The European Journal of Contraception & Reproductive Health Care ISSN: 1362-5187 (Print) 1473-0782 (Online) Journal homepage: http://www.tandfonline.com/loi/iejc20 Yes we can! Successful examples of disallowing ‘conscientious objection’ in reproductive health care Christian Fiala, Kristina Gemzell Danielsson, Oskari Heikinheimo, Jens A. Guðmundsson & Joyce Arthur To cite this article: Christian Fiala, Kristina Gemzell Danielsson, Oskari Heikinheimo, Jens A. Guðmundsson & Joyce Arthur (2016) Yes we can! Successful examples of disallowing ‘conscientious objection’ in reproductive health care, The European Journal of Contraception & Reproductive Health Care, 21:3, 201-206, DOI: 10.3109/13625187.2016.1138458 To link to this article: http://dx.doi.org/10.3109/13625187.2016.1138458 Published online: 03 Feb 2016. Submit your article to this journal Article views: 374 View related articles View Crossmark data Citing articles: 1 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iejc20 Download by: [81.223.16.2] Date: 28 October 2016, At: 06:29 THE EUROPEAN JOURNAL OF CONTRACEPTION AND REPRODUCTIVE HEALTH CARE, 2016 VOL. 21, NO. 3, 201–206 http://dx.doi.org/10.3109/13625187.2016.1138458 SOCIODEMOGRAPHIC ARTICLE Yes we can! Successful examples of disallowing ‘conscientious objection’ in reproductive health care Christian Fialaa,b, Kristina Gemzell Danielssonb, Oskari Heikinheimoc, Jens A. Guômundssond and Joyce Arthure aGynmed Clinic for Abortion and Family Planning, Vienna, Austria; bDivision of Obstetrics and Gynaecology, Department of Women’s and Children’s Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden; cDepartment of Obstetrics and Gynecology, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland; dDepartment of Obstetrics and Gynecology, Women’s Clinic, University of Iceland and Landspitali University Hospital, Reykjavı´k, Iceland; eAbortion Rights Coalition of Canada, Vancouver, Canada ABSTRACT ARTICLE HISTORY Reproductive health care is the only field in medicine where health care professionals (HCPs) are Received 15 October 2015 allowed to limit a patient’s access to a legal medical treatment – usually abortion or Revised 30 December 2015 contraception – by citing their ‘freedom of conscience.’ However, the authors’ position is that Accepted 1 January 2016 ‘conscientious objection’ (‘CO’) in reproductive health care should be called dishonourable Published online 2 February disobedience because it violates medical ethics and the right to lawful health care, and should 2016 therefore be disallowed. Three countries – Sweden, Finland, and Iceland – do not generally permit KEYWORD HCPs in the public health care system to refuse to perform a legal medical service for reasons of Abortion; conscientious ‘CO’ when the service is part of their professional duties. The purpose of investigating the laws and objection; dishonourable experiences of these countries was to show that disallowing ‘CO’ is workable and beneficial. It disobedience; Sweden; facilitates good access to reproductive health services because it reduces barriers and delays. Other Finland; Iceland; refusal to benefits include the prioritisation of evidence-based medicine, rational arguments, and democratic treat; reproductive health laws over faith-based refusals. Most notably, disallowing ‘CO’ protects women’s basic human rights, care avoiding both discrimination and harms to health. Finally, holding HCPs accountable for their professional obligations to patients does not result in negative impacts. Almost all HCPs and medical students in Sweden, Finland, and Iceland who object to abortion or contraception are able to find work in another field of medicine. The key to successfully disallowing ‘CO’ is a country’s strong prior acceptance of women’s civil rights, including their right to health care. Introduction no monitoring or enforcement processes in place to ensure this referral process is taking place or to prevent misuse. This is Reproductive health care is the only field in medicine where evident by a history of many objecting doctors – even those in societies accept the argument that the ‘freedom of consci- liberal countries such as Italy [4] – refusing to refer and ence’ of health care professionals (HCPs) and institutions can claiming it makes them ‘complicit.’ Therefore, abuse [5] of ‘CO’ limit a patient’s access to a legal medical treatment. is systemic [6] and mostly unsanctioned [7] across Europe and The authors’ position is that ‘conscientious objection’ (‘CO’) the rest of the world. in reproductive health care is a misnomer, and has little to do Only a handful of western countries [8] – including with freedom of conscience. Instead, we argue it is an Sweden, Finland, and Iceland – do not permit HCPs in the unethical refusal of care, and an abandonment of one’s public health care system to refuse to perform a legal professional obligations to patients. ‘CO’ in reproductive medical service for reasons of ‘CO’ when the service is within health care is more aptly called dishonourable disobedience (a their scope and professional duty. This article looks at the term first coined by co-authors Fiala and Arthur in 2014,[1] laws and positive experiences of these Nordic countries to because it violates medical ethics and the right to lawful show not only that ‘CO’ can be successfully disallowed, but health care. that this is the only workable solution to avoid the many Almost all western countries allow HCPs and even hospitals negative consequences of ‘CO’ on women’s health. to exercise ‘CO’, which is usually regulated via law, policy, or a code of ethics. For example, 21 countries in the European Sweden Union grant ‘CO’ by law.[2] While countries generally regulate ‘CO’ themselves, some international organisations [3] have put The Swedish Abortion Act [9] (enacted in 1975) gives women forward a compromise approach. Typically, this compromise the right to safe abortion on request without delay. It is a allows doctors to object to performing procedures, but rights-based law (not in the criminal code) and women requires them to make an effective referral to another cannot be punished. Women do not need to state a reason doctor who will provide the care, as well as provide accurate and can self-refer until 18 weeks of pregnancy. Thereafter, information on all options, and provide or arrange for they must apply for permission to the Board of Health and emergency care when required. However, there are virtually Welfare and an indication (reason) is required. After 18 weeks, CONTACT Christian Fiala, Medical Director [email protected] Gynmed Clinic for Abortion and Family Planning, Mariahilfergu¨rtel 37, A-1150 Vienna, Austria ß 2016 The European Society of Contraception and Reproductive Health 202 C. FIALA ET AL. the law has no fixed upper limit or restrictions as to reason, Occasionally, Sweden is targeted for anti-choice initiatives but in practice, abortions are done for social indications up to around ‘CO’, and abortion opponents have recently become 21 weeks and 6 days, with no gestational limit for more systematic and better organised in their attacks. Even pregnancies of non-viable fetuses or those that pose a risk so, all initiatives have failed so far. In June 2015, the European to the woman’s life. Committee of Social Rights (ECSR) rejected claims [12] by the All hospital obstetrical/gynaecological departments are Federation of Catholic Family Associations in Europe (FAFCE) obligated by law to perform abortions without delay up to 18 that Swedish health care providers had a right to ‘conscien- weeks on request and thereafter as soon as permission is tious objection’ and could refuse to provide abortion services granted. A central committee deals with the applications under the European Social Charter: every week or earlier if needed. Less than 1% of abortions Two other challenges to the ban on ‘CO’ are still pending occur after 18 weeks and the majority are for serious foetal but do not appear to pose much of a threat to the status quo. abnormalities. In 2013, a Swedish midwife’s contract was rescinded [13] by a Compared to most other western countries, access to hospital because she refused to provide abortions (she was abortion is arguably better in Sweden. Unlike in most also against intrauterine contraception). She was later countries, Swedish women do not need to travel for abortion, rejected from other hospitals where she applied because which shows that the law is meeting their needs. Hospitals they required her to provide abortions. She filed a complaint, are located throughout the country and all of them do which was denied [14] by Sweden’s Equality Ombudsman, abortions, along with some private clinics. Midwives can and later in 2015 a district court in Sweden also ruled against provide medical abortion, as well as contraceptive counsel- her.[15] The public interest of having safe and accessible ling, prescriptions, and aftercare. Abortion is viewed as abortion care was deemed more important than her freedom emergency care and is therefore free for refugees. For of religion. Public sentiment also went against her, with most Swedish women, the cost is the same as for all other public people questioning why she was engaged in a profession health care – about 20–30 Euros, which covers the abortion that required provision of abortion services if she was against and all associated services,