Improper use of conscientious objection to abortion.
Here we will argue that contrary to what this study claims, the pervasive practices they mention are not based on conscientious objection. This clarification is needed in respect to those who are objectors and also in respect to the exercise of practices based on conscience.
Practices such as preventing patients from having an abortion, providing misleading legal and medical information, and refusing to refer their patients, or objecting on a case-by-case basis are the type of practices that should be classified as barriers to and unjustified denial of services, not based on conscience, but rather based on not agreeing with a woman's decision and not acknowledging her right to have an abortion.
As was recently discussed at the II Regional Seminar on Institutional Conscientious Objection held in Bogota in August 2016 by a group of experts gathered by prominent organizations such as La Mesa por la Vida y la Salud de las Mujeres, Catolicas por el Derecho a Decidir, and PROFAMILIA, conscience (1) is a personal attribute that is present in both the denial and the provision of abortion services. Conscientious objection should not be accepted as an excuse to obstruct the provision of services or be a barrier to obtaining services, nor should conscientious objection be accepted as moral stress caused by disagreement with the law (1) or as civil disobedience.
Conscientious objection allows a doctor to refuse to provide a service based on deeply held religious, moral or ethical beliefs, even if the service is legal and pertains to the technical skills of the doctor's profession. This privilege does not dismiss the ethical obligation of all health care professionals to safeguard their patients' well-being, to not hurt them or conceal information from them, and to not interfere with their autonomy. To hinder access to a necessary medical procedure violates these three principles, especially when done from a position of power deriving from the medical context. Far from being an exercise of conscience, it becomes an imposition of beliefs.
Conscientious objectors refuse to provide a service because the provision of this service contradicts the very core of their human existence, not because they disagree with the law, favor the life of the fetus or disagree with a woman's decision. Whatever their opinions, conscientious objectors cannot let their personal beliefs intrude when making medical decisions affecting the lives of their patients.
The Catholic Church has mandated that all Catholics object to performing abortions in order to prevent the provision of legal abortion services. While we understand the importance of respecting religious freedom, we believe that this type of denial of services imposed as a widespread political action contradicts all the elements of conscientious objection.
Conscientious objection is a mechanism aimed at protecting certain fundamental rights of providers (such as freedom of conscience and faith) or even a fundamental right in itself according to certain regulations. Yet conscientious objection must also respect the conscience of the women who request and need care. From this perspective, conscientious objection is inherently based on deep, explicit, consistent and sincere beliefs. Denials or barriers that are not subject to these criteria cannot therefore be recognized as conscientious objection.
Conscientious objection aims at the protection of minorities and cannot affect the rights of others. It is an exception rather than a routine practice to avoid responsibilities. Providers have the right not to perform a procedure but do not have the right to be an obstacle to care. When damage occurs (as in the cases mentioned in the article as nonreferral, denial of services or provision of misleading information), it is not conscientious objection; it is denial of services without reasons of conscience and thus defection of medical duty. (2)
The illegitimate use of "conscientious objection" is punishable by fines for failure to provide care or services; constitutes misuse of public resources; and carries civil, administrative and ethical (3) responsibilities and consequences.
In a recent survey conducted by Grupo Medico por el Derecho a Decidir, Colombia, and the Federation of Societies of Obstetrics and Gynecology, more than half of the participating obstetrician-gynecologists said they believed that abortion in Colombia should be more restricted, (4) reflecting the attitudes of an important sector of the population on this issue. In general, those who considered themselves objectors were found to provide information and refer patients to a provider who could meet their need. According to the survey, only 47% of the participants performed abortions, only 25% did not provide abortions on the basis of conscientious objection and almost 30% refused to provide the service because they did not agree with the law or refused to provide abortions on a case-by-case basis.
Accepting the study's classification of "extreme, moderate or partial objectors" as objecting due to conscience validates, from a moral and ethical point of view, an act that ignores women's rights. This validation is not acceptable for professionals who, based on a profound practice of conscience, believe it is not possible to practice medicine without recognizing, respecting and guaranteeing these rights.
We urge that medical professionals be classified by the way they address requests for abortion. Doing so would make it possible to identify professionals as providers, conscientious objectors or obstructors of abortion services and to identify strategies to raise awareness, provide training and, ultimately, sanction those who, by imposing their beliefs on patients, negatively affect the health and lives of women who seek medical care. Conscientious objectors who refrain from providing abortions in order to protect their own morals and beliefs, without actively or passively hindering access to abortions, must be recognized and never be confused with professionals who obstruct access to legal medical care.
What is improper is the use of the term conscientious objection, along with the use of a variety of mechanisms and arguments, to prevent women from exercising their rights, which are well described and characterized by the authors. These practices should be condemned.
Ana Cristina Gonzalez Velez, MD
Laura Gil Urbano, MD
Grupo Medico por el Derecho a Decidir, Colombia Bogota
(1.) Wicclair M, Conscientious Objection in Health Care An Ethical Analysis, Cambridge, UK: Cambridge University Press, 2011.
(2.) Alegre M, Derechos en disputa y analisis desde la filosofia politica o la fiosofia del derecho, acerca del reconocimiento a la objecion de conciencia institucional, presented at the II Regional Seminar on Conscientious Objection, Bogota, Colombia, Aug. 4, 2016.
(3.) Medical Ethics National Court ruling 83-09 on appeal of order 680 of the Medical Ethics Sectional Court of Caldas, Nov. 24, 2009.
(4.) Gil L, Resultados sondeo objecion de conciencia entre Miembros de FECOLSOG, presented at the National Obstetrics and Gynecology Federation Congress, Cali, Colombia, May 26, 2016.
The letter by Global Doctors for Choice-Colombia (GDC-Colombia) in response to our article adds an important perspective to the conversation about provider refusal to provide abortion. Several particularly insightful points stand out and are worth repeating. The authors remind us that it is unethical and illegal for providers to prevent women seeking abortion care from obtaining safe services from a competent health professional in a timely manner. They also highlight the inherent power dynamic between physicians and patients; this dynamic allows physicians to use conscientious objection to impose decisions based on their personal beliefs or judgments. This behavior is clearly seen in the extreme objectors we describe in our article, some of whom report misinforming patients about the law and subjecting them to long lectures about exaggerated "dangers" of induced abortion.
The authors of the letter argue, convincingly, that conscientious objection should be an exception, not routine practice, and that the ethos of conscientious objection centers on the protection of minorities. The authors state that the Catholic Church's mandate that all Catholics refuse to provide abortions constitutes a "widespread political action" and is thus distinct from--and should not be confused with--a person's right to act according to his or her individual conscience. In a country with a large Catholic population, Catholic medical schools and Catholic hospitals that have attempted to assert institutional objection to abortion provision, regulation and even restriction of conscientious objection may be necessary to ensure that abortion care remains accessible to women who need it. We hope that our article helped to expose some of the actions that may require regulation.
Inconsistency--as seen in case-by-case objectors who use nonstandard metrics to determine whether or not to provide an abortion--is another key issue, and we thank the authors for addressing it so eloquently. They write, "[C]onscientious objection is inherently based on deep, explicit, consistent and sincere beliefs." Anything else, they say, should not be recognized as conscientious objection. While we welcome the authors' interpretation of the behavior of some of the providers described in our article as "defection of medical duty" rather than "conscientious objection" in a legal or regulatory sense, our article followed the conventions of qualitative research to the best of our understanding of such conventions. As a 2002 Family Practice article on ethical issues in qualitative health service research puts it, "By constructing identities for their participants, qualitative research risks seriously breaching respect for participants' autonomy and may also lead to negative stereotyping." (1) Although we welcome the letter authors' interpretation of the evidence we presented, it would have been beyond the scope of our academic work to write judgmentally about our participants, using terminology such as "defection of medical duty." In developing our study, we sought to describe, rather than to judge, the diversity of providers who self-identify as conscientious objectors with an aim toward identifying the behaviors of providers who, under the guise of conscientious objection, act as obstructors rather than facilitators of care.
We believe it is the role of the qualitative researcher to set aside personal biases and opinions and focus on participants' opinions and experiences as they themselves present them. Once such data have been presented, advocacy groups and policy experts such as GDC-Colombia may interpret the evidence and make judgments that inform regulatory action. We thank the authors of the letter for bringing us into the conversation, but we respectfully disagree with their suggestion that we reconsider our characterization of participants in this particular study.
We share the authors' concern that conscientious objection, as practiced, presents a barrier for Colombian women in need of abortion care. We refer the authors to the moderate objectors described in our article for one perspective on how conscientious objection can be performed in a way that preserves the dignity and rights of the patient. We agree with the letter authors about the need to "identify strategies to raise awareness, provide training and, ultimately, sanction those who, by imposing their beliefs on patients, negatively affect the health and lives of women who seek medical care." We hope that our article will help advocates in Colombia as they develop trainings and advocate for regulation. We believe that the attitudes of moderate objectors may be used as a starting point for trainings aimed at bringing more extreme objectors into compliance with the law.
The three categories proposed by GDC-Colombia, "providers, conscientious objectors or obstructors of abortion services," reframe our results in a way that speaks more directly to the development of policy, and we thank the authors for their reframing. However, we caution that this categorization may miss an important demographic--physicians who object based on gestational age. Whether or not it is explicitly addressed in policy, our data suggest that conscientious objection based on gestational age will continue to be common practice among abortion-providing physicians. In a country where many physicians wish to object entirely, the contribution to abortion access made by physicians who object only after a specified gestational age is most likely significant. Thus, we caution policymakers to regulate rather than prohibit conscientious objection on the basis of gestational age.
We would like to reiterate our appreciation for Global Doctors for Choice-Colombia for their careful and nuanced reading of our article, and for their meaningful critique. In this response, we sought to clarify the methodological reasons behind the language used in our article. Nevertheless, we agree with the authors on principle and share their concerns. We hope that our academic work has contributed to this important conversation about improper use of conscientious objection as a barrier to safe abortion access for women in Colombia, throughout the Americas, and around the world.
(1.) Richards HM and Schwartz LJ, Ethics of qualitative research: are there special issues for health services research? Family Practice., 2002, 19(2): 135-139.
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|Publication:||International Perspectives on Sexual and Reproductive Health|
|Date:||Dec 1, 2016|
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