their unintended pregnancy (Berglas et al., 2018; Madden et al., 2017; Moss et al., 2015; Simmonds & Likis, 2005; Singer, 2004). Pregnancy options counseling, ultimately, should assist the patient in making a pregnancy resolution decision. Pregnancy resolutions are typically defined as the following: continuation of pregnancy and parenting, continuation of pregnancy and forming an adoption plan (including kinship care), or ending the pregnancy through an elective abortion (i.e., medication abortion or surgical abortion). About 40% of unintended pregnancies will end in abortion, approximately one-percent will result in adoption placement and roughly 50% will resolve in continuing the pregnancy and then parenting (CDC, 2014; Finer & Zolna, 2011; Moss et al., 2015).
Pregnancy Options Counseling and Social Work Ethics
The National Association of Social Work’s (NASW) Code of Ethics (2021) identifies Self Determination (1.02) and Informed Consent (1.03) as important factors to consider in social work practice. Self-determination provides individuals choice in their own decision making and the Code (2021) empowers social workers to encourage patient self-determination, while also respecting their rights and empowering patients to pursue their goals (Hollenberger & Yancey, 2021). Pregnancy options counseling inherently promotes self-determination of patients; simultaneously, pregnancy options counseling also necessitates the inclusion of Informed Consent. Informed Consent ensures patients are fully educated and advised about potential interventions and treatment. In their paper reflecting on pregnancy options counseling, faith and policy, Hollenberger and Yancey (2021) note The Code (2021) guides “social workers to provide services to patients on valid informed consent and then states social workers should use clear language to inform of purpose and potential risks and limits, relevant costs, alternatives, patients’ right to refuse or withdraw consent, and the time frame covered by the consent and create an environment where patients have the ability to ask questions” (p. 5). The ethical principles introduced here are nested in the social work value of the dignity and worth of the person and highlight the importance of human relationships. When integrated in practice these are the ethical building blocks of achieving competence.
Ethical Considerations for the Pregnancy Options Counselor
Pregnancy options counseling, like many health care interventions, has the potential to be complicated for the counselor, specifically as it relates to ethics and ethical dilemmas. Competing values, goals, agendas, and needs coupled with a patient’s vulnerability can create a messy and complex decision-making process that can range from leaving a patient satisfied with her choice to her feeling exploited, manipulated, or even coerced. Given this, this paper seeks to address some of the salient factors and concerns that a pregnancy options counselor will have to manage to provide the best care for their patients.
We suggest that counselors providing effective, competent, and ethical pregnancy options counseling should be in an ongoing process of examining, reflecting on, and deconstructing their own motivations for engaging in this important work with patients. The paper will end with a focus specifically on equipoise and describe how equipoise as a state of being with patients may create the safest spaces for individuals to make informed decision about their pregnancies.
The concept of equipoise originates in the medical field, and describes when researchers or medical professionals experience a genuine state of uncertainly about the superior option when there are several viable treatment options (Dahlen, 2021). It is often described as a clinical treatment feature when healthcare providers are in the position of influencing a patient decision where there are collaborative decision-making options available (Politi et al, 2021). Dobkin and colleagues (2013) describe pregnancy options counseling as an example of healthcare equipoise because there are two (or more) clinically sound approaches a client can choose. To better situate the meaning of this term where a pregnancy options counselor would find it useful, we turn to Motivational Interviewing training where clinicians are taught that equipoise is placing oneself in a neutral position when there are value laden decisions with moral dimensions about which the clinician may have a strong preference. A state of equipoise is sought to prevent steering a client in a particular direction (Forman & Moyers, 2021). Equipoise is achieved when the worker uses their power to create an environment where the patient has freedom and safety to explore their own desires and options without pressure to make a specific choice.
Agency Goals and Values
Counselors engaging in pregnancy options counseling will work at a variety of agencies with differing agendas and goals undergirded by different values. Commonly, pregnancy options counseling is provided by physicians in outpatient medical settings, by adoption professionals working with adoption agencies, by professionals in faith-based pregnancy resource centers, and by health care providers at women’s health clinics or abortion clinics. It is important to note that organizations may refer to pregnancy options counseling as pregnancy options education, however pregnancy counseling or abortion counseling are not synonymous terms with pregnancy options counseling/education. Counselors ostensibly self-select an organization that has a closeness of fit with their own personal values. But even so, organizations and organizational leadership may create an environment in which a worker feels pressure to direct or guide a patient toward a particular outcome. This can potentially occur across the spectrum of places where a helper can work or at any agency which provides options available to a patient. It is important for counselors to engage in a high level of critical thinking and reflexivity, and work toward personal objectivity by centering their patients’ needs, wants, wishes, and values during the time they spend together, and to do this regardless of the context in which workers find themselves. Two important questions counselors must ask themselves are “can I functionally isolate my patient from my agency’s values,” and “can I support a patient no matter their choice?”
Personal values often guide our choice of occupation and where we choose to work. These values have been inculcated through multiple pathways across the lifespan including by authority figures (parents), teachers, media/social media, politicians, religious institutions/leaders, books, sacred texts, as well as neighborhoods, communities, and regional culture, among many others. Given this complex set of beliefs and values, pregnancy options counselors may be uncomfortable with or express bias toward patients’ decisions to either continue or terminate unplanned pregnancies (Dobkin et al., 2013; Singer, 2004). In her influential article on options counseling technique, obstetric nurse Janet Singer (2004) reminds health care providers of the need to understand and accept a woman’s pregnancy goals even when they conflict with their own values. Singer (2004) suggests that pregnancy options counselors provide non-judgmental and non-directive care by, ideally, showing “disinterest” in the pregnancy decision (p. 236). Pregnancy options counselors should also explore and reflect on their own values surrounding reproductive decision making. Again, reflexivity, self-awareness, and enough safe space to examine “why” the counselor has chosen a certain type of work or agency setting are critical to the counselor being as objective as possible.
Presently, across healthcare and social service settings, there is little research on pregnancy options counseling interventions and techniques. Pregnancy options counseling is considered a best practice and is noted as a vital skill for all physicians who treat women of childbearing age (Lupi et al., 2016). In medical schools across the nation, medical students are expected to show competency in this intervention before graduation and are evaluated in their competency through objective structured clinical examination (OSCE) (Lupi et al., 2016, 2017). At the time of this paper, however, no scale has been found to measure the competency of pregnancy options counseling of those working in social or human services settings. Because counselors are providing time-sensitive information and interventions with women who experience an unplanned pregnancy, it is important that counselors provide counseling competently, which includes the need to be aware that women may encounter political, social, and economic challenges when making decisions about their unplanned pregnancies (Dobkin et al., 2013) Additionally, counselors need to be aware of and provide accurate pregnancy options information related to abortion, adoption, and parenting, including policies that may impact each decision. Doing such aligns with the Code of Ethics, which provides professional guidance on the importance of competence and the social worker’s need to develop their knowledge and skills (NASW, 2021).
Potential Ethical Dilemmas in Pregnancy Options Counseling
The ethical principle of self-determination is important for health care professionals across disciplines, especially social work, and may often be a source of dilemma and value conflict; there are, however, other potential situations that could create tensions within the pregnancy options counseling setting which we discuss next.
Religious and personal value conflict
Sometimes the counselor’s values, whether named as personal or religious or some combination thereof, are in direct conflict with, or even opposed to, what a patient wants. Providers of pregnancy options counseling (e.g., nurses, social workers, physicians, etc.) may experience their own responses and feelings when counseling women with unintended pregnancies. It would not be uncommon for a counselor to feel deeply conflicted about patient’s pregnancy choice, or for the counselor to feel complete agreement. Personal feelings must be examined, internally acknowledged, and then isolated or managed so they do not impact a patient’s ability to freely make an informed choice. In an effort to assist professionals with this particular ethical dilemma, Simmonds and Likis (2005) list several resources to encourage providers to be self-reflective in their practice settings. For example, when counselors find their personal values and professional responsibilities are not reconcilable, the patient’s concerns should be prioritized so that they receive ethical, comprehensive options counseling through another provider or setting entirely (Simmonds & Likis, 2005).
Providing fetal development information and offering ultrasound to ambivalent clients has been a source of contention in the current policy landscape surrounding reproductive health. There are presently variations in this practice as some healthcare and social service agencies are not providing fetal development information to individuals facing an unplanned pregnancy and others are, as guided by state or organizational policies, or even a patient’s request for more information as it relates to gestational age and development. This could become an ethical dilemma for the counselor who believes the patient should fully know and understand fetal development prior to making a pregnancy decision. Additionally, if the client refuses the information, the counselor may feel the client does not have all the information needed to make an informed choice. On the other hand, providing fetal development information to client’s (including ultrasound) is often dictated by agency or state policy. In this situation, clients may refuse information, which also creates an ethical dilemma for the pregnancy options counselor.
The decision of the counselor to provide information related to a pregnant person’s fetal development is one example of a potential dilemma in practice and ought to be ultimately driven by standards of informed consent, as opposed to other external forces, like agency and state policy. For social workers, providing informed consent is an ethical principal in the Code of Ethics (2021) and practioners, and researchers alike, need to determine what information is helpful for a patient’s decision-making process.
Rape related pregnancy
Unfortunately, rape and sexual assault will be experienced by approximately 18% of women in the United States; 5% of these sexual attacks will result in pregnancy (Perry et al., 2015). While rape related pregnancy commonly ends in pregnancy termination, women may experience ambivalence in decision-making, may have a moral opposition to abortion, or may be emotionally connected to their abuser, which makes pregnancy decision making challenging. In these situations, providers need to provide timely, unbiased, education to women.
Whether or not a standardized way to deliver pregnancy options counseling is developed, the heart or spirit of effective counseling should always be deep engagement with a patient which centers the patient’s experiences, needs, wishes, and wants. This sounds like it might be easy but holding the major factors we discuss in this paper in tension with being fully present with a patient can potentially be a challenge when doing pregnancy options counseling. There are several ways to think about what it means to work with women making decisions about pregnancy to achieve equipoise. First, to achieve equipoise a counselor must keep in mind that any person seeking support or help during an unplanned or unwanted pregnancy is vulnerable. Vulnerability does not mean weak or without power, it simply means they are at high risk to be coerced or even injured by a person or agency because of the magnitude of their present need and the power or influence that the agency or the person representing the agency wields. Given the vulnerability inherent in the situation, the counselor should take appropriate steps to know the patient. What a patient needs and wants should be more important, by far, than any agenda or goal of an agency. This is reiterated here because this field of practice is comprised of agencies with strong underlying value assumptions embedded in the culture that workers routinely navigate. There are ample anecdotes of workers feeling pressure inside of organizations to guide patients toward certain outcomes.
Second, the way to know the patient is to approach the relationship with curiosity and empathy. Curiosity is diametrically opposed to judgment. Curiosity seeks to know more about the patient’s lives, their stories, and how they got to where they are. It avoids assumptions and judgements. Empathy assumes, if anything, that there is a compelling and likely complex reason why the patient is in her current situation. It approaches the patient with a deep interest in what her life is like and what the decision she is facing might look like through her eyes.
Third, to achieve equipoise, the counselor must trust the patient and assume that patients are capable of making decisions in their best interests. This is necessary because it assumes the client is the expert (not an agency or a particular moral outcome) and is consistent with the ethical standard of self-determination. Without such an understanding, the counselor is at risk to persuade, fix, talk into, or talk down to patients. The counselor should fully humanize the patient and recognize that being human involves choosing, to the fullest extent possible, what their life will look like.
Fourth, the counselor may be an expert or have specialized knowledge, but this expertise should be offered with caution and with the patient’s permission. Expert knowledge and information should help the patient learn about all the available options, what accessing them would look like, and to the extent possible, a calculation of the risks and benefits as seen through the patient’s eyes. Projections of a certain future outcome based on a patient’s potential choice should never be made by a counselor and cannot ethically enter the equation. If patients are concerned about how their choices would affect them, the counselor should help them explore what this means for them. Asking probing questions and maintaining a curious stance is a way of showing interest in a patient and investing in them without being invested in what they choose to do.
As the practice of pregnancy options counseling evolves and research expands, we propose that equipoise or achieving a balance of power with a patient who is facing an unintended pregnancy is at the heart of effective and competent practice, and it should characterize the way a counselor approaches a relationship with a patient. Specific questions and techniques may be found to be effective and useful in the future, but in the meantime a patient-centered approach in a complex and very value-laden health context is, what we believe, the best approach to serving patients.
When counselors have strong reactions to the choices patients are considering, or experience strong urges to steer their clients, these may be signs that significant additional work needs to be done to achieve equipoise. We hope this paper is a necessary push for important conversations around power, vulnerability, and self-determination in pregnancy options counseling, but specifically to invite deeper reflection and self-awareness among those who do this work and those who are being trained to work in this field.
Social workers play a vital role in the health care settings and social workers who provide pregnancy options counseling within the medical setting need to be aware of ethical dilemmas that may arise when working with patients who experience unplanned pregnancies. Social workers, and other professionals who provide this intervention, should work to ensure patients receive adequate education on their reproductive options while learning to effectively navigate ethical dilemmas that could arise.
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