Conscious Oppression: Conscientious Objection in the Sphere of Sexual and Reproductive Health

Marcelo Alegre
Publication Date: 2009
download full article: [pdf]

Abstract
Although for centuries conscientious objection was primarily claimed by those who for religious or ethical reasons refused to join the ranks of the military (whether out of a general principle or in response to a particular violent conflict), in recent decades a significant broadening of the concept can be seen. InThailand, for example, doctors recently refused medical attention to injured policemen suspected of having violently repressed a demonstration. In Argentina a few public defenders have rejected for conscientious reasons to represent individuals accused of massive human rights violations. In different countries all over the world there are doctors who refuse to perform euthanasia, schoolteachers who reject to teach the theory of evolution, and students who refuse to attend biology classes where frogs are dissected.

Comments: Paper delivered at SELA 2009, Law and Sexuality, in Asunción, Paraguay, as part of the panel on “The Foundational Ideals.”
Recommended Citation

Alegre, Marcelo, “Conscious Oppression: Conscientious Objection in the Sphere of Sexual and Reproductive Health” (2009). SELA (Seminario en Latinoamérica de Teoría Constitucional y Política) Papers. Paper 65.
http://digitalcommons.law.yale.edu/yls_sela/65

 

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Conscentious Objection in Medicine: private ideological convictions must not supercede Public Service Obligations

U. Schuklenk
Bioethics ISSN 0269-9702 (print); 1467-8519 (online) doi:10.1111/bioe.12167
Volume 29 Number 5 2015 pp ii–iii

Canada’s Supreme Court decided that Canadians’ constitutional
rights are violated by the criminalisation of assisted dying. Canada’s politicians are currently scrambling to come up with an assisted dying regime within the 12 month period that the Supreme Court gave them to fix the problem.

Since then, the Canadian Medical Association, the country’s doctors’ lobby organisation, has insisted not only that doctors must not be forced to provide assisted dying but also that doctors must not be required to transfer patients asking for assisted dying on to a colleague who they know will oblige these patients.1

In many countries, including Canada, conscientious objection clauses protect – mostly – healthcare professionals from being forced to act against their individual ideological convictions. I suspect it isn’t unfair to note that these protections in the real world are nothing other than protections for Christian doctors who are unwilling to deliver services they would be obliged to deliver to patients who are legally entitled to receive these services, were it not for their religiously motivated objections.2
Secular healthcare professionals could arguably avail themselves of conscience clauses, but in a liberal democracy, what reasonable conscience-based cause could they have to refuse the provision of healthcare services to patients? Conscience clauses today are by and large a concession of special rights to Christian healthcare professionals, at least in secular Western democracies.

An uneasy compromise is often struck that stipulates that conscientious objectors must not be forced to deliver the healthcare services that they object to, but that they must ensure that patients will be transferred to a healthcare professional willing to provide the requested service. Typically they are prohibited from engaging in activities aimed at persuading the patient to see the errors of their ways. Typically they must also transfer the patient in an expeditious manner to their more obliging colleague.

Looked at from a conscientious objector’s perspective, this compromise is anything but a compromise. If I object to abortion because I believe that abortion is akin to murder, as Christian objectors happen to believe, surely my moral responsibility is barely smaller if I knowingly pass a pregnant woman looking for an abortion on to a colleague who will commit the act rather than if I do it myself. Christians are not typically known to see these issues through a consequentialist analytical lense, but even from their perspective, moral responsibility is barely reduced by the compromise. I sympathise with their objections to the compromise, because it is not a compromise. A compromise under the circumstances arguably is not feasible to begin with.

Patients are entitled to receive uniform service delivery from healthcare professionals. They ought not to be subjected to today’s conscientious objection lottery. The Canadian Medical Association proposes that Canada ought to establish a website where patients can ascertai where the nearest non-objecting doctor is located.3
One difficulty with this proposition is that in many rural areas there might be only one doctor and the next, more obliging, healthcare professional might actually be a flight away. Nothing would stop us from taking this proposal to its absurd logical conclusion: why not establish comprehensive websites where patients can find out whether their doctor objects on grounds of conscience to treating sexually active gay patients, or perhaps whether their conscience prohibits them from treating patients of a particular objectionable ethnicity?
Consequentialists might well decide not to treat Ebola Virus Disease patients because of the risk involved, call it their consequentialist conscience. Healthcare service delivery would soon become a random event, entirely based on the vagaries of conscientious objections. Incidentally, Canadian doctors’ legal conscience protections do not actually cover these kinds of objections, because
really these protections are designed to protect Christian doctors’ convictions, despite feeble attempts at giving them a lick of neutrality paint. The odd thing about conscientious objections is that there is no way to find out whether they are genuine or just a matter of convenience. Even if they were genuinely held beliefs, why
should that constitute a sound reason for refusing service delivery?

The very idea that we ought to countenance conscientious objection in any profession is objectionable.4 Nobody forces anyone to become a professional. It is a voluntary choice. A conscientious objector in medicine is not dissimilar to a taxi driver who joins a taxi company that runs a fleet of mostly combustion engine cars and who objects on grounds of conscience to drive those cars due to environmental concerns. Why did she become a taxi driver in the first place? Perhaps she should have opened a bicycle taxi company instead. I recall well, during an extended teaching stint in a dental school, that in every intake there were a fair number of dental students mentioning that they settled on going to dental school rather than medical school because of their objections to abortion. That seems a much more reasonable decision than to join a medical school and throughout one’s working life cause problems for patients seeking medical care for health issues that they are legally entitled to receive medical care for but that one objects to for one
reason or another. Societies ought not to prioritise individual ideological commitments of some healthcare professionals over patients’ rights to receive professional care in a timely and hassle free fashion. Dying patients living in rural areas should not be subjected to an access-to-assisted-dying-lottery caused by conscientious objectors. Doctors are first and foremost providers of
healthcare services. Society has every right to determine what kinds of services they ought to deliver.

__________________________

1 S. Kirkey. Unacceptable to force doctors to participate in assisted
dying against their conscience: CMA. National Post 2015 March 5.
http://news.nationalpost.com/2015/03/05/unacceptable-to-forcedoctors-
to-participate-in-assisted-dying-against-their-conscience-cmahead/
[cited 2015 March 26]
2 B. Leiter. Why Tolerate Religion? Princeton, NJ: Princeton University
Press; 2013.
3 S. Kirkey. op.cit. note 1.
4 J. Savulescu. Conscientious objection in medicine. BMJ 2006; 332:
294.

Source: www.academia.edu

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Accommodating conscience in medicine

by Roger Trigg
JME Online First, published on May 26, 2014 as 10.1136/medethics-2013-101892

ABSTRACTS:

The issue of conscientious objection to agreed public policy is a vexed one. The clearest example is that of conscientious objection to military service. A free and democratic society has to respect the consciences of those who believe that killing in battle is absolutely wrong. Many disagree with the moral stance being taken, but it has been seen as the mark of a mature and civilised society to respect the conscience of pacifists. The freedom to be able to live by what one thinks most important has been seen as a constituent element in the freedoms that others have fought to preserve.

Respect for the conscience of those medical professionals who feel unable to participate in abortion appears to be in the same category (as would be respect for those who refused to participate in assisted suicide or euthanasia). Issues about the value of human life are at stake. Matters are undoubtedly complicated in the case of abortion by arguments over the supposed ‘humanity’ or ‘personhood’ of a fetus. Even so, some sincerely regard abortion as murder. Mutual respect is easy between people who agree. The problem in a democratic society arises when there is significant disagreement, but it is …

Source: jme.bmj.com/

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Eliminating CO in reproductive healthcare

The unregulated practice of CO in reproductive healthcare has become entrenched in many countries and health systems, resulting in widespread negative consequences for the women concerned and violations of their rights (Council of Europe Parliamentary Assembly, 2010). Even where a law or policy allows limited CO, abuse of that right is common. This implies that objecting personnel cannot be trusted to exercise the right responsibly, and that those who abuse CO are not qualified to be healthcare workers. Even doctors who exercise CO within the law are arguably unsuited for their position because they are demonstrating an inability to perform their job — that is, they are allowing religious beliefs or some other personal issue to interfere with their job performance to the extent of negating their professional duty to patients.

Abortion is the most frequently performed surgical intervention in the obstetrics/gynecology specialty (although it is also performed by many general practitioners). Becoming an Ob/Gyn engenders a special responsibility towards female patients, since a significant number of them will experience an unwanted pregnancy leading them to request abortions. Ob/Gyns have serious ethical obligations to those patients.

We argue that healthcare personnel should respect the accepted ethical standard of a non-judgmental approach towards their patients for all essential healthcare, with no exceptions. Consequently, we propose that healthcare providers be prohibited from a blanket right to refuse to perform or refer for abortion or dispense contraception for personal or religious reasons. Our recommended prohibition is specific to abortion and contraception because these two medical services are both essential and common, but are overwhelmingly the ones that objectors refuse to deliver.

Further, we propose the following specific remedies to reduce and eventually eliminate CO in reproductive healthcare. Everyone aspiring to enter health professions that involve reproductive healthcare should be required to declare that they will not allow their personal beliefs to interfere with their management of patients to the point of discrimination.  Medical students entering the Ob/Gynspecialty should be informed about the full scope of the specialty, including treating women with unwanted pregnancies. Students should be rejected if they do not wish to learn and prescribe contraception or perform abortions for CO reasons. All Ob/Gyns should be required to dispense birth control and perform abortions as part of their practice (unless there is a legitimate medical or professional reason not to). General practitioners should be expected to dispense contraception if requested, and perform abortions if they have the skills and capacity, or else refer appropriately. Pharmacists should be compelled to dispense all lawfully prescribed drugs without exceptions. Institutional CO should be completely prohibited for health systems and businesses that serve the general public.

Monitoring and enforcement measures should be put into place to ensure that prohibitions on CO are followed. After all, CO is a form of resistance to rules or laws, so those who exercise CO must be prepared to accept punishment for their disobedience,  just as in any other profession. Doctors should be sanctioned when they violate laws or codes of ethics that prohibit CO. Disciplinary measures could include a review process, an official reprimand and order to correct, and could escalate to loss of medical license, dismissal, or even criminal charges. In addition, any costs involved in the exercise of CO should be borne by the health professional or institution, who must be held liable for any health risks and negative consequences of their refusal. Patients should be legally entitled to sue and to claim compensation for any physical or mental harm, and for additional costs resulting from the refusal to treat.

Over time, such measures should result in a reduction in the number of anti-choice healthcare workers in the field of reproductive healthcare who refuse to deliver patient-centered care. Those who decide to remain and provide abortions and contraception could adopt an attitude of ‘‘professional distance’’ in order to separate their personal beliefs from their work duties. They could derive satisfaction from obeying laws and codes of ethics, respecting patient needs and autonomy, keeping their jobs or licenses, and furthering workplace harmony (McLeod, 2008) Outside their work lives, they are free to express their beliefs in many other ways.

Implementing such measures may seem like a daunting task given the ongoing stigma against abortion and the strength of the anti-choice movement. But with political will, much could be done at local, national, and international levels to ensure that contraception and abortion services are widely available and accessible to all who need them. For example, governments could regulate public health systems to guarantee abortion provision, and provide financial aid to hospitals to recruit abortion providers. Other needed measures include compulsory training in contraception provision and abortion techniques at medical schools, security measures to protect doctors and patients such as clinic buffer zones, full funding of contraception and abortion through government health insurance,  public education to reduce abortion stigma, and other initiatives. The Council of Europe has already recommended that States should ‘‘guarantee women’s effective exercise of their right of access to a safe and legal abortion;. . .lift restrictions which hinder. . .access to safe abortion, and. . .offer suitable financial cover.’’ (Council of Europe Parliamentary Assembly, 2008b)

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014), http://dx.doi.org/10.1016/j.woman.2014.03.001

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Institutional CO and violation of pro-choice right to conscience

Most CO laws and policies shield only healthcare professionals who refuse to participate in a given medical service like abortion, but fail to protect those who are ready to perform such interventions. Bioethicist Bernard Dickens refers to the stance of pro-choice healthcare workers as‘‘conscientious commitment,’’ pointing out that ‘‘religion has no monopoly on conscience’’. For example, many doctors and healthcare personnel working in illegal settings around the world have provided safe abortions to women in desperate need. ‘‘Conscientiously committed practitioners often need courage to act against prevailing legal, religious, and even medical orthodoxy following the honourable medical ethic of placing patients’ interests above their own.’’(Dickens, 2008) Such practitioners deserve legal and institutional protection for their commitment to their patients. Physician Lisa H. Harris has also recognized that caregivers may be compelled by conscience to provide abortion services, noting that the one-sided ‘‘equation of conscience with non-provision of abortion contributes to the stigmatization of abortion providers,’’ leading to provider shortage sand even harassment and violence (Harris, 2012).

A prime example of negating a pro-choice right to conscience is when health systems such as Catholic hospitals claim the right to exercise their ‘‘conscience’’ by refusing to perform some reproductive health services, and then imposing that on all their staff and patients regardless of differing personal beliefs. Such policies may even be unwritten because they are based on the personal religious beliefs of hospital administrators (Nowicka, 2008). In Austria, almost all hospitals, both Catholic and public, refuse to provide legal abortions (Wimmer-Puchinger, 1995), and the director of a Catholic hospital even admitted in a media interview that a doctor would be fired for performing an abortion (Pongauer Nachrichten, 2004).

However, many Catholic healthcare personnel believe they are helping women and saving lives by providing abortions, and that being prohibited from doing so — even to save a woman’s life — would be a violation of their own religious beliefs, as well as medical ethics and the directive to ‘‘do no harm’’. Indeed, 37% of obstetricians/gynaecologists who practice in religiously affiliated institutions have had a conflict with their institution over its doctrinal-based policies (not just abortion), including 52% of Ob/Gyns in Catholic institutions (Stulberg et al., 2012).

At a Catholic hospital in Arizona, a nun in charge of the hospital’s ethics committee was ‘‘automatically excommunicated’’ and ‘‘reassigned’’ after she decided to save a woman’s life by providing an emergency abortion. As further punishment, the local bishop even revoked the hospital’s Catholic designation (Associated Press, 2010). In Germany, two separate Catholic hospitals refused to give a raped woman a gynaecological examination to preserve evidence,or even any counseling or support. Staff had been threatened with dismissal for treating her, because the hospitals wanted to avoid having to offer advice on abortion or emergency contraception (The Local (Germany), 2013).

American women experiencing an ectopic pregnancy or miscarriage have been denied emergency life-saving treatment by religiously affiliated hospitals, in violation of accepted medical standards and federal laws (National Women’s Law Center, 2011). Ectopic pregnancies, in which the embryo implants outside the uterus, are life-threatening to women. The pregnancy cannot be saved under any circumstance, so the standard of care is to immediately administer the drug methotrexate or to surgically remove the pregnancy. But because methotrexate is also used for abortion, Catholic hospitals refuse to provide it. Instead, they frequently force women to wait until their fallopian tube ruptures, increasing the woman’s suffering and putting her life and future fertility at serious risk.

When CO is invoked by a health system on behalf of all its employees, it will likely impede women’s access to sexual and reproductive health services far more than CO by individual doctors. In smaller communities, religiously based hospitals are often the only facility around, which reduces or eliminates access to a range of reproductive health services (female sterilization, emergency contraception, abortion etc.) for the entire region. This abandons local women to risk needless suffering or even death if they require essential reproductive healthcare (Berer, 2013; Catholics for a Free Choice, 2003). The woman’s religion or beliefs are disregarded by the institution, even though Catholic women in the U.S. have abortions at the same rates as non-Catholics, and 98% have used a form of contraception banned by their Church (Catholics for Choice, 2011). Further, institutional CO sanctions only one sectarian religious view among many, since most organized religions, including Catholicism, have liberal streams of thought that support the right to abortion in some or most cases (Maguire Daniel, 2001). Despite this, most religiously affiliated institutions that exercise CO are publicly funded and serve entire communities with diverse views. In effect, female citizens of countries with government-funded healthcare are paying taxes to support a discriminatory system that denies them essential care based on their child-bearing capacity.

An amended resolution allowing institutional CO was forced through by anti-choice voting members in October 2010 at the Council of Europe, via a series of political tactics that subverted a democratic vote. The original resolution would have provided the first-ever official recommendations on how governments could ‘‘balance’’ women’s right to required healthcare with healthcare workers’ claim of CO. The corrupted resolution elevated a foetus over a woman’s life, even the life of her family and other children, and essentially gave hospitals in Europe an escape clause from being held responsible or financially liable for neglect or harm inflicted onto patients (Council of Europe Parliamentary Assembly, 2010). The resolution still stands, although later decisions by the European Court of Human Rights in abortion-related cases (R.R. v. Poland; P. and S. v.Poland) tried to redress the situation with this oxymoronicruling: ‘‘States are obliged to organize their health service system. . .to ensure that the effective exercise of freedom of conscience by health professionals. . .does not prevent patents from obtaining access to services to which they are entitled. . .’’ (European Court of Human Rights, 2012)

International human rights frameworks confirm that the right to freedom of thought, conscience, and religion is a right that only individual human beings can enjoy. In the words of Christine McCafferty, the Rapporteur for the committee that produced the Council of Europe report: ‘‘. . .only individuals can have a soul or a conscience. . . Institutions such as hospitals cannot, by definition, have a conscience.’’(Council of Europe Parliamentary Assembly, 2010)

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014), http://dx.doi.org/10.1016/j.woman.2014.03.001

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Impacts of CO on abortion provision

The exercise of CO can exacerbate the lack of access to abortion care by further reducing the pool of providers. Even pro-choice doctors may decline to or be unable to provide abortion care for a variety of other reasons besides CO, most of which are unique to abortion because of its politicized nature.

The stigma and misconceptions around abortion turn CO into an attractive solution for individual healthcare providers (ironically reinforcing those negative attitudes and beliefs). Allowing CO also encourages opportunistic refusals— doctors who are ambivalent about abortion may begin to adopt CO when given that option, making it very difficult to stop its growth (Millward, 2010). The refusal to perform or assist with abortion is often not even related to personal beliefs. Most pro-choice doctors who should or could perform abortions (obstetricians/gynaecologists and general practitioners) never do them, frequently because they fear that their reputation or livelihood will suffer because of social stigma. In North America, the atmosphere of fear and intimidation created by anti-choice extremists has worsened the provider shortage. The well-publicized violence against providers gives doctors ample reason to back away from performing abortions, irrespective of their personal beliefs.

Doctors who invoke CO to not perform abortions can benefit professionally by spending more of their time delivering more ‘‘reputable’’ or higher status treatments compared to their abortion-providing colleagues. As a result, they can escape stigma and boost their careers, reputations, and salaries.

Doctors who nevertheless want to provide abortion care may be prevented from doing so by their healthcare institution or employer for a variety of reasons, or by a lack of support from their collegial and social networks (Joffe, 2009). Physicians cite obstacles such as an anti-choice climate in their workplace, and widespread ‘‘no-abortion policies’’ that exist in many hospitals and private practices (Coletti, 2011), which may threaten health care providers with instant dismissal if they provide any banned treatment. Further, many doctors are simply unable to find work or training opportunities in an environment where abortion is legally restricted and stigmatized.

Lack of training and expertise is a common reason for not doing abortions, even though early abortion is a simple procedure and doctors routinely treat miscarriage using the same techniques as for surgical abortion. In general though,specific medical school training in common abortion techniques such as vacuum aspiration is often inadequate or non-existent, even in many western countries (Koyama and Williams, 2005).

When access to abortion care is reduced, restricted, and stigmatized in so many ways, allowing any degree of CO adds further to the already serious abrogation of patients’ rights and medical ethics.

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014), http://dx.doi.org/10.1016/j.woman.2014.03.001

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Impacts of CO on women’s autonomy and human rights

Abortion is a necessary health intervention, as well as highly ethical. Women with wanted pregnancies can experience serious medical or fetal complications to the point where abortion becomes the ‘‘standard of care’’ — a medically required, evidence-based service that any practitioner should be expected to provide. CO undermines the standard of care by preventing patients from receiving accurate and unbiased information about their treatment options, and by inhibiting their ability to access such care (Weitz and Berke Fogel, 2010).

Termination of unwanted pregnancy is ethical because women do so only if they don’t see any responsible way to care for that potential child. It protects their families and their future, since women may have existing children that they can barely afford to care for, or they may want to delay their first child until they finish school (Finer et al., 2008). Their decision is well-thought out and based on personal circumstances that only they can fully appreciate. Once the decision to terminate is made, most women will go to great lengths to carry it out, regardless of the law or the risk to their safety. Globally, 40% of all pregnancies are unintended (Guttmacher Institute, 2011). Over a quarter of all pregnant women will have either an abortion or an unwanted birth (Koyama and Williams, 2005), but 49% of the 43.8 million abortions that take place every year are unsafe and mostly illegal (Sedgh et al., 2012). An estimated 47,000 women die annually from unsafe abortion (Shah and Ahman, 2010) and 8.5 million are injured (Guttmacher Institute, 2010). This is why legalizing abortion has a dramatic impact on saving women’s lives and improving their health, a phenomenon that has been demonstrated in dozens of countries over the last few decades. Internationally, women have established human rights and constitutional equality in most western countries, and the exercise of CO infringes those rights. Access to abortion (and contraception) frees women to pursue an education and career and to participate fully in public life, thereby advancing their equality, liberty, and other human rights. It allows women to better plan and provide for their families (well over half of all women requesting an abortion already have at least one child (Guttmacher Institute, 2013b)), which also benefits the entire community and society. Births of unwanted children can be detrimental to women who were denied abortion (and to their families),leading to a higher risk of poverty, health complications,and domestic violence (Foster et al., 2012). Unwanted children themselves are at higher risk for lifelong dysfunction, including child abuse or neglect, emotional handicaps, and stunted intellectual and educational development (Arthur,1999; David, 2011).

Further, the decision to have an abortion is closely linked to social and economic circumstances, and the support or sanction of the societies that women live in. Women are much more likely to experience unintended pregnancy and seek abortion if they are adolescents, live in poverty, have chaotic lives or an abusive partner, or have poor access to contraception (Major et al., 2009).

Historically, one of the prime objectives of past governments was to increase their population, with little if any consideration for the quality of life of women and their children. Former monarchies, dictatorships, and warleading countries wanted soldiers to increase their empires and serve as cannon fodder (Museum of Contraception and Abortion, 1916). This fundamental conflict between the state and the individual resulted in laws in almost everycountry that essentially forced women to have more children than they wanted. Much progress has been made over the last century, with many countries liberalizing their abortion laws. In 2010, the United Nations Special Rapporteur on the Right to Health called for immediate decriminalization of abortion around the world because legal restrictions had discriminatory and stigmatizing effects and violated the right to health by leading to preventable deaths and injuries (United Nations General Assembly, 2011). Canada already struck down its law entirely in 1988 and never replaced it, proving that criminal abortion laws are unnecessary and counter-productive. The Supreme Court of Canada said:‘‘Forcing a woman, by threat of criminal sanction, to carry a fetus to term unless she meets certain criteria unrelated to her own priorities and aspirations, is a profound interference with a woman’s body and thus a violation of her security of the person.’’ (Abortion Rights Coalition of Canada, 2013).

In western countries today, the anti-choice movement wants women to bear children to reverse declining population levels and mitigate the effects of an ageing demographic. Invoking CO is one strategy to achieve this goal. But history provides ample evidence of the ineffectiveness of such restrictive strategies and the catastrophic consequences they lead to. Perhaps the most well-known‘‘social experiment’’ took place in Romania between 1966 and 1990. Former dictator Nicolae Ceausescu decided to increase the population by criminalizing contraception and abortion. Women were even subjected to regular gynaecological examinations to detect any pregnancy. But underground abortion networks mushroomed (as they do in any society where abortion is banned), and over the course of 20 years, an estimated 10,000 women died needlessly from illegal abortions alone. As a consequence of many unwanted pregnancies carried to term, state orphanages were overwhelmed with tens of thousands of children abandoned every year, most of whom ended up living on the street (U.S. Embassy, 2001; Westend Film+TV Produktion, 2004)

Anti-choice objections to providing abortions are based on a denial of this evidence and historical experience. The provision of safe, legal abortion is a vital public interest that negates any grounds for CO.

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014), http://dx.doi.org/10.1016/j.woman.2014.03.001

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Impacts of CO on women’s healthcare

Because reproductive healthcare is largely delivered to women, CO in this field has implications for women’s humanrights and constitutes discrimination. Women are often expected to fulfil a motherhood role, so they frequently face ignorance, disapproval, or even hostility when requesting abortion. In these circumstances, the exercise of CO becomes a paternalistic initiative to compel women to give birth.

Refusals to provide emergency contraception also force women to risk unwanted pregnancy, while referrals to other pharmacies can cause delays that reduce the effectiveness of the medication. Prescriptions for birth control or emergency contraception have been refused by anti-choice pharmacists in the U.S. (Planned Parenthood (Affiliates of New Jersey), 2005) and occasionally in other countries such as the U.K. (Brooke, 2010) and New Zealand (Sparrow, 2012). At least six U.S. states explicitly allow pharmacists to refuse to dispense contraception (Guttmacher Institute, 2013a). As with abortion, refusals to dispense contraception are not a mere inconvenience to women, but cause genuine harm to their reproductive autonomy, their sense of security, and their moral identity as people who deserve to be treated respectfully when requesting sexual and reproductive healthservices (McLeod, 2010). Public confrontations with objecting pharmacists compromise patient confidentiality and can shame or humiliate women.

The presumption that only a small minority of healthcare professionals will exercise CO and that others will be available to perform the medical service places limited CO on a foundation of shifting sand, further revealing its contradictory and dangerous nature. Indeed, CO can become quite widespread, leaving women without access to services across entire regions. In Italy, 69% of all gynaecologist srefuse to perform abortions, with the figure rising to over 80% in some regions (Italy Ministry of Health, 2007—2008).
In Austria, abortion providers must travel from Vienna to Salzburg once a week to do abortions at one public hospital, because gynaecologists in the region invoked CO after intense pressure from the Catholic Church and anti-choice groups. Abortion is unavailable elsewhere in Salzburg or the surrounding county (Fiala, 2013).

The example of South Africa is an important lesson in the anti-democratic nature of CO and the negative impact it can have on women. Abortion was illegal during Apartheid, and one of the first actions of the newly elected democratic government was to legalize abortion to improve women’s health (in 1996). But religious groups mounted campaigns against abortion that significantly reduced the number of willing providers. As a result, most of the healthcare professionals who should be responsible for performing abortions refuse to participate. Because of the latitude given to CO in South Africa, almost a third of South African women believe abortion is still banned, illegal abortions appear to be more common than legal ones (van Bogaert, 2002), and women who show up at public hospitals with complications are often mistreated and shamed (SANGONeT, 2012).

In countries with a minority of anti-choice doctors, women may suffer worse hardship than a short delay and a minor inconvenience, even if the doctor makes a referral. Women may be burdened with additional costs, such as for travel or daycare, and may need to take more time off work — if they can find and get to another doctor or clinic. Delayed access to abortion can also result in significant morbidity. Waiting extra weeks or even months for the procedure increases the medical risk of abortion and may require a more complicated method (for example, D&C instead of vacuum aspiration) (Cheng, 2008). Further, the delay may lead to debilitating symptoms such as severe nausea and psychological distress from a developing pregnancy they want to terminate. They may also need to hide the pregnancy from employers, friends, and family members.

Low-income and rural women are hurt the most by the exercise of CO, because such women may not have there sources to seek services elsewhere. It also disproportionately affects women from ethnic minorities, and women who experience intimate partner violence or sexual violation, who are twice as likely to need abortion services than women who don’t experience such violence (World Health Organization, 2013).

Finally, allowing CO for abortion ignores the realities of poor abortion access and the negative impact of allowing CO in that environment. Abortion is probably the most heavily restricted medical procedure in the world, despite it being one of the most common — and one that only women need, often desperately.  In such a context, governments and health systems have an even greater obligation to ensure that abortion care is fully available and accessible. Instead,abortion is frequently singled out as the main or only target for CO in many countries, reducing access even further.

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014), http://dx.doi.org/10.1016/j.woman.2014.03.001

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