New Study Identifies Avenues for Intervention

August 10, 2016

Health care providers who invoke conscientious objection to providing or participating in abortion care in Bogotá, Colombia, can be categorized along a spectrum of objection—extreme, moderate and partial—finds a new study published in International Perspectives on Sexual and Reproductive Health. The study, “‘The Fetus Is My Patient, Too’: Attitudes Toward Abortion and Referral Among Physician Conscientious Objectors in Bogotá, Colombia,” by Lauren Fink of Emory University, et al., seeks to understand conscientious objection from the perspective of objectors themselves in order to help identify potential interventions to ease the burden of conscientious objection as a barrier to care.

When the Colombian Constitutional Court partially decriminalized abortion in 2006, the Court established a right to abortion in three circumstances: when the life or health (including mental well-being) of the mother is at risk; when a fetal anomaly is incompatible with life; and when the pregnancy is the result of rape, incest or forced insemination. The Court also outlined guidelines for health care providers who wish to invoke conscientious objection. Individuals can object, but institutions cannot; objecting physicians have a duty to refer patients to another provider; and conscientious objection “may not involve disregard for the rights of women.” Nevertheless, improperly exercised conscientious objection is not uncommon in Colombia, leading many women to seek clandestine abortions, which are often unsafe. The authors conducted in-depth interviews with 13 key informants and 15 Colombian physicians who self-identified as conscientious objectors to better understand how conscientious objection is exercised.

On the basis of these interviews, the study finds that objection falls along a spectrum; it identifies three types of objectors, according to a set of characteristics shared among them. Extreme objectors believe it is their medical, ethical and religious duty to refuse to perform abortions and to prevent their patients from having an abortion. To that end, they try to change their patients’ minds, provide misleading legal and medical information, and refuse to refer their patients.

Moderate objectors tend to be religious, but are more tolerant of other perspectives; they do not seek to actively stop their patients from having abortions and do provide referrals. They also tend to be strong advocates for birth control, including emergency contraception, which they view as preventing abortions. They are generally informed by medical ethics and a commitment to “protect life,” including that of the fetus.

Partial objectors fall into two subcategories: They object either on the basis of gestational age or on a case-by-case basis. Those whose objection is based on gestational age are not motivated by religion and do not consider themselves opponents of abortion. Many are concerned about performing abortions on potentially viable fetuses, although some refuse to perform abortions even early in gestation, citing other concerns. More research is needed on the motivations of case-by-case objectors; one physician interview and comments by key informants suggest that this kind of partial objection is not unusual.

The researchers urge that in order to develop effective interventions to reduce improper use of conscientious objection as a barrier to safe and legal abortion, objectors should not be treated as a homogenous group. Instead, interventions should be tailored to target different types of objectors. For example, dialogues on the value of referral between moderate and extreme objectors who share religious beliefs could help some extreme objectors move toward offering referrals so that their patients do not seek clandestine—and potentially unsafe—abortions. The authors also recommend that continuing medical education and medical school curricula be revised to broaden the bioethical perspective on abortion and reflect the decriminalization of abortion. Furthermore, all physicians, regardless of their objector status, would benefit from values clarification exercises and training about the health exception in the abortion law. Finally, the researchers suggest that the limited nature of the decriminalization of abortion in Colombia allows conscientious objectors to act as gatekeepers and mislead women about their rights. Expanding the country’s abortion law to allow abortion on request, they say, would maintain objectors’ rights while reducing their ability to act as barriers to safe, legal abortion care.

“‘The Fetus Is My Patient, Too’: Attitudes Toward Abortion and Referral Among Physician Conscientious Objectors in Bogotá, Colombia,” by Lauren Fink et al., appears in International Perspectives on Sexual and Reproductive Health and is currently available online.

Source: Guttmacher Institute