There are many questions that arise for healthcare professionals involved with abortion care. Who should perform abortions? How and where should they be performed? What training should clinicians have? Many think the answer to the question, ‘Do you perform or assist in abortions?’ is simply yes or no; however, the reality is that ‘maybe’ is also a possible answer. This issue is not black and white, there are many grey areas.
What is conscientious objection (CO)? It is an objection to an action based on moral, religious or philosophical grounds. The issue of CO first became prominent during the World War I, when men refused to fight on religious or political grounds.
What is a conscience? It is an attribute that allows a person to form a sense of right and wrong, and to decide how one should behave when faced with a moral choice. It is a unique faculty that is fundamental to our humanity. Conscience is not infallible and can change.
In New Zealand, the statutes that govern abortion are the Contraception, Sterilisation and Abortion Act 1977, the New Zealand Bill of Rights Act 1990 and the Health Practitioners Competence Assurance Act 2003. This legislation is adapted for healthcare providers in the following documents:
- For the Medical Council of New Zealand (MCNZ): Good Medical Practice
- For the Nursing Council of New Zealand: Code of Conduct
- For the Midwifery Council of New Zealand: Code of Conduct
I feel privileged to work in New Zealand, a country where my right to object to performing abortions is protected by law.1 Doctors in Sweden, Finland and Iceland who work in public hospitals do not have this protection. In many countries, nurses do not have this protection either.2 3 The three countries I have worked in each have different laws and, more importantly, different attitudes and interpretation of laws, which leads to markedly different practices. New Zealand employs many medical professionals who have trained and practised in other countries. I have worked in five New Zealand hospitals and, until my current hospital, I had never been asked if I had an objection to performing abortions. I have had to negotiate my own way. This has often been difficult, as some situations have been in conflict with my conscience and my team has not always been prepared for this.
A year ago, I unwittingly joined a discussion on abortion in the tea room. The nurses were discussing a historical event, where a woman undergoing a medical termination began bleeding heavily. The gynaecology registrar conscientiously objected to abortion and declined to attend. The obstetric registrar was unavailable and the nurses felt isolated, unsupported and angry with the registrar. Not realising how traumatic the event had been, I enthusiastically joined the conversation. The staff were surprised to discover that I, too, did not perform abortions. I attempted, without success, to put across the fact that we work in teams and that the hospital is responsible, overall, for women being treated in their facility. I realised there were some very strong views and, sadly, the discussion became personal. I was surprised and disappointed that other viewpoints were not tolerated4 and that the law and rights of a healthcare provider5 were misunderstood. I do not know the full details of the event, but it sounded like the doctor involved was also misinformed. This further supports my view that we should be more open about abortion services.
It was after this encounter that I approached the clinical director to start a conversation on CO. I argued that, if we want to give women the best care, we should not leave it to individuals to negotiate their way through a crisis, to only talk about it again after the next crisis. After many emails between the clinical leads, I was asked to prepare a talk for the department. I found some of the responses interesting, further supporting my arguments. One colleague thought some registrars were too young to know their views on abortion. In my talk preparation, I found the District Health Board I worked in had a policy that outlined rights, responsibilities and expectations of both the employer and the employee. There was even a form to sign at the commencement of employment. I discovered that only staff who had worked at my hospital for decades had signed the form when the hospital first starting offering abortion services. The form had somehow fallen by the wayside.
A person who objects to abortion does not need to explain why they object or justify their position. They do, however, need to outline what role they are willing to take, so that the service can be run efficiently and safely. In an emergency, staff who conscientiously object to abortion must assist, because emergency intervention is for the woman’s benefit, rather than for the purpose of procuring the termination. Ongoing emergency intervention should not be used to facilitate an abortion where staff involved object.
Women have a right to terminate a pregnancy. However, medical staff have a right not to be involved in the care of women terminating a pregnancy. People object for different reasons, to differing degrees. Upbringing, religious beliefs, laws, the political climate and personal experience all influence a person’s decisions. As a house officer, I had a registrar who changed her views when she herself became pregnant for the first time, from having no objection to abortion to only wanting to be involved when there was a serious threat to the woman’s life.
Problems arise if two ‘camps’ are created; those who perform terminations and those who do not, with each passionately defending their position. Unfortunately, the women needing care can fall between the two ‘camps’. The disagreement causes an uncomfortable and unsafe work environment. Answers to some questions need to be clarified. What is routine care? What is an emergency? Whose role or responsibility is it? Whose job is it?
I believe there needs to be ongoing organised, open discussion about abortion care. There needs to be education and upskilling of all staff involved. We should encourage mutual respect, compassion and understanding.
In my discussions with the MCNZ and my defence union, they made it clear it is important that women receive the treatment they need and are well looked after. The Medical Council are not concerned about whose role it is within an organisation, as long as it is within the clinician’s scope of practice and clinical skills set. In the document Good Medical Practice, the MCNZ does not specify abortion and applies the same standards to CO for any treatment.
I do not perform abortions. I am comfortable discussing treatment options that include abortion, for example, second-trimester rupture of membranes. However, I will refer women to a colleague if abortion is their chosen option.
Discussions around abortion can be difficult, as people have strong views and they do have a right to hold their view. I am challenged when the discussion is aimed at changing my view. I believe it is more constructive and women-centred if the discussion is focused on how to make the termination service work safely, given that I do not perform abortions.
I worked as a Senior House Officer in a Scottish hospital that had a well-run abortion service. In 2004, the termination rate in the Grampian region was around 13 in 1000 women aged 15–44 years.6 This led to at least five inpatient medical terminations a day at our hospital. The department displayed a list at the nurses’ station of medical staff who were willing to be involved in abortion care.
The abortion service was run by two specialist nurses and two gynaecologists. It was clear that those who had an objection were not to be approached for routine abortion care, including prescriptions, other than to treat sexually transmitted infections or for contraception. For prescriptions not in the standing orders, the nurses sought doctors who had no objection first. If a doctor objected to involvement, including in an emergency, the next doctor was sought, including the consultant or even the anaesthetist. We were given comprehensive training on problems in early pregnancy, including first-trimester miscarriages, and skills are transferable to first-trimester abortions. In this hospital, the registrar and consultant were offsite, so when on-call out of hours, I was the only doctor for gynaecology.
If routine medications were not charted and no one willing to do the abortion was available, the treatment was deferred or cancelled. This was a very rare occurrence. I had a very positive experience in this hospital.
We cancel or defer oncology cases if the patient needs ICU and there are no beds, yet we are happy to embark on an abortion procedure without fully equipping staff to handle emergencies and other complex situations, which require an escalation plan.
Statements that I feel are not conducive to an open, progressive discussion about abortion care:
- Why did you choose gynaecology?
- If you care about women, you should have no objection.
- It’s about the women, not about you.
- The woman has to wait for someone else when you are right here?
- You are creating more work for your colleagues.
- You are violating women’s rights.
- You are violating your oath (the original oath forbade abortion).
- The termination has already started so what difference does it make?
- It was a feticide and the baby is already dead.
- The fetus has severe malformations.
- It is your job.
In the near future, as a consultant, I may be the only doctor available with the skills that could save a dying woman’s life. I have opened a dialogue about this with myself.
We need to start talking about abortion care in our hospitals and we need to continue this conversation, because we all care about women.