Abortions in adolescents

This review discusses the problem of abortion in adolescents across the world and highlights the gaps in knowledge. It also examines the need for adolescent-friendly services.

Informed or Misinformed Consent? Abortion Policy in the United States

Since 2010, the United States has witnessed a dramatic expansion of state-based restrictions on abortion. The most common of these are informed consent statutes, which require that a woman seeking an abortion receive a state-authored informational packet before the abortion procedure can be performed. These laws, in addition to requiring the provision of information about alternatives to and risks of abortion, all also require details of embryological and fetal development. This article presents the findings of a comprehensive study of state-authored informed consent materials regarding embryological and fetal development. To conduct this study, we recruited a panel of experts in human anatomy to assess the accuracy of these materials in the context of the constitutional standard established inPlanned Parenthood of Southeastern Pennsylvania et al. v. Robert P. Casey et al.(505 U.S. 833 (1992)): that such information must be "truthful" and "nonmisleading." We find that nearly one-third of the informed consent information is medically inaccurate, that inaccurate information is concentrated primarily in the earlier weeks of pregnancy and is clustered around particular body systems. We discuss the implications of our findings for the question of the constitutionality of informed consent laws as they have been implemented in practice.

Challenging the principle of proportionality

The first objective of this article is to examine one aspect of the principle of proportionality (PP) as advanced by Alan Gewirth in his 1978 bookReason and Morality Gewirth claims that being capable of exercising agency to some minimal degree is a property that justifies having at least prima facie rights not to get killed. However, according to the PP, before the being possesses the capacity for exercising agency to that minimal degree, the extent of her rights depends on to what extent she approaches possession of agential capacities. One interpretation of PP holds that variations in degree of possession of the physical constitution necessary to exercise agency are morally relevant. The other interpretation holds that only variations in degree of actual mental capacity are morally relevant. The first of these interpretations is vastly more problematic than the other. The second objective is to argue that according to the most plausible interpretation of the PP, the fetus' level of development before at least the 20th week of pregnancy does not affect the fetus' moral rights status. I then suggest that my argument is not restricted to such fetuses, although extending my argument to more developed fetuses requires caution.

Future healthcare professionals' knowledge about the Argentinean abortion law

OBJECTIVE

We assessed healthcare students' knowledge and opinions on Argentinian abortion law and identified differences between first- and final-year healthcare students.

METHODS

In this cross-sectional study, self-administered anonymous questionnaires were administered to 760 first- and 695 final-year students from different fields of study (medicine, midwifery, nursing, radiology, nutrition, speech therapy, and physiotherapy) of the School of Medicine at the University of Buenos Aires, in 2011-2013.

RESULTS

Compared to first-year students, a higher percentage of final-year students knew that abortion is legally restricted in Argentina (p < 0.001). A significantly higher percentage of final-year students could correctly identify the circumstances in which abortion is legal: woman's life risk (87.4% last vs. 79.1% first year), rape of a woman with developmental disability (66.2% first vs. 85.4% last-year; p < 0.001). More final-year students chose severe foetal malformations (37.3% first year vs. 57.3% final year) despite its being illegal.

CONCLUSIONS

Although most final-year students knew that abortion is legally restricted in Argentina, misconceptions regarding circumstances of legal abortion were observed; this may be due to the fact that abortion is inadequately covered in the medical curricula. Medical schools should ensure that sexual and reproductive health topics are an integral part of their curricula. Healthcare providers who are aware of the legality of abortion are more likely to provide the public with sound information and ensure abortions are appropriately performed.

Under the Cover of Night: Abortion Across Borders

Jessica and Robert* had a three-year-old son and were excited about their second child, a daughter. When Jessica was 21 weeks pregnant, the routine ultrasound was normal. At 26 weeks, she was in a minor car accident and her obstetrician referred her for a specialized ultrasound, concerned about the baby's heart. This was how Jessica and Robert discovered that their daughter had a serious heart defect. After meeting with a perinatologist, a genetics counselor and a pediatric cardiologist, they realized the prognosis was dire. After birth, their daughter would need urgent open-heart surgery, and would need two more surgeries in her first year of life. If she survived long enough, her only real chance would be a heart transplant. They cried, they raged, and then they turned to the Internet. They felt the only way they could protect their daughter from a lifetime of suffering was to terminate the pregnancy. When they arrived at our clinic in New Mexico, they looked beaten down, fragile. "I feel like we snuck across state borders under the cover of night," Jessica told us, "but what choice did we have?"

Why Governments That Fund Elective Abortion Are Obligated to Attempt a Reduction in the Elective Abortion Rate

If elective abortion is publicly funded, then the government is obligated to take active measures designed to reduce its prevalence. I present two arguments for that conclusion. The first argument is directed at those pro-choice thinkers who hold that while some or all elective abortions are morally wrong, they still ought to be legally permitted and publicly subsidized. The second argument is directed at pro-choice thinkers who hold that there is nothing morally wrong with elective abortion and that it should be both legally permitted and publicly subsidized. The second argument employs premises that generalize beyond the abortion debate and that may serve to shed light on broader questions concerning conscience and the requirements of political compromise in a democracy.

Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide

Much of the debate on conscience has addressed the ethics of refusal: the rights of providers to refuse to perform procedures to which they object and the interests of the patients who might be harmed by their refusals. But conscience can also be a positive force, grounding decision about offering care.

[An ethical and medical perspective on the voluntary termination of pregnancy]

"Voluntary termination of pregnancy" can refer to actions intended to make a delivery easier, to provide medical care to the fetus, or to protect the life or health of the mother. All of these are proper medical actions and are by definition voluntary. In other cases, the expression denotes a termination of pregnancy before the embryo or fetus is viable, leading to the death of the latter. This action is constitutive of abortion under current Chilean law. The product of conception living being, who develops in the womb during pregnancy, is an individual, both in the sense that it is different from its mother and father, and in that it is a biological individual. For these reasons, such living being constitutes another patient in itself. The free and voluntary medical action of health care professionals is geared toward disease prevention or health recovery and medical terminations of pregnancy, as distinguished from abortion, are not criminalized in our country. Therefore, the idea of legalizing abortive terminations of pregnancy so that they become "legitimate health care services" is a call to the medical community, which should engage in a debate about the meaning and consequences of an eventual mandate of the State that would be at odds with the Hippocratic tradition. A woman can feel that her health is at risk due to her pregnancy, and she certainly has the right to request medical help. Health professionals should care both at the medical and emotional level for all those who require their services, especially when such persons are undergoing situations of vulnerability and distress. When requested to perform an abortion, the physician faces dilemmas that should be addressed in line with the present state of the medical art.

Medical Abortion in Australia: What Are the Clinical and Legal Risks? Is Medical Abortion Over-regulated?

This article examines the clinical and legal risks of early medical abortion. After providing an overview of the history of mifepristone in Australia, the evidence concerning the efficacy and safety of medical abortion is discussed. It is argued that the negligible medical risks associated with mifepristone do not justify the restrictive regulatory measures imposed on medical practitioners. The article then turns to the legal risks and considers whether medical practitioners are vulnerable to prosecution under existing State and Territory laws. It is argued that providing early medical abortion services in a number of jurisdictions is legally ambiguous, potentially posing a threat of prosecution to medical practitioners. The need for law reform is evident by the fact that in four jurisdictions it remains in the criminal statutes, creating legal uncertainty for both medical practitioners and women. The article concludes that there is sufficient evidence to allow some “demedicalisation” of medical abortion. However, this is only possible if the legal status of abortion in State and Territory laws is addressed.

[[Abortive Pollution in the Sacred Laws of Cyrene and Kos].]

In the society of the ancient Greece sacred laws on the abortion are a typical example of a mixture between the temple wisdom tradition and the medical tugvr. The epigraphic discoveries made between the end of the nineteenth century and the beginning of the twentieth century in Cos and Cyrene offered meaningfid evidences of the cooperation between priests and physicians to evaluate each single case of abortion and impose the right atonement. This contribution aims at showing how firm the line of continuity between medicine as wisdom and medicine as T Xvn was in the ancient Greece, focusing on the hot topic of the abortion. The question will be analyzed from a multidisciplinary approach which includes history of language, history of medicine and history of religion as the nature of the topic and of the evidences reauires.

'This Is Real Misery': Experiences of Women Denied Legal Abortion in Tunisia

Barriers to accessing legal abortion services in Tunisia are increasing, despite a liberal abortion law, and women are often denied wanted legal abortion services. In this paper, we seek to explore the reasons for abortion denial and whether these reasons had a legal or medical basis. We also identify barriers women faced in accessing abortion and make recommendations for improved access to quality abortion care. We recruited women immediately after they had been turned away from legal abortion services at two facilities in Tunis, Tunisia. Thirteen women consented to participate in qualitative interviews two months after they were turned away from the facility. Women were denied abortion care on the day they were recruited due to three main reasons: gestational age, health conditions, and logistical barriers. Nine women ultimately terminated their pregnancies at another facility, and four women carried to term. None of the women attempted illegal abortion services or self-induction. Further research is needed in order to assess abortion denial from the perspective of providers and medical staff.

[Elective abortions, a right to defend]

Every year in France, almost 210 000 women request a termination of an unwanted pregnancy. Two thirds of them were however using a form of contraception, hence the importance, for caregivers, of encouraging women to find the method which works best for them. The right to abortion is the fruit of a long fight for a woman's right to control her own body. It is a right which must be protected.

RISKS, REASONS AND RIGHTS: THE EUROPEAN CONVENTION ON HUMAN RIGHTS AND ENGLISH ABORTION LAW

Although there is no right to abort in English law but rather abortion is a crime, the lawful grounds for which are instantiated in the Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990), the regulation of abortion is sometimes perceived as being fairly 'liberal'. Accordingly, the idea that aspects of English law could be criticised under the European Convention on Human Rights, with which the UK must comply following the Human Rights Act 1998, may seem unlikely. Indeed, English law is compatible with the consensus amongst contracting states that abortion should be available on maternal health grounds. However, analysis of the UK's negative obligations under Article 8 shows that section 1(1)(a) of the Act is problematic as it operates in the first trimester. Further, given the European Court of Human Rights' emphasis on the reduced margin of appreciation once a state has legalised abortion to some degree and its jurisprudence relating to a state's positive obligations, the analysis shows that, while English law may not be problematic in relation to the lack of guidelines relating to the lawful grounds for abortion, it may well be in relation to the lack of a formal system for the review of any two doctors' decision not to grant a termination. Notwithstanding the morally serious nature of the decision to abort, the analysis overall raises questions about the need for at least some degree of abortion law reform, particularly in relation to the first trimester, towards a more autonomy-focused, though time-limited, rights-based approach.

Ethical and legal issues in cross-system practice in India: Past, present and future

Recent changes in policies allowing practitioners of Ayurveda, Yoga, Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) to integrate into the mainstream of healthcare and also allowing practitioners of Ayurveda and Homoeopathy to perform medical termination of pregnancy (MTP) under the proposed amendment to the MTP bill have brought crosssystem practice into the limelight. We evaluate cross-system practice from its legal and ethical perspectives. Across judgments, the judiciary has held that cross-system practice is a form of medical negligence; however, it is permitted only in those states where the concerned governments have authorized it by a general or special order. Further, though a state government may authorize an alternative medicine doctor to prescribe allopathic medicines (or vice versa), it does not condone the prescription of wrong medicines or wrong diagnosis. Courts have also stated that prescribing allopathic medicines and misrepresenting these as traditional medicines is an unfair trade practice and not explaining the side-effects of a prescribed allopathic medicine amounts to medical negligence. Finally, the Supreme Court has cautioned that employing traditional medical practitioners who do not possess the required skill and competence to give allopathic treatment in hospitals and to let an emergency patient be treated by them is gross negligence. In the event of an unwanted outcome, the responsibility is completely on the hospital authorities. Therefore, there is an urgent need to abolish cross-system practice, invest in healthcare, and bring radical changes in health legislations to make right to healthcare a reality.

Do State-Based Policies Have an Impact on Teen Birth Rates and Teen Abortion Rates in the United States?

OBJECTIVES

The United States has one of the highest teen birth rates among developed countries. Interstate birth rates and abortion rates vary widely, as do policies on abortion and sex education. The objective of our study is to assess whether US state-level policies regarding abortion and sexual education are associated with different teen birth and teen abortion rates.

METHODS

We carried out a state-level (N = 51 [50 states plus the District of Columbia]) retrospective observational cross-sectional study, using data imported from the National Vital Statistics System. State policies were obtained from the Guttmacher Institute. We used descriptive statistics and regression analysis to study the association of different state policies with teen birth and teen abortion rates.

RESULTS

The state-level mean birth rates, when stratifying between policies protective and nonprotective of teen births, were not statistically different-for sex education policies, 39.8 of 1000 vs 45.1 of 1000 (P = .2187); for mandatory parents' consent to abortion 45 of 1000, vs 38 of 1000 when the minor could consent (P = .0721); and for deterrents to abortion, 45.4 of 1000 vs 37.4 of 1000 (P = .0448). Political affiliation (35.1 of 1000 vs 49.6 of 1000, P < .0001) and ethnic distribution of the population were the only variables associated with a difference between mean teen births. Lower teen abortion rates were, however, associated with restrictive abortion policies, specifically lower in states with financial barriers, deterrents to abortion, and requirement for parental consent.

CONCLUSION

While teen birth rates do not appear to be influenced by state-level sex education policies, state-level policies that restrict abortion appear to be associated with lower state teen abortion rates.

The regulatory cliff edge between contraception and abortion: the legal and moral significance of implantation

In regulating the voluntary interruption of pregnancy, English law has accorded particular significance to two biological events. First, 'viability', the moment when a fetus is said to acquire the capacity for independent life, plays an important role in grounding restrictions on access to legal abortion later in pregnancy. Second, equally significantly but far less frequently discussed, 'implantation' marks the point in pregnancy from which abortion laws apply. This paper focuses on this earlier biological event. It suggests that an unquestioning reliance on implantation as marking an appropriate moment of transition between two radically different legal frameworks is deeply problematic and is rendered still less sustainable in the light of the development of new technologies that potentially operate shortly after the moment of implantation.

WHEN CONSCIENCE ISN'T CLEAR: GREATER GLASGOW HEALTH BOARD v DOOGAN AND ANOTHER [2014] UKSC 68

The Supreme Court's judgment in Doogan is a judicial review of a decision by Greater Glasgow Health Board regarding the scope of the conscience-based exemption in section 4(1) of the Abortion Act 1967. The case progressed through the Outer and Inner Houses of the Court of Session in Edinburgh before final judgment was delivered in the Supreme Court by Baroness Hale on December 17 2014. The Supreme Court eschewed consideration of the human rights dimension of the case (which had featured in the Outer House decision) and approached its judgment as 'a pure question of statutory construction'. This commentary engages with the judgment on its own terms, assessing it as an exercise in statutory interpretation, and leaves it to others who may wish to do so to comment on the human rights aspects of the case.

"If a woman has even one daughter, I refuse to perform the abortion": Sex determination and safe abortion in India

In India, safe abortion services are sought mainly in the private sector for reasons of privacy, confidentiality, and the absence of delays and coercion to use contraception. In recent years, the declining sex ratio has received much attention, and implementation of the Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act (2003) has become stringent. However, rather than targeting sex determination, many inspection visits target abortion services. This has led to many private medical practitioners facing negative media publicity, defamation and criminal charges. As a result, they have started turning women away not only in the second trimester but also in the first. Samyak, a Pune-based, non-governmental organization, came across a number of cases of refusal of abortion services during its work and decided to explore the experiences of private medical practitioners with the regulatory mechanisms and what happened to the women. The study showed that as a fallout from the manner of implementation of the PCPNDT Act, safe abortion services were either difficult for women to access or outright denied to them. There is an urgent need to recognize this impact of the current regulatory environment, which is forcing women towards illegal and unsafe abortions.

The experiences and adaptations of abortion providers practicing under a new TRAP law: a qualitative study

OBJECTIVE

Abortion laws are proliferating in the United States, but little is known about their impact on abortion providers. In 2011, North Carolina instituted the Woman's Right to Know (WRTK) Act, which mandates a 24-h waiting period and counseling with state-prescribed information prior to abortion. We performed a qualitative study to explore the experiences of abortion providers practicing under this law.

STUDY DESIGN

We conducted semistructured interviews with 31 abortion providers (17 physicians, 9 nurses, 1 physician assistant, 1 counselor and 3 clinic administrators) in North Carolina. Interviews were audio-recorded and transcribed. Interview transcripts were analyzed using a grounded theory approach. We identified emergent themes, coded all transcripts and developed a thematic framework.

RESULTS

Two major themes define provider experiences with the WRTK law: provider objections/challenges and provider adaptations. Most providers described the law in negative terms, though providers varied in the extent to which they were affected. Many providers described extensive alterations in clinic practices to balance compliance with minimization of burdens for patients. Providers indicated that biased language and inappropriate content in counseling can negatively impact the patient-physician relationship by interfering with trust and rapport. Most providers developed verbal strategies to mitigate the emotional impacts for patients.

CONCLUSIONS

Abortion providers in North Carolina perceive WRTK to have a negative impact on their clinical practice. Compliance is burdensome, and providers perceive potential harm to patients. The overall impact of WRTK is shaped by interaction between the requirements of the law and the adaptations providers make in order to comply with the law while continuing to provide comprehensive abortion care.

IMPLICATIONS

Laws like WRTK are burdensome for providers. Providers adapt their clinical practices not only to comply with laws but also to minimize the emotional and practical impacts on patients. The effects on providers, frequently not a central consideration, should be considered in ongoing debates regarding abortion regulation.

Mutual scorn within the abortion debate: some parallels with race relations

By emphasizing the parallels between both racial vilification and the vilification that takes place when we discuss abortion in our society, I hope to provide a new perspective on the way the United States converses about this divisive issue. This perspective, in turn, can help us see how we can move forward from the stagnate polemics that have permeated the abortion debate in the United States for the past 40 years.

"Right tool," wrong "job": Manual vacuum aspiration, post-abortion care and transnational population politics in Senegal

The "rightness" of a technology for completing a particular task is negotiated by medical professionals, patients, state institutions, manufacturing companies, and non-governmental organizations. This paper shows how certain technologies may challenge the meaning of the "job" they are designed to accomplish. Manual vacuum aspiration (MVA) is a syringe device for uterine evacuation that can be used to treat complications of incomplete abortion, known as post-abortion care (PAC), or to terminate pregnancy. I explore how negotiations over the rightness of MVA as well as PAC unfold at the intersection of national and global reproductive politics during the daily treatment of abortion complications at three hospitals in Senegal, where PAC is permitted but induced abortion is legally prohibited. Although state health authorities have championed MVA as the "preferred" PAC technology, the primary donor for PAC, the United States Agency for International Development, does not support the purchase of abortifacient technologies. I conducted an ethnography of Senegal's PAC program between 2010 and 2011. Data collection methods included interviews with 49 health professionals, observation of PAC treatment and review of abortion records at three hospitals, and a review of transnational literature on MVA and PAC. While MVA was the most frequently employed form of uterine evacuation in hospitals, concerns about off-label MVA practices contributed to the persistence of less effective methods such as dilation and curettage (D&C) and digital curettage. Anxieties about MVA's capacity to induce abortion have constrained its integration into routine obstetric care. This capacity also raises questions about what the "job," PAC, represents in Senegalese hospitals. The prioritization of MVA's security over women's access to the preferred technology reinforces gendered inequalities in health care.

The Right to Travel for Abortion Services: A Case Study in Irish 'Cross-border Reproductive Care'

Abortion is illegal in Ireland, except in very limited circumstances, but the Irish Constitution guarantees the right of women to travel abroad to obtain abortion services. Every year, large numbers of women travel to the UK to obtain abortions. This article argues that this can be regarded as an illustration of cross-border reproductive care (CBRC). CBRC is the phenomenon whereby people travel abroad to obtain assisted reproduction services that are illegal in their country of origin. A leading commentator, Guido Pennings, argues that CBRC is to be welcomed as a means by which society might compromise on issues of profound moral disagreement. Other commentators believe CBRC is highly problematic. This article argues that the Irish abortion example, when examined as an example of CBRC, illustrates both the advantages and disadvantages of CBRC identified by Pennings and his critics.

Tasmania's Reproductive Health (Access to Terminations) Act 2013: An analysis of conscientious objection to abortion and the "obligation to refer"

This article focuses on Tasmania's Reproductive Health (Access to Terminations) Act 2013, which decriminalises abortion in that State. The article first provides an overview of the Tasmanian legislation, comparing it with Victoria's Abortion Law Reform Act 2008. It then provides a more in-depth analysis of a doctor's right to "conscientious objection" and the requirement in both Acts of an "obligation to refer". The article concludes that ultimately, as a democratic society, it is important that both a woman's right to terminate a pregnancy and a doctor's right to freedom of conscience is respected. Where these rights conflict, as is the case when a doctor with a conscientious objection to abortion is confronted with a patient who seeks information about abortion, they must be balanced. The Victorian and Tasmanian Acts represent a considered and reasonable approach to balancing the rights at issue.

Conscientious objection: personal and professional ethics in the public square

English law expects health professionals to have, and act upon, consciences, but formal conscience clauses are not the main legal recognition of this expectation. Rather, they should be regarded as an anomaly with roots in very specific political settlements between society and health professions, whose legitimacy is historically contingent, and as an aspect of the 'price' to be paid for securing services. There are sound reasons for the protection of conscientious discretion as an aspect of professional identify, but specific rights of personal conscientious objection are difficult to reconcile with legitimate public expectations of comprehensive and non-discriminatory services. Professional identities include moral commitments, such as the privileging of patient safety over administrative convenience. These should not be permitted to be overridden by personal moralities during the course of service delivery (as opposed to debating in the abstract what the proper courses of action should be). Consequently, formal conscientious objection clauses should be reduced to a minimum and regularly revisited. It is generally more satisfactory to address clashes between the personal moralities of professionals and public expectations through more flexible means, enabling accommodation of a plurality of views where possible but acknowledging that this is a matter of striking an appropriate balance. Employment law rather than healthcare law provides the best mechanism for regulating this process.

'In good conscience': conscience-based exemptions and proper medical treatment

Lack of clarity about the proper limits of conscientious refusal to participate in particular healthcare practices has given rise to fears that, in the absence of clear parameters, conscience-based exemptions may become increasingly widespread, leading to intolerable burdens on health professionals, patients, and institutions. Here, we identify three factors which clarify the proper scope of conscience-based exemptions: the liminal zone of 'proper medical treatment' as their territorial extent; some criteria for genuine conscientiousness; and the fact that the exercise of a valid conscience-based exemption carries certain duties with it. These restricting factors should reassure those who worry that recognising rights of conscience at all inevitably risks rampant subjectivity and self-interest on the part of professionals. At the same time, they delineate a robust conscience zone: where a claim of conscience relates to treatment with liminal status and satisfies the criteria for conscientious character, as well as the conditions for conscientious performance, it deserves muscular legal protection.

The importance of considering the evidence in the MTP 2014 Amendment debate in India - unsubstantiated arguments should not impede improved access to safe abortion

With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.

[Abortion and conscientious objection]

Polish laws specify the parties responsible for lawful medical care in the availability of abortion differently than the Resolution of the Council of Europe. According to Polish regulations they include all Polish doctors while according to the Resolution, the state. Polish rules should not discriminate against anyone in connection with his religion or belief, even more so because the issue of abortion is an example of an unresolved ethical dispute. The number of lawful abortion in Poland does not exceed 1000 per year and can be carried out by only a few specialists contracted by the National Health Fund. Sufficient information and assistance should be provided to all pregnant women by the National Health Fund. The participation of all physicians in the informing process is not necessary, as evidenced by the lack of complaints to provide information on where in vitro fertilization treatment can be found - until recently only available when paid for by the individual and performed in much larger numbers than abortion. Entities performing this paid procedure made sure to provide information on their own. The rejection of the right to the conscientious objection clause by negating the right to refuse information may lead some to give up the profession or cause the termination of certain professionals on the basis of the professed worldview. Meanwhile, doctors are not allowed to be discriminated against on the basis of their conscience or religion.