From Uruguay to Chile, medical staff are refusing to provide abortion services even after their legalization.
By Diana Cariboni / 07.18.2018
Women’s rights to legal abortion have increased in Latin America – but so have campaigns and policies for medical staff to be able to ‘conscientiously object’ and refuse to participate in these procedures.
“We didn’t see it coming,” said feminist activist Lilián Abracinskas in Uruguay, a secular country where abortion, same-sex marriage and the marijuana market were each legalised in the last decade.
Abracinskas told 50.50 that many people assumed conscientious objection provisions “would have no impact” on services in the country. “We really never discussed it, and then it became a problem,” she said.
“Conscientious objection is a serious barrier” to women’s access to services in Chile, where a 2017 law relaxed some restrictions on abortion, added sociologist and sexual and reproductive rights advocate Claudia Dides.
“There is a strong group of anti-abortion doctors; midwives can’t practice abortions by themselves, so this is an obstacle,” she said.
The use of ‘conscientious objection’ arguments is common in both Uruguay and Chile. Available estimates suggest that at least one out of three gynecologists in these countries are objectors, and even more in some areas.
In several cities and clinics, 50.50 has learned, there are no doctors who do not object, forcing women to travel and some to struggle to access their recently-won rights – hitting the poorest women hardest.
In Argentina, meanwhile, women’s rights advocates fear new efforts to widen the scope of ‘conscientious objection’ if the country passes historic abortion rights reforms, expected this August.
Ana Cristina González, a Colombian physician and member of the NGO Global Doctors for Choice told 50.50 that the spread of conscientious objection to abortion services is “an attack on gender equality.”
Conscientious objection emerged as a significant concept in the twentieth century, as one’s right to refuse to serve in the military. Now, it’s increasingly being used to claim exemptions to laws that go against individuals’ beliefs.
According to a study from the International Women’s Health Coalition, there are at least 70 countries or other jurisdictions that recognise conscientious objection in the context of providing abortion care.
Candlelight vigils have been being organised to defend conscientious objectors and protest against abortion clinics including in Colombia and Mexico, as part of the global anti-choice movement 40 Days for Life.
Internationally, conscientious objection arguments are also becoming more common in countries where abortion has been legal for generations.
In Italy, where abortion has been legal for 40 years, as many as 70% of doctors are conscientious objectors (and even more in some regions).
A bill currently in the UK House of Lords would allow medical staff to refuse to participate in abortion as well as in pre- and post-abortion care.
In Uruguay, a 2012 law legalised abortion on request within the first 12 weeks of pregnancy. But doctors may object to providing these services.
In 2013, Uruguay’s courts ruled that doctors should not be barred from influencing patients’ decisions (though they refused to extend objection rights to staff participating in other pre- and post-abortion care).
Today, local media reports often say that 30% of gynaecologists in the country are conscientious objectors, but the source of this figure is unclear. There are no official registries of objectors.
In response to a public information request earlier this year, the NGO that Abracinskas leads, Women and Health in Uruguay (MYSU), obtained an incomplete list of objection rates at 47 public and private medical institutions.
According to this document, seen by 50.50, eight institutions reported such rates of 80-100%. Another 14 disclosed those of 50-67%.
Ana Visconti at the health ministry, who estimates that the nationwide rate for objectors is actually 40%, told 50.50 that providing information on specific cities without abortion services could infringe on doctors’ privacy rights.
“What matters is that every woman seeking an abortion gets it, even if they have to be transferred to a different city. We make sure of that,” she said.
Though women may still struggle to access legal abortions in Uruguay amid conscientious objection combined with other complexities in the law.
Before receiving abortion pills, a woman must also undergo five days of ‘reflection’ and three separate medical consultations (including one with a three-member gynaecologist, psychologist and social worker team).
In small towns with high rates of conscientious objectors, or without the required professionals for these required consultations, women may need to travel up to three times to go through the necessary steps.
Francisco Coppola, associate professor of gynaecology at the University of the Republic’s School of Medicine, told 50.50 that some conscientious objectors will refer patients to other doctors who do not object.
“They are not hindering the law and we protect them,” he said. But, Coppola added, there are others who “misuse” objection provisions and “instead of informing and helping [a patient], they just tell her: ‘what you do is killing.’”
In Argentina, abortion is currently restricted to cases such as rape or if the woman’s life or health is at risk – though a historic bill to change this and widen abortion rights is currently before Congress.
Soledad Deza, a lawyer and member of Catholics for Choice previously represented Belén, a young woman who presented at an emergency room in 2014 with serious vaginal bleeding due to a miscarriage.
Accused of having had an illegal abortion, charged with aggravated murder and sentenced to eight years in prison, Belén was exonerated and released in 2017 after more than two years behind bars.
Deza has been a prominent campaigner for the bill to legalise abortion in Argentina which passed the House of Representatives in June and is now pending approval in the Senate, expected to vote on it in August.
She said conscientious objection also came up in this bill’s debates and that it was included in its text as a “key bargaining chip” for conservatives.
Already, conscientious objection is recognised in Argentina in sterilisation, contraception and (currently severely-restricted) abortion procedures.
Due to widespread use of such objections, only two of five public hospitals in Tucumán province can guarantee provision of the few abortions presently permitted by law, according to a public information request Deza submitted.
Though no objectors were reported at private clinics in the province – even if the same doctors may work at both public and private facilities. “That’s a double standard” against poor women, said Deza.
Catholics for Choice found the same thing in Jujuy, Salta, and Entre Ríos provinces and in Buenos Aires: significant numbers of conscientious objectors reported at public hospitals, but none at private clinics.
Currently, there are limits on what doctors can refuse to do. They cannot, for example, refuse to provide information on abortion and objectors are also required to perform abortions when other non-objector staff are not available.
Such limits, Deza’s concerned, could soon be challenged.
In neighbouring Chile, a 2017 law relaxed restrictions on abortions in cases of rape, where a woman’s life is at risk, or the fetus is not viable. Previously abortion had been banned in all circumstances, since 1989.
Chile’s law also recognises conscientious objection rights of gynaecologists and other health staff. The constitutional court further ruled that these rights should apply to private health facilities on an institutional level.
According to figures published in June, an average of 47% of public health gynaecologists in 33 Chilean cities are conscientious objectors. In 16 cities, these rates go beyond 50%. In seven, they range from 70% to 100%.
Other figures don’t add up – and suggest that clandestine abortions are still happening, despite legal reforms.
According to official statistics, only 309 legal abortions were performed in Chile since the law was approved, whereas previous estimates of clandestine abortions ranged from 19,000 to 160,000 a year.
Visconti at Uruguay’s health ministry said these estimates were never correct. But Abracinskas, at the NGO MYSU, said current statistics fail to capture the full picture too as they only reflect abortions performed by medical staff.
For women’s rights advocates the threat is clear: conscientious objection, popularised by pacifists as a moral argument against going to war, is putting at risk women’s access to much-needed services.
Here, Deza says, the potential result “is not a state losing a soldier – it’s a woman losing her right to access safe, legal healthcare.”
Originally published by openDemocracy under a Creative Commons Attribution-NonCommercial 4.0 International licence.