In a letter in the February issue of JOGC, Rebecca J. Cook and Bernard M. Dickens state, “Physicians who feel entitled to subordinate their patient’s desire for well-being to the service of their own personal morality or conscience should not practise clinical medicine” (emphasis added). The statement is unsupported by their own legal references, and it has little to recommend it as an ordering principle in the practice of medicine.
Abstract The legal approach to abortion is evolving from criminal prohibition towards accommodation as a life-preserving and health-preserving option, particularly in light of data on maternal mortality and morbidity. Modern momentum for liberalization comes from international adoption of the concept of reproductive health, and wider recognition that the resort to safe and dignified healthcare is a major human right. Respect for women’s reproductive self-determination legitimizes abortion as a choice when family planning services have failed, been inaccessible, or been denied by rape. Recognition of women’s rights of equal citizenship with men requires that their choices for self-determination be legally respected, not criminalized.
Extract After Roman Catholic leaders issued strong criticism about its trampling of religious freedom, the American Medical Association approved a watered-down measure supporting continued community access to a full range of reproductive services following hospital consolidations. The AMA’s amended resolution stopped short of saying Catholic hospitals should have to perform all reproductive health procedures. . . The AMA instead upheld its policy that physicians and hospitals not be forced to perform services that violate their moral principles. . .
Abstract In this note, Katherine A. White explores the conflict between religious health care providers who provide care in accordance with their religious beliefs and the patients who want access to medical care that these religious providers find objectionable. Specifically, she examines Roman Catholic health care institutions and HMOs that follow the Ethical and Religious Directives for Catholic Health Care Services and considers other religious providers with similar beliefs. In accordance with the Directives, these institutions maintain policies that restrict access to “sensitive” services like abortion, family planning , HIV counseling, infertility treatment, and termination of life-support. White explains how most state laws protecting providers’ right to refuse treatments in conflict with religious principles do not cover this wide range of services. Furthermore, many state and federal laws and some court decisions guarantee patients the right to receive this care. The constitutional complication inherent in this provider-patient conflict emerges in White’s analysis of the interaction of the Free Exercise and Establishment Clauses of the First Amendment and patients’ right to privacy. White concludes her note by exploring the success of both provider-initiated and legislatively mandated compromise strategies. She first describes the strategies adopted by four different religious HMOs which vary in how they increase or restrict access to sensitive services. She then turns her focus to state and federal “bypass” legislation, ultimately concluding that increased state supervision might help these laws become more viable solutions to provider-patient conflicts.
Abstract Objectives In 2 successive decades since 1967, legal accommodation of abortion has grown in many countries. The objective of this study was to assess whether liberalizing trends have been maintained in the last decade and whether increased protection of women’s human rights has influenced legal reform.
Methods A worldwide review was conducted of legislation and judicial rulings affecting abortion, and legal reforms were measured against governmental commitments made under international human rights treaties and at United Nations conferences.
Results Since 1987, 26 jurisdictions have extended grounds for lawful abortion, and 4 countries have restricted grounds. Additional limits on access to legal abortion services include restrictions on funding of services, mandatory counseling and reflection delay requirements, third party authorizations, and blockades of abortion clinics.
Conclusions Progressive liberalization has moved abortion laws from a focus on punishment toward concern with women’s health and welfare and with their human rights. However, widespread maternal mortality and morbidity show that reform must be accompanied by accessible abortion services and improved contraceptive care and information.
JE Steinauer, T DePineres, AM Robert, J Westfall, P Darney
Family Planning Perspectives
Abstract The majority of residents responding to a 1995 survey of program directors and chief residents at 244 family medicine residency programs in the United States reported they had no clinical experience in cervical cap fitting, diaphragm fitting or IUD insertion and removal. For all family planning methods except oral contraceptives, no more than 24% of residents had experience with 10 or more patients. Although 29% of programs included first-trimester abortion training as either optional or routine, only 15% of chief residents had clinical experience providing first-trimester abortions. Five percent of residents stated they certainly or probably would provide abortions, while 65% of residents stated they certainly would not provide abortions. A majority (65%) of residents agreed that first-trimester abortion training should be optional within family practice residency programs. Residents were more likely to agree with inclusion of optional abortion training and with the appropriateness of providing abortions in family practice if their program offered the training.
Abstract Debates regarding the development of new reproductive technologies (NRTs), funding for infertility treatments, and non-medical criteria for access to infertility treatments frequently invoke “rights to reproduce” or “procreative rights”. The claim of this right – literally the right to have children – is not the same thing as many other “reproductive rights” that are invoked in contraception, abortion, and pregnancy management discussions.
The author argues that the claim of a right to bear or beget children, which may in turn support research into NRTs and then funding and access claims, is not justified. Framing procreative decisions in terms of rights claims is a problematic ethical project, which in turn creates difficulties for the establishment of legal procreative rights. There are two critical problems: first, the distinction between positive (entitlement) and negative (liberty) rights claims leaves those requiring reproductive assistance in need of a different justification for their claims than those who need no help; second, a procreative right is generally claimed to be limited by the rights or interests of the future children, but a right of non-conception is an intemally contradictory concept.
The author then discusses variations of procreative rights claims, including claims of rights to enter reproductive contracts or to seek assistance, and other conceptual foundations for reproductive decisions. Thus, while reproductive rights are often helpful in protecting individuals and families from undue governmental intrusion, rights are shown to be a problematic, inadequate, and inappropriate framework to describe both the legal and moral status of claims for assisted procreation.
Extract After I read the articles on abortion in CMAJ I began to wonder if ready access to abortion is the main issue. Are we faced with a Yes-No decision, or are we looking at a symptom of something deeper? . . . The world is overpopulated, yet more and more children are being born. Despite the efforts of many dedicated people (especially women) to take information on birth con- trol to the most afflicted parts of the world, little progress is being made. All the solutions are “Band-Aid” ones, and almost all – contraceptives, abortifacients and abortion itself – are directed toward women, whose reproductive capacity is certainly the root of so much trouble. To cure these ills, nothing short of a redirection of human nature is necessary. . . .the earth’s mad population increase will surely go on to a cataclysmic end. We can put this off temporarily if we follow the Chinese example (one-child or two-children families) worldwide, with strict supervision of female reproduction.
Extract Conclusion When President Bush successfully thwarted passage of the Emergency Chinese Immigration Relief Act of 1989 and implemented his own order insisting upon “careful consideration” of victims who plead for political asylum because of coercive population control measures in their homelands, he unwittingly illustrated the need for a change in the statutory language. The Executive Order unwisely forces the issue of coercive population control policies into statutory language designed to protect victims of discrimination. Such manipulations would not be necessary if the Refugee Act of 1980 were amended to encompass the Handbook’s interpretation of the U.N. Protocol.
The interpretative guidelines to the U.N. Protocol, and derivatively to the Convention, call for a “conscientious objector” exception to military service. The grant of refugee status to individuals who prove “valid reasons of conscience,” even reasons distinct from religious claims, recognizes that fitting an individual within the protections of the refugee definition requires a judgment on the means other nations use to implement their policy ends, not just the ends themselves. Rather than relying solely on the five narrow grounds for granting asylum that were developed in response to the atrocities of World War II, the U.N. Protocol, as interpreted by the Handbook, also advocates protection for the individual persecuted by virtue of mandatory participation in a military service with which he morally disagrees. Because the debate regarding coercive population control considers the legitimacy of means employed in achieving governmental policy objectives, the logic of the conscientious objector exception also applies to claims such as that of Chang.
Extract In response to Dr. Myre Sim’s shopworn fulminations (Can Med Assoc 11988; 138: 742- 743), I am one doctor who has been off the fence and on firm ground for some time on the matter of abortion. . . The key to reducing the problem of ethically troublesome abortions remains quick, easy access to abortion, which includes improvement in the early identification of genetic defects. The key to reducing the numbers of abortions includes increasing awareness of the still dire need of children for information about sex, sexuality and birth control and increasing promotion of ethics as an object of study in school.
