Abortion and conscientious objection: rethinking conflicting rights in the Mexican context

Conscientious objection and barriers to abortion within a specific regional context - an expert interview study

BACKGROUND

While most countries that allow abortion on women's request also grant physicians a right to conscientious objection (CO), this has proven to constitute a potential barrier to abortion access. Conscientious objection is regarded as an understudied phenomenon the effects of which have not yet been examined in Germany. Based on expert interviews, this study aims to exemplarily reconstruct the processes of abortion in a mid-sized city in Germany, and to identify potential effects of conscientious objection.

METHODS

Five semi-structured interviews with experts from all instances involved have been conducted in April 2020. The experts gave an insight into the medical care structures with regard to abortion procedures, the application and manifestations of conscientious objection in medical practice, and its impact on the care of pregnant women. A content analysis of the transcribed interviews was performed.

RESULTS

Both the procedural processes and the effects of conscientious objection are reported to differ significantly between early abortions performed before the 12th week of pregnancy and late abortions performed at the second and third trimester. Conscientious objection shows structural consequences as it is experienced to further reduce the number of possible providers, especially for early abortions. On the individual level of the doctor-patient relationship, the experts confirmed the neutrality and patient-orientation of the vast majority of doctors. Still, it is especially late abortions that seem to be vulnerable to barriers imposed by conscientious objection in individual medical encounters.

CONCLUSION

Our findings indicate that conscientious objection possibly imposes barriers to both early and late abortion provision and especially in the last procedural steps, which from an ethical point of view is especially problematic. To oblige hospitals to partake in abortion provision in Germany has the potential to prevent negative impacts of conscientious objection on women's rights on an individual as well as on a structural level.

Bioethics training in reproductive health in Mexico

Bioethical approaches to reproductive health have been of utmost importance for the last three decades in Mexico. As Mexican laws regarding abortion, assisted reproduction, and conscientious objection have been modified, a number of social actors with an interest in these areas have realized that they have to educate the different agents who take part in these procedures in a bioethical approach to reproductive health and rights. This strategy was first used in Mexico by the Catholic Church and many Catholic universities. Advocates, scientists, and feminist organizations, as well as some public universities, have also realized that a grounding in bioethics could help health providers to have an ethical frame that supports the provision of abortion services. Bioethics is also a good framework for supporting the legalization of abortion and for more liberal laws regarding assisted reproduction. So, for the last few years, one of the priorities of these two sides, Catholic and secular groups, has been to train healthcare personnel, lawyers, and members of ethics committees and members of Congress in the application of their respective bioethical perspectives.

Medical and midwifery students' views on the use of conscientious objection in abortion care, following legal reform in Chile: a cross-sectional study

BACKGROUND

In August 2017, Chile lifted its complete ban on abortion by permitting abortion in three limited circumstances: 1) to save a woman's life, 2) lethal fetal anomaly, and 3) rape. The new law allows regulated use of conscientious objection (CO) in abortion care, including allowing institutions to register as objectors. This study assesses medical and midwifery students' support for CO, following legal reform.

METHODS

From October 2017 to May 2018, we surveyed medical and midwifery students from seven universities located in Santiago, Chile. Universities included 4 secular (2 public and 2 private) and 3 private religiously-affiliated universities; all offering medical degrees with a specialization in obstetrics and gynecology (ob-gyn) and five offering midwifery degrees. We used generalized estimating equations (GEE) to identify characteristics associated with student support for CO, intentions to use CO to refuse to care for someone seeking abortion, and support for CO at the institutional level.

RESULTS

333 of the 413 eligible students who opened the survey, completed the questions on conscientious objection; 26% were seeking medical degrees with an ob-gyn specialty, 25% were seeking midwifery degrees, and 49% were seeking medical degrees and had not yet decided their specialty. While nearly all endorse requirements for conscientious objecting clinicians to inform (92%) and refer (91%) abortion-seeking patients, a minority (18%) would personally use conscientious objection to avoid caring for a patient seeking abortion (12% secular and 39% religious university students). About half of religious-university students (52%) and one-fifth of secular-university (20%) students support objections at the institutional level.

CONCLUSIONS

Most students support the regulated use of CO which preserves patients' access to abortion care. Religious-university student views on the use of conscientious objection in abortion care are discordant with those of their institutions which currently support institutional-level objections.

The Politicization of Abortion and Hippocratic Disobedience in Islamist Sudan

In Sudan's Islamist state, abortion is politicized through its association with illegal pregnancy. Fornication is a crime against God punishable with 100 lashes, and pregnancy outside a marriage contract constitutes sufficient evidence of a woman's immorality. This enables a strong link between the crime of fornication and the crime of illegal abortion, to the extent that our interviewees often conflate the two in the term "illegal pregnancy." While abortion does not appear in the domestic political debate on women's reproductive and maternal health and is not on the agenda of the national women's movement, it has become politicized in the implementation of the law. A number of bureaucratic barriers, in addition to a strong police presence outside maternity wards in public hospitals, make it difficult for unmarried women to access emergency care after complications of an illegal abortion. These women put themselves at risk of arrest for fornication and illegal abortion. However, many doctors, honoring the Hippocratic oath, disobey state policy and refrain from reporting such crimes to the police to protect unmarried and vulnerable women from prosecution.

Twelve years after abortion decriminalization in Mexico City: Can we still remain an island of liberties?

Latin America hosts the most restrictive abortion legislation globally. In 2007, Mexico, the second largest Catholic country in the world, decriminalized elective abortion within the first twelve weeks of pregnancy in the capital: Mexico City (also known as Federal District of Mexico). Following the reform, the Mexico City Ministry of Health (MX-MOH) implemented safe and legal services. Free services are provided to Mexico City residents and a sliding fee of up to $100 is applied to women from other Mexican states. Conscientious objection (CO) was addressed and included in service provision guidelines. Since 2007, 18 of 32 states amended their penal codes to restrict abortion. The road toward increasing access to abortion services at the MX-MOH included a shift from dilation and curettage (D&C) to medical abortion (MA), first with the misoprostol-alone regimen, followed by the combined mifepristone-misoprostol regimen. Manual vacuum aspiration is offered to out-of-state-women or to those beyond the gestational age where MA is less effective. Contraceptive uptake among abortion seekers is high (up to 95% of them prefer a free method of their choice). The Legal Interruption of Pregnancy program at the MX-MOH continues to provide effective, safe, reliable, and free services. However, women from indigenous groups residing in rural areas, those with low schooling, and adolescents with an unintended pregnancy who live in rural, urban, peri-urban districts, and at the state level are underserved despite being legally eligible to receive abortion services. Therefore, information and services for the disadvantaged groups need to be strengthened.