Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons

Abstract

BackgroundFreedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion.MethodWe conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection.ResultsOf an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons (n = 58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories.ConclusionsWe identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.

Accommodating conscientious objection in the midwifery workforce: a ratio-data analysis of midwives, birth and late abortions in 18 European countries in 2016

“…[29] However, in the last two years the topic of midwives or nurses in relation to conscientious objection has come to the fore with two articles emphasising their invisibility. [9,28] Taking into account the divergence of opinions shown by both academic writers and policy makers and the lack of visibility of midwives, we believe that the whole debate on conscientious objection would benefit from giving consideration to numerical data, not simply considering the numbers of abortions but their relationship to other variables.…”

“…[10] This has the potential to cause much pain and controversy for both service users and providers. One of the major arguments in the present time, rather than concerning the right of women to have abortions, is about the rights of health professionals to object on conscience grounds to providing abortion services [9] a key issue being that this could create imbalances in the workforce. Such arguments exist despite most countries laws including this right and conscience, as a core element of human rights, being protected in documents such as the European Convention on Human Rights.…”

Accommodating conscientious objection in the midwifery workforce: a ratio-data analysis of midwives, birth and late abortions in 18 European countries in 2016

“…Conversely, many European countries permit abortion on the request of the women in the first trimester of pregnancy, while others require medical authorisation from the outset. Despite legislation, abortion remains a very volatile subject, with arguments highly polarised; [6] the topic often being portrayed in the media as pro-life vs pro-choice or even rampant feminism vs religious fanaticism. [7] This has the potential to cause much pain and controversy for both service users and providers.…”

“…[7] This has the potential to cause much pain and controversy for both service users and providers. One of the major arguments in the present time, rather than concerning the right of women to have abortions, is about the rights of health professionals to object on conscience grounds to providing abortion services [6] a key issue being that this could create imbalances in the workforce. Such arguments exist despite most countries laws including this right and conscience, as a core element of human rights, being protected in documents such as the European Convention on Human Rights.…”

“…[20] Taking a nuanced approach, Neal [21] suggests that the apparent expansion of conscientious objection claims is based on poorly defined or even contradictory professional guidelines and there is a need for sound research establishing working definitions. What is evident from the literature is that its key focus is on medical practitioners and if midwives are mentioned it is in a secondary position [6] despite the WHO's emphasis on them as key providers of abortion services. [24] This has most recently been discussed in two articles, one specifically focusing on abortion [6] and the other on end of life care,[25] each of which urged nurses and midwives respectively to be more proactive in contributing to the debate.…”