Volume 123, Supplement 3 (2013) - OSSyR · Volume 123, Supplement 3 (2013) Amsterdam Boston London New York Oxford Paris Philadelphia San Diego St. Louis. ... previous work and to

Volume 123 Supplement 3 (2013)

Amsterdam bull Boston bull London bull New York bull Oxford bull Paris bull Philadelphia bull San Diego bull St Louis

Editor

Editor Emeritus

Associate Editor

Associate Editor Emeritus

Managing Editor

Manuscript Editor

Honorary AssociateEditor

Associate Editors

Ethical and Legal Issuesin Reproductive Health

Enabling Technologies

FIGO Staging of GynecologicCancer

Contemporary Issues inWomenrsquos Health

Statistical Consultant

Editorial Office

T Johnson (USA)

J Sciarra (USA)

W Holzgreve (Germany)P Serafini (Brazil)J Fortney (USA)

L Keith (USA)

C Addington (UK)

P Chapman (UK)

L Hamberger (Sweden)

R Cook (Canada)B Dickens (Canada)

M Hammoud (USA)

L Denny (South Africa)

R Adanu (Ghana)V Boama (South Africa)V Guinto (Philippines)C Sosa (Uruguay)

A Vahratian (USA)

FIGO Secretariat FIGO HouseSuite 3 - Waterloo Court 10 Theed StreetLondon SE1 8ST UKTel +44 20 7928 1166Fax +44 20 7928 7099E-mail ijgofigoorg

International Journal of

GYNECOLOGYamp OBSTETRICS

Supplement to

International Journal of Gynecology amp Obstetrics

Volume 123 Supplement 3

Conscientious objection to the provision of reproductive healthcare

Guest Editor

Wendy Chavkin MD MPH

Publication of this supplement was made possible with support from Ford Foundation andan anonymous donor We thank all Global Doctors for Choice funders for making the projectpossible

This journal and the individual contributions contained in it are protected under copyright by InternationalFederation of Gynecology and Obstetrics and the following terms and conditions apply to their use

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Although all advertising material is expected to conform to ethical (medical) standards inclusion in thispublication does not constitute a guarantee or endorsement of the quality or value of such product orof the claims made of it by its manufacturer

Printed by Henry Ling Dorchester

The paper used in this publication meets the requirements of ANSINISO Z3948-1992 (Permanence of Paper)

CONTENTS

Volume 123 Supplement 3December 2013

EDITORIAL

W ChavkinUSA

Conscientious objection to the provision of reproductive healthcare S39

CONSCIENTIOUS OBJECTION

W Chavkin L Leitman KPolinfor Global Doctors for ChoiceUSA

Conscientious objection and refusal to provide reproductive healthcareA White Paper examining prevalence health consequences and policyresponsesThe present White Paper examines the prevalence and impact of conscience-based refusal ofreproductive healthcare on women health systems and providers in addition to reviewingpolicy efforts to balance competing interests while safeguarding health and medical integrity

A Fauacutendes GA DuarteMJ Duarte OsisUK Brazil

Conscientious objection or fear of social stigma and unawareness ofethical obligationsWhen used to hide fear of stigma conscientious objection to providing legal abortion ignoresthe primary conscientious duty of providing benefitpreventing harm to patients

BR Johnson Jr E KismoumldiMV Dragoman M TemmermanSwitzerland

Conscientious objection to provision of legal abortion careTo eliminate harmful effects of conscientious objection to provision of legal abortion statesshould ensure accessible safe legal abortion services for all women and adolescents

C ZampasCanada

Legal and ethical standards for protecting womenrsquos human rights and thepractice of conscientious objection in reproductive healthcare settingsInternational human rights and medical ethical bodies are increasingly developing standardsto guide state regulation of the practice of conscientious objection in reproductive healthcaresettings and address related human rights violations However much more needs to be doneto address the various contexts in which the practice is arising

International Journal of Gynecology and Obstetrics 123 (2013) S39ndashS40

EDITORIAL

Healthcare providers who cite conscientious objection asgrounds for refusing to provide components of legal reproduc-tive care highlight the tension between their right to exercise theirconscience and womenrsquos rights to receive needed care There arealso societal obligations and ramifications at stake including the re-sponsibility for negotiating balance between all of these competinginterests

Global Doctors for Choice (GDC) is a transnational networkof physicians who advocate for reproductive health and rights(httpwwwglobaldoctorsforchoiceorg)

GDC became concerned about the impact of conscience-basedrefusal on reproductive healthcare as we began to hear increasingreports of harms from many parts of the globe Therefore we beganto talk with colleagues and colleague organizations to compile dataand to review policy efforts to resolve the competing interests atplay This supplement presents the result of these efforts

GDC starts from the premise that both individual conscienceand autonomy in reproductive decision making are essential rightsAs a physician group we advocate for the rights of individualphysicians to maintain their integrity by honoring their conscienceWe simultaneously advocate that physicians maintain the integrityof the profession by according first priority to patient needs andto adherence to the highest standards of evidence-based care Webroaden the frame beyond individual physician and patient to alsoconsider the impact of conscientious objection on other clinicianson health systems and on communities

When we embarked on this investigation we found legal andethical analyses but far fewer data regarding health Thus weoffer a health-focused White Paper [1] as a complement to thisprevious work and to spur the design of a research agenda GDC isparticularly eager to bring the findings to the attention of membersof FIGO who care about physician and patient rights about healthand about the consequences for all of the different players andinterests involved We intend this compilation and analysis ofhealth-related information to provide the evidence base to groundour efforts as we move forward creatively together to uphold therights and health of all

This supplement also includes commentaries from 3 criticalvantage points Fauacutendes et al [2] provide a perspective fromthis professional medical society and contrast FIGOrsquos clear-cutarticulation that ldquothe primary conscientious duty of obstetricianndashgynecologists is at all times to treat or provide benefit andprevent harm to the patients for whose care they are responsiblerdquo[3] with the patchy and inconsistent physician behaviors theydescribe They call for improved dissemination and educationregarding bioethical principles and FIGO positions Johnson et al [4]discuss the application of WHOrsquos second edition of Safe Abortion

Technical and Policy Guidance for Health Systems [5] They spellout ways in which adherence to the individual and institutionalresponsibilities described therein allows individuals to exerciseconscience as it requires them to refer and provide urgently neededcare and expects systemic provision of sufficient facilities providersequipment and medications to assure uncompromised access tosafe legal abortion services Zampas [6] discusses internationalhuman rights law and state obligation to harmonize the practiceof conscientious objection with womenrsquos rights to sexual andreproductive health services She reports that UN human rightstreaty-monitoring bodies have raised concern about the insufficientregulation of the practice of conscientious objection to abortionand consistently recommend that states ensure that the practice iswell defined and well regulated in order to avoid limiting womenrsquosaccess to reproductive healthcare She emphasizes that womenrsquosconscience must also be fully respected

This supplement reflects the work of many We are grateful toDrs Dragoman Fauacutendes Johnson and Temerman and to GracianaAlves Duarte Maria Joseacute Duarte Osis Eszter Kismoumldi and ChristinaZampas for the cogent commentaries they have authored We arealso very appreciative of their ongoing collaboration

Further GDC thanks the following for their contributions to theWhite Paper the writing team (Wendy Chavkin Liddy Leitmanand Kate Polin) the research team (Mohammad Alyafi LindaArnade Teri Bilhartz Kathleen Morrell Kate Polin and DanaSchonberg) and the supplement peer reviewers (Giselle CarinoAlta Charo Kelly Culwell Bernard Dickens Debora Diniz Monica VDragoman Laurence Finer Jennifer Friedman Ana Cristina GonzaacutelezVeacutelez Lisa H Harris Brooke Ronald Johnson Eszter Kismoumldi AnneLyerly Alberto Madeiro Terry McGovern Howard Minkoff JoannaMishtal Jennifer Moodley Sara Morello Charles Ngwena AndreaRufino Siri Suh Johanna Westeson Christina Zampas and Silvia deZordo)

There are too many barriers to access to reproductive health-care Conscience-based refusal of care may be one that we cansuccessfully address

Conflict of interest

The author has no conflicts of interest

References

[1] Chavkin W Leitman L Polin K for Global Doctors for Choice Conscientiousobjection and refusal to provide reproductive healthcare A White Paperexamining prevalence health consequences and policy responses Int J GynecolObstet 2013123(Suppl 3)S41ndash56 (this issue)

S40 Editorial International Journal of Gynecology and Obstetrics 123 (2013) S39ndashS40

[2] Fauacutendes A Alves Duarte G Duarte Osis MJ Conscientious objection or fearof social stigma and unawareness of ethical obligations Int J Gynecol Obstet2013123(Suppl 3)S57ndash9 (this issue)

[3] FIGO Committee for the Ethical Aspects of Human Reproduction andWomenrsquos Health Ethical Issues in Obstetrics and Gynecology httpwwwfigoorgfilesfigo-corpEnglish20Ethical20Issues20in20Obstetrics20and20Gynecologypdf Published October 2012

[4] Johnson BR Jr Kismoumldi E Dragoman M Temmerman M Conscientious objectionto provision of legal abortion care Int J Gynecol Obstet 2013123(Suppl3)S60ndash2 (this issue)

[5] WHO Safe Abortion Technical and Policy Guidance for Health Systems SecondEdition Geneva WHO 2012

[6] Zampas C Legal and ethical standards for protecting womenrsquos human rightsand the practice of conscientious objection in reproductive healthcare settingsInt J Gynecol Obstet 2013123(Suppl 3)S63ndash5 (this issue)

Wendy ChavkinGlobal Doctors for Choice New York USA

60 Haven Avenue B-2 New York NY 10032 USATel +1 646 649 9903

E-mail address wendyglobaldoctorsforchoiceorgwc9columbiaedu

Conscientious objection and refusal to provide reproductive healthcareA White Paper examining prevalence health consequences and policy responses

Wendy Chavkin abc Liddy Leitman a Kate Polin a for Global Doctors for ChoiceaGlobal Doctors for Choice New York USAbCollege of Physicians and Surgeons Columbia University New York USAcMailman School of Public Health Columbia University New York USA

A R T I C L E I N F O A B S T R A C T

KeywordsAbortionAssisted reproductive technologiesConscience-based refusal of careConscientious commitmentConscientious objectionContraceptionPolicy responseReproductive health services

Background Global Doctors for Choicemdasha transnational network of physician advocates for reproductivehealth and rightsmdashbegan exploring the phenomenon of conscience-based refusal of reproductive healthcareas a result of increasing reports of harms worldwide The present White Paper examines the prevalence andimpact of such refusal and reviews policy efforts to balance individual conscience autonomy in reproductivedecision making safeguards for health and professional medical integrityObjectives and search strategy The White Paper draws on medical public health legal ethical and social sci-ence literature published between 1998 and 2013 in English French German Italian Portuguese and Span-ish Estimates of prevalence are difficult to obtain as there is no consensus about criteria for refuser statusand no standardized definition of the practice and the studies have sampling and other methodologic limita-tions The White Paper reviews these data and offers logical frameworks to represent the possible health andhealth system consequences of conscience-based refusal to provide abortion assisted reproductive technolo-gies contraception treatment in cases of maternal health risk and inevitable pregnancy loss and prenataldiagnosis It concludes by categorizing legal regulatory and other policy responses to the practiceConclusions Empirical evidence is essential for varied political actors as they respond with policies or reg-ulations to the competing concerns at stake Further research and training in diverse geopolitical settingsare required With dual commitments toward their own conscience and their obligations to patientsrsquo healthand rights providers and professional medicalpublic health societies must lead attempts to respond toconscience-based refusal and to safeguard reproductive health medical integrity and womenrsquos livescopy 2013 International Federation of Gynecology and Obstetrics Published by Elsevier Ireland Ltd All rights reserved

1 Introduction

How can societies find the proper balance between womenrsquosrights to receive the reproductive healthcare they need and health-care providersrsquo rights to exercise their conscience Global Doctorsfor Choice (GDC)mdasha transnational network of physician advocatesfor reproductive health and rights (wwwglobaldoctorsforchoiceorg)mdashbegan exploring the phenomenon of conscience-based refusalof reproductive healthcare in response to increasing reports ofharms worldwide The present White Paper addresses the variedinterests and needs at stake when clinicians claim conscientiousobjector status when providing certain elements of reproductivehealthcare (While GDC represents physicians in the present WhitePaper we use the terms providers or clinicians to also addressrefusal of care by nurses midwives and pharmacists) As the focusis on health we examine data on the prevalence of refusal lay

Corresponding author Wendy Chavkin 60 Haven Avenue B-2 New York NY10032 USA Tel +1 646 649 9903 fax +1 646 366 1897

E-mail address wendyglobaldoctorsforchoiceorg wc9columbiaedu(W Chavkin)

out the potential consequences for the health of patients and theimpact on other health providers and health systems and reporton legal regulatory and professional responses Human rights areintertwined with health and we draw upon human rights frame-works and decisions throughout We also refer to bedrock bioethicalprinciples that undergird the practice of medicine in general suchas the obligations to provide patients with accurate information toprovide care conforming to the highest possible standards and toprovide care that is urgently needed Others have underscored theconsequences of negotiating conscientious objection in healthcarein terms of secularreligious tension Our contribution which com-plements all of this previous work is to provide the medical andpublic health perspectives and the evidence We focus on the rightsof the provider who conscientiously objects together with thatproviderrsquos professional obligations the rights of the women whoneed healthcare and the consequences of refusal for their healthand the impact on the health system as a whole

Conscientious objection is the refusal to participate in an activitythat an individual considers incompatible with hisher religiousmoral philosophical or ethical beliefs [1] This originated as op-position to mandatory military service but has increasingly been

S42 W Chavkin et al International Journal of Gynecology and Obstetrics 123 (2013) S41ndashS56

raised in a wide variety of contested contexts such as educationcapital punishment driverrsquos license requirements marriage licensesfor same-sex couples and medicine and healthcare While healthproviders have claimed conscientious objection to a variety ofmedical treatments (eg end-of-life palliative care and stem celltreatment) the present White Paper addresses conscientious objec-tion to providing certain components of reproductive healthcare(The terms conscientious objection and conscience-based refusalof care are used interchangeably throughout) Refusal to providethis care has affected a wide swath of diagnostic procedures andtreatments including abortion and postabortion care componentsof assisted reproductive technologies (ART) relating to embryo ma-nipulation or selection contraceptive services including emergencycontraception (EC) treatment in cases of unavoidable pregnancyloss or maternal illness during pregnancy and prenatal diagnosis(PND)

Efforts have been made to balance the rights of objectingproviders and other health personnel with those of patients In-ternational and regional human rights conventions such as theConvention on the Elimination of All Forms of Discriminationagainst Women [2] the International Covenant on Civil and PoliticalRights (ICCPR) [1] the American Convention on Human Rights [3]and the European Convention for the Protection of Human Rightsand Fundamental Freedoms [4] as well as UN treaty-monitoringbodies [56] have recognized both the right to have access to qual-ity affordable and acceptable sexual and reproductive healthcareservices andor the right to freedom of religion conscience andthought The Protocol to the African Charter on Human and PeoplesrsquoRights on the Rights of Women in Africa recognizes the right to befree from discrimination based on religion and acknowledges theright to health especially reproductive health as a key human right[7] These instruments negotiate these apparently competing rightsby stipulating that individuals have a right to belief but that thefreedom to manifest onersquos religion or beliefs can be limited in orderto protect the rights of others

The ICCPR a central pillar of human rights that gives legal forceto the 1948 UN Universal Declaration of Human Rights states inArticle 18(1) that [1]

Everyone shall have the right to freedom of thoughtconscience and religion This right shall include freedomto have or to adopt a religion or belief of his choice andfreedom either individually or in community with othersand in public or private to manifest his religion or beliefin worship observance practice and teaching

Article 18(3) however states that [1]

Freedom to manifest onersquos religion or beliefs may besubject only to such limitations as are prescribed by lawand are necessary to protect public safety order health ormorals or the fundamental rights and freedoms of others

International professional associations such as the World Medi-cal Association (WMA) [8] and FIGO [9]mdashas well as national medicaland nursing societies and groups such as the American Congressof Obstetricians and Gynecologists (ACOG) [10] Grupo Meacutedico porel Derecho a DecidirGDC Colombia [11] and the Royal College ofNursing Australia [12]mdashhave similarly agreed that the providerrsquosright to conscientiously refuse to provide certain services must besecondary to his or her first duty which is to the patient Theyspecify that this right to refuse must be bounded by obligations toensure that the patientrsquos rights to information and services are notinfringed

Conscience-based refusal of care appears to be widespread inmany parts of the world Although rigorous studies are few esti-mates range from 10 of OBGYNs refusing to provide abortions

reported in a UK study [13] to almost 70 of gynecologists whoregistered as conscientious objectors to abortion with the ItalianMinistry of Health [14] While the impact of the loss of providersmay be immediate and most obvious in countries in which maternaldeath rates from pregnancy delivery and illegal abortion are highand represent major public health concerns consequences at indi-vidual and systemic levels have also been reported in resource-richsettings At the individual level decreased access to health servicesbrought about by conscientious objection has a disproportionateimpact on those living in precarious circumstances or at otherwiseheightened risk and aggravates inequities in health status Indeedtoo many women men and adolescents lack access to essentialreproductive healthcare services because they live in countries withrestrictive laws scant health resources too few providers and slotsto train more and limited infrastructure for healthcare and meansto reach care (eg roads and transport) The inadequate numberof providers is further depleted by the ldquobrain drainrdquo when trainedpersonnel leave their home countries for more comfortable techni-cally fulfilling and lucrative careers in wealthier lands [15] Accessto reproductive healthcare is additionally compromised when gy-necologists anesthesiologists generalists nurses midwives andpharmacists cite conscientious objection as grounds for refusing toprovide specific elements of care

The level of resources allocated by the health system greatlyinfluences the impact caused by the loss of providers due toconscience-based refusal of care In resource-constrained settingswhere there are too few providers for population need it is log-ical to assume the following chain of events further reductionsin available personnel lead to greater pressure on those remain-ing providers more women present with complications due todecreased access to timely services and complications requirespecialized services such as maternalneonatal intensive care andmore highly trained staff in addition to incurring higher costs Theincreased demand for specialized services and staffing burdens anddiverts the human and infrastructural resources available for otherpriority health conditions However it is difficult to disentangle theimpact of conscientious objection when it is one of many barriersto reproductive healthcare It is conceptually and pragmaticallycomplicated to sort the contribution to constrained access to repro-ductive care attributable to conscientious objectors from that dueto limited resources restrictive laws or other barriers

What are the criteria for establishing objector status and whois eligible to do so In the military context conscientious objectorapplicants must satisfy numerous procedural requirements andmust provide evidence that their beliefs are sincere deeply heldand consistent [16] These requirements aim to parse genuineobjectors from those who conflate conscientious objection withpolitical or personal opinion For example the true conscientiousobjector to military involvement would refuse to fight in anywar whereas the latter describes someone who disagrees witha particular war but who would be willing to participate in adifferent ldquojustrdquo war Study findings and anecdotal reports frommany countries suggest that some clinicians claim conscientiousobjection for reasons other than deeply held religious or ethicalconvictions For example some physicians in Brazil who describedthemselves as objectors were nonetheless willing to obtain orprovide abortions for their immediate family members [17] APolish study described clinicians such as those referred to asthe White Coat Underground who claim conscientious objectionstatus in their public sector jobs but provide the same services intheir fee-paying private practices [18] Other investigations indicatethat some claim objector status because they seek to avoid beingassociated with stigmatized services rather than because they trulyconscientiously object [19]

Moreover some religiously affiliated healthcare institutions claimobjector status and compel their employees to refuse to provide

W Chavkin et al International Journal of Gynecology and Obstetrics 123 (2013) S41ndashS56 S43

legally permissible care [2021] The right to conscience is generallyunderstood to belong to an individual not to an institution asclaims of conscience are considered a way to maintain an indi-vidualrsquos moral or religious integrity Some disagree however andargue that a hospitalrsquos mission is analogous to a consciencendashidentityresembling that of an individual and ldquowarrant[s] substantial def-erencerdquo [22] Others dispute this on the grounds that healthcareinstitutions are licensed by states often receive public financingand may be the sole providers of healthcare services in communi-ties Wicclair and Charo both argue that since a license bestowscertain rights and privileges on an institution [22ndash24] ldquo[W]henlicensees accept and enjoy these rights and privileges they incurreciprocal obligations including obligations to protect patients fromharm promote their health and respect their autonomyrdquo [22]

There are also disputes as to whether obligations and rightsvary if a provider works in the public or private sector Publicsector providers are employees of the state and have obligationsto serve the public for the greater good providing the highestldquostandard of carerdquo as codified in the laws and policies of thestate [22] The Institute of Medicine in the USA defines standardof care as ldquothe degree to which health services for individualsand populations increase the likelihood of desired health outcomesand are consistent with current professional knowledgerdquo andidentifies safety effectiveness patient centeredness and timelinessas key components [25] WHO adds the concepts of equitabilityaccessibility and efficiency to the list of essential components ofquality of care [26] There are legal precedents limiting the scopeof conscientious objection for professionals who operate as stateactors [23] Some argue that such limitations can be extended tothose who provide health services in the private sector becauseas state licensure grants these professions a monopoly on a publicservice the professions have a collective obligation to patients toprovide non-discriminatory access to all lawful services [2327]However it is more difficult to identify conscience-based refusalof care in the private sector because clinicians typically havediscretion over the services they choose to offer although thesame professional obligations of providing patients with accurateinformation and referral pertain

An alternative framing is provided by the concept of consci-entious commitment to acknowledge those providers whose con-science motivates them to deliver reproductive health services andwho place priority on patient care over adherence to religious doc-trines or religious self-interest [2829] Dickens and Cook articulatethat conscientious commitment ldquoinspires healthcare providers toovercome barriers to delivery of reproductive services to protectand advance womenrsquos healthrdquo [28] They assert that because pro-vision of care can be conscience based full respect for consciencerequires accommodation of both objection to participation andcommitment to performance of services such that the latter groupof providers also have the right to not suffer discrimination on thebasis of their convictions [28] This principle is articulated by FIGO[9] according to the FIGO ldquoResolution on Conscientious ObjectionrdquoldquoPractitioners have a right to respect for their conscientious convic-tions in respect both not to undertake and to undertake the deliveryof lawful proceduresrdquo [30]

We begin the present White Paper with a review of the limiteddata regarding the prevalence of conscience-based refusal of careand objectorsrsquo motivations Descriptive prevalence data are neededin order to assess the distribution and scope of this phenomenonand it is necessary to understand the concerns of those whorefuse in order to design respectful and effective responses Wereview the data point out the methodologic geographic andother limitations and specify some questions requiring furtherinvestigation Next we explore the consequences of conscientiousobjection for patients and for health systems Ideally we wouldevaluate empirical evidence on the impact of conscience-based

refusal on delay in obtaining care for patients and their familiessociety healthcare providers and health systems As such researchhas not been conducted we schematically delineate the logicalsequence of events if care is refused

We then look at responses to conscience-based refusal of careby transnational bodies governments health sector and otheremployers and professional associations These responses includeestablishment of criteria for obtaining objector status requireddisclosure to patients registration of objector status mandatoryreferral to willing providers and provision of emergency care Wedraw upon analyses performed by others to categorize the differentmodels used legislative constitutional case law regulatory em-ployment requirements and professional standards of care Finallywe provide recommendations for further research and for waysin which medical and public health organizations could contributeto the development and implementation of policies to manageconscientious objection

The present White Paper draws upon medical public healthlegal ethical and social science literature of the past 15 years inEnglish French German Italian Portuguese and Spanish availablein 2013 It is intended to be a state-of-the-art compendium usefulfor health and other policymakers negotiating the balance ofan individual providerrsquos rights to ldquoconsciencerdquo with the systemicobligation to provide care and it will need updating as furtherevidence and policy experiences accrue It is intended to highlightthe importance of the medical and public health perspectivesemploy a human rights framework for provision of reproductivehealth services and emphasize the use of scientific evidence inpolicy deliberations about competing rights and obligations

2 Review of the evidence

21 Methods

We reviewed data regarding the prevalence of conscientiousobjection and the motivations of objectors in order to assessthe distribution and scope of the phenomenon and to have anempirical basis for designing respectful and effective responsesHowever estimates of prevalence are difficult to obtain thereis no consensus about criteria for objector status and thus nostandardized definition of the practice Moreover it is difficult toassess whether findings in some studies reflect intention or actualbehavior The few countries that require registration provide themost solid evidence of prevalence

A systematic review could not be performed because the dataare limited in a variety of ways (which we describe) makingmost of them ineligible for inclusion in such a process Wesearched systematically for data from quantitative qualitative andethnographic studies and found that many have non-representativeor small samples low response rates and other methodologiclimitations that limit their generalizability Indeed the studiesreviewed are not comparable methodologically or topically Themajority focus on conscience-based refusal of abortion-relatedcare and only a few examine refusal of emergency or othercontraception PND or other elements of care Some examineprovider attitudes and practices related to abortion in generalwhile others investigate these in terms of the specific circumstancesfor which people seek the service for example financial reasonssex selection failed contraception rapeincest fetal anomaly andmaternal life endangerment Some rely on closed-ended electronicor mail surveys while others employ in-depth interviews Mostfocus on physicians fewer study nurses midwives or pharmacists

These investigations are also limited geographically becausemore were conducted in higher-income than lower-income coun-tries Because of both greater resources and more liberalizedreproductive health laws and policies many higher-income coun-

tries offer a greater range of legal services and consequentlymore opportunities for objection Assessment of the impact ofconscience-based refusal of care in resource-constrained settingspresents additional challenges because high costs and lack of skilledproviders may dwarf this and other factors that impede accessAcknowledging that conscientious objection to reproductive health-care has yet to be rigorously studied we included all studies wewere able to locate within the past 15 years and present thecross-cutting themes as topics for future systematic investigation

22 Prevalence and attitudes

The sturdiest estimates of prevalence come from a limitedsample of those few places that require objectors to register assuch or to provide written notification 70 of OBGYNs and 50 ofanesthesiologists have registered with the Italian Ministry of Healthas objectors to abortion [31] While Norway and Slovenia requiresome form of registration neither has reported prevalence data[32ndash34] Other estimates of prevalence derive from surveys withvaried sampling strategies and response rates In a random sampleof OBGYN trainees in the UK almost one-third objected to abortion[35] 14 of physicians of varied specialties surveyed in HongKong reported themselves to be objectors [36] 17 of licensedNevada pharmacists surveyed objected to dispensing mifepristoneand 8 objected to EC [37] A report from Austria describes manyregions without providers and a report from Portugal indicates thatapproximately 80 of gynecologists there refuse to perform legalabortions [38ndash40]

Other studies have investigated opinions about abortion andintention to provide services A convenience sample of Spanishmedical and nursing students indicated that most support access toabortion and intend to provide it [41] A survey of medical nursingand physician assistant students at a US university indicated thatmore than two-thirds support abortion yet only one-third intend toprovide with the nursing and physician assistant students evincingthe strongest interest in doing so [42] The 8 traditional healersinterviewed in South Africa were opposed to abortion [43] and anethnographic study of Senegalese OBGYNs midwives and nursesreported that one-third thought the highly restrictive law thereshould permit abortion for rapeincest although very few werewilling to provide services (unpublished data)

Some studies indicate that a subset of providers claim to be con-scientious objectors when in fact their objection is not absoluteRather it reflects opinions about patient characteristics or reasonsfor seeking a particular service For example a stratified randomsample of US physicians revealed that half refuse contraceptionand abortion to adolescents without parental consent although thelaw stipulates otherwise [44] A survey of members of the US pro-fessional society of pediatric emergency room physicians indicatedthat the majority supported prescription of EC to adolescents butonly a minority had done so [45] A study of the postabortioncare program in Senegal intended to reduce morbidity and mor-tality due to complications from unsafe abortion found that someproviders nonetheless delayed care for women they suspected ofhaving had an induced abortion (unpublished data)

Willingness to provide abortions varies by clinical context andreason for abortion as demonstrated by a stratified random sampleof OBGYN members of the American Medical Association (AMA)[46] A survey of family medicine residents in the USA assessingprevalence of moral objection to 14 legally available medicalprocedures revealed that 52 supported performing abortion forfailed contraception [47] Despite opposition to voluntary abortionmore than three-quarters of OBGYNs working in public hospitalsin the Buenos Aires area from 1998 to 1999 supported abortion formaternal health threat severe fetal anomaly and rapeincest [48]While 10 of a random sample of consultant OBGYNs in the UK

described themselves as objectors most of this group supportedabortion for severe fetal anomaly [13]

Other inconsistencies regarding refusal of care derived from theproviderrsquos familiarity with a patient experience of stigmatizationor opportunism A Brazilian study reported that Brazilian gynecol-ogists were more likely to support abortion for themselves or afamily member than for patients [17] Physicians in Poland andBrazil reported reluctance to perform legally permissible abortionsbecause of a hostile political atmosphere rather than because ofconscience-based objection The authors also noted that consci-entious objection in the public sphere allowed doctors to funnelpatients to private practices for higher fees [19]

Not surprisingly higher levels of self-described religiosity wereassociated with higher levels of disapproval and objection regardingthe provision of certain procedures [49] Additionally a randomsample of UK general practitioners (GPs) [50] a study of Idaholicensed nurses [51] a study of OBGYNs in a New York hospital[52] and a cross-sectional survey of OBGYNs and midwives inSweden [53] found self-reported religiosity to be associated withreluctance to perform abortion A study of Texas pharmacists foundthe same association regarding refusal to prescribe EC [54]

Higher acceptance of these contested service components andlower rates of objection were associated with higher levels oftraining and experience in a survey of medical students andphysicians in Cameroon and in a qualitative study of OBGYNclinicians in Senegal [5556] Similar patterns prevailed in a surveyof Norwegian medical students [57] and among pharmacists andOBGYNs in the USA [45]

Cliniciansrsquo refusal to provide elements of ART and PND alsovaried at times motivated by concerns about their own lackof competence with these procedures And while the majorityof Danish OBGYNs and nurses (87) in a non-random samplesupported abortion and ART 69 opposed selective reduction [49]A random sample of OBGYNs from the UK indicated that 18would not agree to provide a patient with PND [13]

Several studies report institutional-level implications conse-quent to refusal of care Physicians and nurse managers in hospitalsin Massachusetts said that nurse objection limited the ability toschedule procedures and caused delays for patients [58] Half ofa stratified random sample of US OBGYNs practicing primarilyat religiously affiliated hospitals reported conflicts with the hos-pital regarding clinical practice 5 reported these to center ontreatment of ectopic pregnancy [59] 52 of a non-random sampleof regional consultant OBGYNs in the UK said that insufficientnumbers of junior doctors are being trained to provide abortionsowing to opting out and conscientious objection [35] A 2011 SouthAfrican report states that more than half of facilities designatedto provide abortion do not do so partly because of conscien-tious objection resulting in the persistence of widespread unsafeabortion morbidity and mortality [60] A non-random sample ofPolish physicians reported that institutional rather than individualobjection was common [19] Similar observations have been madeabout Slovakian hospitals [61]

A few investigations have explored clinician attitudes towardregulation of conscience-based refusal of reproductive healthcareTwo studies from the USA indicate that majorities of familymedicine physicians in Wisconsin and a random sample of USphysicians believe physicians should disclose objector status topatients [4447] A survey of UK consultants revealed that half wantthe authority to include abortion provision in job descriptions forOBGYN posts and more than one-third think objectors should berequired to state their reasons [35] Interviews with a purposivesample of Irish physicians revealed mixed opinions about theobligation of objectors to refer to other willing providers as wellas awareness that women traveled abroad for abortions and relatedservices that were denied at home [62]

While the reviewed literature indicates widespread occurrenceof conscientious objection to providing some elements of reproduc-tive healthcare it does not offer a rigorously obtained evidentiarybasis from which to map the global landscape Assessment of theprevalence of conscientious objection requires ascertainment of thenumber objecting (numerator) and the total count of the rele-vant population of providers comprising the denominator (eg thenumber of OBGYNs claiming conscientious objection to providingEC and the total population of OBGYNs) Registration of objec-tors as required by the Italian Ministry of Health provides suchdata Professional societies could also systematically gather databy surveying members on their practices related to conscience-based refusal of care or by including such self-identification onstandard mandatory forms Academic institutions or other researchorganizations could conduct formal studies or add questions onconscience-based refusal of care to ongoing general surveys ofclinicians

Aside from prevalence there are a host of key questions Furtherresearch on motivations of objectors is required in order to bet-ter understand reasons other than conscience-based objection thatmay lead to refusal of care As the studies reviewed indicate thesefactors may include desire to avoid stigma to avoid burdensomeadministrative processes and to earn more money by providingservices in private practice rather than in public facilities knowl-edge gaps in professional training and lack of access to necessarysupplies or equipment Qualitative studies would best probe thesecomplicated motivations

What is the impact of conscience-based refusal of care Inthe next section we outline systemic and biologically plausiblesequences of events when specified care components are refusedResearch is needed to see whether these hold true and havehealth consequences for women and practical consequences forother clinicians and the health system as a whole Researchcould illuminate womenrsquos experiences when refused caremdashtheirunderstanding access to safe and unsafe alternatives emotionalresponse and course of action Investigations on the clinician sidecould further explore the experiences of those who do provideservices after others have refused to do so Each of these questionsis likely to have context-specific answers so research should takeplace in varied geopolitical settings and the contextual nature ofthe findings must be made clear

Do clinicians consider conscientious objection to be problem-atic What kinds of constraints on provider behavior do cliniciansconsider appropriate or realistic When enacted have such poli-cies or regulations been implemented Have those implementedeffectively met their purported objectives What mechanismsof regulation do women consider reasonable Do they perceiveconscience-based refusal of care as a significant barrier to reproduc-tive health services Could enhanced training and updated medicaland nursing school curricula devoted to reproductive health addressthe lack of clinical skills that contributes to refusal of care Couldfurther education clarify which services are permitted by law andunder which circumstances and thus reassure clinicians sufficientlysuch that they provide care Empirical evidence is essential asvaried political actors try to respond to these competing concernswith policies or regulations

3 Consequences of refusal of reproductive healthcare forwomen and for health systems

We lay out the potential implications of conscience-basedrefusal of care for patients and for health systems in 5 areasof reproductive healthcaremdashabortion and postabortion care ARTcontraception treatment for maternal health risk and unavoidablepregnancy loss and PND Because we lack empirical data toexplore the impact of conscience-based refusal of care on patients

and health systems we build logical models delineating plausibleconsequences if a particular component of care is refused Weprovide visual schemata to represent these pathways and we usedata and examples of refusal from around the world to groundthem

We attempt to isolate the impact of conscientious objection foreach of the 5 reproductive health components although we recog-nize the difficulties of identifying the contributions attributable toother barriers to access These include limited resources inadequateinfrastructure failure to implement policies sociocultural practicesand inadequate understanding of the relevant law by providers andpatients alike

We start from the premise that refusal of care leads to fewerclinicians providing specific services thereby constraining access tothese services We posit that those who continue to provide thesecontested services may face stigma andor become overburdenedWe specify plausible health outcomes for patients as well as theconsequences of refusal for families communities health systemsand providers

31 Conscience-based refusal of abortion-related services

The availability of safe and legal abortion services varies greatlyby setting Nearly all countries in the world allow legal abortionin certain cases (eg to save the life of the woman in cases ofrape and in cases of severe fetal anomaly) Few countries prohibitabortion in all circumstances While some among these allow thecriminal law defense of necessity to permit life-saving abortionsChile El Salvador Malta and Nicaragua restrict even this recourseOther countries with restrictive laws are not explicit or clear aboutthose circumstances in which abortion is allowed [63]

In many countries particularly in low-resource areas accessto legal services is compromised by lack of resources for healthservices lack of health information inadequate understanding ofthe law and societal stigma associated with abortion [64]

There is substantial evidence that countries that provide greateraccess to safe legal abortion services have negligible rates ofunsafe abortion [65] Conversely nearly all of the worldrsquos unsafeabortions occur in restrictive legal settings Where access to legalabortion services is restricted women seek services under unsafecircumstances Approximately 216 million of the worldrsquos annual46 million induced abortions are unsafe with nearly all of these(98) occurring in resource-limited countries [6566] In low-income countries more than half of abortions performed (56)are unsafe compared with 6 in high-income areas [66] Nearlyone-quarter (more than 5 million) of these result in seriousmedical complications that require hospital-based treatment [6768] 47000 women die each year because of unsafe abortion and anadditional unknown number of women experience complicationsfrom unsafe abortions but do not seek care [68] While theinternational health community has sought to mitigate the highrates of maternal morbidity and mortality caused by unsafe abortionthrough postabortion care programs [56] the implementation andeffectiveness of these have been undermined by conscience-basedrefusal of care [245669]

We posit that conscience-based refusal of care will have less ofan impact at the population level in countries with available safelegal abortion services than in those where access is restrictedWomen living in settings in which legal abortion is widely availableand who experience provider refusal will be more likely to findother willing providers offering safe legal services than women insettings in which abortion is more highly restricted We groundour model (Fig 1) in the following examples (1) in South Africawidespread conscientious objection limits the numbers of willingproviders and thus access to safe care and the number of unsafeabortions has not decreased since the legalization of abortion in

Fig 1 Consequences of refusal of abortion-related services

1996 [7071] (2) although Senegalrsquos postabortion care programis meant to mitigate the grave consequences of unsafe abortionconscientious objection is nevertheless often invoked when abor-tion is suspected of being induced rather than spontaneous [56](unpublished data)

32 Conscience-based refusal of components of ART

Infertility is a global public health issue affecting approximately8ndash15 of couples [7273] or 50ndash80 million people [74] worldwideAlthough the majority of those affected reside in low-resourcecountries [7273] the use of ART is much more likely in high-resource countries

Access to specific ART varies by socioeconomic status and ge-ographic location between and within countries In high-resourcecountries the cost of treatment varies greatly depending on thehealthcare system and the availability of government subsidy [75]For example in 2006 the price of a standard in vitro fertilization(IVF) cycle ranged from US $3956 in Japan to $12513 in the USA[76] After government subsidization in Australia the cost of IVFaveraged 6 of an individualrsquos annual disposable income it was50 without subsidization in the USA [77] In low-income countriesdespite high rates of infertility there are few resources availablefor ART and costs are generally prohibitive for the majority ofthe population Because these economic and infrastructural factorsdrive lack of access to ART in low-income countries we posit thatdenial of services owing to conscience-based refusal of care is not amajor contributing factor to limited access in these settings There-fore for the model (Fig 2) we primarily examine the consequencesof conscientious objection to components of ART in middle- tohigh-income countries At times regulations and policies regardingART stem from empirically based concerns grounded in medicalevidence about health outcomes for women and their offspring orhealth system priorities Our focus however is on those instancesin which some physicians practice according to moral or religiousbeliefs even when these contradict best medical practices In someLatin American countries despite the medical evidence that mater-

nal and fetal outcomes are markedly superior when fewer embryosare implanted the objection to embryo selectionreduction andcryopreservation promoted by the Catholic Church has reportedlyled many physicians to avoid these [78] Anecdotal reports fromArgentina describe ART physiciansrsquo avoidance of cryopreservationand embryo selectionreduction following the self-appointment of alawyer and member of Opus Dei as legal guardian for cryopreservedembryos [7879] The only example that illustrates the implicationsof denial of preimplantation genetic diagnosis (PGD) refers to alegal ban rather than conscience-based refusal of care Nonethelesswe use it to describe the potential consequences when such care isdenied In 2004 Italy passed a law banning PGD cryopreservationand gamete donation [80] This ban compelled a couple who wereboth carriers of the gene for β-thalassemia to wait to undergoamniocentesis and then to have a second-trimester abortion ratherthan allow the abnormality to be detected prior to implantation[80] (Fig 2)

33 Conscience-based refusal of contraceptive services

The availability of the range of contraceptive methods varies bysetting as does prevalence of use [81] In general contraceptiveuse is correlated with level of income In 2011 613 of womenaged 15ndash49 years married or in a union in middlendashupper-incomecountries were using modern methods compared with 25 inthe lowest-resource countries [8182] Within countries access toand use of methods also vary For example according to the 2003Demographic and Health Survey of Kenya (a cross-sectional study ofa nationally representative sample) women in the richest quintilewere reported to have significantly higher odds for using long-termcontraceptive methods (intrauterine device sterilization implants)than women in the poorest quintile [82]

The legal status of particular contraceptive methods also variesby setting In Honduras Congress passed a bill banning EC whichhas not yet been enacted into law [83] Even when contraception islegal lack of basic resources allocated by government programs maycompromise availability of particular methods High manufacturing

Fig 2 Consequences of refusal of components of assisted reproductive technologies

costs or steep prices can also undermine access [84] In other casesindividual health providers opt not to provide contraception to allor to certain groups of women Some providers refuse to providespecific methods such as EC or sterilization In Poland there iswidespread refusal to provide contraceptive services (J Mishtalpersonal communication April 2012) In Oklahoma a rape victimwas denied EC by a doctor [85] and in Germany a rape victimwas denied EC by 2 Catholic hospitals in 2012 [86] In Fig 3we delineate potential implications of conscience-based refusal ofcontraceptive services

34 Conscience-based refusal of care in cases of risk to maternal healthand unavoidable pregnancy loss

In some circumstances pregnancy can exacerbate a serious ma-ternal illness or maternal illness may require treatment hazardousto a fetus In these cases women require access to life-saving treat-ment which may include abortion Yet women have been deniedappropriate treatment Women seeking completion of inevitablepregnancy loss due to ectopic pregnancy or spontaneous abortionhave also been denied necessary care

It is beyond the scope of the present White Paper to definethe full range of conditions that may be exacerbated by pregnancy

and jeopardize the health of the pregnant woman Howeverthe incidence of ectopic pregnancy ranges from 1 to 16 [87ndash90] and 10ndash20 of all clinically recognized pregnancies end inspontaneous abortion [90] Often refusal of care in circumstancesof maternal health risk occurs in the context of highly restrictiveabortion laws We refer to 3 cases from around the world (Fig 4)to highlight this phenomenon in our model In Ireland in 2012Savita Halappanavar 31 presented at a Galway hospital withruptured membranes early in the second trimester She was refusedcompletion of the inevitable spontaneous abortion developedsepsis and subsequently died [91] Zrsquos daughter a young Polishwoman was diagnosed with ulcerative colitis while she waspregnant [92] She was repeatedly denied medical treatmentphysicians stated that they would not conduct procedures or teststhat might result in fetal harm or termination of the pregnancy[92] She developed sepsis experienced fetal demise and died Theonly example that illustrates the implications of denial of treatmentfor ectopic pregnancy derives from legal bans rather than froman example of conscience-based refusal of care In El Salvador atotal prohibition on abortion has led to physician refusal to treatectopic pregnancy [93] in Nicaragua the abortion ban results indelay of treatment for ectopic pregnancies despite law and medicalguidelines mandating the contrary [94] (Fig 4)

Fig 3 Consequences of refusal of contraceptive services

35 Conscience-based refusal of PND

The availability of PND varies greatly by settingmdashwith thosein middlendashupper-income countries having access to testing for avariety of genetic conditions and structural anomalies and fewerhaving access to a more limited series of testing in low-incomecountries Access to PND provides women with information sothat they can make decisions andor preparations when severe orlethal fetal anomalies are detected Outcomes for affected neonatesvary by country resource level PND enables physicians to planfor the level of care needed during delivery and in the neonatalperiod With PND families are also afforded the time to securethe necessary emotional and financial resources to prepare for thebirth of a child with special needs [9596] In settings in whichthere are fewer resources available for PND conscientious objectionfurther restricts womenrsquos access to services Figure 5 presentspathways and implications of provider conscience-based refusal toprovide PND services Because most data on access to PND arefrom high-resource countries we must project what would happenin lower-income countries We use the example of RR a Polishwoman who was repeatedly refused diagnostic tests to assess fetalstatus after ultrasound detection of a nuchal hygroma [97] (Fig 5)

4 Policy responses to manage conscience-based refusal ofreproductive healthcare

Here we review various policy interventions related toconscience-based refusal of care Initially we look at the con-text established by human rights standards or human rights bodieswherein freedom of conscience is enshrined The UN Committee onEconomic Social and Cultural Rights (CESCR) the UN Committeeon the Elimination of Discrimination against Women (CEDAW) andthe UN Human Rights Committee have commented on the needto balance providersrsquo rights to conscience with womenrsquos rights tohave access to legal health services [98ndash104] CEDAW asserts thatldquoit is discriminatory for a country to refuse to legally provide forthe performance of certain reproductive health services for womenrdquoand that if healthcare providers refuse to provide services on thebasis of conscientious objection ldquomeasures should be introducedto ensure that women are referred to alternative health providersrdquo[99] CESCR has called on Poland to take measures to ensure thatwomen enjoy their rights to sexual and reproductive health in-cluding by ldquoenforcing the legislation on abortion and implementinga mechanism of timely and systematic referral in the event ofconscientious objectionrdquo [104]

The international medical and public health communities in-cluding FIGO in its Ethical Guidelines on Conscientious Objection(2005) [9] and WHO in its updated Safe Abortion Guidelines (2012)[105] have agreed on principles related to the management of

Fig 4 Consequences of refusal of care in cases of risk to maternal health and unavoidable pregnancy loss

Fig 5 Consequences of refusal of prenatal diagnosis

conscientious objection to reproductive healthcare provision Whilethese are non-binding recommendations they do assert profes-sional standards of care These include the following

bull Providers have a right to conscientious objection and not tosuffer discrimination on the basis of their beliefs

bull The primary conscientious duty of healthcare providers is to

treat or provide benefit and prevent harm to patients conscien-tious objection is secondary to this primary duty

Moreover the following safeguards must be in place in order toensure access to services without discrimination or undue delays

bull Providers have a professional duty to follow scientifically andprofessionally determined definitions of reproductive healthservices and not to misrepresent them on the basis of personalbeliefs

bull Patients have the right to be referred to practitioners who donot object for procedures medically indicated for their care

bull Healthcare providers must provide patients with timely accessto medical services including giving information about themedically indicated options of procedures for care includingthose that providers object to on grounds of conscience

bull Providers must provide timely care to their patients whenreferral to other providers is not possible and delay wouldjeopardize patientsrsquo health

bull In emergency situations providers must provide the medicallyindicated care regardless of their own personal objections

These statements support both sides of the tension the rightof patients to have access to appropriate medical care and theright of providers to object for reasons of conscience to providingparticular forms of care They underscore the professional obligationof healthcare providers to ensure timely access to care throughprovision of accurate information referral and emergency care Atthe transnational level human rights consensus documents haveasserted that institutions and individuals are similarly bound bytheir obligations to operate according to the bedrock principlesthat underpin the practice of medicine such as the obligationsto provide patients with accurate information to provide careconforming to the highest possible standards and to provide carein emergency situations

At the country level however there is no agreement as towhether institutions can claim objector status For example Spain[106] Colombia [107] and South Africa [108] have laws statingthat refusal to perform abortions is always an individual not aninstitutional decision Conversely Argentinian law [109110] givesprivate institutions the ability to object and requires private healthcenters to register as conscientious objectors with local healthauthorities In Uruguay the Ethical Code does not require theinstitution employing a conscientious objector to provide referralservices although a newly proposed bill would require such referral[111112] In the USA the question of institutional rights andobligations is hotly debated and the situation is complicated andunresolved Currently federal law forbids agencies receiving federalfunding from discriminating against any healthcare entity thatrefuses to provide abortion services [113] Yet other federal lawrequires institutions providing services for low-income people tomaintain an adequate network of providers and to guarantee thatindividuals receive services without additional out-of-pocket cost[114]

International and regional human rights bodies governmentscourts and health professional associations have developed vari-ous responses to address conscience-based refusal of care Theseresponses differ as to whose rights they protect the rights of awoman to have access to legal services or the rights of a providerto object based on reasons of conscience They might also havedifferent emphases or targets Some focus on ensuring an ade-quate number of providers for a certain service some concentrateon ensuring that women receive timely referrals to non-objectingpractitioners and some seek to establish criteria for designationas an objector For example Norway established a comprehensiveregulatory and oversight framework on conscientious objectionto abortion which includes ensuring the availability of providers

[33115] In Colombia the Constitutional Court affirmed that con-scientious objection must be grounded in true religious convictionrather than in a personal judgment of ldquorightnessrdquo [116]

Some of these responses are legally binding through nationalconstitutional provisions legislation or case law The EuropeanCourt of Human Rights (ECHR) whose rulings are legally bindingfor member nations clarified the obligation of states to orga-nize the practice of conscience-based refusal of care to ensurethat patients have access to legal services specifically to abortion[97] Professional associations and employers have developed otherinterventions including job requirements and non-binding recom-mendations In Germany for example a Bavarian High Adminis-trative Court decision [117] upheld by the Federal AdministrativeCourt [118] ruled that it was permissible for a municipality to in-clude ability and willingness to perform abortions as a job criterionIn Norway employers can refuse to hire objectors and employmentadvertisements may require performance of abortion as a conditionfor employment [112] In Sweden Bulgaria Czech Republic Finlandand Iceland healthcare providers are not legally permitted to con-scientiously object to providing abortion services [38] Some requirereferral to non-objecting providers For example in the recent Pand S v Poland case the ECHR emphasized the need for referrals tobe put in writing and included in patientsrsquo medical records [119]In Argentina [110] and France [120] legislation requires doctorswho conscientiously object to refer patients to non-objecting prac-titioners Similar laws exist in Victoria Australia [121] Colombia[116122123] Italy [124] and Norway [115] Professional and med-ical associations around the world recommend that objectors referpatients to non-objecting colleagues ACOG in the USA [125] andEl Sindicato Meacutedico in Uruguay [126] recommend that objectorsrefer patients to other practitioners The British Medical Association(BMA) specifies that practitioners cannot claim exemption fromgiving advice or performing preparatory steps (including referral)where the request for an abortion meets legal requirements [127]The WMA asserts that if a physician must refuse a certain serviceon the basis of conscience she may do so after ensuring thecontinuity of medical care by a qualified colleague [128] FIGOmaintains that patients are entitled to referral to practitioners whodo not object [9]

Pharmacistsrsquo associations in the USA and UK have made similarrecommendations The American Society of Health-System Phar-macists asserts that pharmacists and other pharmacy employeeshave the right not to participate in therapies they consider to bemorally objectionable but they must make referrals in an objectivemanner [129] the AMA guidelines state that patients have the rightto receive an immediate referral to another dispensing pharmacyif a pharmacist invokes conscientious objection [130] In the UKpharmacists must also have in place the means to make a referralto another relevant professional within an appropriate time frame[131]

Some jurisdictions mandate registration of objectors or requireobjectors to provide advance written notice to employers orgovernment bodies In Spain for example the law requires thatconscientious objection must be expressed in advance and inwritten form to the health institution and the government [106]Italian law also requires healthcare personnel to declare theirconscientious objection to abortion to the medical director ofthe hospital or nursing home in which they are employed andto the provincial medical officer no later than 1 month afterdate of commencement of employment [124] Victoria Australia[118] Colombia [123] Norway [115] Madagascar [132] andArgentina [109] have similar laws In Norway the administrativehead of a health institution must inform the county municipalityof the number of different categories of health personnel whoare exempted on grounds of conscience [115] Argentinian law[109] gives private institutions the ability to object requiring these

institutions to register as conscientious objectors with local healthauthorities and to guarantee care by referring women to othercenters Argentinian law also states that an individual objectorcannot provide services in a private health center that she objectsto the provision of in the public health system [110] Regulation inCanada requires pharmacists to ensure that employers know abouttheir conscientious objector status and to prearrange access to analternative source for treatment medication or procedure [133]The Code of Ethics for nurses in Australia also requires disclosureto employers [134] In Northern Ireland a guidance document bythe Department of Health Social Services and Public Safety assertsthat an objecting provider ldquoshould have in place arrangementswith practice colleagues another GP practice or a Health SocialCare Trust to whom the woman can be referredrdquo for advice orassessment for termination of pregnancy [135]

Other measures require disclosure to patients about providersrsquostatus as objectors For example the law in the state of VictoriaAustralia requires objectors to inform the woman and refer herto a willing provider [121] In Argentina the Technical Guide forComprehensive Legal Abortion Care 2010 [109] requires that allwomen be informed of the conscientious objections of medicaltreating andor support staff at first visit Portugalrsquos medical ethicalguidelines encourage doctors to communicate their objection topatients [136]

The right to receive information in healthcare including repro-ductive health information is enshrined in international law Forexample the ECHR determined that denial of services essential tomaking an informed decision regarding abortion can constitute aviolation of the right to be free from inhuman and degrading treat-ment [97] At the national level laws have mandated disclosureof health information to patients For example according to theSouth African abortion law providers including objectors mustensure that pregnant women are aware of their legal rights toabortion [108] In Spain women are entitled to receive informationabout their pregnancies (including prenatal testing results) fromall providers including those registered as objectors [106] In theUK objectors are legally required to disclose their conscientiousobjector status to patients to tell them they have the right to seeanother doctor and to provide them with sufficient information toenable them to exercise that right [137ndash139]

Professional guidelines have also addressed disclosure of healthinformation In Argentina any delaying tactics provision of falseinformation or reluctance to carry out treatment by health pro-fessionals and authorities of hospitals is subject to administrativecivil andor criminal actions [109] FIGO asserts that the ethicalresponsibility of OBGYNs to prevent harm requires them to providepatients with timely access to medical services including givingthem information about the medically indicated options for theircare [9]

Some require the provision of services in cases of emergencyFor example legislation in Victoria Australia [121] Mexico City[140] Slovenia [141] and the UK [138] stipulates that physiciansmay not refuse to provide services in cases of emergency andwhen urgent termination is required US case law determinedthat a private hospital with a tradition of providing emergencycare was still obliged to treat anyone relying on it even afterits merger with a Catholic institution This sets the standard forcontinuity of access after mergers of 2 hospitals with conflictingphilosophies [142] Also ACOG urges clinicians to provide medicallyindicated care in emergency situations [125] In Argentina technicalguidelines from the Ministry of Health stipulate that institutionsmust provide termination of pregnancy through another providerat the institution within 5 days or immediately if the situation isurgent [109] In the UK medical standards also prohibit conscience-based refusal of care in cases of emergency for nurses and midwives[143]

Other measures address the required provision of services whenreferral to an alternative provider is not possible In Norway forexample a doctor is not legally allowed to refuse care unless apatient has such reasonable access [115] FIGO recommends thatldquopractitioners must provide timely care to their patients whenreferral to other practitioners is not possible and delay wouldjeopardize patientsrsquo health and well being such as by patientsexperiencing unwanted pregnancyrdquo [9]

Some interventions obligate the state to ensure services InColombia for example the health system is responsible for provid-ing an adequate number of providers and institutions must provideservices even if individuals conscientiously object [107] The lawon voluntary sterilization and vasectomies in Argentina obligateshealth centers to ensure the immediate availability of alternativeservices when a provider has objected [144] In Spain the govern-ment will pay for transportation to an alternative willing publichealth facility [106] Italian law requires healthcare institutions toensure that women have access to abortion regional healthcareentities are obliged to supervise and ensure such access which mayinclude transferring healthcare personnel [125] In Mexico City thepublic health code was amended to reinforce the duty of healthcarefacilities to make abortion accessible including their responsibilityto limit the scope of conscientious objection [140]

Some measures specify which service providers are eligible torefuse and when they are allowed to do so In the UK for exampleauxiliary staff are not entitled to conscientiously object [145146]According to the BMA guidelines refusal to participate in paper-work or administration connected with abortion procedures liesoutside the terms of the conscientious objection clause [127] InSpain only health professionals directly involved in termination ofpregnancy have the right to object and they must provide careto the woman before and after termination of pregnancy [106]Similarly doctors in Italy are legally required to assist before andafter an abortion procedure even if they opt out of the proce-dure itself [124] Also medical guidelines in Argentina encouragepractitioners to aid before and after legal abortion procedureseven if they are invoking conscientious objection to participationin the procedure itself [109] During the Bush administration theUS Department of Health and Human Services extended regulatoryldquoconscience protectionsrdquo to any individual peripherally participatingin a health service [147] This regulation was contested vigorouslyand retracted almost fully in February 2011 [148149]

In Table 1 we lay out some benefits and limitations of policyresponses to conscientious objection in order to provide variedactors with a menu of possibilities As criteria are developed forinvoking refusal it is essential to address the questions of who iseligible to object and to the provision of which services We haveadded the categories of ldquodatardquo and ldquostandardizationrdquo as parametersin the table in recognition of the scant evidence available and theresulting inability to methodically assess the scope and efficacy ofinterventions Selection of the various options delineated below willbe influenced by the specific sociopolitical and economic context

5 Conclusion

Refusal to provide certain components of reproductive health-care because of moral or religious objection is widespread andseems to be increasing globally Because lack of access to repro-ductive healthcare is a recognized route toward adverse healthoutcomes and inequalities exacerbation of this through furtherdepletion of clinicians constitutes a grave global health and rightsconcern The limited evidence available indicates that objectionoccurs least when the law public discourse provider custom andclinical experience all normalize the provision of the full range ofreproductive healthcare services and promote womenrsquos autonomyWhile data on both the prevalence of conscience-based refusal of

S52 W Chavkin et al International Journal of Gynecology and Obstetrics 123 (2013) S41ndashS56Ta

tsrsquoa

rsquorig

srsquoob

tsrsquoe

tsrsquo

tsrsquor

srsquoob

rsquosco

rsquorig

rsquosra

nrsquos

srsquone

emsrsquo

care and the consequences for womenrsquos health and health systemfunction are inadequate they indicate that refusal is unevenlydistributed that it may have the most severe impact in those partsof the world least able to sustain further personnel shortages andthat it also affects women in more privileged circumstances

The present White Paper has laid out the available data andoutlined research questions for further management of conscience-based refusal of care It presents logical chains of consequenceswhen refusal compromises access to specific components of re-productive healthcare and categorizes efforts to balance the claimsof objectors with the claims of both those seeking healthcare andthe systems obligated to provide these services We highlight theclaims of those whose conscience compels them to provide suchcare despite hardship As our emphasis is on medicine and sciencewe close by considering ways for medical professional and publichealth societies to develop and implement policies to manageconscientious objection

One recommendation is to standardize a definition of thepractice and to develop eligibility criteria for designation as anobjector Such designation would have accompanying obligationssuch as disclosure to employers and patients and duties to referto impart accurate information and to provide urgently neededcare Importantly professional organizational voices can upholdconformity with standards of care as the priority professionalcommitment of clinicians thus eliminating refusal as an optionfor the care of ectopic pregnancy inevitable spontaneous abortionrape and maternal illness In sum medical and public healthprofessional organizations can establish a clinical standard of carefor conscientious objection to which clinicians could be heldaccountable by patients medical societies and health and legalsystems

There are additional avenues for professional organizations toexplore in upholding standards Clinical specialty boards mightcondition certification upon demonstration of proficiency in specificservices Clinical educators could ensure that trainees and membersare educated about relevant laws and clinical protocolsproceduresHealth systems may consider willingness to provide needed servicesand proficiency as criteria for employment These last are note-worthy because they also move us from locating the issue at theindividual level to consideration of obligations at the professionaland health system levels

These issues are neither simple nor one-sided Conscience andintegrity are critically important to individuals Societies have thecomplicated task of honoring the rights of dissenters while alsolimiting their impact on other individuals and on communitiesAlthough conscientious objection is only one of many barriersto reproductive healthcare it is one that medical societies arewell positioned to address because providers are at the nexus ofhealth and rights concerns They have the unique vantage pointof caring simultaneously about their own conscience and abouttheir obligations to patientsrsquo health and rights and to the higheststandards of evidence-based care The present White Paper hasdisentangled the range of implications for womenrsquos health andrights health systems and objecting and committed providersThus it equips clinicians and their professional organizations tocontribute a distinct medical voice complementary to those oflawyers ethicists and others We urge medical and public healthsocieties to assert leadership in forging policies to balance thesecompeting interests and to safeguard reproductive health medicalintegrity and womenrsquos lives

Acknowledgments

Ford Foundation and an anonymous donor supported the publi-cation of the supplement We thank all GDC funders for making theproject possible

The authors have no conflicts of interest

References

[1] International Covenant on Civil and Political Rights adopted Dec 16 1966GA Res 2200A (XXI) UN GAOR 21st Sess Supp No 16 at 52 UN DocA6316 (1966) 999 UNTS 171 (entered into force March 23 1976)

[2] Convention on the Elimination of All Forms of Discrimination against Womenadopted December 18 1979 GA Res 34180 UN GAOR 34th Sess SuppNo 46 at 193 UN Doc A3446 (entered into force September 3 1981)

[3] Organization of American States American Convention on Human RightsldquoPact of San Joserdquo Costa Rica November 22 1969 httpwwwunhcrorgrefworlddocid3ae6b36510html Accessed February 10 2013

[4] Council of Europe European Convention for the Protection of Human Rightsand Fundamental Freedoms as amended by Protocols Nos 11 and 14November 4 1950 ETS 5 httpwwwunhcrorgrefworlddocid3ae6b3b04html Accessed February 10 2013

[5] UN Committee on Economic Social and Cultural Rights (CESCR) GeneralComment No 14 The Right to the Highest Attainable Standard of Health(Art 12 of the Covenant) August 11 2000 EC1220004 httpwwwrefworldorgdocid4538838d0html Accessed May 7 2013

[6] LC v Peru Communication No 11532003 Human Rights Committee para63 UN Doc CCPRC85D11532003 (2005)

[7] Protocol to the African Charter on Human and Peoplesrsquo Rights on the Rightsof Women in Africa adopted July 11 2003 2nd African Union AssemblyMaputo Mozambique (entered into force 2005)

[8] World Medical Association Declaration of HelsinkimdashEthical Principles forMedical Research Involving Human Subjects Adopted 1964 httpwwwwmaneten30publications10policiesb3 Accessed June 15 2013

[9] FIGO Committee for the Ethical Aspects of Human Reproduction and WomenrsquosHealth Ethical guidelines on conscientious objection FIGO Committee for theEthical Aspects of Human Reproduction and Womenrsquos Health Int J GynecolObstet 200692(3)333ndash4

[10] American College of Obstetricians and Gynecologists (ACOG) ACOGCommittee Opinion Committee on Ethics The Limits of ConscientiousRefusal in Reproductive Health Care Number 385 November 2007(reaffirmed 2010) httpwwwacogorgResources20And20PublicationsCommittee20OpinionsCommittee20on20EthicsThe20Limits20of20Conscientious20Refusal20in20Reproductive20Medicineaspx Ac-cessed March 22 2013

[11] Gonzaacutelez Veacutelez AC Refusal of Care due to Conscientious Objection GrupoMeacutedico por el Derecho a Decidir Global Doctors for ChoiceColombia2012 httpglobaldoctorsforchoiceorgwp-contentuploadsNegaciC3B3n-de-servicios-por-razones-de-concienciapdf Accessed October 23 2013

[12] Royal College of Nursing Australia Position Statement Conscientious Ob-jection httpwwwrcnaorgauwcmRCNAPolicyPosition_statementsrcnapolicyposition_statements_guidelines_and_communiquesaspx AccessedMarch 22 2013

[13] Green JM Obstetriciansrsquo views on prenatal diagnosis and termination of preg-nancy 1980 compared with 1993 British J Obstet Gynaecol 1995102(3)228ndash32

[14] Zampas C Andion-Ibaniez X Conscientious objection to sexual and reproduc-tive health services international human rights standards and European lawand practice Eur J Health Law 201219231ndash56

[15] Dodani S LaPorte R Brain drain from developing countries how can braindrain be converted into wisdom gain J R Soc Med 200598(11)487ndash91

[16] United States Department of Defense Regulations DoD Directive 13006 Con-scientious Objectors httpwwwdticmilwhsdirectivescorrespdf130006ppdf Published May 31 2007 Accessed October 23 2013

[17] Faundes A Duarte GA Neto JA de Sousa MH The closer you are thebetter you understand the reaction of Brazilian obstetrician-gynaecologiststo unwanted pregnancy RHM 200412(24 Suppl)47ndash56

[18] Mishtal J Contradictions of Democratization The Politics of ReproductiveRights and Policies in Postsocialist Poland Dissertation submitted to the Fac-ulty of the Graduate School of the University of Colorado in partial fulfillmentof the requirement for the degree of Doctor of Philosopy Department of An-thropology 2006 httpfederaorgpldokumenty_pdfprawareprodukcyjneMishtal20dissertationpdf Accessed June 17 2013

[19] De Zordo S Mishtal J Physicians and abortion Provision political participa-tion and conflicts on the groundmdashThe cases of Brazil and Poland WomenrsquosHealth Issues 201121(Suppl 3)S32-6

[20] MergerWatch Religious Restrictions Refusals to Provide Care httpwwwmergerwatchorgrefusals Accessed August 17 2012

[21] Shelton DL Chicago Tribune News Appeals court sides with pharmacistsin emergency contraceptives care httparticleschicagotribunecom2012-09-22newsct-met-emergency-contraceptives-20120922_1_emergency-contraceptives-conscience-act-pharmacists Published September 22 2012Accessed March 22 2013

[22] Wicclair MR Refusals by hospitals and emergency contraception CambridgeQuarterly of Healthcare Ethics 201120(1)130ndash8

[23] Charo RA American Constitution Society for Law and Policy HealthCare Provider Refusals to Treat Prescribe Refer or Inform Profession-alism and Conscience The Journal of the ACS Issue Groups 2007119ndash35 httpsmedialawwiscedumyzdkncharo_-_health_care_provider_refusals_-_feb_2007_-_advance_vol_1pdf

[24] Wicclair MR Conscientious Objection in Health Care Cambridge CambridgeUniversity Press 2011

[25] Institute of Medicine Shaping the Future of Health Crossingthe Quality Chasm A New Health System for the 21st Cen-tury httpwwwiomedu~mediaFilesReport20Files2001Crossing-the-Quality-ChasmQuality20Chasm2020012020report20briefpdf Pub-lished 2001 Accessed May 8 2013

[26] WHO Quality of Care A Process for Making Strategic Choices in HealthSystems Geneva WHO 2006 httpwwwwhointmanagementqualityassuranceQualityCare_BDefpdf

[27] Endres v Indiana State Police 349 F3d 922 (7th Cir 2003) (cert denied541 US 989 (2004)) cited in Charo RA American Constitution Society forLaw and Policy Health Care Provider Refusals to Treat Prescribe Referor Inform Professionalism and Conscience The Journal of the ACS IssueGroups 2007 119ndash35 httpsmedialawwiscedumyzdkncharo_-_health_care_provider_refusals_-_feb_2007_-_advance_vol_1pdf

[28] Dickens BM Cook RJ Conscientious commitment to womenrsquos health Int JGynecol Obstet 2011113163ndash6

[29] Harris L Recognizing Conscience in Abortion Provision N Engl J Med2012367(11)981ndash3

[30] FIGO Resolution on Conscientious Objection httpwwwfigoorgprojectsconscientious Published 2005 Accessed June 1 2013

[31] Republic of Italy Ministry of Health Report of the Ministry of Health on thePerformance of the Law Containing Rules for the Social Care of Maternity andVoluntary Interruption of Pregnancy 2006-2007 (2008)

[32] The Act (13 June 1995 no 50) concerning Termination of Pregnancy withAmendments in the Act dated 16 June 1978 no 5 at 14 (Norway)

[33] Health Services Act Art 56 Official Gazette of the Republic of Slovenia(Slovenia)

[34] The Abortion Act Act No 5951974 as amended through Act No 9982007(Sweden)

[35] Roe J Francome C Bush M Recruitment and training of British obstetrician-gynaecologists for abortion provision conscientious objection versus optingout RHM 19997(14)97ndash105

[36] Lo SS Kok WM Fan SY Emergency contraception knowledge attitude andprescription practice among doctors in different specialties in Hong Kong JObstet Gynaecol Research 200935(4)767ndash74

[37] Davidson LA Pettis CT Cook DM Klugman CM Religion and conscientiousobjection a survey of pharmacistsrsquo willingness to dispense medications SocSci Med 201071(1)161ndash5

[38] Heino A Gissler M Apter D Fiala C Conscientious objection and inducedabortion in Europe Euro J Contracept Reprod Health Care 201318231ndash3

[39] Austrian Ministry of Health Austrian Womenrsquos Health Report 20102011Vienna Ministry of Health 2011

[40] Oliveira da Silva M Reflections on the legalisation of abortion in PortugalEur J Contracept Reprod Health Care 200914245ndash8

[41] Rodriacuteguez-Calvo MS Martiacutenez-Silva IM Concheiro L Muntildeoz-Baruacutes JI Univer-sity studentsrsquo attitudes towards Voluntary Interruption of Pregnancy LegalMedicine 201214(4)209ndash13

[42] Guttmacher Institute Attitudes and intentions of future health care providerstoward abortion provision Perspectives Sexual Reprod Health 200436(2)58ndash63

[43] Rakhudu MA Mmelesi AMM Myburgh CPH Poggenpoel M Exploration ofthe views of traditional healers regarding the termination of pregnancy (TOP)law Curationis 200629(3)56ndash60

[44] Curlin FA Lawrence RE Chin MH Lantos JD Religion conscience andcontroversial clinical practices N Engl J Med 2007356(6)593ndash600

[45] Goyal M Zhao H Mollen C Exploring emergency contraception knowledgeprescription practices and barriers to prescription for adolescents in theemergency department Pediatrics 2009123(3)765ndash70

[46] Harris LH Cooper A Rasinski KA Curlin FA Lyerly AD Obstetricianndashgynecologistsrsquo objections to and willingness to help patients obtain anabortion Obstet Gynecol 2011118(4)905ndash12

[47] Frank JE Conscientious refusal in family medicine residency training FamilyMedicine 201143(5)330ndash3

[48] Gogna M Romero M Ramos S Petracci M Szulik D Abortion in a restrictivelegal context the views of obstetrician-gynaecologists in Buenos AiresArgentina RHM 200210(19)128ndash37

[49] de la Fuente Fonnest I Sondergaard F Fonnest G Vedsted-Jacobsen A Atti-tudes among health care professionals on the ethics of assisted reproductivetechnologies and legal abortion Acta Obstet Gynecol Scand 200079(1)49ndash53

[50] Marie Stopes International General practitioners attitudes to abor-

tion 2007 httpwwwmariestopesorgukdocumentsGP20attitudes20to20abortion202007pdf Published 2007 Accessed June 17 2013

[51] Davis S Schrader V Belcheir MJ Influencers of ethical beliefs and the impacton moral distress and conscientious objection Nurs Ethics 201219(6)738ndash49

[52] Aiyer AN Steinman A Ho GY Influence of physician attitudes on willingnessto perform abortion Obstet Gynecol 199993(4)576ndash80

[53] Hammarstedt M Jacobsson L Wulff M Lalos A Views of midwives and gy-necologists on legal abortionmdasha population-based study Acta Obstet GynecolScand 200584(1)58ndash64

[54] Griggs SK Brown CM Texas community pharmacistsrsquo willingness to partici-pate in pharmacist-initiated emergency contraception JAPhA 200747(1)48ndash57

[55] Wonkam A Hurst SA Acceptance of abortion by doctors and medical studentsin Cameroon Lancet 2007369(9578)1999

[56] Suh S Abortion Politics without Borders The Implementation and Practice ofPost-Abortion Care in Senegal SSRN 2013 httpssrncomabstract=2250193Published April 13 2013

[57] Hagen GH Hage CO Magelssen M Nortvedt P Attitudes of medical studentstowards abortion Tidsskr Nor Laegeforen 2011131(18)1768ndash71

[58] Kade K Kumar D Polis C Schaffer K Effect of nursesrsquo attitudes on hospital-based abortion procedures in Massachusetts Contraception 200469(1)59ndash62

[59] Stulberg DB Dude AM Dahlquist I Curlin FA Obstetrician-gynecologistsreligious institutions and conflicts regarding patient-care policies Am JObstet Gynecol 2012207(1)73 e1ndash5

[60] Guttmacher Institute Making Abortion Services Accessible in The Wake ofLegal Reforms A Framework And Six Case Studies httpwwwguttmacherorgpubsabortion-services-lawspdf Published 2012 Accessed June 15 2013

[61] International Planned Parenthood Federation Abortion Legislation inEurope httpwwwippfenorgNRrdonlyresED17CA78-43A8-4A49-ABE7-64A836C0413E0Abortionlegislation_May2012corrpdf Updated May 2012Accessed May 8 2013

[62] Mishtal J Quiet Contestations of Irish Abortion Law Reproductive HealthPolitics in Flux In Penny Light T Stettner S eds The History and Politics ofAbortion Toronto University of Toronto Press 2014 (in press)

[63] Center for Reproductive Rights The Worldrsquos Abortion Laws Map 2013 and Up-date httpreproductiverightsorgsitescrrcivicactionsnetfilesdocumentsAbortionMap_Factsheet_2013pdf and httpworldabortionlawscom Pub-lished 2013 Accessed June 15 2013

[64] Cohen SA Facts and Consequences Legality Incidence and Safety of AbortionWorldwide Guttmacher Policy Review 200912(4)

[65] Grimes DA Benson J Singh S Romero M Ganatra B Okonofua FE et alUnsafe abortion the preventable pandemic Lancet 2006368(9550)1908ndash19

[66] Guttmacher Institute In Brief Fact Sheet Facts on Induced AbortionWorldwide httpwwwguttmacherorgpubsfb_IAWhtml Published 2012Accessed June 17 2013

[67] Singh S Hospital admissions resulting from unsafe abortion estimates from13 developing countries Lancet 2006369(9550)1887ndash92

[68] Guttmacher Institute Media Kit Worldwide Abortion Legality Inci-dence and Safety httpwwwguttmacherorgmediapresskitsabortion-WWstatsandfactshtml Accessed June 15 2013

[69] Ipas Report on successes in achieving UN Global Strategy for Womenrsquosand Childrenrsquos HealthndashSeptember 2012 httpwwwwhointwoman_child_accountabilityiergreports2012_10S_Ipas_submission_forIERGreport_1May2012pdf Published 2012 Accessed June 15 2013

[70] Sangonet Unsafe Abortion in South Africa A Preventable Pandemichttpwwwngopulseorgblogsunsafe-abortion-south-africa-preventable-pandemic Published July 2012 Accessed May 8 2013

[71] Republic of South Africa Saving Mothers Short httpwwwdohgovzadocsreports2012savingmothersshortpdf Published 2012

[72] Poongothai J Genetics of human male infertility Singapore Med J200950(4)337

[73] WHO Mother or nothing The agony of fertility Bull World Health Organ201088(12)877ndash953

[74] WHO Genomic Resource Centre Gender and Genetics Assisted Reproduc-tive Technologies (ARTs) httpwwwwhointgenomicsgenderenindex6htmlwhointgenomicsgenderenindex6html Accessed October 23 2013

[75] Inhorn M Global infertility and the globalization of new reproductivetechnologies illustrations from Egypt Soc Sci Med 200356(9)1837ndash51

[76] Chambers GM Sullivan EA Ishihara O Chapman MG Adamson GD Theeconomic impact of assisted reproductive technology a review of selecteddeveloped countries Fertil Steril 200991(6)2281ndash94

[77] Chambers GM The costs and consequences of assisted reproductive technol-ogy an economic perspective Hum Reprod Update 20106(6)603ndash13

[78] Chavkin W The Old Meets the New Religion and assisted reproductivetechnologies Development 200649(4)78ndash83

[79] Giubellino G I Would Not Freeze My Children Clariacuten httpedantclarincomdiario20050726sociedads-03101htm Published July 26 2005

[80] Turone F Italian court upholds couplersquos demands for preimplantation geneticdiagnosis BMJ 2007335(7622)687

[81] United Nations Department of Economic and Social Af-fairs Population Division World Contraceptive Use 2011Wall Chart Front Side httpwwwunorgesapopulationpublicationscontraceptive2011contraceptive2011htm Accessed May 8 2013

[82] Creanga AA Gillespie D Karklins S Tsui AO Low use of contraceptionamong poor women in Africa an equity issue Bull World Health Organ201189(4)258ndash66

[83] Center for Reproductive Rights Over 700000 Petitioners DemandHonduran Congress Reject Law Criminalizing Emergency Contracep-tion httpreproductiverightsorgenpress-roomover-700000-petitioners-demand-honduran-congress-reject-law-criminalizing-emergency-contrPublished May 16 2012

[84] WHO Emergency Contraception Pills Too Expensive httpwwwwhointreproductivehealthtopicsfamily_planningecenindexhtml Accessed Oc-tober 23 2013

[85] Pieklo J Care2 Oklahoma Rape Victim Turned Away from Hospi-tal httpwwwcare2comcausesoklahoma-rape-victim-turned-away-from-hospitalhtml Published 2012 Accessed June 15 2013

[86] Spiegel Online Cologne Archbishop Meisner approves ldquomorning af-terrdquo pill for rape victims httpwwwspiegeldepanoramagesellschaftkoelner-erzbischof-meisner-billigt-pille-danach-fuer-vergewaltigungsopfer-a-880814html Published January 31 2013 Accessed June 15 2013

[87] Murray H Baakdah H Bardell T Tulandi T Diagnosis and treatment of ectopicpregnancy CMAJ 2005173(8)905

[88] Togas T Incidence risk factors and pathology of ectopicpregnancy httpwwwuptodatecomcontentsincidence-risk-factors-and-pathology-of-ectopic-pregnancy Accessed February 23 2012

[89] Sivalingam VN Duncan WC Kirk E Shephard LA Home AW Diagnosisand management of ectopic pregnancy J Fam Plann Reprod Health Care201137(4)231ndash40

[90] American Pregnancy Association Promoting Pregnancy Wellness Miscarriagehttpamericanpregnancyorgpregnancycomplicationsmiscarriagehtml Ac-cessed February 23 2012

[91] Berer M Termination of pregnancy as emergency obstetric care the interpre-tation of Catholic health policy and the consequences for pregnant womenAn analysis of the death of Savita Halappanavar in Ireland and similar casesRHM 201321(41)9ndash17

[92] Case of Z v Poland Application no 4613208 Judgment (Merits andJust Satisfaction) httphudocechrcoeintsiteseng-presspagessearchaspxi=001-114521itemid[001-114521] Published 2012 Accessed June 152013

[93] Harvard University David Rockefeller Center for Latin American StudiesRemobilization Demobilization and Incarceration Women and Abortionin Post-war El Salvador httpwwwdrclasharvardedunode853 AccessedOctober 23 2013

[94] Mollmann M Over Their Dead BodiesmdashDenial of Access to Emergency Obstet-ric Care and Therapeutic Abortion in Nicaragua Human Rights Watch200719(2)(B) httpwomenshealthnewsblogspotcom200604women-of-el-salvadorhtml Published 2009 Accessed June 8 2013

[95] Skotko B Mothers of children with Down syndrome reflect on their postnatalsupport Pediatrics 2005115(1)64ndash77

[96] Hoehn KS Wernovsky G Rychik J Tian ZY Donaghue D Gaynor JW etal Parental decision-making in congenital heart disease Cardiol Young200414(2004)309ndash14

[97] RR v Poland No 2761704 ECHR (2011)[98] UN Human Rights Committee General Comment 22 Article 18 The Right

to Freedom of Thought Conscience and Religion A4840 vol I (1993) para112

[99] UN Committee on the Elimination of Discrimination against Women GeneralRecommendation 24 Article 12 of the Convention (women and health)(20th Sess 1999) para11 httpwwwunorgwomenwatchdawcedawrecommendationsrecommhtmrecom24 Accessed February 23 2012

[100] UN Committee on the Elimination of Discrimination against Women Con-cluding Observations Croatia UN Doc A5338 (1998) paras 109 117

[101] UN Committee on the Elimination of Discrimination against Women Con-cluding Observations Italy UN Doc A5238 Rev1 Part II (1997) paras 353360

[102] UN Committee on the Elimination of Discrimination against Women Con-cluding Observations South Africa UN Doc A5338Rev1 (1998) para113

[103] UN Report of the Special Rapporteur on the right of everyone to theenjoyment of the highest attainable standard of physical and mental healthAnand GrovermdashMission to Poland 20 May 2010 UN Doc AHRC1420Add3

[104] CESCR Committee Concluding Observations Poland UN Doc EC12POLCO5(2009) para 28

[105] WHO Safe abortion technical and policy guidance for health sys-tems Second edition httpappswhointirisbitstream106657091419789241548434_engpdf Published 2012 Accessed June 8 2013

[106] Ley Orgaacutenica 22010 de 3 de marzo de Salud Sexual y Reproductiva y dela Interrupcioacuten Voluntaria del Embarazo [Law of Sexual and ReproductiveHealth and Abortion] (2010) Arts17(4) and 14(a) (Spain)

[107] Law C-355 of 2006 (Colombia)[108] Choice of Termination of Pregnancy Act 1996 (South Africa)[109] Regulation to National Law No 25673 Art10 (Argentina) Ministerio de

Salud de la Nacioacuten [National Health Ministry] Guiacutea Teacutecnicapara la AtencioacutenIntegral de los Abortos No Punibles [Technical Guide for Comprehensive Carefor Legal Abortions] (2010) (Argentina)

[110] National Law No 26130 Art6 (Argentina)[111] Codigo de Eacutetica Medica [Ethical Medical Code] Chapter 5

(Uruguay) httpwwwsmuorguyelsmuinstituciondocumentosdoccemhtmlcap5 Accessed February 23 2013

[112] Vique AB Cabrera OA Lugo FG Hevia M Women and Health inUruguay The Uruguayan Executive Veto for the Decriminalization ofAbortion Deconstructing the fundamentals Notebooks Contributions tothe debate on health citizenship and right 2010 Epoca 1 (1) httpwwwarchivoshacelosvalerorgCuaderno20120Finalpdf Published 2010Accessed February 23 2012

[113] Public Health Service Act (1973) (United States)[114] Sonfeld A Guttmacher Institute Delineating the Obligations That Come with

Conscientious Refusal A Question of Balance Guttmacher Policy Review200912(30) httpwwwguttmacherorgpubsgpr123gpr120306html

[115] Regulations for the Implementation of the Act dated 13 June 1995 no 50concerning Termination of 31 Pregnancy with Amendments in the Act dated16 June 1978 no 66 sect20 (Norway)

[116] Constitutional Court Decision T-209 of 2008 (Colombia) httpwwwalcaldiabogotagovcosisjurnormasNorma1jspi=30206 Published February28 2008

[117] Judgment of the Bavarian Higher Administrative Court of 03071990 BayVGHDVB1 1990 880-82 41 (Federal Republic of Germany)

[118] Judgment of the Federal Administrative Court of 12131991 BVerwGE 89260-70 (Federal Republic of Germany)

[119] P and S v Poland Application no 5737508 Decision Octo-ber 30 2012 httphudocechrcoeintsitesengpagessearchaspxi=001-11409822itemid22[22001-11409822] Accessed February 23 2012

[120] Code de la Sante Publique arts L2212-8 R4127-18 32 (France)[121] Abortion Law Reform Act Sec 8 (Australia Victoria)[122] Constitutional Court Decision T-388 of 2009 (Colombia)[123] Colombia Ministry of Social Protection Governmental Decree 4444 of 2006

article 6 httpwwwwomenslinkworldwideorgpdf_programses_prog_rr_col_legaldocs_decreto4444pdf Accessed July 19 2012

[124] Law No 194 of 22 May 1978 on the social protection of motherhood and thevoluntary termination of pregnancy Gazz Uff Part I 22 May 1978 No 1403642-46 (Italy) httpwwwcolumbiaeduitchistorydegraziacourseworkslegge_194pdf Accessed February 23 2012

[125] American Congress of Obstetricians and Gynecologists ACOG CommitteeOpinion The Limits of Conscientious Refusal in Reproductive Medicine 2007Opinion Number 385 httpwwwacogorgResources_And_PublicationsCommittee_OpinionsCommittee_on_EthicsThe_Limits_of_Conscientious_Refusal_in_Reproductive_Medicine Accessed August 27 2013

[126] El Sindicato Meacutedico del Uruguay [Medical Association of Uruguay] Chap5 Art 37 (Uruguay) httpwwwsmuorguypublicacioneslibroslaeticacemhtmcap5 Accessed August 20 2013

[127] British Medical Association Ethics Department The Law and Ethics ofAbortion BMA Views November 2007

[128] World Medical Association World Medical Association Declaration on Thera-peutic Abortion httpwwwwmanetepolicya1htm Published 2006

[129] American Society of Health-System Pharmacists Council on Legal and PublicAffairs ASHP Statement Pharmacistrsquos Right of Conscience and Patientrsquos Rightof Access to Therapy (0610) 2010

[130] Anderson RM Bishop LJ Darragh M Gray H Nolen A Poland SC et alNational Reference Center for Bioethics Literature The Joseph and RoseKennedy Institute of Ethics Pharmacists and Conscientious Objection httpbioethicsgeorgetownedupublicationsscopenotessn46pdf Accessed August27 2013

[131] General Pharmaceutical Council Standards of conduct ethics and perfor-mance July 2012

[132] Decree No 98-945 of 4 December 1998 setting forth the Code of MedicalEthics (Madagascar)

[133] National Association of Pharmacy Regulatory Authorities Model StatementRegarding Pharmacistsrsquo Refusal to Provide Products or Services for Moralor Religious Reasons httpwwwnbpharmacistscaLinkClickaspxfileticket=wcx0ugUqRRE3Damptabid=261ampmid=695 Published 1999

[134] Code of Ethics for Nurses in Australia developed under the auspicesof Australian Nursing and Midwifery Council Royal College of NursingAustralia Australian Nursing Federation 2008

[135] Guidance on the Termination of Pregnancy The Law and Clinical Practice inNorthern Ireland 16 July 2008 the Department of Health Social Services andPublic Safety

[136] Codigo Deontologico da Ordem dos Medicos [Code of Ethics of the Associationof Doctors] (2008) Art 37 (Portugal) 39 Lei No [Law No] 162007 de 17de abril Exclusatildeo da ilicitudenos casos de interrupccedilatildeo voluntaacuteria da gravidez[Exclusion of cases of voluntary interruption of pregnancy] 40 (Portugal)

[137] Health Service Guidance HSG (94)39 (US)[138] Abortion Act 1967 (England) (Section 4(1) of the 1967 Act permits that ldquono

person shall be under any duty whether by contractor by any statutory orother legal requirement to participate in any treatment to which he has aconscientious objectionrdquo This does not apply to emergency procedures)

[139] Enright and another v Kwun and Another [2003] EWHC 1000 (QB)[140] Decree reforming Articles 145 and 148 of the new Penal Code of Mexico City

and adding Articles 16 bis 6 and 16 bis 7 to the Health Law of Mexico Cityreported in Official Gazette of Mexico City 14 no 7 24 January 2004 pp6-7 (Mexico)

[141] Health Services Act Art 56 Official Gazette of the Rep of Slovenia 36 No 9enacted 1992 (Slovenia)

[142] Wilmington General Hospital v Manlove 174 A2d 135 (Del SC 1961) (US)[143] Nursing and Midwifery Council The Code of Conduct Professional standards

for nurses and midwives (UK)

[144] National Law on Medical Practice Dentistry and Auxiliary Practices Law17132 (Argentina)

[145] Janaway v Salford Health Authority 1988 (UK)[146] Brahams D Conscientious Objection and Referral Letter for Abortion Lancet

1988331(8590)893[147] 73 Fed Reg 78071 (December 19 2008) 45 CFR Part 88 (2008)[148] Galston WA Rogers M Brookings Institute Governance Studies at Brookings

Health Care Providersrsquo Consciences and Patientsrsquo Needs The Quest forBalance httpwwwbrookingsedu~mediaresearchfilespapers201222320health20care20galston20rogers0223_health_care_galston_rogerspdfPublished February 23 2012

[149] Office of the Secretary of Health and Human Services Final Rule Regulationfor the Enforcement of Federal Health Care Provider Conscience Protec-tion Laws httpwwwgpogovfdsyspkgFR-2011-02-23pdf2011-3993pdfPublished February 23 2011

Conscientious objection or fear of social stigma and unawareness of ethicalobligations

Anibal Fauacutendes ab Graciana Alves Duarte b Maria Joseacute Duarte Osis b

aFIGO Working Group for the Prevention of Unsafe Abortion London UKbCenter for Research on Human Reproduction of Campinas Campinas Brazil

KeywordsConscientious objectionEthical principlesLegal abortion

Conscientious objection is a legitimate right of physicians to reject the practice of actions that violate theirethical or moral principles The application of that principle is being used in many countries as a justifi-cation to deny safe abortion care to women who have the legal right to have access to safe terminationof pregnancy The problem is that often this concept is abused by physicians who camouflage under theguise of conscientious objection their fear of experiencing discrimination and social stigma if they per-form legal abortions These colleagues seem to ignore the ethical principle that the primary conscientiousduty of OBGYNs ismdashat all timesmdashto treat or provide benefit and prevent harm to the patients for whosecare they are responsible Any conscientious objection to treating a patient is secondary to this primaryduty One of the jobs of the FIGO Working Group for the Prevention of Unsafe Abortion is to change thisparadigm and make our colleagues proud of providing legal abortion services that protect womenrsquos lifeand health and concerned about disrespecting the human rights of women and professional ethical prin-ciplescopy 2013 International Federation of Gynecology and Obstetrics Published by Elsevier Ireland Ltd All rights reserved

1 The concept of conscientious objection

Conscientious objection is a legitimate right of physicians toreject the practice of actions that violate their ethical or moralprinciples It allows them for example to reject participation in theprocess of interrogation of suspects which may include proceduresreaching the limits of torture In the context of providing legalabortion care the FIGO Committee for the Study of Ethical Aspectsof Human Reproduction and Womenrsquos Health states that [1]

Some doctors feel that abortion is not permissible what-ever the circumstances Respect for their autonomy meansthat no doctor (or other member of the medical team)should be expected to advise or perform an abortionagainst his or her personal conviction Their careersshould not be prejudiced as a result Such a doctor how-ever has an obligation to refer the woman to a colleaguewho is not in principle opposed to termination

The application of that principle is being used in several coun-tries in Latin America and other parts of the world as a justificationto deny safe abortion care to women who have the legal right tohave access to safe termination of pregnancy

Corresponding author Anibal Fauacutendes PO Box 6181 Campinas Satildeo Paulo13084971 Brazil Tel +55 19 32892856 fax +55 19 32892440

E-mail address afaundesuolcombr (A Fauacutendes)

2 Inappropriate utilization of conscientious objection to denylegal abortion services

Latin America is a region with very restrictive abortion laws andit includes most of the few countries in the world where abortionis not permitted in any circumstances Chile Honduras El Salvadorand more recently Dominican Republic and Nicaragua (all of whichare relatively small countries) [2] In most other countries in LatinAmerica abortion is considered a crime but is not punished incertain circumstances for example when performed to preservewomenrsquos life andor health in cases of rape or incest and in thepresence of very severe fetal defects incompatible with extrauterinelife

Abortion is permitted in broad circumstances in Cuba MexicoCity Colombia and more recently Uruguay up to 12 weeks ofpregnancy [2ndash5] The problem is that most women who meetthe requirements for obtaining a permissible abortion do notreceive the care they need in public hospitalsmdashinstead resorting toclandestine abortions which can be unsafe In recent years therehave been efforts from private organizations and governments tomake abortion accessible to women who meet the legal conditionsfollowing International Conference on Population and Developmentrecommendations [6] The main obstacle to the provision of servicesis unwillingness of physicians claiming conscientious objection toproviding abortion care

The problem is that often the concept of conscientious objectionis abused by physicians in at least 2 different ways

S58 A Fauacutendes International Journal of Gynecology and Obstetrics 123 (2013) S57ndashS59

(1) By not respecting their obligation to give priority to theneeds of the women for whose care they are responsible In thewords of the FIGO Committee for the Ethical Aspects of HumanReproduction and Womenrsquos Health ldquoThe primary conscientiousduty of obstetricianndashgynecologists is at all times to treat or providebenefit and prevent harm to the patients for whose care they areresponsible Any conscientious objection to treating a patient issecondary to this primary dutyrdquo [1]

(2) By camouflaging under the guise of conscientious objectiontheir fear of experiencing discrimination if they perform legalabortions

A previous study surveyed 3337 members of the BrazilianFederation of Gynecology and Obstetrics Societies who responded toan anonymous questionnaire inquiring under which circumstancesabortion should be permitted by law Almost 85 agreed thatwomen who become pregnant after rape should have the legal rightto obtain a safe termination of pregnancy Only 50 however werewilling to perform such an abortion or prescribe abortifacient drugs[7]

A subsequent qualitative study of 30 OBGYNs from the state ofSao Paulo showed that the reasons for refusing to perform legalabortion derived mostly from personal convictions and religiousprinciples [8] Religious justification is usually accepted withoutargument Some study participants however expressed their doubtthat the religious rationale was always genuine because theysuspected that the main reason for unwillingness to performabortion was the fear of social stigma [9]

Physicians know that refusal to perform pregnancy terminationwhile alleging conscientious objection will have no consequencessuch as complaints or disciplinary action against them By contrastthey fear negative legal or social consequences if they do performterminations and prefer to avoid these The concept that ldquotheprimary conscientious duty of obstetricianndashgynecologists is at alltimes to treat or provide benefit and prevent harm to the patientsfor whose care they are responsiblerdquo is rarely taken into account[1] It is much easier to use conscientious objection to hide the realreason which is that it is simply more comfortable to deny theservice that the woman needs than to fulfill their professional andethical obligation of providing safe abortion services according tothe countryrsquos law

It is disappointing to observe that many of our colleagues atleast in the Latin American region appear to fear being stigma-tized for carrying out a legal procedure that would avert the seriouscomplications that could occur if the procedure were performed un-safely and clandestinely but are not afraid of being stigmatized foravoiding their ethical duty ldquoto treat or provide benefit and preventharm to the patients for whose care they are responsiblerdquo [1]

3 How to promote proper balance between conscientiousobjection and ethical obligations to patients

It appears that those of us who occupy positions of leadershipin the professional organizations of gynecologists and obstetricianshave not done our job sufficiently in terms of promoting and nor-malizing these ethical principles among our colleagues It appearsthat they are unaware that our ldquo primary conscientious duty isat all times to provide benefit and prevent harm to the patientsrdquounder our care [1]

We have often been in meetings with honest and sensitivecolleagues who in general promote and defend womenrsquos sexualand reproductive rights but who nevertheless find excusesmdashunderthe guise of conscientious objectionmdashfor not providing abortionservices within the limits of the local law

One explanation for this situation is the incorrect idea thatfacilitating access to safe and legal abortion services promotes

abortions Many obstetricians accustomed to work protecting thelife and health of the fetuses of women who want to have childrenfeel uncomfortable with the notion of increasing the number ofabortions This indicates that we have failed to disseminate theevidence of the statistically significant inverse relationship betweenthe proportion of women living in countries with liberal abortionlaws and the induced abortion rate among the same women Thesedata show unequivocally that giving broader access to safe legalabortion does not lead to increased rates of abortion [9]

In other words rather than solely criticizing the behavior ofthe many colleagues who hide their fear of stigma under the guiseof conscientious objection we should work to disseminate somebasic ethical principles clearly stated by the FIGO Committee on theEthical Aspects of Human Reproduction and Womenrsquos Health Weshould also disseminate the evidence that making legal abortionmore broadly available does not increase the abortion rate but doesreduce maternal mortality and morbidity

The FIGO Working Group for the Prevention of Unsafe Abortionpromotes the prevention of unintended pregnancy as a primarystrategy and then asserts that if unintended pregnancy has oc-curred and the abortion is inevitable safe abortion services shouldbe available within the limits of the law [10] Although someprogress has occurred in Latin Americamdashnamely in Brazil Colom-bia Argentina and Uruguaymdashthere is still strong resistance frommany of our colleagues and the number of women with legal rightsto abortion who lack access to services is much greater than thenumber of women who receive appropriate care The situation isnot much different in Africa and many countries in Asia indicatingthat we have to seek stronger commitments from national OBGYNsocieties who are all bound to follow the FIGO ethical guidelinesdescribed above

The FIGO Working Group for the Prevention of Unsafe Abortionwill need the support of the FIGO Committee for the Study ofEthical Aspects of Human Reproduction and Womenrsquos Health tochange this paradigm and make our colleagues proud of providinglegal abortion services that protect womenrsquos life and health andconcerned about disrespecting the human rights of women andprofessional ethical principles That is our task for the immediatefuture

References

[1] FIGO Committee for the Ethical Aspects of Human Reproduc-tion and Womenrsquos Health Ethical Issues in Obstetrics and Gyne-cology httpwwwfigoorgfilesfigo-corpEnglish20Ethical20Issues20in20Obstetrics20and20Gynecologypdf Published October 2012

[2] Center for Reproductive Rights The Worldrsquos Abortion Laws Map2011 httpreproductiverightsorgsitescrrcivicactionsnetfilesdocumentsAbortionMap_2011pdf Published 2011 Accessed August 15 2013

[3] Decree reforming Articles 145 and 148 of the new Penal Code of Mexico Cityand adding Articles 16 bis 6 and 16 bis 7 to the Health Law of Mexico Cityreported in Official Gazette of Mexico City 14 no 7 24 January 2004 pp 6ndash7(Mexico)

[4] Center for Reproductive Rights The Worldrsquos Abortion Laws Map 2013Update Fact Sheet httpreproductiverightsorgsitescrrcivicactionsnetfilesdocumentsAbortionMap_Factsheet_2013pdf Accessed August 15 2013

[5] Law C-355 of 2006 (Colombia)[6] UN Report of the International Conference on Population and Development

Cairo United Nations 5ndash13 September 1994 httpwwwunfpaorgwebdavsiteglobalshareddocumentspublications2004icpd_engpdf Accessed August15 2013

[7] Fauacutendes A Simoneti RM Duarte GA Andalaft-Neto J Factors associated toknowledge and opinion of gynecologists and obstetricians about the Brazilianlegislation on abortion Rev Bras Epidemiol 200710(1)6ndash18

[8] Fauacutendes A Hardy E Duarte G Osis MJD Makuch MY The role of religionover the perspective and actions of gynecologists with reference to legal

A Fauacutendes International Journal of Gynecology and Obstetrics 123 (2013) S57ndashS59 S59

termination of pregnancy emergency contraception and use of IUD Finalreport presented to PROSARE Cemicamp 2005

[9] Sedgh G Singh S Shah IH Aringhman E Henshaw SH Bankole A Inducedabortion incidence and trends worldwide from 1995 to 2008 Lancet 2012379(9816)625ndash32

[10] FIGO Working Group for the Prevention of Unsafe Abortion Prevention ofUnsafe Abortion httpwwwfigoorgaboutworking_groupsunsafe_abortionAccessed August 15 2013

Conscientious objection to provision of legal abortion care

Brooke R Johnson Jr a Eszter Kismoumldi b Monica V Dragoman a Marleen Temmerman a

aUNDPUNFPAUNICEFWHOWorld Bank Special Programme of Research Development and Research Training in Human Reproduction World Health Organization Geneva SwitzerlandbIndependent International Human Rights Lawyer Geneva Switzerland

KeywordsAbortionConscientious objectionHuman rightsMaternal healthWomenrsquos health

Despite advances in scientific evidence technologies and human rights rationale for providing safe abortiona broad range of cultural regulatory and health system barriers that deter access to abortion continues toexist in many countries When conscientious objection to provision of abortion becomes one of these barriersit can create risks to womenrsquos health and the enjoyment of their human rights To eliminate this barrier statesshould implement regulations for healthcare providers on how to invoke conscientious objection withoutjeopardizing womenrsquos access to safe legal abortion services especially with regard to timely referral for careand in emergency cases when referral is not possible In addition states should take all necessary measuresto ensure that all women and adolescents have the means to prevent unintended pregnancies and to obtainsafe abortioncopy 2013 International Federation of Gynecology and Obstetrics Published by Elsevier Ireland Ltd All rights reserved

1 Introduction

Over the past 2 decades the scientific evidence technologiesand human rights rationale for providing safe abortion care haveadvanced considerably Despite these advances however a broadrange of cultural regulatory and health system barriers thatdeter access to abortion continues to exist in many countriesand the numbers and proportion of unsafe abortions continue toincrease especially in low- and middle-income countries [1] Whenconscientious objection to provision of abortion becomes one ofthese barriers it can create risks to womenrsquos health and theirhuman rights

In view of the continuing need for evidence- and human rights-based recommendations for providing safe abortion care WHOpublished the second edition of Safe Abortion Technical and PolicyGuidance for Health Systems in June 2012 [2] In addition to pro-viding recommendations for clinical care and service delivery thedocument highlights a number of regulatory and policy barriers in-cluding conscientious objection and provides guidance to eliminatethem If implemented at country level the WHO guidance providesa comprehensive framework that can have a substantive publichealth impact on reducing preventable abortion-related deaths anddisability

Corresponding author Brooke R Johnson Jr RHRHRP World Health Organiza-tion 20 Avenue Appia 1211 Geneva 27 Switzerland Tel +41 22 791 2828 fax+41 22 791 4171

E-mail address johnsonbwhoint (BR Johnson Jr)

2 What is conscientious objection to provision of abortion

Conscientious objection means that healthcare professionals orinstitutions exempt themselves from providing or participating inabortion care on religious andor moral or philosophical groundsWhile other regulatory and health system barriers also hinderwomenrsquos right to obtain abortion services conscientious objectionis unique because of the tension existing between protecting re-specting and fulfilling womenrsquos rights and health service providersrsquoright to exercise their moral conscience Although the right tofreedom of thought conscience and religion is protected by in-ternational human rights law the law stipulates that freedom tomanifest onersquos religion or beliefs may be subject to limitationsto protect the fundamental human rights of others [3] Thereforelaws and regulations should not entitle health service providers orinstitutions to impede womenrsquos access to legal health services [4]

Health services should be organized in such a way as toensure that an effective exercise of the freedom of conscience ofhealthcare professionals does not prevent women and adolescentsfrom obtaining access to services to which they are entitled underthe applicable legislation [2] Based on available health evidence andhuman rights standards the WHO safe abortion guidance stipulatesthat healthcare professionals who claim conscientious objectionmust refer women to a willing and trained service provider in thesame or another easily accessible healthcare facility in accordancewith national law Where referral is not possible the healthcareprofessional who objects must provide safe abortion to save thewomanrsquos life and to prevent damage to her health Furthermorewomen who present with complications from an abortion includingillegal or unsafe abortion must be treated urgently and respectfullyin the same way as any other emergency patient without punitiveprejudiced or biased behaviors [2] Adherence to the individual

BR Johnson Jr et al International Journal of Gynecology and Obstetrics 123 (2013) S60ndashS62 S61

and institutional responsibilities outlined in the WHO guidanceallows for the exercise of moral conscience without compromisingwomenrsquos and adolescentsrsquo access to safe legal abortion servicesif sufficient facilities service providers necessary equipment anddrugs are made available

3 Conscientious objection as a barrier to abortion care

In theory conscientious objection need not be a barrier towomen seeking abortion However not all claims to conscientiousobjection reflect a genuine concern about compromising an individ-ual providerrsquos moral integrity rather they may represent reluctanceto provide certain sexual and reproductive health services such asabortion discriminatory attitudes or other motivations stemmingfrom self-interest [5] In practice individual or institutional refusalto provide timely referral and emergency care interferes withwomenrsquos access to services and may increase health risks In addi-tion to limiting womenrsquos access to lawful services in general abuseof conscientious objection can result in inequities in access creat-ing disproportionate risks for poor women young women ethnicminorities and other particularly vulnerable groups of women whohave fewer alternatives for obtaining services Womenrsquos access tohealth services is jeopardized not only by providersrsquo refusal of carebut also by governmentsrsquo failure to ensure adequate numbers anddistribution of providers and facilities to offer abortion services

In contexts in which conscientious objection risks harmingwomenrsquos health and their human rights it is likely to coexistwith a broad range of other regulatory and health system barrierswhich may be intended to discourage and limit womenrsquos accessto legal abortion For example lack of public information aboutsafe abortion poorly defined or narrowly interpreted legal groundsfor abortion requirements for third-party authorizations to receiveabortion mandatory waiting periods requirements for medicallyunnecessary tests or procedures restrictions on public funding andprivate insurance coverage and requirements for the provisionof misleading or inaccurate information may all be intended todiscourage women from having an abortion [26] In addition un-regulated conscientious objection opens the door for disingenuousclaims of moral conscience for refusing care and compromisesaccountability for ensuring timely access to care When combinedthese and other barriers may exacerbate inequities to access anddelays in seeking services or serve as a deterrent to seeking legalservices altogether potentially increasing the likelihood of unsafeabortion

Any barrier including abuse of conscientious objection poten-tially causes delays in gaining access to a needed health serviceLegal abortion using WHO-recommended methods and practice isone of the safest of all medical procedures that women undergoHowever although the risk of mortality from safe abortion is lowthe risk increases for each additional week of gestation A study onlegal abortion in the USA from 1988 to 1997 found that the overallrisk of death from abortion was 07 per 100000 legal abortions[7] with gestational age at time of abortion the greatest risk factorfor abortion-related death The mortality rate for abortions at agestational age of 8 or fewer weeks was 01 but for abortions at 21or more weeks the rate was 89 which was comparable to mortalityassociated with childbirth in the USA between 1998 and 2005 [8]

Because conscientious objection is just one of a potentially largenumber of interconnected barriers to safe abortion services it isdifficult to evaluate the direct impact on access of disingenuousclaims of conscientious objection of conscientious objection with-out referral and of refusal to treat emergencies Indeed the extentto which conscientious objection to abortion directly results inpregnancy-related mortality and morbidity is unknown and meritsfurther investigation

4 Policy health system and service delivery interventions toprotect womenrsquos health and their human rights

UN treaty-monitoring bodies and regional and national courtshave increasingly called upon states to provide comprehensivesexual and reproductive health information and services to womenand adolescents to eliminate regulatory and administrative barriersthat impede womenrsquos access to safe abortion services and toprovide treatment for abortion complications [9ndash33] This requiresstates to train and equip health service providers along withother measures to ensure that such abortion is safe and accessible[34] Human rights bodies have also called upon states to ensurethat the exercise of conscientious objection does not preventindividuals from obtaining services to which they are legallyentitled [1718263536] When laws policies and programs donot take into consideration the multiple challenges inherent inimplementing conscientious objection to abortion care womenrsquoshealth and their human rights can be compromised Specificallythere should be regulations for health service providers on howto invoke conscientious objection without jeopardizing womenrsquosaccess to safe legal abortion services especially with regard toreferral and in emergency cases when referral is not possible

In addition to providing guidance for regulating providersrsquoconscientious objection to legal abortion the WHO safe abortiondocument highlights a number of health system interventions thatcan facilitate equitable access to and availability of safe abortion [2]As a first step the provision and use of effective contraception canreduce the likelihood of unintended pregnancy and thus womenrsquosneed for recourse to abortion As a remedy to shortages of willingproviders of legal abortion care states should consider improvingaccess through training mid-level providers and offering abortionservices at the primary-care level and through outpatient servicesAbortion care can be safely provided by any properly trainedhealthcare provider including nurses midwives clinical officersphysician assistants family welfare visitors and others who aretrained to provide basic clinical procedures related to reproductivehealth Abortion care provided at the primary-care level andthrough outpatient services in higher-level settings can be donesafely and minimizes costs while maximizing the convenience andtimeliness of care for the woman Allowing home use of misoprostolfollowing provision of mifepristone at the healthcare facility canfurther improve the privacy convenience and acceptability ofservices without compromising safety Financing mechanisms canfacilitate equitable access to good-quality services and to the extentpossible abortion services should be mandated for coverage underinsurance plans

Governments have many options for facilitating good access tosafe legal abortion Ultimately to mitigate the potential impactsof conscientious objection well-trained and equipped healthcareproviders and affordable services should be readily available andwithin reach of the entire population This is essential for ensuringaccess to safe abortion and should be both a public health and ahuman rights priority

The authors have no conflicts of interest BRJ MVD and MTare staff members of WHO The authors alone are responsible forthe views expressed in the present article which do not necessarilyrepresent the decisions policy or views of WHO

References

[1] WHO Unsafe Abortion Global and Regional Estimates of the Incidence ofUnsafe Abortion and Associated Mortality in 2008 Sixth Edition GenevaWHO 2011

S62 BR Johnson Jr et al International Journal of Gynecology and Obstetrics 123 (2013) S60ndashS62

[3] International Covenant on Civil and Political Rights Article 18 United Nationsentry into force 23 March 1976

[4] Verein Kontakt-Information-Therapie (KIT) and Hagen v Austria No 1192186ECHR (1988)

[5] Dressers R Professionals conformity and conscience Hastings Cent Rep2005359ndash10

[6] Guttmacher Institute An Overview of Abortion Laws State Policies in BriefNew York Guttmacher Institute 2013

[7] Bartlett LA Berg CJ Shulman HB Zane SB Green CA Whitehead S et al Riskfactors for legal induced abortion-related mortality in the United States ObstetGynecol 2004103(4)729ndash37

[8] Raymond EG Grimes DA The comparative safety of legal induced abortionand childbirth in the United States Obstet Gynecol 2012119(2 Part 1)215ndash9

[9] UN Human Rights Committee General comment 28 equality of rights betweenmen and women (Article 3) United Nations 20 March 2000

[10] UN Human Rights Committee Concluding observations Ecuador UnitedNations 18 August 1998

[11] UN Human Rights Committee Concluding observations Guatemala UnitedNations 27 August 2001

[12] UN Human Rights Committee Concluding observations Poland United Na-tions 2 December 2004

[13] UN Human Rights Committee Concluding observations Madagascar UnitedNations 11 May 2007

[14] UN Human Rights Committee Concluding observations Chile United Nations18 May 2007

[15] UN Human Rights Committee Concluding observations Colombia UnitedNations 26 May 2004

[16] UN Human Rights Committee Karen Noella Llantoy Huaman v Peru UN DocCCPRC85D11532003 United Nations 2005

[17] UN Committee on the Elimination of Discrimination against Women Conclud-ing observations Columbia United Nations 5 February 1999

[18] UN Committee on the Elimination of Discrimination against Women Conclud-ing observations Nicaragua United Nations 2 February 2007

[19] UN Committee on the Elimination of Discrimination against Women Conclud-ing observations Brazil United Nations 10 August 2007

[20] UN Committee on the Elimination of Discrimination against Women Conclud-ing observations Nepal United Nations 24 September 2001

[21] UN Committee on Economic Social and Cultural Rights Concluding observa-tions Costa Rica United Nations 22 April 2008

[22] UN Committee on the Rights of the Child Concluding observations ChileUnited Nations 23 April 2007

[23] African Commission on Human and Peoplesrsquo Rights Protocol to the AfricanCharter on Human and Peoplesrsquo Rights on the Rights of Women in AfricaArticle 142 Maputo African Commission on Human and Peoplesrsquo Rightsadopted 11 July 2003

[24] UN Committee on Economic Social and Cultural Rights Concluding observa-tions Malta United Nations 4 December 2004

[25] UN Committee on Economic Social and Cultural Rights Concluding observa-tions Monaco United Nations 13 June 2006

[26] UN Committee on the Elimination of Discrimination against Women Generalrecommendation no 24 Women and health (Article 12) United Nations1999

[27] UN Committee on the Elimination of Discrimination against Women Conclud-ing comments Dominican Republic United Nations 18 August 2004

[28] UN Committee on Economic Social and Cultural Rights Concluding observa-tions Nepal United Nations 29 August 2001

[29] UN Committee on Economic Social and Cultural Rights Concluding observa-tions Chile United Nations 1 December 2004

[30] UN Committee on the Elimination of Discrimination against Women Conclud-ing observations Sri Lanka United Nations 1 February 2002

[31] UN Committee on the Elimination of Discrimination against Women Conclud-ing observations Honduras United Nations 10 August 2007

[32] UN Committee on the Elimination of Discrimination against Women LC vPeru CEDAWC50D222009 United Nations 4 November 2011

[34] Key actions for the further implementation of the Programme of Action ofthe International Conference on Population and Development adopted by thetwenty-first special session of the General Assembly New York 30 Junendash2 July1999 New York United Nations 1999

[35] UN Human Rights Committee Concluding observations Zambia United Na-tions 9 August 2007

[36] RR v Poland No 2761704 ECHR (2011)

Legal and ethical standards for protecting womenrsquos human rights and the practiceof conscientious objection in reproductive healthcare settings

Christina Zampas International Reproductive and Sexual Health Law Program Faculty of Law University of Toronto Toronto Canada

KeywordsAbortionConscientious objectionHuman rightsInternational lawReproductive health

The practice of conscientious objection by healthcare workers is growing across the globe It is most commonin reproductive healthcare settings because of the religious or moral values placed on beliefs as to when lifebegins It is often invoked in the context of abortion and contraceptive services including the provision ofinformation related to such services Few states adequately regulate the practice leading to denial of accessto lawful reproductive healthcare services and violations of fundamental human rights International ethicalhealth and human rights standards have recently attempted to address these challenges by harmonizing thepractice of conscientious objection with womenrsquos right to sexual and reproductive health services FIGO ethi-cal standards have had an important role in influencing human rights development in this area They considerregulation of the unfettered use of conscientious objection essential to the realization of sexual and reproduc-tive rights Under international human rights law states have a positive obligation to act in this regard Whileethical and human rights standards regarding this issue are growing they do not yet exhaustively cover allthe situations in which womenrsquos health and human rights are in jeopardy because of the practice The presentarticle sets forth existing ethical and human rights standards on the issue and illustrates the need for furtherdevelopment and clarity on balancing these rights and interestscopy 2013 International Federation of Gynecology and Obstetrics Published by Elsevier Ireland Ltd All rights reserved

1 Introduction

Ethical health and human rights standards have attempted toharmonize the practice of conscientious objection with womenrsquosright to sexual and reproductive health services They considerregulation of the unfettered use of conscientious objection essentialto the realization of sexual and reproductive rights Under inter-national human rights law states have a positive obligation to actin this regard These standards and recommendations should beuniversally adopted and applied While ethical and human rightsstandards on this issue are growing they do not yet exhaustivelycover all the situations in which womenrsquos health and human rightsare in jeopardy because of the practice The present article setsforth existing ethical and human rights standards on the issueand illustrates the need for further development and clarity onbalancing these rights and interests

The practice of conscientious objection by healthcare workersis growing across the globe It is most common in reproductivehealthcare settings because of the religious or moral values placedon beliefs as to when life begins It is often invoked in the contextof abortion and contraceptive services including the provision ofinformation related to such services Frequently such invocation is

Corresponding author Christina Zampas Birger Jarlsgatan 113C 11356 Stock-holm Sweden Tel +46 707452803

E-mail address christinazampasorg (C Zampas)

not transparent and women are neither directly told of providersrsquobeliefs nor referred to another provider Instead they are subjectedto attempts to sway them away from undergoing abortion WhileOBGYNs may most often be the healthcare workers claimingconscientious objection pharmacists nurses anesthesiologists andcleaning staff have been reported to refuse to fill their job duties inconnection to acts they consider objectionable In addition publichealthcare institutions are informally refusing to provide certainreproductive health services often owing to beliefs of individualhospital administrators [1]

The practice arises in countries with relatively liberal abortionlaws such as the USA Slovakia and South Africa as well as incountries with more restrictive laws such as most Latin Americanand certain African countries [23] The implications for womenrsquoshealth and lives can be grave in both contexts and urgent questionsarise as to how to effectively reconcile respect for the practice ofconscientious objection with the right of women to have access tolawful reproductive healthcare services

Ethical standards in this area can provide some answers Infact ethical standards have not only helped shape the developmentof national law but also recently influenced the developmentof international human rights law in this area While these arewelcome developments many gaps remain both in ethics and inlaw

S64 C Zampas International Journal of Gynecology and Obstetrics 123 (2013) S63ndashS65

2 International human rights law

The right to access to reproductive healthcare is grounded innumerous human rights including the rights to life to health tonon-discrimination to privacy and to be free from inhuman anddegrading treatment as explicitly articulated by UN and regionalhuman rights bodies Such rights place obligations on states toensure transparent access to legally entitled reproductive healthservices and to remove barriers limiting womenrsquos access to suchservices [45] Such barriers include conscientious objection UNbodies monitoring state compliance with international humanrights treaties have raised concern about the insufficient regulationby states of the practice of conscientious objection to abortion Theyhave consistently recommended that states ensure that the practiceis well defined and well regulated in order to avoid limitingwomenrsquos access to reproductive healthcare They encourage forexample implementing a mechanism for timely and systematicreferrals and ensuring that the practice of conscientious objectionis an individual personal decision and not that of an institution asa whole [16ndash8]

The UN Special Rapporteur on the Right to the Highest Attain-able Standard of Health issued a groundbreaking report in 2011on the negative impact that the criminalization of abortion hashad on womenrsquos health and lives and specifically articulated stateobligations to remove barriersmdashincluding some laws and practiceson conscientious objectionmdashthat interfere with individual decisionmaking on abortion The report notes that such laws and their usecreate barriers to access by permitting healthcare providers andancillary personnel to refuse to provide abortion services infor-mation about procedures and referrals to alternative facilities andproviders These and other laws make safe abortions unavailableespecially to poor displaced and young women The report notesthat such restrictive regimes serve to reinforce the stigma of abor-tion being an objectionable practice The Rapporteur recommendedthat in order to fulfill their obligations under the right to healthstates should ldquo[E]nsure that conscientious objection exemptions arewell-defined in scope and well-regulated in use and that referralsand alternative services are available in cases where the objectionis raised by a service providerrdquo [9]

Conscientious objection is grounded in the right to freedom ofreligion conscience and thoughtmdashrecognized in many internationaland regional human rights treaties as well as in national consti-tutions Under international and regional human rights law thefreedom to manifest onersquos religion or beliefs can be limited forthe protection of the rights of others including reproductive rights[810ndash12]

The Human Rights Committee which monitors state compliancewith the International Covenant on Civil and Political Rights (one ofthe major UN human rights treaties) has recognized that religiousattitudes can limit womenrsquos rights and called on states to ldquo ensure that traditional historical religious or cultural attitudes arenot used to justify violations of womenrsquos right to equality beforethe law and to equal enjoyment of all Covenant rightsrdquo [13]

Two recent decisions of the European Court of Human Rightsshed light on the meaning of such limitations in the contextof conscientious objection to abortion-related reproductive healthservices In these separate cases against Poland an adolescent and awoman have complained that access to lawful abortion and prenataldiagnostic services was hindered in part by the unregulatedpractice of conscientious objection While Poland has one of themost restrictive abortion laws in Europe the law does allow forabortion in cases of threat to a pregnant womanrsquos health or lifeand in cases of rape and cases of fetal abnormality It also entitleswomen to receive genetic prenatal examinations in this context InRR v Poland (2011) the applicant was repeatedly denied prenatalgenetic testing after her doctor discovered fetal abnormalities

during a sonogram [14] The exam results would have informedRRrsquos decision on whether to terminate her pregnancy yet doctorshospitals and administrators repeatedly denied her informationand diagnostic tests until the pregnancy was too advanced forabortion to be a legal option [14] In a case decided a year laterP and S v Poland (2012) a 14-year-old who became pregnant asa result of rape faced numerous barriers and delays in obtaininga lawful abortion including coercive and biased counseling by apriest divulgence of confidential information about her pregnancyto the press and others removal from the custody of her motherwho supported her decision to undergo an abortion and theunregulated practice of conscientious objection [15] The procedureeventually took place but in a clandestine-like manner and withoutproper postabortion care [15]

In both cases the Court found violations of Articles 3 (right to befree from inhuman and degrading treatment) and 8 (right to privatelife) of the European Convention on Human Rights for obstructingaccess to lawful reproductive healthcare information and services[16] With regard to conscientious objection it held that theConvention does not protect every act motivated or inspired byreligion ldquo States are obliged to organise the health servicessystem in such a way as to ensure that an effective exercise of thefreedom of conscience of health professionals in the professionalcontext does not prevent patients from obtaining access to servicesto which they are entitled under the applicable legislationrdquo [1415]

It also noted problems with lack of implementation and respectfor the existing law governing this practice and specified thatreconciliation of conscientious objection with the patientrsquos interestsmakes it mandatory for such refusals to be made in writingand included in the patientrsquos medical record mandating that theobjecting doctor refer the patient to another physician competentand willing to carry out the same service [15]

These cases are groundbreaking for numerous reasons but forthe purposes of the present article I will focus on 2 reasons Firstit is the first time any international or regional human rights bodyin an individual complaint has articulated statesrsquo positive obligationsto regulate the practice of conscientious objection in relation toabortion and to prenatal diagnostic services These cases requiredan international human rights tribunal to take a look at abuseof the practice in a specific situation and the experiences of thewomen subject to the practice The Courtrsquos finding in the caserelated to prenatal diagnostic care is groundbreaking because itis the first time a human rights body has addressed objection toproviding information to a patient about her health While theCourtrsquos judgments provide minimal guidance it is developing itsstandards in this area

The second reason is that for the first time the Court directlyrelied on FIGOrsquos ethical standardsguidelines and resolution on theissue of conscientious objection to support its decision [1417]

3 Ethical and health standards

The FIGO Committee for the Study of Ethical Aspects of HumanReproduction and Womenrsquos Health submitted an amicus brief in thecase of RR v Poland presenting its resolution and ethical guidelineson conscientious objection to the Court [18] In articulating stateobligations to regulate the practice the Court directly relied on theinformation provided by FIGO to support its judgment citing thematerial provided in FIGOrsquos amicus brief as a source of relevant lawand practice [14] FIGOrsquos ethical guidelines and resolution on thesubject have thus directly influenced the emerging human rightsstandards regarding conscientious objection to reproductive healthservices This is a rare example of how ethical standards can shapethe development of international human rights law and reflects thecritical importance that ethical standards can have in protectingand promoting human rights

C Zampas International Journal of Gynecology and Obstetrics 123 (2013) S63ndashS65 S65

In fact FIGO has the most comprehensive ethical guidelines onconscientious objection of any international medical professionalorganization The ethical guidelines note that any conscientiousobjection to treating a patient is secondary to the primary dutymdashwhich is to treat provide benefit and do no harm and includesprovision of accurate information and referralobligatory provisionof care when referral is not possible or need is urgent [17] Aresolution mirroring these guidelines was adopted a year later bythe FIGO General Assembly [19] The resolution also recognizedthe duty of practitioners as professionals to abide by scientificallyand professionally determined definitions of reproductive healthservices and not to mischaracterize them on the basis of personalbeliefs [18]

WHO has also recognized that as a barrier to lawful abortionservices conscientious objection can impede women from reachingthe services for which they are eligible potentially contributing tounsafe abortion In its recent edition of guidelines on safe abortionWHO notes that health services should be organized in such away as to ensure that an effective exercise of the freedom ofconscience of health professionals does not prevent patients fromobtaining access to services to which they are entitled under theapplicable legislation It recommends the establishment of nationalstandards and guidelines facilitating access to and provision of safeabortion care including the management of conscientious objection[182021]

While these health and ethical standards provide some guidancefor regulating the practice of conscientious objection and havean important role in influencing the development of the nascenthuman rights standards on the topic many issues that arise in thiscontext are not fully addressed by international legal health orethical standards

4 Conclusion

International ethical and health bodies and international andregional human rights mechanisms are well positioned to fill inthe gaps in guidance Such standards can help in the developmentof national laws and regulations on the subject and can be usedto hold states accountable when associated violations of humanrights occur The standards should cover the numerous systemicand individual barriers leading to denial of services Such guidanceshould clearly establish that only individuals not institutions canhave a conscience and that only those involved in the directprovision of services should be allowed to invoke conscientiousobjection Medical students for example cannot object to learningto perform a service that they may need to provide in case ofemergency They should also establish under which circumstancesindividuals can and cannot object For example the practiceshould be prohibited when a patientrsquos life or physicalmentalhealth is in danger In addition the types of services for whichobjection is impermissible should be specified such as providingreferrals information and diagnostic services Standards should alsoclearly articulate state obligations to guarantee that the practiceof conscientious objection does not hinder the availability andaccessibility of providers including by employing sufficient staffwho are available and willing to deliver services competently byensuring oversight and monitoring of the practice and by holdingto account those in violation [161222]

Moreover as in all circumstances healthcare systems should betransparent and services should respect womenrsquos dignity and

autonomy in decision making In other words womenrsquos conscienceshould be fully respected [23]

References

[1] Zampas C Andion-Ibaniez X Conscientious objection to sexual and reproduc-tive health services international human rights standards and European lawand practice Eur J Health Law 201219(3)231ndash56

[2] Lema VM Conscientious objection and reproductive health service delivery insub-Saharan Africa Afr J Reprod Health 201216(1)15ndash21

[3] Casas L Invoking Conscientious Objection in Reproductive Health CareEvolving Issues in Latin America [thesis] Toronto University of Toronto 2005

[4] Cook RJ Transparency in the delivery of lawful abortion services CMAJ2009180(3)272ndash3

[5] UN Committee on the Elimination of Discrimination against Women GeneralRecommendation 24 Article 12 of the Convention (women and health)(20th Sess 1999) para 11 httpwwwunorgwomenwatchdawcedawrecommendationsrecommhtmrecom24 Published 1999 Accessed October31 2013

[6] Dickens B Legal Protection and Limits of Conscientious Objection WhenConscientious Objection is Unethical Medicine and Law 200928337ndash47

[7] UN Committee on the Elimination of Discrimination against Women Conclud-ing Observations Hungary UN Doc CEDAWCHUNCO7-8 (2013)

[8] Bueno de Mesquita J Finer L University of Essex Human Rights Cen-tre Conscientious Objection Protecting Sexual and Reproductive HealthRights httpwwwessexacukhrcresearchprojectsrthdocsConscientious_objection_finalpdf Published 2008 Accessed October 31 2013

[9] UN Report of the Special Rapporteur on the right of everyone to theenjoyment of the highest attainable standard of physical and mental healthInterim report Anand Grover 3 August 2011 UN Doc A66254 2011

[10] International Covenant on Civil and Political Rights adopted Dec 16 1966GA Res 2200A (XXI) UN GAOR 21st Sess Supp No 16 at 52 article 18UN Doc A6316 (1966) 999 UNTS 171 (entered into force March 23 1976)

[11] UN Human Rights Committee General Comment 22 Article 18 The Right toFreedom of Thought Conscience and Religion A4840 vol I (1993) 208 para112

[12] Skuster P When a Health Professional Refuses Legal and regulatory limits onconscientious objection to provision of abortion care Ipas 2012

[13] UN Human Rights Committee General Comment 28 Article 3 The equality ofrights between men and women UN Doc CCPRC21Rev1Add10 (2000)

[14] RR v Poland No 2761704 ECHR (2011)[15] P and S v Poland Application no 5737508 Decision October 30 2012 para

106[16] Westeson J Reproductive health information and abortion services Standards

developed by the European Court of Human Rights Int J Gynecol Obstet2013122(2)173ndash6

[17] FIGO Committee for the Ethical Aspects of Human Reproduction and WomenrsquosHealth Ethical Guidelines on Conscientious Objection Int J Gynecol Obstet200692(3)333-4

[20] WHO Safe abortion technical and policy guidance for healthsystems Second edition httpappswhointirisbitstream106657091419789241548434_engpdf Published 2012 Accessed June 8 2013

[21] Johnson BR Jr Kismoumldi E Dragoman MV Temmerman M Conscientious objec-tion to provision of legal abortion care Int J Gynecol Obstet 2013123(Suppl3)S60ndash2 (this issue)

[22] Chavkin W Leitman L Polin K for Global Doctors for Choice Conscientiousobjection and refusal to provide reproductive healthcare A white paperexamining prevalence health consequences and policy responses Int JGynecol Obstet 2013123(Suppl 3)41ndash56 (this issue)

[23] Dickens BM Cook RJ Conscientious commitment to womenrsquos health Int JGynecol Obstet 2011113(2)163ndash6


References

Conscientious objection and refusal to provide reproductive healthcare A White Paper examining prevalence health consequences and policy responses

1 Introduction


21 Methods


3 Consequences of refusal of reproductive healthcare for women and for health systems




34 Conscience-based refusal of care in cases of risk to maternal health and unavoidable pregnancy loss


4 Policy responses to manage conscience-based refusal of reproductive healthcare

5 Conclusion

Acknowledgments


References

Conscientious objection or fear of social stigma and unawareness of ethical obligations


2 Inappropriate utilization of conscientious objection to deny legal abortion services

3 How to promote proper balance between conscientious objection and ethical obligations to patients


References


1 Introduction



4 Policy health system and service delivery interventions to protect womens health and their human rights


References

Legal and ethical standards for protecting womens human rights and the practice of conscientious objection in reproductive healthcare settings

1 Introduction



4 Conclusion


References

Editor

Editor Emeritus

Associate Editor

Associate Editor Emeritus

Managing Editor

Manuscript Editor

Honorary AssociateEditor

Associate Editors

Ethical and Legal Issuesin Reproductive Health

Enabling Technologies

FIGO Staging of GynecologicCancer

Contemporary Issues inWomenrsquos Health

Statistical Consultant

Editorial Office

T Johnson (USA)

J Sciarra (USA)

W Holzgreve (Germany)P Serafini (Brazil)J Fortney (USA)

L Keith (USA)

C Addington (UK)

P Chapman (UK)

L Hamberger (Sweden)

R Cook (Canada)B Dickens (Canada)

M Hammoud (USA)

L Denny (South Africa)

R Adanu (Ghana)V Boama (South Africa)V Guinto (Philippines)C Sosa (Uruguay)

A Vahratian (USA)

FIGO Secretariat FIGO HouseSuite 3 - Waterloo Court 10 Theed StreetLondon SE1 8ST UKTel +44 20 7928 1166Fax +44 20 7928 7099E-mail ijgofigoorg

International Journal of

GYNECOLOGYamp OBSTETRICS

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C ZampasCanada

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Documents

Volume 123, Supplement 3 (2013) - OSSyR · Volume 123, Supplement 3 (2013) Amsterdam Boston London New York Oxford Paris Philadelphia San Diego St. Louis. ... previous work and to