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The no correlation argument: can the
morality of conscientious objection be
empirically supported? the Italian case
Marco Bo
1,2
, Carla Maria Zotti
3*
and Lorena Charrier
3
Abstract
Background: The legitimacy of conscientious objection to abortion continues to fuel heated debate in Italy. In two
recent decisions, the European Committee for Social Rights underlined that conscientious objection places safe,
legal, and accessible care and services out of reach for most Italian women and that the measures that Italy has
adopted to guarantee free access to abortion services are inadequate. Nevertheless, the Ministry of Health states
that current Italian legislation, if appropriately applied, accommodates both the right to conscientious objection
and the right to voluntary abortion.
Main body: One empirical argument used to demonstrate that conscientious objection does not create barriers to
abortion is the “no correlation”argument, which the Italian Committee for Bioethics employed to demonstrate that
no association exists between conscientious objection and waiting times for voluntary abortion in Italy and to
support the weak form of conventional comprise adopted by the Italian legislation to balance the conflict between
women’autonomy and healthcare professionals’moral integrity. Conversely, we showed how the “no correlation”
argument fails to demonstrate the absence of a relationship between the number of conscientious objectors and
waiting times for voluntary abortion, and that the limitations of the “no correlation”argument itself demonstrate
how it is still difficult to describe the real effect of conscientious objection on the access to abortion services and to
evaluate the suitability of conventional compromise to effectively balance conflicting moral principles.
Conclusion: Further studies are needed to better describe the relationship between conscientious objection and
waiting times for voluntary abortion. If new evidence would show that the increasing proportion of objectors does
undermine the efficacy of the Italian law and the right of a woman to freely obtain a voluntary abortion, new ways
will need to be found to address the conflict between moral principles and restrict the protection accorded to the
principle of moral integrity. This would inevitably imply the need to constrain and to redefine the terms and
conditions for claiming conscientious objection.
Keywords: Conscientious objection, Voluntary abortion, Waiting times, Correlation, Moral principles, Moral integrity,
Right
Background
The legitimacy of conscientious objection to abortion
continues to fuel heated public debate in Italy. Media
reports of barriers to abortion created by the lack of
hospital staff willing to perform termination of preg-
nancy have galvanized opinion on both sides of the issue
[1, 2]. The Italian Ministry of Health has countered these
claims by arguing that current Italian legislation –when
appropriately applied –accommodates the right to con-
scientious objection and the right to voluntary termin-
ation of pregnancy.
In response, stakeholders and a trade union filed col-
lective claims with the European Committee for Social
Rights (ECSR). In two recent decisions, the Committee
stated that Italy violated art. 11§1 (right to health) and
art. E (right to no discrimination) of the European Con-
vention of Social Rights. In particular, the ECSR under-
lined that conscientious objection places safe, legal, and
* Correspondence: carla.zotti@unito.it
3
Department of Public Health and Pediatrics, University of Turin, Via Santena
5 bis, 10126 Torino, Italy
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Bo et al. BMC Medical Ethics (2017) 18:64
DOI 10.1186/s12910-017-0221-x
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
accessible care and services out of reach for most Italian
women and that the measures that Italy has adopted
remain inadequate [3, 4].
To demonstrate that the right to exercise conscien-
tious objection does not deny the right to obtain abor-
tion, the Government principally resorted to empirical
data from the Italian healthcare information system on
voluntary abortion. One of the empirical arguments ral-
lied to demonstrate that conscientious objection does
not create a barrier to access to abortion has been firstly
proposed by the Italian Committee for Bioethics (CNB)
in its opinion statement on conscientious objection in
healthcare and qualified as the “no correlation argu-
ment”. The no correlation argument works as follows:
by comparing from two non-consecutive years the pro-
portion of objectors and the proportion of women who
obtain abortion promptly (within 14 days from the
request) or later (between 22 and 28 days), data show
different if not opposing “trends”at the regional level (in
some regions waiting time decreases as the proportion
of objectors increases, while in others waiting time in-
creases as the proportion of objectors decreases). Based
on these results, the no correlation argument concludes
that no relationship exists between conscientious objec-
tion and waiting times for voluntary abortion in Italy,
and that waiting time is a consequence of the way
regional healthcare systems organize the delivery of
abortion services. Thus, conscientious objection per se
does not impair women’s right to abortion [5].
This paper aims to show that the no correlation argu-
ment fails to demonstrate the absence of correlation
between conscientious objection and waiting times for
voluntary abortion in Italy and that the argument cannot
exclude an association between the two phenomena.
Moreover, the paper will show that the limitations of the
no correlation argument underline that it is still difficult
to understand the effect of conscientious objection on
voluntary abortion in Italy and that using an empirical
argument to sustain the morality of conscientious objec-
tion raises a series of questions about which instruments
should be used to describe facts and to empirically dem-
onstrate or exclude causal effects.
Main text
Conscientious objection to voluntary abortion in Italy:
Legislation and balance between moral principles
Under Italian law 194/78 on voluntary abortion, a woman
may freely and anonymously obtain a voluntary abortion
in a public hospital. In order to obtain abortion, a woman
must submit a written request to an authorized physician.
After having verified that the legal requirements for a vol-
untary abortion have been met, the physician must issue a
medical certificate. But the law imposes a 7-day waiting
period before the woman can go to a hospital to obtain
termination of pregnancy.
Healthcare providers can claim conscientious objec-
tion to performing an abortion. The refusal to perform
abortions is definitive, and healthcare providers can
claim conscientious objection by written statement at
any time in their career. Objectors are under no obliga-
tion to explain or justify the reasons for their objection
or to perform other duties to compensate for their
decision not to perform abortions. The Italian abortion
law mandates the regional healthcare systems to
organize the delivery of abortion services through staff
mobility and differentiated recruitment of non-objecting
providers. Further, the regional healthcare systems must
collect annual data about the number of voluntary abor-
tions performed and the number of conscientious objec-
tors on duty at facilities. Finally, the Ministry of Health
sends the Parliament an annual national report on the
application of the law.
Theoretically, the Italian law on voluntary abortion
seeks to strike a compromise between the principle of
reproductive autonomy –which states that an individual
has the right to decide whether and how to reproduce –
and the right to individual moral integrity –which states
a person cannot be forced to act against his/her own
conscience. According to Italian law, prima facie both
principles should assume equal value, so that they must
receive the same degree of legal protection: women can
obtain an abortion and healthcare providers can opt out
of performing it.
Nevertheless, any healthcare provider can unquestion-
ably refuse to perform an abortion, independent of the
number of objectors who are already on duty. Thus, the
proportion of objectors may theoretically increase and
raise the total number of healthcare providers available
in a geographic area. In such a scenario, the State has no
way of guaranteeing the right to abortion, because there
could be no more professionals willing to perform the
procedure.
It is evident that although prima facie the law was
intended to ensure equal value to both principles, it has
the inherent the risk of conferring an absolute value to
the principle of moral integrity, thus overriding the
principle of reproductive autonomy which has de facto a
relative value.
Beyond such extreme situations, it is rational to
recognize that it is difficult –if not impossible –to en-
sure the adequate provision of abortion services when
the proportion of conscientious objectors is as high as it
now is in some Italian regions (80.7% in Abbruzzi and
Latium, 93.3% in Molise). Under these conditions and
given the low number of non-objectors, it is unlikely
that regional healthcare services and local health trusts
can appropriately guarantee this right by implementing
Bo et al. BMC Medical Ethics (2017) 18:64 Page 2 of 6
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management strategies such as conflating abortion ser-
vices, assigning non-objecting physicians or resorting to
non-objector staff mobility to cover them. It is not by
coincidence that many women have reported they faced
serious difficulties to obtain an abortion within the first
trimester of pregnancy or had to travel to another prov-
ince, region or country to obtain an abortion.
In this context, defense of the current legal right to
conscientious objection rests on the ability to demon-
strate that access to abortion services is ensured even
when a healthcare provider’s right to exercise conscien-
tious objection is unquestionable.
The no correlation argument
The no correlation argument, as first expressed by the
CNB, was developed according to the following lines:
the proportion of objectors and the proportion of
women who obtained an abortion promptly (within
14 days of submission of their request) or later (between
22 and 28 days) were compared by region and nationally
for two non-consecutive years (2006 and 2009) [5]. The
analysis showed that when 2006 and 2009 were directly
compared, the proportion of objectors increased and
waiting times decreased nationally: an increase from
69.2% to 70.7% among gynecologist objectors; an in-
crease from 56.7% to 59.3% among women who waited
less than 14 days to obtain an abortion; and a decrease
from 12.4% to 11.1%, among women who waited 22-
28 days. A similar “trend”was reportedly found for some
regions (e.g., Latium and Piedmont), whereas in other
regions (Lombardy and Umbria) the proportion of objec-
tors among gynecologists decreased and the waiting
times for abortion increased (the proportion of women
who waited less than 14 days decreased and the propor-
tion of women who waited 22-28 days increased). Differ-
ently, both the proportion of gynecologist objectors and
waiting times for abortion decreased in Emilia-Romagna.
The abortion data show different if not opposing
“trends”at the regional level: waiting time decreased as
the proportion of objectors increased in some regions,
while in others waiting time increased as the proportion
of objectors decreased (Table 1). In brief, no correlation
can be found between the number of objectors and the
length of waiting time for abortion. From this perspec-
tive, it is not the number of objectors per se that defines
access to voluntary abortion, but rather how health
trusts organize the delivery of abortion services.
In its 2015 annual report, the Ministry of Health used
the same argument based on a comparison between the
national data sets for 2006 and 2013 [6]: the proportion
of objectors among gynecologists rose from 69.2% to
70%; the proportion of women who waited less than
14 days increased from 56.7% to 62.3%; and the propor-
tion of those who waited 22-28 days decreased from
12.4% to 10.2%. The Health Ministry concluded that
while the proportion of objectors had increased, the
length of waiting times had decreased –in other words
–had improved. As in the previous comparison, the
regional data showed a decrease in waiting times despite
the increase in the proportion of objectors (e.g., Latium
and Piedmont), whereas an inverse “trend”was found
for Lombardy and Umbria, and a decrease in both wait-
ing times and the proportion of objectors in Emilia-
Romagna (Table 1).
The limitations of the no correlation argument
In authors’opinion, as currently formulated, the no
correlation argument shows significant limitations. First,
the way the data were selected limits the extent to which
conclusions can be drawn from them. The Italian
national surveillance system collects data on voluntary
abortion since 1980, and ministerial reports are pre-
sented annually to the Italian Parliament. Nonetheless,
data collected during two non-consecutive years were
compared, assuming that a consistent trend was present
in the period between those 2 years and in the previous
ones. While any reason to explain this is absent the
choice seems to have been an arbitrary one and risks
describing random facts related to the years chosen for
the comparison as representing a consistent trend.
To demonstrate this limitation, we can apply the pro-
cedure used to develop the no correlation argument to
data sets from a different couple of years. For example,
if we compare data collected in 2009 and 2013, instead
of those from 2006 and 2009 (or 2006 and 2013), we will
see that at the national level both the proportion of ob-
jectors and the length of waiting time for voluntary
abortion decreased. Indeed, the proportion of objectors
decreased from 70.7% in 2009 to 70% in 2013, the pro-
portion of women who waited 14 days or less to have an
abortion increased from 59.3% to 62.3%, while those
who waited 22-28 days to have an abortion decreased
from 11.1% to 10.2% (Table 1).
Second, the term “correlation”is inappropriately used
for the no correlation argument. In everyday life “correl-
ation”means some form of association between events
that seem to be linked (e.g., children’s height and age).
In statistics, correlation indicates an association between
two quantitative variables and it assumes that this asso-
ciation is linear. The degree of this type of association is
usually measured by calculating a correlation coefficient
(Pearson’s r or Spearman’s rho) on a scale that varies
from +1 (perfect positive correlation) to −1 (perfect
negative correlation), and 0 means the complete absence
of correlation [7]. Based on this definition, what the
CNB did is just a direct comparison of prevalences
extrapolated from two arbitrarily chosen years.
Bo et al. BMC Medical Ethics (2017) 18:64 Page 3 of 6
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Third, the no correlation argument excludes a causal
effect between conscientious objection and waiting times
for abortion based on the lack of a clear association be-
tween the proportion of objectors and the proportion of
women who obtained an abortion within specific waiting
periods (14 days or later). In our opinion, this conclu-
sion is incorrect if not misleading. Correlation studies
evaluate whether two events are directly (A increases as
B increases) or indirectly (A decreases as B increases)
linearly related, but they cannot be used to demonstrate
causal effects. Thus, if we take two parameters (A and B)
which can assume different values during time and in
space (a1, a2,…an e b1, b2,…bn), and we observe that B
decreases by a fixed amount for each unit increase in A,
we may state that A and B –and the events they
describe –are correlated, but we cannot state that B
decreases because of an increase in A. Thus, observing
an indirect correlation between the proportion of objec-
tors and the proportion of women who obtained a
voluntary abortion within 14 days of the request does
not mean that the increase in the proportion of objec-
tors caused a decrease in the proportion of women who
quickly obtained an abortion. Similarly, finding no
correlation (meant as a linear relationship) between two
parameters cannot exclude other types of relationships
(non linear) between them.
In a previous ecological study in which we used both
national and regional data (extrapolated from ministerial
reports) from a longer time period (from 1997 to 2011)
and took into account the increased workload for non-
objectors due to the presence of objectors working at
the same facility, we found a correlation (in its statistical
meaning) between the gynecologists’workload and the
proportion of women who obtain an abortion within dif-
ferent time intervals. In particular, the increased work-
load for non-objectors was inversely correlated with the
proportion of women who promptly obtained an abor-
tion (within 14 days of their request) and was directly
Table 1 Proportion of conscientious objectors and women who obtained a voluntary abortion promptly (≤14 days) or later (22-
28 days): three comparisons
Gyn. objectors
% (n)
Waiting time ≤14 days
% (n)
Waiting time 22-28 days
% (n)
Comparison (2006 vs 2009) proposed by the Italian Commitee for Bioethics
2006 2009 changes 2006 2009 changes 2006 2009 changes
Italy 69.2 (3780) 70.7 (3985) ↑56.7 (68217) 59.3 (65919) ↑12.4 (14875) 11.1 (12313) ↓
Latium 77.7 (443) 80.2 (315) ↑47.8 (7190) 54.0 (7070) ↑17.2 (2584) 13.3 (1738) ↓
Piedmont 62.9 (285) 63.8 (284) ↑51.1 (5635) 60.1 (5705) ↑13.7 (1508) 10.8 (1020) ↓
Lombardy 68.6 (578) 66.9 (560) ↓58.6 (12763) 56.0 (9868) ↓11.3 (2463) 11.5 (2024) ↑
Umbria 70.2 (73) 63.3 (62) ↓51.0 (1089) 40.0 (754) ↓13.3 (284) 19.0 (358) ↑
Emilia-Romagna 53.5 (198) 52.4 (205) ↓56.8 (6510) 62.0 (6712) ↑11.1 (1274) 8.3 (899) ↓
Comparison (2006 vs 2013) proposed by the Italian Ministry of Health
2006 2013 2006 2013 2006 2013
Italy 69.2 (3780) 70.0 (3481) ↑56.7 (68217) 62.3 (61254) ↑12.4 (14875) 10.2 (10013) ↓
Latium 77.7 (443) 80.7 (314) ↑47.8 (7190) 54.0 (6020) ↑17.2 (2584) 13.5 (1509) ↓
Piedmont 62.9 (285) 67.4 (269) ↑51.1 (5635) 68.3 (5775) ↑13.7 (1508) 7.4 (626) ↓
Lombardy 68.6 (578) 63.6 (565) ↓58.6 (12763) 54.4 (8708) ↓11.3 (2463) 13.5 (2157) ↑
Umbria 70.2 (73) 65.6 (63) ↓51.0 (1089) 43.8 (717) ↓13.3 (284) 17.6 (288) ↑
Emilia-Romagna 53.5 (198) 51.8 (231) ↓56.8 (6510) 73.7 (6754) ↑11.1 (1274) 4.8 (442) ↓
Comparison (2009 vs 2013) proposed by the authors
2009 2013 2009 2013 2009 2013
Italy 70.7 (3985) 70.0 (3481) ↓59.3 (65919) 62.3 (61254) ↑11.1 (12313) 10.2 (10013) ↓
Latium 80.2 (315) 80.7 (314) ↑54.0 (7070) 54.0 (6020) ≈13.3 (1738) 13.5 (1509) ↑
Piedmont 63.8 (284) 67.4 (269) ↑60.1 (5705) 68.3 (5775) ↑10.8 (1020) 7.4 (626) ↓
Lombardy 66.9 (560) 63.6 (565) ↓56.0 (9868) 54.4 (8708) ↓11.5 (2024) 13.5 (2157) ↑
Umbria 63.3 (62) 65.6 (63) ↑40.0 (754) 43.8 (717) ↑19.0 (358) 17.6 (288) ↓
Emilia-Romagna 52.4 (205) 51.8 (231) ↓62.0 (6712) 73.7 (6754) ↑8.3 (899) 4.8 (442) ↓
Data refer to those cited in ‘The no correlation argument’section of the paper and are an extract of data published in the 2012 opinion of the Italian Committee
for Bioethics (2006 vs 2009) and in the 2015 Ministerial report (2006 vs 2013). ↑: the proportion increased; ↓: the proportion decreased; ≈: the proportion did
not change
Bo et al. BMC Medical Ethics (2017) 18:64 Page 4 of 6
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correlated with the proportion of women who obtained
an abortion 21 days after the request or even later, at
both the national level and in seven Italian regions [8].
Fourth, the no correlation argument considers only
gynecologist conscientious objectors, whereas conscien-
tious objection to abortion is a very complex phenomenon
to describe and understand. It is the result of the inter-
action of many actors who operate at the same time or at
different times in different services: a surgical abortion
involves a surgical team composed of a gynecologist, a
midwife, and an anesthesiologist, all of which must be
non-objectors. Furthermore, these professionals work dif-
ferent shifts and are on duty in different wards (e.g.,
gynecology, anesthesiology, operating room). It is clear
that the proportion of non-objectors among gynecologists
and their workload are only two of the many factors that
go into the analysis of how conscientious objection may
affect access to voluntary abortion.
Can we state that conscientious objection does not
restrict women’s access to voluntary abortion?
The data extrapolated from the ministerial reports are
unsuitable to evaluate whether or not conscientious
objection restricts access to voluntary abortion among
Italian women. Nevertheless, it is not by chance that two
recent ECSR judgments stated that the Italian Government
did not provide suitable data to prove that the claimants’
thesis were wrong [3, 4]. In order to empirically sustain the
thesis that conscientious objection does not restrict
women’s access to abortion, other studies are needed that
take into account the effect of potential confounders that
may influence the relationship between conscientious ob-
jection and waiting times for abortion (e.g., age, nationality,
civil status, education, previous pregnancies of the women
involved, location and opening times of the services, etc.).
A desirable step forward could be to analyze data at
the individual level rather than in an aggregate form, as
has been done till now. With this approach, we could
evaluate for each case of voluntary abortion whether –
during her clinical path –the woman, complete with her
social, demographic, and clinical characteristics, met
objectors or had gone to a health facility that had re-
fused to perform the procedure, how many times, in
which facilities, and whether these facts influenced the
time interval between the day the abortion was per-
formed and the day it had been requested.
Moreover, it would be important to know how health
trusts manage the provision of abortion services: e.g.,
their number and location (in urban, rural or mountain
areas), the number and type of providers (gynecologists,
anesthesiologists, midwives, etc.) willing to perform an
abortion, the number of surgical voluntary abortions,
whether the populations served significantly differ across
facilities, waiting times and active and passive mobility
for the delivery of voluntary abortion services at each fa-
cility. Current abortion legislation does not mandate
such analyses, which demand time, dedicated personnel,
economical resources, and periodical updates. In
addition, such studies work well if supported by central
coordination of an adequate number of health trusts in
order to obtain a representative sample at the national
or regional level.
Conclusions
The no correlation argument fails to exclude a relation-
ship between the number of conscientious objectors and
waiting times for voluntary abortion. Indeed, it cannot
exclude the possibility that the increase in the number
of objectors restricts women’s access to abortion in Italy.
Furthermore, its limitations and methodological flaws
underline that the data used till now are insufficient to
answer the question. Currently, we do not know the real
effect of conscientious objection on access to voluntary
abortion in Italy, as compared with other countries
where conscientious objection is allowed and involves a
relevant proportion of healthcare providers. This is why it is
necessary and urgent to conduct further studies designed to
better describe the relationship between conscientious
objection and waiting times for voluntary abortion. If new
data show that the increasing proportion of objectors un-
dermines the efficacy of the legal provisions to ensure the
delivery of voluntary abortion, new ways will need to be
found to address the conflict between the principles of
reproductive autonomy and moral integrity. This would in-
evitably imply the need to constrain and to better define the
terms and conditions for claiming conscientious objection.
At that point, nearly 40 years after abortion became legal in
Italy, the stage will be set for a more balanced debate on the
morality of conscientious objection to abortion and for a
re-evaluation of whether it is appropriate to grant this right
or it is preferable to follow the example of European coun-
tries where conscientious objection is not contemplated.
Abbraviations
CNB: National Committee for Bioethics; ECSR : European Committee for
Social Rights
Acknowledgements
The authors wish to thank Kenneth Britsch who has assisted with linguistic
revision.
Funding
No funding was received for this study.
Availability of data and materials
Not applicable.
Authors’contributions
All authors contributed to the design of the manuscript. MB and LC were
major contributors in writing the manuscript. CZ revised the manuscript. All
authors read and approved the final manuscript.
Bo et al. BMC Medical Ethics (2017) 18:64 Page 5 of 6
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Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Research Group in Bioethics, University of Turin, Turin, Italy.
2
Consulta di
Bioetica onlus, Turin, Italy.
3
Department of Public Health and Pediatrics,
University of Turin, Via Santena 5 bis, 10126 Torino, Italy.
Received: 9 May 2017 Accepted: 7 November 2017
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