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Conscientious Objection in Italy
Abstract
The law regulating abortion in Italy gives healthcare practitioners the option to make a conscientious objection to activities that are specific and necessary to an abortive intervention. Conscientious objectors among Italian gynaecologists amount to about 70%. This means that only a few doctors are available to perform abortions, and therefore access to abortion is subject to constraints. In 2012 the International Planned Parenthood Federation European Network (IPPF EN) lodged a complaint against Italy to the European Committee of Social Rights, claiming that the inadequate protection of the right to access abortion implies a violation of the right to health. In this paper I will discuss the Italian situation with respect to conscientious objection to abortion and I will suggest possible solutions to the problem.
... Both the US (Sasani 2023;Simmons-Duffin 2023;Noor 2023a) and Italy (Cavallaro 2019;Caruso 2020) have experienced high-profile cases where abortion patients were denied urgently necessary care and faced dire consequences and even death. These cases come about because of a combination of healthcare personnel who are uncertain about their legal obligations (Pullan 2024a;De Vos et al. 2023;Simmons-Duffin 2023) and those personnel who actively oppose abortion and refuse care even in situations when they are mandated to provide it (Minerva 2015). While such cases have occurred elsewhere (e.g., Savita Halappanavar's death in Ireland and Izabela in Poland), this is not common in most of the world (Ralph 2020, chap. ...
... Italy's abortion regime is less well-researched but still substantial. Several scholars focus on the role of conscientious objection in Italian abortion policy (Minerva 2015;Bo, Zotti, and Charrier 2015;2017;De Zordo 2017) and the relationship between objection and abortion access (Pullan and Gannon 2024a). By exploring the difference between what the law prescribes and what actually happens in implementation (Caruso 2023;Pullan 2024a), scholars find that patients in different regions have quite different experiences with accessing abortion (Gannon and Pullan 2024;Gannon 2023) and sometimes need to leave their region (Autorino, Mattioli, and Mencarini 2020) or the country (De Garnsey et al. 2021) to receive care. ...
... In Canton Ticino, the farthest southern region of Switzerland, between 2009 and 2015, 24.2 percent of all abortions were performed on Italian patients (Reinholz et al. 2018). Additionally, so many Italian patients were crossing the border into Nice, France for abortion care that the city hospital stopped accepting Italian patients (Minerva 2015). One study of patients traveling to England for abortion care found that Italian patients were second only to Irish patients in number traveling to England for abortion care ). ...
This paper elaborates a typology of regionalized abortion policy based on a comparative case study of Italy and the United States. Italy originally legalized abortion in 1978 and has seen little effort to modify the law since. Contrastingly, the United States' abortion landscape has been in near constant flux since 1974, when, in Roe v. Wade, the Supreme Court recognized a constitutional right to abortion. This became even more unstable in 2022 when the Supreme Court overruled Roe in Dobbs v. Jackson Women's Health and held there is no constitutional right to abortion. Despite their differences in national abortion policy, both Italy and the US have regionalized the implementation of their abortion policies. Italy's law is national, but implementation is interpreted differently at the regional level. Since Dobbs, US states have proposed and passed many laws about abortion, creating even greater regional variation than before. We propose a typology of regionalized abortion access: "Sanctuaries" where abortion is most protected and available; "Islands" with liberal policies that are surrounded by more restrictive territories; and "Deserts" with minimal abortion access. Through qualitative analysis of policies, political activities , and firsthand accounts by abortion providers and advocates working in places of each type, we then highlight the long-term implications of each of these components of the typology, analyzing the ways that they impact abortion providers and patients.
... The situation abroad is a little more varied [1]. In Italy, there is a greater diffusion of conscientious objectors than in other nations; this occurs for various reasons (e.g., cultural, religious) and may cause possible difficulties in guaranteeing the abortion service [2]. Contrary to what happens in other countries, abortions in Italy can only be performed by gynecologists, and never by general practitioners, even when the abortion could be obtained pharmaceutically using RU486 (Mifepristone) [2]. ...
... In Italy, there is a greater diffusion of conscientious objectors than in other nations; this occurs for various reasons (e.g., cultural, religious) and may cause possible difficulties in guaranteeing the abortion service [2]. Contrary to what happens in other countries, abortions in Italy can only be performed by gynecologists, and never by general practitioners, even when the abortion could be obtained pharmaceutically using RU486 (Mifepristone) [2]. In 2022, Italian objectors among healthcare professionals comprised the following: 64.6% of gynecologists, 44.6% of anesthetists and 36.2% of other healthcare personnel. ...
... In 2022, Italian objectors among healthcare professionals comprised the following: 64.6% of gynecologists, 44.6% of anesthetists and 36.2% of other healthcare personnel. Access to voluntary abortion could also be more complex in some specific areas (i.e., Southern Italy) [2]. The numbers of TOP in Italy remain among the lowest internationally; the abortion rate (number of TOP per 1000 women residents aged 15-49 years) was equal to 5.4 per 1000 in 2020 (−6.7% compared to 2019) [3]. ...
Background and Objectives: Conscientious objection to voluntary abortion remains a hot debate topic. This could affect the accessibility to pregnancy termination. Our aim is to evaluate the possible aspects related to an operators’ choice about objection for voluntary abortion, such as the following: the abolition of the time limit, the instruction of a multi-collegiate commission, the introduction of pharmacological rather than surgical procedures, the fetal/maternal illness and the case of sexual violence. Materials and Methods: This is an observational, descriptive study that involves a cohort of Italian healthcare workers who answered a web-survey. Results: Of the total 352 respondents, only 20.8% affirmed to be objectors versus 79.2% of non-objectors. For the objectors, 72.2% declared that they would not change status in case of pharmacological abortion; 79.7% would not suspend their choice for interruption in the second trimester; 63.3% would suspend the objection with a multi-collegiate commission, and 69.0% would discontinue their objection in the case of sexual violence. 72.0% of the total participants declared that the abolition of the time limit could have a resecuring impact on women’s choice. Conclusions: Most operators declared that the abolition of the time limit could have beneficial effects. Among the objectors, the status would change especially with the introduction of a multi-collegiate commission, and in case of serious maternal/fetal illness and/or sexual violence.
... Conscientious objection is a common aspect of abortion policy, though the level of objection in Italy is uniquely disruptive (Pullan and Gannon Forthcoming;Minerva 2015;Autorino et al 2020;Bo et al 2015). Of 27 states in the European Union, 21 allow conscientious objection to abortion as well as many countries in Latin America, including Colombia, Bolivia, and Mexico (Anedda et al 2018;Küng et al 2021;Fink et al 2016). ...
... Objection is technically only allowed in voluntary abortion services, not in therapeutic abortion services. Despite this, many hospitals do not involve objectors even in therapeutic abortions and there are several reports of patients suffering because objectors refused to step in to perform the abortion (Cirant 2020;Eduati 2012;Gannon 2023;Minerva 2015), including the infamous and tragic death of Valentina Milluzzo (Cavallaro 2019;Caruso 2020). It is also worth noting that Law 194 specifically regulates abortion, and the morning after pill is medically distinct from abortion, though some pharmacists root their claim to objection in the strong cultural tolerance of conscientious objection and misconceptions that equate medication abortion and the morning after pill. ...
... Nominally, Law 194 charges regional administrators with ensuring provision of abortion services in every public hospital with a gynaecology department (Minerva 2015). In practice, however, conscientious objection status is usually reported to each hospital's head of gynaecology for the sake of assigning work tasks. ...
The Italian Ministry of Health reports annually on activities related to abortion and fertility, providing quantitative data that looks ripe for analysis. Actors ranging from activists to medical providers to European courts have criticised the data as misleading, but the Ministry reports have not changed. In this piece, we bring together different perspectives on this data from inside and outside academia and offer guidance on how it should—and should not—be used in research.
In this article, we collect a wide variety of publications ranging from civil society groups’ reports to court decisions, academic articles and investigative reporting and harmonise the way they engage with the Italian Ministry of Health’s data regarding abortion and particularly conscientious objection.
Analyses rooted in the demographic and medical data about abortion seekers, the abortion rates over time, the different methods of abortion, etc are trustworthy and can be used to extrapolate levels of abortion access. This dataset on conscientious objectors systematically undercounts objectors, implying a false equivalence between people who do not object and people who actually work in an abortion service. We recommend that the Ministry report both the number of objectors and the number of medical doctors working in abortion services.
The Italian Ministry of Health produces some valuable data about abortion, but conscientious objection is the key feature of abortion access in Italy, and this key datapoint is flawed. The Ministry could improve clarity and increase citizens’ trust in government reports by adding data on the number of abortion providers.
... 9 The literature on conscientious objection also poses important questions on the ethical obligations of medical service providers towards their patients. 45 The consensus around a "moderate view" states that healthcare providers can reserve the right to refuse to perform a certain activity, but they are required to refer their patients to a willing service provider. 45 In fact, the Irish Medical Council's Guide to Professional Conduct and Ethics mentions that non-providing doctors have an obligation to either signpost their patients to the MyOptions helpline or refer them to a providing GP. 7 However, as Minerva argues, such an approach fails to offer an effective solution in areas with a high percentage of conscientious objectors 45 and does not provide a viable solution in rural areas with low service coverage. ...
... 45 The consensus around a "moderate view" states that healthcare providers can reserve the right to refuse to perform a certain activity, but they are required to refer their patients to a willing service provider. 45 In fact, the Irish Medical Council's Guide to Professional Conduct and Ethics mentions that non-providing doctors have an obligation to either signpost their patients to the MyOptions helpline or refer them to a providing GP. 7 However, as Minerva argues, such an approach fails to offer an effective solution in areas with a high percentage of conscientious objectors 45 and does not provide a viable solution in rural areas with low service coverage. ...
... 45 The consensus around a "moderate view" states that healthcare providers can reserve the right to refuse to perform a certain activity, but they are required to refer their patients to a willing service provider. 45 In fact, the Irish Medical Council's Guide to Professional Conduct and Ethics mentions that non-providing doctors have an obligation to either signpost their patients to the MyOptions helpline or refer them to a providing GP. 7 However, as Minerva argues, such an approach fails to offer an effective solution in areas with a high percentage of conscientious objectors 45 and does not provide a viable solution in rural areas with low service coverage. ...
This article focuses on access to early medical abortion care under Section 12 of the Health (Regulation of Termination of Pregnancy) Act 2018, in Ireland and identifies existing barriers resulting from gaps in current policy design. The article draws primarily on qualitative interviews with 24 service users, 20 primary healthcare providers in the community and 27 key informants, including from grassroots groups that work with women from different migrant communities, to examine service users' experiences accessing early medical abortions on request up to 12 weeks gestation. The interviews were part of a wider mixed-methods study from 2020-2021 examining the barriers and facilitators to the implementation of abortion policy in Ireland. Our findings highlight care seekers' experiences with the GP-led service provision, including delays, facing non-providers, the mandatory three-day waiting period, and oversubscribed women's health and family planning clinics. Our findings also highlight the compounding challenges for migrants and additional barriers posed by the geographical distribution of the service and the 12-week gestational limit. Finally, it focuses on the remaining challenges for racialised and other marginalised groups. In order to provide a "thick description" of women's lives and the complexity of their experiences with abortion services in Ireland, we also present two narrative vignettes of service users, and their experiences with delays and navigating the healthcare system as migrants. To this effect, this article applies a reproductive justice framework to the results to highlight the compounding effects of these barriers on people located along multiple axes of social inequality.
... Además, en caso de alegarse por un médico la objeción de conciencia, este debe proceder inmediatamente a remitir a la mujer a otro profesional que sí pueda llevar a cabo el procedimiento o la intervención (5). Situaciones similares justificadas como objeción de conciencia se han presentado en otros países como Argentina, Italia o Estados Unidos, que han requerido una reglamentación oficial (43,44). ...
... Después de 16 años de la implementación de la normatividad para ive en Colombia, persisten retos, como una mayor aceptación pública de la normatividad por parte de la ciudadanía, el requerimiento de un mejor registro, información y monitorización a nivel local y nacional de estos eventos. Finalmente, se propone fortalecer los procesos de difusión de políticas, normas, y condiciones de acceso a este servicio, fortalecer la capacitación y educación continua de los profesionales de la salud respecto de los aspectos técnicos, éticos y jurídicos de la prestación de la ive (38,39,44). El médico no debe tener temor de declararse objetor de conciencia, pero, en ejercicio de su derecho, no debe obstaculizar el de la paciente. ...
En Colombia, actualmente, la interrupción voluntaria del embrazo (IVE) está despenalizada hasta la semana 24 y, posteriormente, previo al término del embarazo, si se cumplen las causales indicadas mediante la sentencia C-355 del 2006, las cuales son: (a) si el embarazo pone en riesgo la salud de la mujer; (b) si el embarazo es producto de una violación, y (c) cuando el feto presenta malformaciones incompatibles con la vida. Este trabajo tiene por objeto describir la situación de la IVE en Colombia para los médicos y los pacientes desde su despenalización, mediante un análisis de la literatura y la jurisprudencia. Se caracterizaron los problemas en el ejercicio de la objeción de conciencia y las barreras de acceso a los servicios de IVE. Con base en estos hallazgos, se proponen algunas estrategias para mejorar la implementación de la norma en beneficio de los pacientes y respetar los derechos de los médicos.
... Women of all age groups showed a statistically significant increase in SAs compared to younger women (aged ≤19 years), particularly in the age group 30-34 years (IRR 13.17, 95% CI 10.09-17.2), and in the age group [35][36][37][38][39]95% CI,. Women at any time of gestational age showed a statistically significant decrease in SAs compared to women with gestational age in the lowest class (≤8 weeks of amenorrhea), particularly those with 11 to 12 weeks of amenorrhea (IRR 0.34, 95% CI 0.31-0.37), ...
... There were elevated numbers of health workers that applied conscientious objection (CO), especially in southern regions, such as Apulia, in which CO is chosen by 80% of physicians. Actually, in 2019, the European Committee of Social Rights (CEDS) urged the Italian government to guarantee a more homogeneous distribution of non-objecting personnel, particularly in deficient southern regions [38]. It is possible to hypothesize that the constant decrease in health personnel, linked to the numerous infections among health workers, emphasized the problematic access to VTPs linked to the high numbers of gynecologists, anesthetists, and health professionals who were conscientious objectors [39]. ...
The spread of COVID-19 in Italy required urgent restrictive measures that led to delays in access to care and to hospital overloads and impacts on the quality of services provided by the national health service. It is likely that the area related to maternal and child health was also affected. The objective of the study was to evaluate the intensity of a possible variation in spontaneous abortion (SA) and voluntary termination of pregnancy (VTP) rates in relation to the different restrictive public health measures adopted during the pandemic period of 2020. The analysis concerned the data collected on the SAs and VTPs from public and private structures in Apulia that related to the years 2019 and 2020. The SRR (standardized rate ratio) between the standardized rates by age group in 2019 and those in 2020 were calculated using a multivariable Poisson model, and it was applied to evaluate the effect of public health restrictions on the number of SAs and VTPs, considering other possible confounding factors. The SSR was significantly lower in the first months of the pandemic compared to the same period of the previous year, both for SAs and for VTPs. The major decrease in SAs and VTPs occurred during the total lockdown phase. The results, therefore, highlight how the measures to reduce infection risk could also have modified the demand for assistance related to pregnancy interruption.
... The situation in Italy is frequently cited as an example of where a high prevalance of conscientious objection is compromising abortion provision [43]. Data from the Italian Ministry of Health shows that close to 70% of Italian gynaecologists and over 50% of anaesthetists exercised their right to conscientious object to abortion, as well as a significant percentage of non-medical staff, and this proportion has increased over the last decade. ...
... In these circumstances, it seems pragmatic for both sides to compromise-to endeavour to preserve the right to conscientiously object, but to address the primary concerns of critics regarding service provision. Francesca Minerva outlines three practical suggestions to address the state of conscientious objection and abortion in Italy [43]. First, she suggests changing Italian law to allow general practitioners to perform early term abortions, as currently only gynaecologists and obstetricians can, thereby significantly increasing the number of willing participants. ...
The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as the abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise-a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.
... Un examen de la realidad comparada muestra cómo muchos de esos problemas se vuelven realidad en contextos parecidos al chileno -esto es, en países que transitan desde un régimen prohibicionista del IVE hacia un régimen más permisivo-, y que la Iglesia católica tiene una influencia importante en la esfera pública y en la vida social en general. La OC es utilizada en dichos países como una justificación para denegar el acceso a una IVE segura para las mujeres, siendo abusada por personal de salud que camufla bajo la OC su miedo a sufrir discriminación o estigma social por la realización de IVE, o su activa oposición a la implementación de las leyes de IVE (De Zordo & Mishtal, 2011;Faúndes et al., 2013;Harris et al., 2018, p. 4;Minerva, 2015;Ortiz-Millán, 2018). En Latinoamérica han sido documentados los casos de Uruguay (Coppola et al., 2016), Argentina (Deza, 2017), Colombia (Cabal et al., 2014;Uberoi & Galli, 2017) y México (Ortiz-Millán, 2018. ...
... 298-301). Otros países donde la práctica de la OC, y en particular la regulación que da forma a esa práctica, ha sido criticada por su impacto en el ejercicio de los derechos sexuales y reproductivos han sido Italia (Minerva, 2015) y Estados Unidos (Stulberg et al., 2016). ...
This paper critically analyzes conscientious objection in the context of the new regulation of pregnancy termination in Chile. It affirms that adequate regulation should not be blind to the hostile context in which abortion rights have been enacted and the difficulties experienced. The bioethical requirements that seek to balance the interests involved must consider the legal regulation of the interests at stake, the context in which they are implemented and, fundamentally, the effectiveness of the solutions adopted. Attention should be paid to the risks involved in the proliferation of objections that are not serious and to the political use of conscientious objection to prevent the implementation of women's reproductive rights. In describing the process of entrenchment, strengthening and expansion of the conscientious objection in Chile, we show how this process has overprotected consciousness and the risks of undermining the effectiveness of the new abortion law, hindering and dilating the enjoyment of rights entrenched by the law. In response, regulatory measures are proposed to reverse this situation, which are obtained mainly from the bioethical literature on the subject and that look at the adverse context of the guarantee of women's sexual and reproductive rights.
... To some extent, conscientious objection might be a career choice dictated by the perception that non-objecting gynecologists are professionally disadvantaged because they end up doing mostly abortions (Minerva, 2015). It might also be the consequence of a nuanced stigmatization surrounding abortion providers during training, in and out of the workplace (Lazarus, 1997;Roe et al., 1999;Harris et al., 2011;O' Donnell et al., 2011;Smith et al., 2018). ...
... There are several studies dealing with conscientious objection and abortion from a legal and ethical perspective (e.g., for Italy, Minerva, 2015), and some authors have named conscientious objection, or, more in general, the availability of abortion services, as a possible explanation for the heterogeneity in abortion rates across the Italian regions. For instance, Fig� a-Talamanca et al. (1986) argue that regional differences in availability and access to abortion services might explain why, in Italy, higher abortion rates, similar to those observed in other developed countries, can be observed only in regions where health services are more easily accessible and efficient. ...
Although abortion in Italy is free of charge and legal in a broad set of circumstances, 71% of gynecologists are registered as conscientious objectors, i.e. they are exempted from performing abortions for reasons of religious or moral beliefs. To assess whether this practice limits abortion access, we analyze aggregate regional data on abortion and a dataset of over one million clinical records of single interventions performed between 2002 and 2016. Results, from both cross-regional panel data and microdata analysis, suggest that conscientious objection hampers abortion access at the local level, being a significant driver of a woman's decision of having an abortion out of the region of residence and leading to longer waiting times to have one. Conscientious objection appears to have a stronger impact on women living in lower-income regions or experiencing other forms of economic disadvantage.
... Belief-based denials of abortion care are often expanded to institutions, regions, or whole countries, even though only individuals have a conscience. In Italy, 13 Austria, 14 South Africa, 15 Croatia, 16 and many countries in Latin America, 17 a significant proportion of doctors and hospitalstoo often a majorityclaim the "right" of conscience to refuse to do abortions. ...
The United Kingdom was the first country to legalize the refusal to provide health care in the name of “conscientious objection”, allowing doctors to refuse to provide abortions based on personal or religious beliefs.
A historical review into the origins and motivation behind the “conscientious objection” clause in the 1967 Abortion Act found that Parliamentarians and the medical profession wanted to preserve doctors’ authority over patients, protect objecting doctors from liability, and appease religious anti-abortion beliefs.
These factors point to an unprincipled basis for the introduction of “conscientious objection” into healthcare, which ultimately came at the expense of patients’ rights and health. The “conscience clause” also represented a negation of basic ethical directives in medical practice including patient autonomy and physicians’ fiduciary duty to patients. The term “conscientious objection”— borrowed from the military but misapplied to healthcare — helped mask the practice as a moral “right” of doctors, even while it disregarded patients’ health and dignity.
Refusing to provide treatment on the basis of “conscience” is harmful and discriminatory, and should be phased out gradually using disincentives and other measures to encourage objectors to choose other fields.
... We therefore recognise that even if the law governing TOP were such that made it more straightforward, a significant bottleneck would remain -that of insufficient offer of TOP by providing clinics. This requires a separate solution to go in parallel with changes needed in the law or policy governing TOP, to ensure supply that guarantees equal access to the service [31,43,45]. Measures could include improved monitoring of the phenomenon through obligatory declaration of conscientious objection and updated registries as well as mandatory referral to providing colleagues and obligatory involvement of hospitals in TOP provision [15,[30][31][32]. ...
Background
The provision of prenatal testing through publicly funded healthcare systems, including non-invasive prenatal testing (NIPT), is frequently justified on the basis of supporting reproductive autonomy and informed choice. This includes decision-making around termination of pregnancy (TOP), including where it is due to a diagnosis of fetal anomaly (TOPFA). In Germany, TOP is regulated under the criminal code. However, it is exempt from punishment, if provided upon request from the woman up to 12 weeks after conception (14 weeks gestation) and following mandatory counselling. After this gestational stage, TOP may be provided where it is necessary to ensure the physical and mental wellbeing of the pregnant woman. However, there is a significant lack of clarity about how to interpret and apply this criterion. Fetal anomaly is often detected or confirmed after the time limit for TOP upon request has passed, which introduces uncertainty whether a fetal indication justifies legal access to TOP.
Methods
This study explores attitudes towards TOP, experiences with decision-making and access, and the implications of the German legal and regulatory frameworks. It draws on a qualitative semi-structured interview study, conducted between 2021 and 2022. Participants were 20 German professionals who have experience or expertise regarding the provision of NIPT, as well as 7 women with experiences of pregnancy, reproductive decision-making and the offer of NIPT. Interviews were conducted in German, and then transcribed, translated, and analysed using thematic analysis.
Results
Participants explored the importance of being able to access TOPFA; how the social positioning of TOP as a taboo procedure creates practical and psychosocial barriers to TOPFA access; the tension of who ultimately gets to make the decision about whether TOP can be provided; and how gestational time limits create emotional stress, frustrating informed decision-making and reproductive autonomy.
Conclusions
Our findings highlight that where prenatal testing is provided in the absence of guaranteed access to TOP, women’s wellbeing becomes an empty declaration in German healthcare policy.
... The main conflict on this issue is between those who support CO by defending individual autonomy in the making of moral decisions and those who think that allowing CO will create greater problems for the patient, hence necessitating unequivocal professional standards. If CO is accepted, questions such as how the healthcare system will be organized, how discrimination can be prevented, how the patient can access the healthcare services they need without being burdened, how the additional burden on non-conscientious objector healthcare workers can be justified, how service can be provided if there are too many conscientious objectors, and whether there is a right to CO in emergencies, are heavily debated in the literature [12,13]. The prevailing view in this debate is that a physician who objects on conscientious grounds is obliged to refer the patient to another physician [3]. ...
Background
Physicians’ refusal to perform medical procedures that they deem contrary to their conscience may threaten basic human rights and public health. This study aims to investigate the thoughts and attitudes of future physicians on conscientious objection (CO) and thus contribute to the discussions from a country more heavily influenced by Eastern values.
Methods
A cross-sectional multi-center study was conducted among medical students country-wide, where 2,188 medical students participated via an online survey. The methodology was in accordance with the CHERRIES.
Results
Nearly half of the students think that CO should be a right. If a medical intervention that conflicts with their personal values is requested, two-thirds would request an assignment to take another action if possible, and 8.2% stated that they would refuse to participate at all costs. If CO is recognized as a right, one-third of the participants would not refer the patient. Male participants, the ones who are more religious, and who have chosen medicine for pragmatic reasons, were more supportive of the right to refuse medical interventions that may contradict their moral values, culture, or beliefs (p = 0.000, 0.000, 0.021, respectively). Also, students who thought that conscience is a voice within us that has existed since we were born and who believed everyone must pay for all healthcare services were statistically more likely to agree that CO should be a right (p = 0.000, 0.008, respectively). The participants stated that they would most frequently object to requests for extreme aesthetic interventions (splitting the tongue in half − 39.1%, changing eye color – 28.2%, removing the lowest rib – 26.8%), euthanasia (23.2%), hymen restoration (17.3%), gender change (16.5%), and optional pregnancy termination (14.0%).
Conclusions
Developing undergraduate and post-graduate education that integrates CO as a specific topic, clarifying the conceptual definitions, and improving/developing protocols for exercising CO seem crucial to prevent possible violations of rights and to protect health professionals’ integrity. These interventions should be carried out with the participation of all parties to come together in open communication and respectful dialogue in this delicate matter.
... This article also contributes to a growing literature on abortion access in Europe and especially in Italy, where conscientious objection is a defining feature of its policy, as we will discuss below. Other scholars have sought to explain why Italy has such a high rate of conscientious objection (Gannon 2023;Pullan 2022a;Minerva 2015), analyze the effects this law has on patients (Gerdts et al. 2016;Guzzetti et al. 2021;Zanini et al. 2021) anddoctors (De Zordo 2018), how the Italian law came to be from a legal perspective (Caruso 2020), and how the law's implementation affects demographic trends such as abortion rates and patient characteristics (Autorino, Mattioli, and Mencarini 2020;Aiken et al. 2021;Fiala et al. 2022). ...
Supranational cultural institutions and communities play an interesting role in the development of abortion policy both historically and today. In this paper, we consider two such institutions: the Catholic Church and the European community. The Church is famously anti-abortion, and we describe the ways in which the Catholic position manifests itself in different countries. Conversely, almost all European countries have liberal laws that allow abortion on demand for 12 weeks of pregnancy. Italy sits at the intersection of European and Catholic identities. Italy adopted European-style liberal abortion laws early, but Italians continue to identify with the Church in surveys, which is one of the causes of high levels of conscientious objection by medical professionals. Italy’s abortion policy pleases neither Catholics nor secularists. We explain this by understanding Italy’s abortion law as liberal de jure, but its culture is still heavily influenced by Catholicism, resulting in limited abortion access de facto
... 23 Studies on doctors and abortion decision-making have shown, albeit in countries where abortion is legal, that some doctors do refuse to refer for or perform abortions. 24,25 Other common reasons for opposing abortion are moral beliefs, the stigma associated with abortions 24,26 as well as inadequate training, information and support. 27 It is imperative for private GPs to be aware of their values and recognize when to act on personal and professional stances. ...
et al. Managing adolescent pregnancy: The unique roles and challenges of private general practitioners in Malaysia. Malays Fam Physician. 2019;14(3);37-45. Abstract Introduction: Managing adolescent pregnancy in the primary care setting is complex, as it requires doctors to navigate through a combination of medical, social, financial and legal needs. Objective: This study explores the perspectives of private general practitioners on their roles and challenges in managing adolescent pregnancy in Malaysia. Methods: Nineteen private general practitioners in Selangor and Kuala Lumpur participated in in-depth interviews in 2015. A topic guide was used for interview navigation. Participants were asked to discuss their experiences and approaches in managing pregnant adolescents. We used purposive sampling to recruit consenting private general practitioners who had experience in managing adolescent pregnancy. The verbatim transcripts of the audio-recorded interviews were analyzed using thematic analysis. Data reached saturation at the nineteenth in-depth interview. Results: Two themes emerged. Under the theme 'inadvertent advocator,' participants described their tasks with regards to building trust, calming angry parents and delivering comprehensive counseling and care related to the sexual and reproductive health of adolescents, including requests for abortions. Theme two, 'challenges of private general practitioners,' refers mainly to personal and religious conflicts arising from a request for an abortion and deficiencies in support and multidisciplinary integration within their practice settings. Conclusion: General practitioners practicing in the private sector identify themselves as active players in supporting pregnant adolescents but face many challenges arising from the personal, religious, professional and community levels. Addressing these challenges is important for optimal care delivery to pregnant adolescents in this community.
... Typically, conscience clauses allowing conscientious refusal in laws that legalise or decriminalise abortion do not undermine the legal availability of the procedure-although they could undermine the availability in practice. 30 Thus, conscientious refusal to provide abortion can be legally consistent with the legalisation of abortion. ...
We argue that, in certain circumstances, doctors might be professionally justified to provide abortions even in those jurisdictions where abortion is illegal. That it is at least professionally permissible does not mean that they have an all-things-considered ethical justification or obligation to provide illegal abortions or that professional obligations or professional permissibility trump legal obligations. It rather means that professional organisations should respect and indeed protect doctors’ positive claims of conscience to provide abortions if they plausibly track what is in the best medical interests of their patients. It is the responsibility of state authorities to enforce the law, but it is the responsibility of professional organisations to uphold the highest standards of medical ethics, even when they conflict with the law. Whatever the legal sanctions in place, healthcare professionals should not be sanctioned by the professional bodies for providing abortions according to professional standards, even if illegally. Indeed, professional organisation should lobby to offer protection to such professionals. Our arguments have practical implications for what healthcare professionals and healthcare professional organisations may or should do in those jurisdictions that legally prohibit abortion, such as some US States after the reversal of Roe v Wade .
... If having an abortion is in any case a dramatic event in a woman's life, these data cannot but be judged favorably. 8 In short, Italian law adopts a significantly different approach from the U.S. one. Whereas in the United States, according to Roe, the decision whether to continue her pregnancy during the first trimester was entirely within the liberty rights of the woman, who could not be limited in any way in fulfilling her desires, in Italy, abortion is not something entirely belonging in the domain of women's selfdetermination. ...
The U.S. Supreme Court's Dobbs ruling triggered a global debate about access to abortion and the legislative models governing it. In the United States, there was a sudden reversal of federal guidance about pregnancy termination that is unprecedented in Western and high-income countries. The strong polarization on the issue of abortion and the difficulty of finding a point of compromise lead one to consider the experiences of countries that have had different paths. Italy stands as a candidate for being a partially alternative model because it allows abortion up to 12 weeks, but without considering it a subjective right. The legislation in place since 1978 aims to balance the interests of the fetus and those of the woman. An issue often raised concerning Italian law is that of conscientious objection granted to doctors. Many gynecologists declare themselves objectors, and this makes access to abortion more difficult in some regions of Italy. After discussing this issue and envisaging different ways to deal with it, the article concludes by highlighting new dilemmas about a possible divorce between the law and medical ethics in different directions and offers some avenues to begin setting up a response.
... This received marketing authorisation in July 2009 [6], but the effect became visible a few years later, probably because it was initially difficult for women to find a doctor ready to prescribe it. In fact, conscientious objection by Italian gynaecologists remains a substantial obstacle [7]; about 70% of them use this option and only a few are available to perform VTPs. Another important argument that could lead the Italian women to seek a VTP in Switzerland is the guideline of the Italian Ministry of Health, which recommends a 3-day in-patient stay for medical VTP [8]. ...
In Switzerland, voluntary termination of pregnancy (VTP) can be performed in all public and private hospitals with an obstetrics/gynaecology department. For various reasons, many Italian women use the Swiss healthcare system, in particular in Canton Ticino, a border region adjacent to Italy in the southern part of Switzerland, when they want to have a VTP. In this study, we aimed to illustrate trends in the VTPs in the Canton Ticino between 2008 and 2015 and demonstrate differences between the Swiss women resident in Switzerland (SSR), foreign women resident in Switzerland (FSR) and foreign women resident abroad (FAR), focusing in particular on the Italian women as during this period there were legal changes in Italy. The number of VTPs was constant on a national level (10,924 in 2008, 10,255 in 2015); in contrast, since 2012 the number has progressively decreased (41%) in Ticino, mainly because of the significant reduction in VTPs in women resident in Italy (decrease of 75.7%). In addition, we wanted to evaluate the impact of the pre-VTP counselling at a family planning centre (FPC) on the VTP decision. The high number of pre-VTP consultations suggests that this service is appreciated and helpful. We observed an encouraging trend in changing the decision to have a VTP after the consultation at the FPC, where 12% of the pregnant women decided to continue the pregnancy. Because of its location, the Canton Ticino is an example how availability of certain drugs, methods and laws can influence the cross-border flow of the patients.
... According to the Italian abortion law, in the first ninety days of pregnancy, abortion is permitted whenever childbearing, birth or motherhood could undermine the mother's physical or Global Bioethics Enquiry 2022; 10(1) mental health. This law also grants healthcare personnel the right to refuse to partake in procedures specifically directed at the termination of pregnancy, on grounds of conscientious objection [26]. ...
... En consecuencia, actualmente se ha instalado en el debate público de algunos Estados el cuestionamiento de la legitimidad de la OC, como es el caso de Italia (Minerva, 2015;Bo et al., 2017) o Portugal (Heino et al., 2013). Mientras unos defienden la búsqueda de un equilibrio (Casas, 2009), aquellos que denuncian el incumplimiento de los derechos reproductivos de la mujer, abogan por debilitar los derechos de las y los profesionales de la salud (Vélez, 2009), o por la eliminación del derecho a la OC (Bo et al., 2017). ...
En Chile, la objeción de conciencia (OC) es un obstáculo para garantizar el acceso a la interrupción voluntaria del embarazo (IVE) de las mujeres, debido al alto número de objetores en los servicios públicos de salud, quienes objetan por un conflicto de conciencia entre la práctica médica y la moral o creencias religiosas. El objetivo de este estudio es comprender las diferentes motivaciones de los profesionales de la salud para adherirse a la OC. Para cumplir con este objetivo, nos basamos en teorías de la psicología social y el feminismo, analizando entrevistas con profesionales médicos y no médicos del servicio público de salud de la Región de la Araucanía. Identificamos motivaciones que no califican como creencias morales o religiosas, como son las laborales, la desconfianza en el criterio de la mujer que solicita la IVE y colegas, o el miedo a problemáticas legales. Concluimos que la declaración de la OC está constituida no solo por creencias y valores personales, sino también por factores contextuales y relacional es constitutivos de una pseudo-objeción de conciencia (P-OC), limitando aún más el acceso de las mujeres a la IVE.
... I would, however, note that it is not typically the case that a doctor's conscientious objection would categorically prevent a patient from accessing a service that they sought. Indeed, abortion is, for the most part, readily available in jurisdictions where the procedure is legally permitted (though scholars have highlighted some notable exceptions (Minerva 2015)). Insofar as a doctor's conscientious objection did prevent a patient from obtaining the service they desired, then it seems that the above counterargument fails to undermine the case in favour of conscience rights. ...
Conscience is an idea that has significant currency in liberal democratic societies. Yet contemporary moral philosophical scholarship on conscience is surprisingly sparse. This paper seeks to offer a rigorous philosophical account of the role of conscience in moral life with a view to informing debates about the ethics of conscientious objection in medicine. I argue that conscience is concerned with a commitment to moral integrity and that restrictions on freedom of conscience prevent agents from living a moral life. In section one I argue that conscience is a principle of moral awareness in rational agents, and that it yields an awareness of the personal nature of moral obligation. Conscience also monitors the coherence between an agent’s identity-conferring beliefs and intentions and their practical actions. In section two I consider how human beings are harmed when they are forced to violate their conscience. Restrictions on the exercise of conscience prevent people from living in accord with their own considered understanding of the requirements of morality and undermine one’s capacity for moral agency. This article concludes with a consideration of how a robust theory of conscience can inform our understanding of conscientious objection in medicine. I argue that it is in the interest of individual practitioners and the medical profession generally to foster moral agency among doctors. This provides a prima facie justification for permitting at least some kinds of conscientious objection.
... Giubilini (2014, S. 168) verweist etwa auf die Schwierigkeiten, auch in einigen Ländern, in denen kein gesetzliches Verbot des Schwangerschaftsabbruchs besteht (wie in Italien), einen zur Durchführung eines zu einem Schwangerschaftsabbruch bereiten Gynäkologen zu finden (vgl. Minerva 2015). Eine vergleichbare Lage besteht zumindest gegenwärtig in Deutschland in Sachen Suizidhilfe. ...
Zusammenfassung
Auch unter Befürwortern der Zulässigkeit einer Suizidassistenz durch Ärzte unter bestimmten Bedingungen besteht weitgehendes Einverständnis darüber, dass kein Arzt zu einer Suizidassistenz rechtlich oder berufsrechtlich verpflichtet sein sollte. Auch das Bundesverfassungsgericht hat in seinem Urteil vom Februar 2020 Suizidwilligen unter bestimmten Bedingungen nicht mehr als ein ungerichtetes in rem -Recht auf Suizidhilfe zugesprochen, das keinen Anspruch gegen einen einzelnen Arzt begründet. Mit dem letzten Satz seines Urteils hat es vielmehr die Freiheit jedes einzelnen Arztes – wie auch jedes anderen potenziellen Helfers –, Nein zu sagen, nachdrücklich bekräftigt. Auf dem Hintergrund einer empirischen Untersuchung der Gründe, die in der Schweiz für die Ablehnung entsprechender Patientenanfragen gegeben werden, untersucht und gewichtet der Beitrag die Gründe, die für diese Freiheit sprechen, unter ethischen Gesichtspunkten und verteidigt ein bedingtes Recht auf Ablehnung gegen dessen jüngste Kritiker. In Fällen, in denen die Bedingungen erfüllt sind, durch die das Bundesverwaltungsgericht in seinem Urteil vom März 2017 „extreme Notlagen“ definiert hat, sollte jedoch zumindest eine moralische Pflicht anerkannt werden, den Patienten an einen Arzt zu verweisen, der zu einer Unterstützung bereit ist.
... The committee has in fact ascertained that many hospitals could not provide abortion services, and that patients in some cases had to move to other regions, or even go abroad due to extremely long waiting lists [39]. The Committee has therefore urged the Italian government to ensure a more homogeneous distribution of non-objecting personnel, and the effectiveness of the service throughout the national territory within October 2019 [40]. The inability to terminate one's pregnancy in due time also negatively affects the right enshrined in law no. ...
The COVID-19 health emergency has thrown the health systems of most European countries into a deep crisis, forcing them to call off and postpone all interventions deemed not essential or life-saving in order to focus most resources on the treatment of COVID-19 patients. To facilitate women who are experiencing difficulties in terminating their pregnancies in Italy, the Ministry of Health has adapted to the regulations in force in most European countries and issued new guidelines that allow medical abortion up to 63 days, i.e., 9 weeks of gestational age, without mandatory hospitalization. This decision was met with some controversy, based on the assumption that the abortion pill could “incentivize” women to resort to abortion more easily. In fact, statistical data show that in countries that have been using medical abortion for some time, the number of abortions has not increased. The authors expect that even in Italy, as is the case in other European countries, the use of telemedicine is likely to gradually increase as a safe and valuable option in the third phase of the health emergency. The authors argue that there is a need to favor pharmacological abortion by setting up adequately equipped counseling centers, as is the case in other European countries, limiting hospitalization to only a few particularly complex cases.
... 24 There are many areas of debate in the ethical and legal literature about conscientious objection provisions in health law, including: whether conscientious objection provisions should exist at all, 25 26 what counts as a conscientious objection, 27 28 whether health professionals should be expected to register or report their conscientious objection, 29 the relationship between institutions and conscientious objection 30 31 and the impact of conscientious objection on equitable access to services. [32][33][34] The importance of allowing conscientious objection is central to key professional associations' positions on VAD. The Australian Medical Association (AMA) states: ...
In jurisdictions where voluntary assisted dying (VAD) is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture.
... It is essential, according to that rationale, to acknowledge the different roles played by values and conscience in public or private life: belief systems should mould and steer policy discussions as to what kind of health system to build, but they should never affect what kind of care individual physicians provide to their patients, lest the door be opened to 'value-driven medicine' and unscientific, discriminatory dynamics [46]. Outlawing CO-based refusals is also presumably effective in upholding the patients' human rights; to buttress their argument, opponents point to developed countries such as Italy, when CO is so widespread as to make access to abortion extremely difficult, particularly in southern regions, which could entail both discrimination and prejudice to the patients' health [47,48]. In that regard, it is noteworthy that the European Committee of Social Rights (ECSR), the Council of Europe body which oversees compliance with the European Social Charter (ESC), found two instances in which Italy had violated ESC precepts in 2014 and 2016, namely the right to health (enshrined in ESC Article 11), in light of the inability of women to carry out voluntary terminations of pregnancy due to extremely high CO rates [49,50]. ...
Purpose
The article aims to elaborate on two recent European Court of Human Rights (ECtHR) decisions which have rejected, on grounds of non-admissibility, the appeals by two Swedish midwives who refused to carry out abortion-related services, basing their refusal on conscientious objection, and to expound upon the legal and ethical underpinnings and core standards applied to the framing process of such a ECtHR decision.
Materials and Methods
By drawing upon relevant recommendations from international institutions, the authors have aimed to assess how the ECtHR rationale could affect the balance between CO and patient rights; searches have been conducted up until December 2020.
Results
In both decisions the European Court has asserted that the right to exercise conscientious objection must give way to the protection of the right to health of women seeking to have an abortion.
Conclusions
ECtHR judges concluded that the failure to provide for a right to conscientious objection does not constitute, in fact, a violation of the more general right to freedom of thought, conscience and religion, if provided for by a state law to protect the right to health. The legal ethical and social ramifications of such a decision are of enormous magnitude.
... Second, often there are indeed professional gains in objecting to procedures like abortion, for example in hospitals or even countries (e.g., Italy), where conscientious objection is very widespread, including in medical hierarchies in hospitals, and the "outliers" are the non-objecting doctors. That 70 to 80 per cent of gynaecologists in Italy have a conscientious objection to abortion (Minerva 2015) is quite telling of the cultural climate in those healthcare settings. ...
In this response paper, we respond to the criticisms that Michal Pruski raised against our article “Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests.” We defend our original position against conscientious objection in healthcare by suggesting that the analogies Pruski uses to criticize our paper miss the relevant point and that some of the analogies he uses and the implications he draws are misplaced.
... In fact, PSR is not a part of the essential procedures of the care process; on the other hand, the doctor who decides to carry out this procedure becomes morally responsible for upholding the rights of the deceased in terms of procreation. Hence, doctors should not be bound to meet such requests (40,41). In addition, a sentient new life could result from the doctor's decision to proceed with PSR. ...
Aim Postmortem sperm retrieval with consequent artificial insemination has become a technically possible option for future use in
assisted reproductive technology (ART). The authors have set out
to discuss the social and ethical significance of posthumous sperm
retrieval, and the laws currently in force in Italy, the United States
and elsewhere.
Methods International literature from 1997 to 2020 has been
reviewed from Pubmed database, Google Scholar and Scopus,
drawn upon American, Italian and international sources (an ethically acceptable solution can only be achieved through an overhaul of the laws currently in effect). One of the most contentious
issues was about donor consent. In Italy, a donor's will to retrieve
his sperm in the event of premature disappearance can be proven
according to the Law 219/2017, through advance health care directives.
Results A substantial increase, both in requests and protocols, was
documented in the United States. In Italy, over the last two years,
three rulings were issued concerning posthumous insemination.
However, no official standardized protocols, guidelines or targeted
legislation exist at the national level to regulate medical activity in
that realm, whereas established laws often set implicit limitations.
Conclusion Current legal frameworks appear to be inadequate,
because in most cases they were conceived under conditions that
have radically changed. The need for newly-updated regulatory
frameworks to promptly bridge that gap is increasingly clear, if
current social needs related to reproductive rights are to be met in
the foreseeable future.
... The legislation does not acknowledge conscientious objection rights for doctors (5)(6)(7)(8)(9), though it does lay out three scenarios in which doctors may legally disregard advance directives: unreasonable requests, directives that no longer reflect the patient's current clinical conditions, and the availability of new forms of treatment, unpredictable at the time the directives were drawn up, and potentially capable of significantly improving the patient's quality of life. In such cases, doctors have a duty to disregard the advance directives; patients in fact are not entitled to demand forms of treatment that are unlawful, or run counter to medical ethics and clinical best practice guidelines (10,11). ...
Following drawn out, contentious parliamentary deliberations, the Italian legislature has enacted bill n.219/17, meant to regulate advance healthcare directives. The letter's authors are critical of some key aspects relative to advance directives, contending that it would be preferable to opt for advance care planning, which enables already severely ill patients who are fully aware of the consequences of their disease to choose what therapeutic pathway to undertake.
... 2,3 Such laws and regulations create a patchwork legal landscape, and limit access to abortion. [4][5][6] A recent 158-country analysis of abortion policies demonstrates that barriers to abortion access, including regulatory requirements, may delay abortion care-seekingcausing some people seeking abortion to exceed the gestational limits specified by a country's abortion laws. 7 Recent evidence suggests that people seeking abortion care in countries where abortion is legal, but where legal Dr Giulia Zanini was a Postdoctoral Fellow at the University of Barcelona when the study presented in this paper was carried out. ...
Objectives:
Little is known about the experiences of women who travel within Europe for abortion care from countries with relatively liberal laws. This paper aims to assess the primary reasons for travel among a sample of women who travelled from European countries with relatively liberal abortion laws to obtain abortion care mainly in the UK and the Netherlands.
Design:
Multi-country, 5-year mixed methods study on barriers to legal abortion and travel for abortion.
Setting:
UK, the Netherlands and Spain.
Population or sample:
We present quantitative data from 204 surveys, and qualitative data from 30 in-depth interviews with pregnant people who travelled to the UK, the Netherlands, and Spain from countries where abortion is legal on broad grounds within specific gestational age (GA) limits.
Methods:
Mixed-methods.
Main outcome measures:
GA when presenting at abortion clinic, primary reason for abortion-related travel.
Results:
Study participants overwhelmingly reported travelling for abortion because they had exceeded GA limits in their country of residence. Participants also reported numerous delays and barriers to receiving care.
Conclusions:
Our findings highlight the need for policies that support access to abortion throughout pregnancy and illustrate that early access to it is necessary, but not sufficient to meet people's reproductive health needs.
... Italian law allows health care professionals to refuse to carry out activities specific to abortion, on the grounds of conscientious objection. It has been estimated that about 70% of Italian gynaecologists are conscientious objectors [17,18]. In Greece and Italy, as in Poland, abortion is considered to be a mortal sin. ...
Objectives
The study aimed to determine the influence of religious and moral beliefs on contraceptive use, assisted reproduction and pregnancy termination in Polish women requesting a termination of pregnancy for medical reasons.
Methods
Between 1 June 2014 and 31 May 2016, women deemed eligible for a termination of pregnancy for medical reasons at a Polish tertiary care centre received an anonymous questionnaire comprising 65 items. A total of 150 completed questionnaires were collected.
Results
Of the respondents, 95% described themselves as Catholics, including 60% practising Catholics. The study revealed a discrepancy between respondents’ beliefs and the teachings of the Catholic Church: an overwhelming majority of respondents used contraception, and 79% were in favour of in vitro fertilisation and believed the treatment should be refunded by the state. Interestingly, 66% of the respondents who attended confession did not perceive abortion as sinful.
Conclusion
The study detected a considerable discrepancy between declared religiosity and individual interpretations of the commandments and teachings of the Catholic Church. Despite stating they were Catholics, most women did not perceive abortion as sinful and did not follow the teachings of the Catholic Church regarding the sacraments for deceased children.
... 40, passed on 19 th February 2004) (10,11). There are no statutory rules authorizing conscientious objection in the prescription and in the supply of the "morning-after pill" or any other EC method (12,13). In a certain way, conscientious objection on moral grounds manifests itself when there is a disconnect between sexuality and procreation; IVF has somehow caused a biological and emotional separation between sex and reproduction, which was initiated by contraception. ...
Emergency Contraception (EC) has been gaining attention for its controversial nature, from the ethical, moral and religious perspectives. Objecting health professionals feel that the implementation of certain procedures or the prescription of some drugs would engender a conflict of conscience. That is also true in the context of reproductive medicine and not only limited to EC, but including abortion and some medically-assisted procreation procedures; all such procedures have created a rift between sexuality and procreation that has substantial ethical complexities. Provided that respect for conscience is essential, and codified in many national and international statutes, any refusal to provide services or medication should be limited if it might negatively affect a patient's health, is based on scientific misinformation, or could bring about inequalities of any kind. First and foremost, any imposition of religious or moral beliefs on patients should not be countenanced. In fact, any form of conscientious objection that could harm patient well-being should be allowed only if the fundamental duty towards patients can be effectively discharged. The right to thorough and unbiased information is crucial so as to enable patients to make well-informed decisions. Moreover, as the WHO has remarked, access to safe and legal reproductive services should be fostered particularly in at-risk, resource-poor areas.
... 40). 60,61 Hence, no statutory norms exist to allow for conscientious objection in the prescription and in the supply of any ec method. 62 Nonetheless, article 22 of the 2014 italian code of medical ethics allows operators who are required performances or services that are in contrast with their beliefs to refuse their work, unless such a denial constitutes a serious and immediate damage to the health of the patient. ...
Emergency contraception (EC) has been prescribed for decades, in order to lessen the risk of unplanned and unwanted pregnancy following unprotected intercourse, ordinary contraceptive failure, or rape. EC and the linked aspect of unintended pregnancy undoubtedly constitute highly relevant public health issues, in that they involve women's self-determination, reproductive freedom and family planning. Most European countries regulate EC access quite effectively, with solid information campaigns and supply mechanisms, based on various recommendations from international institutions herein examined. However, there is still disagreement on whether EC drugs should be available without a physician's prescription and on the reimbursement policies that should be implemented. In addition, the rights of health care professionals who object to EC on conscience grounds have been subject to considerable legal and ethical scrutiny, in light of their potential to damage patients who need EC drugs in a timely fashion. Ultimately, reproductive health, freedom and conscience-based refusal on the part of operators are elements that have proven extremely hard to reconcile; hence, it is essential to strike a reasonable balance for the sake of everyone's rights and well-being.
... 23 Studies on doctors and abortion decision-making have shown, albeit in countries where abortion is legal, that some doctors do refuse to refer for or perform abortions. 24,25 Other common reasons for opposing abortion are moral beliefs, the stigma associated with abortions 24,26 as well as inadequate training, information and support. 27 It is imperative for private GPs to be aware of their values and recognize when to act on personal and professional stances. ...
Introduction:
Managing adolescent pregnancy in the primary care setting is complex, as it requires doctors to navigate through a combination of medical, social, financial and legal needs. Objective: This study explores the perspectives of private general practitioners on their roles and challenges in managing adolescent pregnancy in Malaysia.
Methods:
Nineteen private general practitioners in Selangor and Kuala Lumpur participated in in-depth interviews in 2015. A topic guide was used for interview navigation. Participants were asked to discuss their experiences and approaches in managing pregnant adolescents. We used purposive sampling to recruit consenting private general practitioners who had experience in managing adolescent pregnancy. The verbatim transcripts of the audio-recorded interviews were analyzed using thematic analysis. Data reached saturation at the nineteenth in-depth interview. Results: Two themes emerged. Under the theme 'inadvertent advocator,' participants described their tasks with regards to building trust, calming angry parents and delivering comprehensive counseling and care related to the sexual and reproductive health of adolescents, including requests for abortions. Theme two, 'challenges of private general practitioners,' refers mainly to personal and religious conflicts arising from a request for an abortion and deficiencies in support and multidisciplinary integration within their practice settings.
Conclusion:
General practitioners practicing in the private sector identify themselves as active players in supporting pregnant adolescents but face many challenges arising from the personal, religious, professional and community levels. Addressing these challenges is important for optimal care delivery to pregnant adolescents in this community.
... According to the Law 194/1978, the voluntary interruption of pregnancy is allowed in the Italian legal system. However, the practice is widely condemned by health care professionals who often refuse to practice it in public hospitals (Lalli, 2016;Minerva, 2014). Furthermore, Italian parents cannot obtain the legal permission to bury their deceased children if the death happens before the 28th week of pregnancy since Italian law (DPR 285/1990) establishes that such fetuses can be buried only if the parents immediately request it formally to the local health care unit. ...
The grieving process after perinatal loss has unique properties. This qualitative study examines one aspect of the grieving process: continuing bonds experienced by the mothers. We offer an interpretative phenomenological analysis of interviews with 15 Italian mothers. Three main relevant themes emerged: “continuing bonds between externalized and internalized presence,” “a difficult guilt to manage,” and “relationships are crucial support systems.” The first one illustrates the ongoing connections to the deceased on the part of mothers and siblings, the second one explores a fixation on finding the cause of the death and related feelings of guilt, while the third one describes the mothers’ process of elaboration of the event, especially with the support of the husband and the community. The findings highlight unique qualities of continuing bonds after perinatal loss and factors that might influence mother’s griefwork, while also suggesting that psychodrama and art therapy could be useful in the management of this kind of loss.
This work is aimed to analyze the difficulty of establishing clear limits between conscientious objection and civil disobedience taken as example the specific case of those healthcare professionals opposed to the Spanish Royal Decree 16/2012. The approval of this law, directed to the sustainability of the National Health System, meant a change in the previous configuration of the constitutional right to healthcare, characterized by being public and freely accessible to all the inhabitants in the country. As a consequence, undocumented migrant people had no longer a universal access to healthcare. In this situation, some healthcare professionals expressed their opposition to the law providing their services to undocumented patients. Might this behavior be considered a form of conscientious objection? Was a case of civil disobedience? Was just an act of altruism? Plausible answers to these questions will be argued along this paper.
The Element examines ethical and conceptual issues about conscientious objection in medicine. Concepts analyzed include conscientious objection, conscientious provision, conscience, moral complicity, and moral integrity. Several ongoing ethical controversies are identified and critically analyzed. One is a disagreement about whether conscientious objection is compatible with physicians' professional obligations. The Element argues that incompatibilists fail to offer a justifiable specification of professional obligations that supports their position. The Element also argues that a challenge for compatibilists who support a reason-giving requirement is to specify justifiable and unambiguous criteria for reviewing objectors' reasons. Arguments for and against requirements to inform and refer patients are critically analyzed, and an alternative, context-dependent requirement is offered. Another subject of controversy is about the justifiability of asymmetry between responses to conscientious objectors and conscientious providers. Typically, only the former receive accommodation. The Element critically examines arguments for asymmetry and maintains that none provides a convincing justification.
The concept of conscience continues to play a central role in our ethical reasoning as well as in public and philosophical debate over medical ethics, religious freedom, and conscientious objection in many fields, including war. Despite this continued relevance the nature of conscience itself has remained a relatively neglected topic in recent philosophical literature. In this paper I discuss some historical background to the concept and outline the essential features required for any satisfactory account of conscience and its significance for a coherent moral psychology. It will become clear that conscience is a complex concept resisting reduction to any one of its component features. In doing so I critique recent accounts of conscience which have been insufficiently attentive to these complexities and as a consequence have drawn mistaken conclusions about the legitimate role of conscience in moral reasoning. I also discuss the significance of various distortions of conscience such what I call “the fanaticised conscience”. Clarifying our concept of conscience helps us avoid both conceptual confusion in moral psychology and misapplications of the concept in our understanding of conscientious objection both theoretically and in practice.
Background
Despite the right for health professionals to abstain from providing abortion services existing for over 50 years, literature on conscientious objection to abortion scarcely mentions midwives. In addition, little empirical research has been carried out concerning midwives’ views surrounding what constitutes participation in abortion and in turn, what areas of care they can withdraw from.
Aim
To explore midwives’ beliefs regarding the extent of and limitations to the exercising of their legal right to objection to abortion on conscience grounds.
Design
Qualitative study with 17 midwives in Glasgow and Liverpool, UK.
Method
Face to face semi-structured interviews, transcribed verbatim and analysed using a thematic analysis and Human Rights framework for midwifery care.
Findings
The extent of and limitations to CO to abortion-related care was reflected in four themes: respecting and protecting, making informed decisions, providing non-discriminatory care and experience and culture. There was an overriding sense of support for midwives to be able to exercise their right to conscientious objection, how this is operationalised in practice however continues to be fraught with complexity, which in turn poses constant challenges to midwives who object, their colleagues and managers.
Conclusions
Midwives’ beliefs regarding the exercising of their legal right to object to abortion-related care on conscience grounds can be summarized in the challenge of “finding a balance”. A national picture of how to accommodate CO to abortion is needed, so that all midwives can continue to give optimal care to women and receive it themselves, within a human rights framework.
Euthanasia and the duty to die have both been thoroughly discussed in the field of bioethics as morally justifiable practices within medical healthcare contexts. The existence of a narrow connection between both could also be established, for people having a duty to die should be allowed to actively hasten their death by the active means offered by euthanasia. Choosing the right time to end one’s own life is a decisive factor to retain autonomy at the end of our lives. However, there is no definitive consensus on why physicians should be the ones performing the medical procedure to end a person’s life. The moral problems arising from such assertion are not to be taken lightly, for medical tradition has long regarded the duty not to kill, not to actively end a patient’s life, as the core moral obligation that gives meaning to the medical profession. Our concern is to question the moral justifiability of the arguments offered by physicians not to actively help patients die.
The book provides a detailed introduction to a major debate in bioethics, as well as a rigorous account of the role of conscience in professional decision-making. Exploring the role of conscience in healthcare practice, this book offers fresh counterpoints to recent calls to ban or severely restrict conscience objection. It provides a detailed philosophical account of the nature and moral import of conscience, and defends a prima facie right to conscientious objection for healthcare professionals. The book also has relevance to broader debates about religious liberty and civil rights, such as debates about the rights and duties of persons and institutions who refuse services to clients on the basis of a religious objection. The book concludes with a discussion of how to regulate individual and institutional conscientious objection, and presents general principles for the accommodation of individual conscientious objectors in the healthcare system. This book will be of value to students and scholars in the fields of moral philosophy, bioethics and health law.
Objectives
Over-the-counter emergency contraception (EC) purchase was legalised in Italy in 2015. Knowledge and access gaps, however, remain. The goal of this study was to explore women’s and men’s EC informational and access needs.
Methods
As part of a larger reproductive study, researchers conducted 42 in-depth interviews (May–June 2019) with English-speaking women and men aged 18–50 years (mean ± standard deviation, 29.1 ± 7.9 years) living in or near Florence, Italy, and using the Italian health care system. Researchers completed qualitative data analysis to identify emergent themes related to EC knowledge, attitudes and access. HyperRESEARCH aided data organisation and analysis. Researchers used a comparative method to contextualise data and identify emergent themes.
Results
Findings demonstrated that peer communication and experiences served as influential factors in others’ EC use. This propagated misinformation, reducing participants’ confidence in EC efficacy and safety. Women described the relevance of relationship type in whether to engage men in EC discussion, while men desired an active supportive role. Finally, participants described various messaging and access channels to increase EC knowledge and access.
Conclusion
Findings offer practical recommendations to guide social marketing and behaviour change interventions to increase EC access among women and men in Italy. The utility of pharmacists to individuals wishing to access EC is explored.
Introduction
Induced abortion is legal in Italy but with restrictions. The online abortion provider Women on Web (WoW) serves as an alternative way to access abortion. The COVID-19 pandemic has affected sexual and reproductive health worldwide. Italy was one of the first countries hit by the pandemic and imposed strict lockdown measures. We aimed to understand why women requested WoW abortion in Italy and how this was affected by the pandemic.
Methods
We conducted an observational study analysing requests made to WoW before and during the pandemic. We analysed 778 requests for medical abortion from Italy between 1 March 2019 to 30 November 2020 and compared the characteristics of requests submitted before and during the pandemic. We also performed subgroup analysis on teenagers and COVID-19-specific requests.
Results
There was an increase in requests during the COVID-19 pandemic compared with the previous year (12% in the first 9 months). The most common reasons for requesting a telemedicine abortion through WoW were privacy-related (40.9%); however, this shifted to COVID-19-specific (50.3%) reasons during the pandemic. Requests from teenagers (n=61) were more frequently made at later gestational stages (p=0.003), had a higher prevalence of rape (p=0.003) as the cause of unwanted pregnancies, and exhibited less access to healthcare services compared with adult women.
Conclusions
There was an increase in total demand for self-managed abortion during the pandemic and reasons for requesting an abortion changed, shifting from privacy-related to COVID-19-specific reasons. This study also highlighted the uniquely vulnerable situation of teenagers with unwanted pregnancies seeking self-managed abortion.
In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.
Debates about the ethics of health care and medical research in contemporary pluralistic democracies often arise partly from competing religious and secular values. Such disagreements raise challenges of balancing claims of religious liberty with claims to equal treatment in health care. This paper proposes several mid-level principles to help in framing sound policies for resolving such disputes. We develop and illustrate these principles, exploring their application to conscientious objection by religious providers and religious institutions, accommodation of religious priorities in biomedical research, and treatment of patients' religious views in doctor-patient encounters. Given that no sound set of guiding principles yields precise solutions for every policy dispute, we explore how morally sound democracies might deliberatively resolve such policy issues, following our proposed principles. Taken together and carefully interpreted, these principles may help in guiding difficult decision making in the indefinitely large realm where government, medical providers, and patients encounter problems concerning religion and medicine.
Conscientious objection in healthcare is often granted by many legislations regulating morally controversial medical procedures, such as abortion or medical assistance in dying. However, there is virtually no protection of positive claims of conscience, that is, of requests by healthcare professionals to provide certain services that they conscientiously believe ought to be provided, but that are ruled out by institutional policies. Positive claims of conscience have received comparatively little attention in academic debates. Some think that negative and positive claims of conscience deserve equal protection in terms of measures that institutions ought to take to accommodate them. However, in this issue of The Journal of Clinical Ethics (JCE), Abram Brummett argues against this symmetry thesis.1 He suggests that the relevant distinction is not between negative and positive claims of conscience, but between negative and positive rights of conscience. He argues that conscientious refusals and positive claims of conscience are both already protected as negative rights of conscience, but that this does not require institutions to accommodate positive claims of conscience. In this article I will argue that both Brummett and the authors he criticizes share a wrong view about the existence of conscience rights in healthcare. I will argue that there is no right to conscientious objection in healthcare, whether positive or negative. Thus, contra Brummett, I argue that the question whether such rights are positive or negative is as irrelevant as the question whether the claims of conscience are positive or negative.
Objectives: Italy’s 2015 emergency contraception (EC) policy made EC available without prescription for individuals aged 18 years and older; however, women living in Italy continue to face barriers to accessing EC. The purposes of this study were to understand EC knowledge, attitudes and behaviours among women living in Italy and explore the impact of the 2015 policy.
Methods: Researchers conducted 30 interviews with women living in Florence, Italy, aged 18–50 years and using the Italian health care system. Researchers used an expanded grounded theory approach to understand women’s EC experiences, with diffusion of innovations (DOI) serving as a conceptual lens. Researchers completed open and axial coding to identify emerging themes.
Results: Participants had low awareness of the 2015 EC policy and suggested increased messaging in strategic locations to overcome this barrier. They held positive and negative attitudes towards EC: while some perceived the advantage of EC compared with unintended pregnancy, others expressed concerns about irresponsible behaviour and safety. Finally, conscientious objection impacted access, despite women’s desire for autonomous EC decision making.
Conclusion: The findings offer practical recommendations to guide EC messaging in Italy to increase women’s access to EC. Recommendations include using theory- and audience-based methods to overcome gaps in policy knowledge and real and perceived barriers to EC access. Incorporating DOI as a theoretical framework with women’s voices presents a novel opportunity to enhance policy and EC dissemination.
Conflict of interests (COIs) in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner’s financial interest conflicts with patients’ interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of “interests” cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners’ moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs.
Empirical research showcases that pre-abortion counseling scarcely reverses the woman's decision either to terminate a pregnancy or not. Growing evidence regarding the high levels of decisional certainty among women seeking abortions renders a careful rethink of the place of mandatory pre-abortion counseling packages. Mandatory counseling packages, when inscribed in the laws, at times contain false information that can deter women from going in for safe abortions. Mandatory waiting times indirectly label opting for an abortion as not being the right thing to do. In areas where abortion stigma from health care providers and communities remains highly prevalent, women are forced to incur extra expenses by travelling to other countries. I argue that pre-abortion counseling on opting-in grounds is ethically sound (enhances the woman's reproductive autonomy), since most clients in need of abortions are certain on their decisions before the abortion care provider and do not regret these decisions after the process. Regrets are prone to be more prevalent in areas with high unsafe abortion practices, generally due to complications from excessive bleeding, pain, and post abortion infections. Allowing systematic mandatory pre-abortion counseling practice as the rule in a competent adult is unjustified ethically and empirically, is time consuming and presents the legality of abortions in most settings an oxymoron.
Los textos incluidos en esta obra precisan los distintos alcances conceptuales, dogmáticos y jurisprudenciales derivados de la creciente relación entre el campo del derecho constitucional y del derecho familiar, en una perspectiva comparada. Con ese objetivo en mente, se da cuenta de una serie de innovaciones teóricas y avances jurisprudenciales observables en distintas jurisdicciones, en especial, las de Argentina, Brasil, Chile, Colombia, los Estados Unidos de América, Holanda, México y Reino Unido. Una obra imprescindible para conocer las perspectivas comparadas en derecho de familia en torno a temas como la constitucionalización del derecho de familia, autonomía y matrimonio, reconocimiento de matrimonio entre parejas del mismo sexo, responsabilidad parental, derecho procesal familiar, entre otros.
https://www.sitios.scjn.gob.mx/cec/biblioteca-virtual
Deeply held religious beliefs may conflict with some aspects of medical practice. But doctors cannot make moral judgments on behalf of patients
Shakespeare wrote that “Conscience is but a word cowards use, devised at first to keep the strong in awe” ( Richard III V.iv.1.7). Conscience, indeed, can be an excuse for vice or invoked to avoid doing one's duty. When the duty is a true duty, conscientious objection is wrong and immoral. When there is a grave duty, it should be illegal. A doctors' conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient's good and the patient's informed desires (box). If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.
Doctors have always given a special place to their own values in the delivery of health care. They have always had greater knowledge of the effects of medical treatment, and this fostered a belief that they should decide which treatments are appropriate for patients— that is, paternalism. Their values crept into clinical decisions.1 2 This has been squarely overturned by greater patient participation in decision making and the importance given to respecting patients' autonomy.3 More recently, doctors' values have reappeared as a right to conscientiously object to offering certain medical services. Examples include, refusal to offer termination of pregnancy, especially late term termination, to women who are legally entitled to it and refusal to provide reproductive advice and help to gay couples, single …
Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any action contrary to their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care.
The literature on conscience in medicine has paid little attention to what is meant by the word 'conscience.' This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one's ability, and (2) the activity of judging that an act one has done or about which one is deliberating would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed.
Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on one's conscience. Second, I sketch an account of the basis of the medical and pharmacy professions' responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the "conventional compromise" as a reasonable accommodation to conflicts between these professions' responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: "Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?".
This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested.
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