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Access to abortion: what women want from abortion services

Ellen R Wiebe, S Sandhu

Journal of Obstetrics and Gynaecology Canada

Abstract
Objective: Whether Canadian physicians can refuse to refer women for abortion and whether private clinics can charge for abortions are matters of controversy. We sought to identify barriers to access for women seeking therapeutic abortion and to have them identify what they considered to be most important about access to abortion services.

Methods: Women presenting for abortion over a two-month period at two free-standing abortion clinics, one publicly funded and the other private, were invited to participate in the study. Phase I of the study involved administration of a questionnaire seeking information about demographics, perceived barriers to access to abortion, and what the women wanted from abortion services. Phase II involved semi-structured interviews of a convenience sample of women to record their responses to questions about access. Responses from Phase I questionnaires were compared between the two clinics, and qualitative analysis was performed on the interview responses.

Results: Of 423 eligible women, 402 completed questionnaires, and of 45 women approached, 39 completed interviews satisfactorily. Women received information about abortion services from their physicians (60.0%), the Internet (14.8%), a telephone directory (7.8%), friends or family (5.3%), or other sources (12.3%). Many had negative experiences in gaining access. The most important issue regarding access was the long wait time; the second most important issue was difficulty in making appointments. In the private clinic, 85% of the women said they were willing to pay for shorter wait times, compared with 43.5% in the public clinic.

Conclusion: Physicians who failed to refer patients for abortion or provide information about obtaining an abortion caused distress and impeded access for a significant minority of women requesting an abortion. Management of abortion services should be prioritized to reflect what women want: particularly decreased wait times for abortion and greater ease and convenience in booking appointments. Since many women are willing to pay for services in order to have an abortion within one week, this option should be considered by policy makers.

Wiebe ER, Sandhu S. Access to abortion: what women want from abortion services. J Obstet Gynaecol Can. 2008 Apr;30(4):327-331.

To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support

Farr A Curlin, Chinyere Nwodim, Jennifer L Vance, Marshall H Chin, John D Lantos

American Journal of Hospice and Palliative Care

Abstract
This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians’ religious characteristics, ethnicity, and experience caring for dying patients.

Curlin FA, Nwodim C, Vance JL, Chin MH, Lantos JD. To Die, to Sleep: US Physicians’ Religious and Other Objections to Physician-Assisted Suicide, Terminal Sedation, and Withdrawal of Life Support. American J Hospice & Pall Care. 2008;25(12):112-120.

Conscientious Commitment

Bernard M Dickens

Extract
Religion has no monopoly on conscience, however. History, both distant and recent, shows how health-care providers and others, driven by conscientious concerns, can defy laws and religious opposition to provide care to vulnerable, dependent populations. They might also defy the medical establishment. Pioneers of the birth control movement were not doctors, and were opposed by medical, state, and religious establishments. As long ago as 1797, Jeremy Bentham advocated means of birth control, and in the following century, John Stuart Mill was briefly imprisoned for distributing birth control handbills. Charles Bradlaugh and Annie Besant were similarly prosecuted, in 1877, for selling pamphlets about birth control.

Dickens BM. Conscientious Commitment. The Lancet. 2008;371(1240-1241.

(Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care

Helen Kohlen

Extract
In this work the institutionalisation of Hospital Ethics Committees in the USA and in Germany will be analysed by focussing on nurses’ participation and the representation of caring issues. Therefore, questions about the design of Hospital Ethics Committees and how their practices really look like, will be raised. The central question is, how the traditional care ethos of the helping professions in medicine and nursing can find its place in discussions of these committees while hospitals have increasingly been organised along economic criteria.

. . . .My observations and interviews in the field work show that care practices in the tradition of Hippocratic Medicine are no longer self-evident for the helping professions. Physicians and nurses do rather struggle for a care ethos especially with regard to end-of- life questions and regulations of tube-feeding. The “cases” for ethics consultation brought into the committees by physicians and nurses did not rarely emerge as social problems and as a lack of professional competence. The problems appeared to be solvable by translating them into a language of principles and making the process manageable. These principle-based discussions in the practical arena of the hospital resemble discourse practices embedded within the larger bioethical debates in the political arena. Technical procedures given by management and administration do fit into the use of abstract principles and contribute to a language that limits the possibilities to think – what is at stake for patients – in terms of caring relations rather than thinking in terms of rules, regulations and control.

Kohlen H. (Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care. Gotfried Wilhelm Leibniz University, Hanover, Germany. 2008 Apr 02.

(Report) Reproductive Rights in Poland: The Effects of the Anti-Abortion Law

Wanda Nowicka

Extract
This report on the monitoring of reproductive rights in Poland was created in the framework of the project financed by the European Commission and realised by the Federation for Women and Family Planning, entitled Proactive monitoring of women’s reproductive rights as a part of human rights in Poland. The report provides a comprehensive overview of reproductive rights in Poland. It deals with the legal issues involved, and the analysis of the Polish legal regulations on reproductive rights (E. Zielińska) deserves special attention, as well as the review of court cases conducted in Poland and at the European Court of Human Rights regarding the lack of access to termination of pregnancy in Poland (A. Bodnar). The report shows the real effects of the current law and social policy with regard to termination of pregnancy, family planning and sexual education (W. Nowicka). Through the use of qualitative research, the report also presents the attitude of the health service to the issues mentioned above and the role of doctors in restricting access to services connected with reproductive health (A. Domaradzka). Moreover, the report publishes guidelines for Poland from international institutions, which aim to improve the respect for human rights regarding reproductive health issues

Nowicka W, editor. Federation for Women and Family Planning. (Report) Reproductive Rights in Poland: The Effects of the Anti-Abortion Law. 2008 Mar;7-97.

Pharmacists and the “Duty” To Dispense Emergency Contraceptives

Jennifer E Spreng

Abstract
Stories abound of both women with prescriptions turned away at the pharmacy door and members of the most trusted health care profession losing jobs and running afoul of ethics rules. Scholars have spilt much intellectual ink divining whether a pharmacist must dispense Plan B, the primary emergency contraceptive. Now, many are calling for a common law “duty to dispense” that could serve as a foundation for a wrongful pregnancy action against a dissenting pharmacist. Such a duty simply does not arise from established tort principles or pharmacist-specific precedents. Only in rare circumstances will a pharmacist and customer have the type and quality of relationship giving rise to a duty to dispense. Nevertheless, law changes over time and makes allowances for unique circumstances. Pharmacists are taking on more responsibility for drug therapy. They have an awkward role in the distribution of Plan B. Moreover, while the law may protect pharmacists’ consciences, it may not be so receptive to pharmacists-as-activists. Dissenting pharmacists can take practical steps to protect themselves today, but tomorrow is another day.

Spreng JE. Pharmacists and the “Duty” To Dispense Emergency Contraceptives. Issues Law Med. 2008 Spring;23(3):215-277.

Accessing Reproductive Technologies: Invisible Barriers, Indelible Harms

Judith F Daar

Berkeley Journal of Gender, Law & Justice

Extract
Conclusion
The constitutional jurisprudence surrounding assisted conception is only beginning to take shape . . . . When conception occurs naturally, both positive and negative rights surrounding procreation are fairly clear, but grow murky as the reproductive process invites third parties to assist. As methods of assisted conception show increasing technological promise for those whose physical characteristics, social status, or both require they look to ART for family formation, worrisome trends suggest that third party actors are quietly mounting status-based barriers to fertility treatment. Barriers to ART are taking shape on the basis of patient characteristics including wealth, race, ethnicity, sexual orientation, and marital status, all under the guise of preventing harm to offspring and society at large. However, judgments by ART providers and public lawmakers that certain individuals will be unfit parents, veer dangerously close to the coercive eugenics practices of early twentieth century America, practices whose only positive legacy is the extreme caution with which we now approach state-sponsored limitations on reproduction.

Like a pentimento, ART barriers are only beginning to come into view from the experiences of an increasingly diverse and nontraditional reproductive medicine patient population. As each barrier emerges-whether it be a provider refusing treatment to a single or gay or lesbian prospective parent, or a lawmaker attempting to limit the availability of a reproductive technology for reasons unrelated to human health-it is essential to evaluate these actions by the same standards we would evaluate barriers to natural conception. . . . State-sponsored or state-approved limitations on any individual’s right to procreate simply cannot stand in a society that acknowledges the preeminence of reproductive freedom. Justice Douglas’ selfevident observation that reproduction is a basic human right is as durable and universal as the human race-it simply must be nurtured in order to continue to thrive.

Daar JF. Accessing Reproductive Technologies: Invisible Barriers, Indelible Harms. Berkeley J Gender Law Just. 2008 Mar;23(1):18-82.

Professional Responsibility and Individual Conscience: Protecting the Informed Consent Process from Impermissible Bias

Frank A Chervenak, Laurence B McCullough

Extract
The ethics of referral for abortion is autonomy based with a beneficence-based component, the clinician’s obligation to protect the woman’s health and life, similar to referral for cosmetic procedures. At a minimum, indirect referral— providing referral information but not ensuring that referral occurs—should be the clinical ethical standard of care. Direct referral for abortion is a matter of individual clinician discretion, not the clinical ethical standard of care. Conscience based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral for termination of pregnancy do not.

Chervenak FA, McCullough LB. Professional Responsibility and Individual Conscience: Protecting the Informed Consent Process from Impermissible Bias. J Clin Ethics. 2008 Spring;19(1):24-25.

The Limits of Conscience: Moral Clashes Over Deeply Divisive Healthcare Procedures

Robin Fretwell Wilson

Extract
Refusals by individual pharmacies and pharmacists to fill prescriptions for emergency contraceptives (“EC”) have dominated news headlines. . .These refusals. . .reflect moral and religious concerns about facilitating an act that would cut-off a potential human life.

Recently, conscience-based refusals have ballooned far beyond EC. Pharmacists are refusing to fill prescriptions for birth control, and other ancillary care professionals are asserting their own conscience concerns.

Conclusion
Ultimately we must decide as a community whether we prize access more highly than religious freedom. The older healthcare conscience clauses offer us a range of methods to manage the clash between competing moral interests. If urgency for the service cannot be achieved through better information, state legislatures could make a number of choices. They could choose not to burden the professional’s choice at all—prizing religious liberty more highly than access. They could force providers to provide every service legally requested—prizing patient access more highly than moral or religious freedom. Or they could choose to allow individuals of conscience to exempt themselves up to the point that it creates a hardship for the patient or employer. In a pluralistic society, a live-and-let-live regime like this may be the most we can hope for.

Wilson RF. The Limits of Conscience: Moral Clashes Over Deeply Divisive Healthcare Procedures. Am J Law Med. 2008 Mar 01;34(1):41-63.

Religion, conscience and clinical decisions

John D Lantos, Farr A Curlin

Extract
However, as long as medicine is practiced in a pluralistic democracy where some people find moral guidance in religions and others do not, situations will arise in which two paediatricians, both acting deliberately and conscientiously, will choose different responses to a given clinical decision. The policy challenge becomes one of specifying the situations for which conscience claims ought to be tolerated. . . For situations in which disagreement is consistent with good medical practice, practitioners must be free to follow the dictates of conscience. The risks of disallowing conscientious practice to the profession are greater than that of allowing grounded and well-articulated zones of moral pluralism.

Lantos JD, Curlin FA. Religion, conscience and clinical decisions. Acta Paediatrica. 2008;97(3):265-266.