Refusal to provide safe abortion care within the limits of the law

Although there is a lack of robust evidence, the available data suggest that the proportion of physicians who refuse to provide legal and safe abortion services is very high, often over 50%, with few exceptions .

The main factor associated with a higher level of refusal to provide care is self-reported religiosity, as shown by several studies conducted in the USA, Latin America, and Europe . This is particularly a problem in countries where a large proportion of healthcare facilities are in the hands of the Catholic Church, as in the USA. In some Catholic hospitals in the USA, physicians reported that administrators and ethicists encouraged or tolerated the provision of referrals. In others, hospital authorities actively discouraged referrals. Patients in need of referrals for abortion were given less support than those seeking referrals for other prohibited services. Respondents felt referrals were not always sufficient to meet the needs of low-income patients or those with urgent medical conditions .

When a large proportion of doctors claim conscientious objection, the number of providers of safe abortion is reduced. When the number of physicians willing to provide abortion services is limited, this always creates a barrier to receiving those services; however, the problem is more severe in countries where there is a shortage of healthcare providers . This is often the situation in sub-Saharan Africa, where physicians are frequently overwhelmed by a demand far greater than their capacity to provide care.

Latin America is also a problematic region because it includes the countries with most restrictive abortion laws and most of the few countries in the world where abortion is not permitted under any circumstances: Chile, Honduras, El Salvador, and, more recently, the Dominican Republic and Nicaragua . In most other Latin American countries, abortion is considered a crime; however, it is permitted under certain circumstances: for example, when performed to preserve a woman’s life and/or health; in cases of rape or incest; and in the presence of very severe fetal defects incompatible with extra-uterine life.

The problem is that most women who meet the requirements for obtaining a legal abortion do not receive the care they need in public hospitals and are obliged to resort to clandestine abortions, which can be unsafe. In recent years, there have been efforts from private organizations and governments to make abortion accessible to women who meet the legal conditions in accordance with the recommendations of the International Conference on Population and Development . The main obstacle to the provision of services is the unwillingness of physicians claiming conscientious objection to provide abortion care. Although there are a number of different barriers to women’s right to obtain abortion services, conscientious objection is the most difficult to deal with because of the ethical dilemma between protecting and promoting women’s rights and defending the providers’ right to exercise their moral conscience. Although conscientious objection is a legitimate right of health providers, physicians often abuse the concept of conscientious objection in at least two different ways, as described below.

Prioritizing personal objection over their primary ethical duty to provide healthcare and prevent harm to their patients

The first unethical behavior to which objectors are exposed is to give priority to their moral or religion objection over their professional duty to attend to the needs of the women for whose care they are responsible. In the words of the FIGO Committee for the Ethical Aspects of Human Reproduction and Women’s Health, “The primary conscientious duty of obstetricians/gynecologists is at all times to treat, or provide benefit and prevent harm to the patients for whose care they are responsible. Any conscientious objection to treating a patient is secondary to this primary duty” . The observation of this primary duty as the model of ethical behavior to be followed by obstetricians gynecologists has been called “conscientious commitment” or “loyalty to duty” (1).

International human rights law establishes the right to freedom of thought and religion; however, the same law stipulates that freedom to act according to one’s religion or beliefs may be subject to limitations to protect the fundamental human rights of others . The concept that conscientious objection cannot be a barrier to the provision of the service women need to preserve their health is present in a number of human rights recommendations. Human rights bodies have called upon states to ensure that the exercise of conscientious objection does not prevent individuals from obtaining services to which they are legally entitled .

Therefore, laws and regulations do not allow health service providers to use the claim of conscientious objection as a barrier to women’s access to legal abortion services.

The World Health Organization (WHO) safe abortion guidance stipulates that healthcare professionals who claim conscientious objection must refer women to a willing and trained service provider in the same or another easily accessible healthcare facility, in accordance with national law . The FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health also states that no doctor (or other member of the medical team) should be expected to advise or perform an abortion against his or her personal conviction. Such a doctor, however, has an obligation to refer the woman to a colleague who is not in principle opposed to termination .

Hospitals and other administrators cannot object to such referral because they will not participate in the procedures that may be provided by others subsequently. Because immediate referral is needed to prevent delay in the provision of care, the objecting providers and hospitals where they work must maintain knowledge of nonobjecting providers to whom their patients must be referred .

FIGO and WHO are more specific on how physicians should ensure that women receive the care they need by stating that where referral is not possible, the healthcare professional who objects must provide safe abortion to save the woman’s life and prevent damage to her health.

Unfortunately, it is not rare for some doctors who claim conscientious objection to not only refuse to provide services and refer the patient to a nonobjector colleague but also actively place additional obstacles to the provision of safe and legal abortion services . It is a clear breach of ethical rules and professional obligations that goes beyond the simple refusal to provide safe abortion care and is common practice by physicians and other healthcare providers who appear unaware of their ethical and professional obligations.

Claiming conscientious objection to hide personal convenience as a reason for refusing to provide safe abortion care

The second way in which some physicians behave unethically is by claiming conscientious objection when the real reason for not providing services is fear of experiencing discrimination if they perform legal abortions or for other personal reasons that do not constitute genuine conscientious objection.

A study conducted among 3337 members of the Brazilian Federation of Gynecology and Obstetrics Societies who responded to an anonymous questionnaire inquiring under which circumstances abortion should be permitted by law showed that almost 85% agreed that women who become pregnant after rape should have the legal right to obtain a safe pregnancy termination; however, only 50% were willing to perform an abortion under these circumstances or prescribe abortifacient drugs . The conclusion was that 35% would not agree to perform an abortion themselves, although they have no moral or religious objection to abortion being provided to women who become pregnant following rape.

In another qualitative study with 30 obstetricians/gynecologists from the state of São Paulo, Brazil, some participants declared that the most frequent reasons for refusing to perform legal abortion were personal convictions and religious principles . Some study participants, however, expressed their doubt that the religious rationale was always genuine as they had reasons to believe that the main motivation for unwillingness to perform abortion was the fear of social stigma . Similar results were found in studies conducted in Poland and in Salvador, Bahia, Brazil . Physicians know that conscientiously objecting to performing a pregnancy termination will have no practical consequences for them. However, they fear the negative social consequences of performing pregnancy terminations and feel more comfortable claiming conscientious objection, which they do not in fact have.

The concept that their ethical obligation “is at all times to treat, or provide benefit and prevent harm to, the patients for whose care they are responsible” is rarely taken into account . It is much easier to claim conscientious objection when denying the woman the service she needs than to full their professional and ethical obligation to provide safe abortion services according to the country’s law.