I am a physician in New York State who considers reproductive autonomy to be a basic human right. Our practice recently started to provide care to a newly pregnant 13-year-old. At this time, she does not want to terminate her pregnancy, although it also does not seem that she necessarily wants to continue her pregnancy. It is fair to say that she is approaching the situation as one might expect of a very young adolescent.
Her mother is involved in her care and is walking the fine line of trying to maintain a relationship with her daughter while firmly guiding her toward terminating the pregnancy. The mother is acutely aware of how generational poverty is perpetuated and wants to break the cycle of young teen pregnancy in her family.
My dilemma relates not to the legal issue of consent but to whether a 13-year-old has an ethical right to assent to care. Parents routinely, and appropriately, force children to receive medical care that they don’t want — flu vaccines, needed surgeries — because they have a maturity and an understanding of the situation young children lack. A 13-year-old cannot be expected to understand the ramifications of continuing a pregnancy in the same way that even an older adolescent might be able to.
This situation feels very different from other medical issues, and yet the fact of the patient’s immaturity remains. So does the fact that for this patient, given her demographic, the risk of death is far higher for a full-term pregnancy than for an abortion. But this demographic has also, historically, been subjected to reproductive coercion. Bearing all this in mind, what can a caring parent ethically require? — Name Withheld
From the Ethicist:
The way we think about freedom relates to ideals of autonomy. John Stuart Mill wrote, in a powerful passage in ‘‘On Liberty,’’ that a free person planning a life ‘‘must use observation to see, reasoning and judgment to foresee, activity to gather materials for decision, discrimination to decide, and when he has decided, firmness and self-control to hold to his deliberate decision.’’ Yet the capacity for reasonable decision-making doesn’t arrive all at once, as if an on switch had been toggled. Many children live somewhere in the borderlands. Born into the world in a state of complete dependency, we grow toward autonomy as we mature, and different people reach different stages along that path at different ages.
When our capacities aren’t fully developed, decisions are entrusted to others — beginning with our parents. And while the law may need to draw sharp boundaries, there’s often uncertainty about whether people have developed the capacities that make it sensible to leave a decision to them. With smaller-stakes decisions, we might want to err on the side of granting youngsters control; one way you grow into autonomy is by practicing taking responsible decisions. But having a baby is not a low-stakes decision. As you recognize, your young patient could suffer all sorts of setbacks if she were to become a mother, especially if she wants to raise the child. Beyond the obvious social and educational consequences, short-term and long-term medical risks are especially high for adolescent girls and for their babies.
In the light of these consequences, the mother’s judgment about the wisest course here seems to me sound. (I acknowledge that there are thoughtful people who believe that abortion involves a terrible wrong and who will disagree.) But as you also recognize, thinking that this is the right decision doesn’t settle the issue of whose choice it is. If the girl were five years younger or five years older, the situation would be clear to you. Ethically, we would not, in normal circumstances, require an 8-year-old to make medical decisions, nor subject an 18-year-old to a procedure without her assent. And in this ambiguous zone of early adolescence? We have to start with the enormity represented by terminating a pregnancy against someone’s will. (In New York State, a minor who is pregnant has the right to choose abortion or to continue the pregnancy, as long as she is mature enough to meet the standard for informed consent.)
Over the course of the past century, we have come to place great weight on bodily autonomy, even for those whose decisional capacity is limited. That’s especially the case when it comes to interventions that are both consequential and elective, in the strict sense of not being medically necessary. Putting aside the legal and practical questions, I’ll note that this girl is plainly someone who has some understanding of her situation. Nor is the equivocation she expresses unknown among grown-ups. The fact that she is far from the ideal of full autonomy doesn’t justify terminating her pregnancy by force or by guile. This teenager may not have an adult’s decision-making capacity; she does have the capacity to experience profound violation from undergoing an abortion against her will, an experience that could result in psychological harm.
What you can responsibly do is to reassure her about what an abortion, including a nonsurgical one, entails — she may have unfounded anxieties about the risks she would face — and also to speak with her, in simple and clear terms, about the risks entailed by a full-term pregnancy. Members of your practice may be able to offer the girl’s mother support in her own conversations — conversations about how the girl’s hopes and dreams would be affected, about the physical demands and dangers of this early pregnancy, about the day-to-day realities of teen pregnancy. There’s every reason to think that, through continued conversation, this family will be able to arrive at a harmonious decision.
Readers Respond
The previous question was from an aggrieved co-worker. He wrote: “There is a growing trend among experienced remote workers in the tech industry to work two full-time jobs at once. Their justification for doing so is that they’re being paid for their services, and as long as they accomplish their tasks before their deadlines, it’s fair play. To me this seems wrong on multiple levels. They’re effectively being paid twice for the same hours of availability, regardless of when they complete their tasks. Surely they have reduced availability for meetings and invent excuses for that, slowing down the pace of work at both companies. And for those companies attempting to set fair and reasonable deadlines, this would cause them to unfairly operate more slowly than competitors whose employees weren’t double-dipping. … Do you have advice for how I might encourage peers to refrain from going down this path without coming across as judgmental or seeming to accuse them of being unethical?”
In his response, the Ethicist noted: “At a time when people worry that the tech industry is crafting systems that will eliminate jobs, how should we feel when its employees have found a way to eliminate jobs more directly? There are the efficiency issues that you raise — by pulling a fast one, these workers may also be pulling a slow one — and, of course, there’s the ongoing dishonesty that comes of juggling two employers who are also providing benefits like subsidized health care and life insurance. … If people like the idea of working for more than one company, they can see if they can become a consultant or another kind of service provider. Then they can identify tasks that they’re to perform, set a fee for them and manage their commitments to as many clients as they see fit. In the meantime, companies will need to determine how to promote a healthy culture among remote employees who don’t have the sort of human interactions that take place in a well-functioning workplace.” (Reread the full question and answer here.)
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The question raised about hoarding jobs is part of a bigger one, where those lucky enough to be in a position to do so will earn way more money than they need, own far more houses than they need, etc. Resource-hoarding is probably the most important problem the world faces. We would all do well to ask this larger ethical question, and act on the obvious answer. — Michael K.
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As a member of Gen Z, many of us are employed in two jobs to help make ends meet, myself included. I do not, however, allow my second, lower-priority job to hinder my efforts at my career-oriented job. As long as the employee is meeting deadlines, is available for meetings and conference calls and is handling their responsibilities effectively, there should be no reason the employee cannot hold two jobs. If a company wants their employees to work only for them, pay the workers more or offer better benefits! — Haley
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I manage a group of developers, several of whom I’m pretty sure hold additional full-time jobs. I don’t care even a little. As long as the work is getting done, it’s none of my business what my employees do outside of that time. The idea that work shouldn’t just be transactional is laughable, as evidenced by all the layoffs in tech last year (although not at my workplace). No employer sees work as anything more than a transaction, so trying to convince workers that it’s something more is deceptive and abusive, and creates a one-sided loyalty where the power dynamic is already horrifically one-sided. If you can effectively work a second job on top of the first, you should do it. You owe your employer nothing beyond doing a good job in exchange for the money they pay you. — Michael Y.
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The reason employees, particularly remote workers, are not loyal to their employers is that they have learned, with the mass layoffs that began with the Great Recession, that employers have no loyalty to them. Workers who were key employees yesterday are now perp-walked out the door with no warning, and whole divisions are cut to meet a quarterly financial goal. American industry is now reaping the disloyalty it has sown. — Tom
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I know this remark is off-topic and nonresponsive to the current letter, but I’d like it said that Tomi Um’s accompanying illustrations are quite imaginative. They delightfully, artfully and often comically depict the questions posed, and on some level enhance them. They are a source of great joy and mirth whenever I read the column. I wonder if other readers share my observation. — Kwasi
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