The Veil of Ignorance

My patient was veiled in layers of heavy black cloth from head to toe. I could see blood staining her white socks as I waited impatiently for a female Arabic translator. Slowly, I told the patient and her sister that I was worried about her pregnancy, and would need to do a pelvic exam. As feared, I soon saw that she had a miscarriage. “Can I see the baby?” she said, gesturing to the container I discreetly covered with a clean towel. “We need to take him home for burial,” the sister added. I hesitated. A 12-week fetus wasn’t an easy image to prepare someone for. I laid it on clean gauze and explained, “It’s very early. It won’t look like a baby.” My patient nodded and held out her hand. At the sight of it, she shrieked, then clutched the fetus to her chest and began to pray.

Later that day, I saw another patient in the ER, again bleeding vaginally. She had taken a pill from the corner bodega to “make her period come down.” She got scared when the bleeding started and came to the hospital. The patient did not look me in the eye while she spoke. Sure enough, my ultrasound exam revealed a healthy-appearing 12-week fetus. Sharing this observation with her, she finally admitted, “My husband just lost his job. We already have 3 kids.” I told her if she wanted, he could come in and we could all talk together. She gratefully accepted. I counseled them extensively on their options and where they can safely follow-up, whatever their final decision.

It’s all in a day’s work for an OB/GYN to sit with couples devastated by lost pregnancies; or lay out the decision-making process for a pregnant woman with newly diagnosed cancer; or listen to a distraught patient confessing that she just can’t have a 7th baby but her husband won’t let her use contraception; or admonish a young lady requesting her 5th abortion because she thinks birth control will make her fat.

Whenever I see ideological debates about abortion in the media, I remember these real women. I find myself wrestling with paradigm shifts, engaging in the arduous task of putting myself in my patients’ shoes. In one instance, no maternal sacrifice would be too great to save a pre-viable fetus. In another, self-preservation trumps bringing new life into the world. I don’t always succeed in empathizing with my patients. Sometimes, I am dismayed by their choices and arguments. Often, I balk at pleas that I lie to their families on their behalf.

What I have learned from my patients is that violent protesters, graphic descriptions, or philosophical discussions about when a fetus becomes a person don’t sway their decisions. Whether or not they can articulate their moral, cultural, or religious beliefs, they already follow some internal creed that brought them to my doorstep. They came seeking a doctor, a counselor to guide them through a difficult, confusing choice because they have been inundated with political sound bites, folklore, and patriarchy. What they need are facts and a confidential, nonjudgmental space to work out their apprehensions about pregnancy and motherhood.

What about the fetus though? Who protects him? I won’t pretend to have the wisdom to argue the fine points of those existential questions with you. My internal compass leads me to focus on treating my patients with as much compassion as I can muster. I think about John Rawl’s veil of ignorance: to create a just society, you need to presume that you don’t know what your status will be in it, whether you will be rich or poor, powerful or weak, someone who will one day need an abortion or not. Unbiased, you are free to devise policies that are good, just, and beneficial for society.

To date, I have yet to meet a pregnant patient, faced with the tangled web of voluntary and involuntary reasons to continue or end a pregnancy, who didn’t take a good look in the mirror and ask herself what she can live with. I can usually see in her body language, the hunger for certainty, the fleeting shame, or the hardened resolve. She alone carries the lifelong burden of her decision. Only she can appreciate the intricate calculus of the costs and benefits at stake. As a doctor, I get to decide if I will add to her pain or start her healing right away.

I believe it is my duty to meet my patients wherever they are, and alleviate their suffering. My personal comfort is not in play, but my ability to counsel without judgment is. Issues of morality, after all, should be imbued with equal parts rigor AND grace. Holding on to this simple truth is what helps me sleep at night.