When Health Care Providers Refuse Care, Whose Rights Are At Stake?

@RHRealityCheck

Recently, an appeals court in Scotland ruled that a wide range of service providers have a right to object to helping with the provision of abortions, even if the care they provide is not directly related to the termination of a pregnancy. In the original ruling, last year, the duties carried out by the two Catholic midwives who brought the case had been considered so removed from the actual abortion that there could be no objection. The appeals court, however, disagreed. Everyone even tangentially involved, it said, has the right to object to providing a wide range of services. The only exception would be life-saving care.

This ruling highlights issues that have relevance beyond Scotland.

The tragic death of Savita Halapannavar in Ireland last year crystallized that no one really knows for sure when a woman is dying from pregnancy-related complications. Over the years, I have interviewed dozens of medical providers in countries with restrictive abortion laws. A key concern for the vast majority of them was how to make sure their actions were legal. Those working in countries where only life-saving abortions are permitted often expressed fear that they would either turn too many women away, with fatal consequences, or ultimately lose their license for providing care to someone who wasn’t “dying enough.”

Let’s apply this notion in a context where anyone involved, however tangentially, in the provision of abortion services, can refuse to treat a woman who is not dying.

This situation raises questions which, regardless of the answers given, compromise quality care. Who gets to determine how lethal each pregnancy is? Can a treating doctor compel assisting midwives or nurses to intervene if she or he believes the patient otherwise will die? And would midwives and others have the right to sue if they had been compelled to help provide an abortion to a woman who ultimately survived? There are no good answers to these questions, and any regulatory solution would almost inevitably lead to substantial delays in care.

Another key concern with a broadly defined right to conscientious objection in the context of health care is access to care in remote—or sometimes not so remote—areas. In the United States, much anti-choice activism is directed at making abortion impossible rather than illegal. Legislators, judges, and other officials in states including Mississippi, Virginia, and North Carolina have made it their goal to run every last abortion provider out of their state. Already, 35 percent of the U.S. population lives in counties without an abortion provider.

Moreover, broad conscientious objection clauses in combination with the stigmatization of abortion generally can stifle the provision of care anywhere. In small communities where everybody knows each other and where abortion is thought of as “evil,” doctors, nurses, and midwives often object to providing care out of fear rather than faith. After all, they still have to make their living where they are.

When I researched access to abortion for rape victims in Mexico, I came across various innovative “solutions” to this problem. In one area, abortion teams were circulated between public hospitals to ensure that no one had to provide care in his or her home town. In another, abortions were provided with the knowledge only of the senior-most officials at selected hospitals, with the result that many women in need of urgent care were turned away because “we don’t do that here” (even at hospitals where they, in fact, did).

Neither of these approaches solved the underlying problem: that abortions are seen as separate from other medical care (which they are not), and that abortion providers are considered different from other medical providers (again, not true). As a result, patients had to seek legal care in a clandestine manner, and in many cases the additional option of conscientious objection for anesthesiologists or nurses—who were not part of the core teams—made abortions virtually impossible to obtain.

Everyone has the right to freedom of thought, religion, and conscience. But international human rights standards do not protect our right to express those thoughts or that conscience in a manner that infringes on other people’s human rights. The more I learn about the concrete repercussions of conscientious objection in the context of health care, the more it is clear to me that there is no room for it. Ultimately, if you don’t want to provide the obstetric or gynecological services your patient needs—which may include an abortion—maybe you should choose another field of specialty.

I Know This Much Is True: Abortion Is A Medical Intervention to Which Women Need Access

@RHRealityCheck

Savita Halappanavar’s death is personal to me.

No one knows for sure yet what happened to Savita Halappanavar. We know that she wanted to be pregnant, that she miscarried, and that the care she received did not save her life. It is important to push for medical accountability in such cases, and to demand a full investigation into whether protocols existed and were followed, and if the patient was subject to discriminatory harassment and remarks, as has been alleged. It is positive that an expert has been appointed to carry out such an investigation.

But we do not have to wait for the investigation to highlight what we already know about abortion in Ireland. For me, this knowledge is weighty and painful.

In 2009, I went to Ireland with a colleague to talk with women, medical providers, and government officials about the impact of Ireland’s restrictive abortion laws on women’s health and lives. No government official agreed to receive us despite multiple requests for meetings. This refusal was the backdrop of the desperation and sadness that was palpable in the voices and testimonies of all the women, doctors, social workers, and community educators we spoke to.

And here is what I learned.

I learned that the Irish government has yet to regulate access to life-saving abortions in Ireland, despite the fact that such medical interventions have been legal in that country for two decades. I learned that the legality of abortion where the pregnant women’s life is in danger was upheld by the Irish Supreme Court in 1992 and supported by a referendum that same year. So while abortion, generally, is criminalized in Ireland, women whose lives are threatened by their pregnancy are constitutionally entitled to have an abortion in Ireland.

And in 2010, I saw that the European Court on Human Rights berated the Irish government for not regulating access to life-saving abortion clearly, creating insecurity for medical providers and patients alike. In 2011 the United Nations Human Rights Council issued various recommendations to the same effect.

My research taught me that many medical providers in Ireland want clarity on when they can intervene and when they cannot. Some asked me how the government proposes they treat a woman who may or may not die as a result of her pregnancy. Should they tell her to come back when she was sure she was going to die? How would she know? And what if it was too late? Who would be responsible for such preventable deaths? In fact, during our research in 2009, and despite the fact that abortion in life-threatening cases had been legal for almost two decades, we were not able to find one single medical provider who had ever heard of a life-saving abortion taking place in Ireland.  

But more than anything, I learned about the pain and fear pregnant women face when something is clearly wrong with their pregnancy and they know they can’t get care near home. I know this because they told me. Some told me with their heads bowed, others sitting straight up. Some told me calmly, others cried. They all spoke with quiet, sad voices about a society that does not see their suffering and a government that does not seem to care.

Savita Halappanavar’s death, however it happened and whomever (if anyone) is responsible for delivering substandard care, should serve as an opportunity for a deeper and more respectful conversation on this topic in Ireland.

Abortion is a medical intervention to which women need access, some to save their lives. This is not an opinion; it is a fact, evidenced by the thousands of women who travel from Ireland to the United Kingdom or mainland Europe to terminate pregnancies every year.

And knowing this, how can we not act?

Access to Abortion in Ireland—A Key Human Rights Issue

(Originally published by the National Women's Council of Ireland)

Last week, Human Rights Watch launched our most recent report on women's rights -- "A State of Isolation: Access to Abortion for Women in Ireland". The report was based on interviews and research we conducted in Dublin, Cork, London, Birmingham, and Washington DC in mid 2008. And though the word "abortion" features prominently in the title, the report is about much more than abortion.

It is about the thousands of women who face crisis pregnancies every year in Ireland. And above all, it is about a government that actively sabotages their health.

Through our interviews with women who had traveled abroad for abortions, with medical practitioners, and with social workers, we documented the consistent obstacles women and girls face to independent and responsible decision-making about their pregnancies. They are not allowed to access the services they need within Ireland, they are aggressively discouraged from seeking the care they need abroad, and they cannot trust that the advice they receive is accurate or complete. Indeed, at the most basic level, the report is about information.

And to demonstrate just how important information can be, I want you to imagine a woman with a crisis pregnancy.

Perhaps she is one of the girls who got pregnant as a result of sexual abuse. Perhaps she is a married woman with 3 existing children and cannot afford to feed a fourth. Perhaps she is a student. Or a refugee going through an asylum procedure. Or perhaps she feels that something is not quite right with her pregnancy, health-wise.

Either way, she is a woman who believes she cannot and must not carry her pregnancy to term. But where can she turn?

Often, she may not know. The government has made sure that information about the termination of pregnancies remains difficult to access -- even information about how to get information about the termination of a pregnancy.

Those who provide accurate information about abortions abroad cannot advertise broadly and are prevented, by law, from supporting their patients in seeking care.

Meanwhile, those agencies who claim not to provide information about abortion remain unregulated, and therefore free to harass women and girls who are already in distress with harrowing medical claims many of which are completely inaccurate.

In many cases, the agencies that provide accurate information are indistinguishable from those that don't.

Worse still, women who depend on maternity hospitals and GPs for support also cannot be sure to get full information. Despite an exception in the law, clarified by the Supreme Court, that women have a right to an abortion within Ireland if their life is threatened by the pregnancy, there is no official protocol on when abortion might be legally performed in Ireland. Mostly doctors are reluctant to guess, and some, as a result, actively discourage pregnant women with complicated pregnancies from seeking full information about their health status: they can't do anything about it anyway.

Some might say: if the government's intention is to discourage women from having abortions, it looks as if their policy is working.

They would be wrong. Thousands of women and girls travel abroad for abortions every year. They are not prevented by the misleading or scarce information from seeking abortions. They are preventing from seeking abortions in a timely manner. This has a detrimental effect on their health, both physically and mentally.

Abortion, as a medical procedure, is safest when provided within the first 8 weeks of the pregnancy. And the longer a woman with a crisis pregnancy has to wait for the services she needs, the deeper her distress and ordeal. If the woman is suffering through a pregnancy with fatal fetal abnormalities or that has been the result of rape or incest, this is in some cases even more true. By stalling women's access to the care they need, the Irish government is complicit in their distress.

In other words: the government contributes directly to undermining women's health, dignity, and human rights. Because though decisions related to abortion are complicated and deeply personal, they are also a question of human rights. And the Irish government has an obligation to provide women with the support and information they need to navigate those decisions.