(June 2018) Unconscionable: When Providers Deny Abortion Care
The International Women’s Health Coalition (IWHC) and Mujer y Salud en Uruguay (MYSU) co-organized a global Convening on Conscientious Objection: Strategies to Counter the Effects, in August 2017. The meeting was designed to analyze and address the phenomenon of health care providers refusing to provide abortion care by using personal belief as a justification. The organizers were called to action by the global expansion of this barrier to abortion access and the experiences of women who were denied their right to an essential service. Forty-five participants from 22 countries convened in Montevideo, Uruguay, including activists and advocates, health care and legal professionals, researchers, academics, and policy-makers. The convening catalyzed an agreement that proponents of women’s rights should challenge the use of conscience claims to deny access to abortion care. The participants also identified strategies to counter the adverse effects that the refusal to provide care can have on the health and rights of those needing services.
Throughout three days of presentations and working groups (appendix B), participants shared their experiences and expertise on policies and legal frameworks, ethics, health care training and provision, activism, research, and communications. The result: recommendations that advocates can use to tackle the growing trend of health providers using claims of “conscientious objection” to deny abortion services. In this report, we present the key points and strategies discussed at the convening, with practical recommendations at the end of each section, and a summary of takeaways in the conclusion.
Excerpts from Executive Summary
The global women’s movement has fought for many years to affirm safe and legal abortion as a fundamental right, and the global trend has been the liberalization of abortion laws. Progress is not linear, however, and persistent barriers prevent these laws and policies from increasing women’s access to services. One such obstacle is the growing use of conscience claims to justify refusal of abortion care.
Often called “conscientious objection,” a concept historically associated with the right to refuse to take part in the military or in warfare on religious or moral grounds, the term has recently been co-opted by anti-choice movements. Indeed, accommodations for health care providers to refuse to provide care are often deliberately inserted into policies with the aim of negating the hard-fought right to abortion care.
Existing evidence reveals a worrisome and growing global trend of health care providers who are refusing to deliver abortion and other sexual and reproductive health care. This phenomenon violates the ethical principle of “do no harm,” and has grave consequences for women, especially those who are already more vulnerable and marginalized.
A woman denied an abortion might have no choice but to continue an unintended pregnancy. She may resort to a clandestine, unsafe abortion, with severe consequences for her health or risk of death. She might be forced to seek out another provider, which can be costly in time and expense. All of these scenarios can lead to health problems, mental anguish, and economic hardship.
International human rights standards to date do not require states to guarantee a right to “conscientious objection” for health care providers. On the contrary, human rights treaty monitoring bodies have called for limitations on the exercise of conscience claims when states do allow them, in order to ensure that providers do not hinder access to services and thus infringe on the rights of patients. They call out states’ insufficient regulation of the use of “conscientious objection,” and direct states to take steps to guarantee patient access to services.
Patients’ health and rights should never be subordinate to providers’ individual concerns. Health care providers who put their personal beliefs over their professional obligations toward their patients threaten the health care profession’s integrity and its objectives. Nothing would stop such individuals from joining the health care profession, but they ought to specialize in fields in which their abilities to provide comprehensive services is not undermined by their personal beliefs.
Joining the health care profession is voluntary, unlike conscripted military service. The military objector pays a price, often undergoing a government vetting process, carrying out obligatory alternative service, and frequently facing stigma and discrimination. In the case of the refusal of health care based on conscience claims, the providers do not pay a price, while others do. The most severely affected, of course, is the person denied care. Providers who refuse to deliver a service also increase the workloads of their peers who choose to uphold their professional obligations to provide comprehensive care. Finally, accommodating providers who refuse to perform essential aspects of their jobs can cause costly disruptions and inefficiencies in the health care system and divert precious resources away from service provision.
Currently, more than 70 jurisdictions have provisions that allow so-called “conscientious objection” in health care, according to an analysis of preliminary data from the World Health Organization’s Global Abortion Policies Database. Many national laws stipulate that health care providers are required to carry out an abortion in case of an emergency, or if no one else is available. Evidence clearly shows, however, that even where regulations are in place, they are extremely difficult—and costly—to enforce. Despite the difficulty of regulating conscience claims, participants agreed that governments should enforce regulations and ensure that all women are able to access affordable, comprehensive health care.
Most convening participants agreed that health care policies should not allow for the refusal to provide services based on conscience claims. Where policy-makers are revising abortion laws or policies, they should not make references to conscience claims. Enshrining into law the notion that providers’ personal beliefs can determine the provision of health care opens up the door to abuses and legitimizes conscience claims.
Finally, the convening participants resoundingly agreed that health care providers and women’s rights advocates must not cede the term “conscience” to those who misapply it to deny others health care, which should more appropriately be called “refusal to provide services” or “denial of services based on conscience claims.” They agreed to bring the agreements from the convening, and the recommendations captured at the end of this report, to their own work, so that no one is denied their right to health care.