Provider Conscientious Refusal of Abortion, Obstetrical Emergencies, and Criminal Homicide Law.

Catholic doctrine's strict prohibition on abortion can lead clinicians or institutions to conscientiously refuse to provide abortion, although a legal duty to provide abortion would apply to anyone who refused. Conscientious refusals by clinicians to end a pregnancy can constitute murder or reckless homicide under American law if a woman dies as a result of such a refusal. Such refusals are not immunized from criminal liability by the constitutional right to the free exercise of religion or by statutes that confer immunity from criminal homicide prosecution. Core principles of the rule of law require the state to protect the lives of all persons equally and to place the life and health of persons above any the interests of providers have in moral integrity or in respecting the moral status of prenatal humans. In some states criminal liability related to conscientious objection also applies to corporate hospital officials.

Maternal-fetal medicine specialists' experiences of conducting feticide as part of termination of pregnancy: a qualitative study.

OBJECTIVES: This study aimed to explore maternal-fetal medicine specialists' experiences of conducting feticide in late termination of pregnancy. METHODS: Participants were recruited via email. Purposeful sampling resulted in ten maternal-fetal specialists. Semistructured interviews were used to examine their experiences of conducting feticide. Interviews occurred across four English National Health Service hospitals. Interpretative phenomenological analysis was used. RESULTS: An ongoing doctor-patient relationship when conducting feticide facilitated participants' self-image as clinicians rather than technicians. Coping involved rationalisation, with feticide viewed as 'part of the job'. Supportive team relationships helped keep emotional expression within control. Participants were not distressed if they felt, through relationship-based decision-making, that the feticide aligned with their values and legal interpretation. To avoid negative judgements, they disclosed selectively, only telling trusted individuals that they conducted feticides. CONCLUSIONS: Participants experienced conducting feticides as difficult but necessary, eliciting pride from the skills involved. Some noted management of personal distress. Optimal conditions were involvement in the process from the initial decision-making and team support. Providing feticides was deemed as potentially stigmatising, with selective disclosure employed. Training in managing feticides and guidance on providing optimal service conditions may decrease selectivity of disclosures and enhance staff well-being and the quality of feticide provisions. © 2015 John Wiley & Sons, Ltd.

Controversies and considerations regarding the termination of pregnancy for foetal anomalies in Islam.

BACKGROUND: Approximately one-fourth of all the inhabitants on earth are Muslims. Due to unprecedented migration, physicians are often confronted with cultures other than their own that adhere to different paradigms. DISCUSSION: In Islam, and most religions, abortion is forbidden. Islam is considerably liberal concerning abortion, which is dependent on (i) the threat of harm to mothers, (ii) the status of the pregnancy before or after ensoulment (on the 120th day of gestation), and (iii) the presence of foetal anomalies that are incompatible with life. Considerable variation in religious edicts exists, but most Islamic scholars agree that the termination of a pregnancy for foetal anomalies is allowed before ensoulment, after which abortion becomes totally forbidden, even in the presence of foetal abnormalities; the exception being a risk to the mother's life or confirmed intrauterine death. SUMMARY: The authors urge Muslim law makers to also consider abortion post ensoulment if it is certain that the malformed foetus will decease soon after birth or will be severely malformed and physically and mentally incapacitated after birth to avoid substantial hardship that may continue for years for mothers and family members. The authors recommend that an institutional committee governed and monitored by a national committee make decisions pertaining to abortion to ensure that ethics are preserved and mistakes are prevented. Anomalous foetuses must be detected at the earliest possible time to enable an appropriate medical intervention prior to the 120th day.

Termination of pregnancy as emergency obstetric care: the interpretation of Catholic health policy and the consequences for pregnant women: an analysis of the death of Savita Halappanavar in Ireland and similar cases.

Issues arising from the death of Savita Halappanavar in Ireland in October 2012 include the question of whether it is unethical to refuse to terminate a non-viable pregnancy when the woman's life may be at risk. In Catholic maternity services, this decision intersects with health professionals' interpretation of Catholic health policy on treatment of miscarriage as well as the law on abortion. This paper explores how these issues came together around Savita's death and the consequences for pregnant women and maternity services worldwide. It discusses cases not only in Ireland but also the Americas. Many of the events presented are recent, and most of the sources are media and individual reports. However, there is a very worrying common thread across countries and continents. If further research unearths more cases like Savita's, any Catholic health professionals and/or hospitals refusing to terminate a pregnancy as emergency obstetric care should be stripped of their right to provide maternity services. In some countries these are the main or only existing maternity services. Even so, governments should refuse to fund these services, and either replace them with non-religious services or require that non-religious staff are available at all times specifically to take charge of such cases to prevent unnecessary deaths. At issue is whether a woman's life comes first or not at all.

Late abortion. Attitudes amongst young physicians in Romania.

PURPOSE: The main purpose of this article is to analyze the way in which young physicians analyze and address the issue of therapeutic abortion. METHODS: A multi-institutional survey was conducted using an online questionnaire containing 10 items. RESULTS: Most respondents agreed with therapeutic abortion (1) if the fetus is not yet viable and the mother is put at immediate risk by the continuation of the pregnancy, and (2) when the pregnancy is over 14 weeks and the prenatal screening identifies a very severe malformation. The lowest rate of acceptance was obtained by the option to terminate the pregnancy after 14 weeks for a minor malformation (polydactyly). The vast majority agreed that the OG physician should be permitted to refuse an abortion on moral grounds, even if permitted by law. CONCLUSIONS: Our study reveals that the main reasons for conducting therapeutic abortion (TA) in the 2nd or 3rd trimester are: (1) if the mother is put in immediate risk by the continuation of the pregnancy and (2) if the congenital anomaly is extremely severe. Even though the number of respondents considering Down syndrome to be a congenital malformation severe enough to allow TA, the value much lower compared with other low and middle income countries. The main reasons for refusing TA in the 2nd or 3rd trimester are the presence of a minor congenital anomaly or if it is against the moral principles of the physician.

Towards a new procreation ethic: the exemplary instance of cleft lip and palate.

The improvement of ultrasound scan techniques is enabling ever earlier prenatal diagnosis of developmental anomalies. In France, apart from cases where the mother's life is endangered, the detection of "particularly serious" conditions, and conditions that are "incurable at the time of diagnosis" are the only instances in which a therapeutic abortion can be performed, this applying up to the 9th month of pregnancy. Thus numerous conditions, despite the fact that they cause distress or pain or are socially disabling, do not qualify for therapeutic abortion, despite sometimes pressing demands from parents aware of the difficulties in store for their child and themselves, in a society that is not very favourable towards the integration and self-fulfilment of people with a disability. Cleft lip and palate (CLP), although it can be completely treated, is one of the conditions that considerably complicates the lives of child and parents. Nevertheless, the recent scope for making very early diagnosis of CLP, before the deadline for legal voluntary abortion, has not led to any wave of abortions. CLP in France has the benefit of a exceptional care plan, targeting both the health and the integration of the individuals affected. This article sets out, via the emblematic instance of CLP, to show how present fears of an emerging "domestic" or liberal eugenic trend could become redundant if disability is addressed politically and medically, so that individuals with a disability have the same social rights as any other citizen.

Legal briefing: conscience clauses and conscientious refusal.

This issue's "Legal Briefing" column covers legal developments pertaining to conscience clauses and conscientious refusal. Not only has this topic been the subject of recent articles in this journal, but it has also been the subject of numerous public and professional discussions. Over the past several months, conscientious refusal disputes have had an unusually high profile not only in courthouses, but also in legislative and regulatory halls across the United States. Healthcare providers' own moral beliefs have been obstructing and are expected to increasingly obstruct patients' access to medical services. For example, some providers, on ethical or moral grounds, have denied: (1) sterilization procedures to pregnant patients, (2) pain medications in end-of-life situations, and (3) information about emergency contraception to rape victims. On the other hand, many healthcare providers have been forced to provide medical treatment that is inconsistent with their moral beliefs. There are two fundamental types of conscientious objection laws. First, there are laws that permit healthcare workers to refuse providing - on ethical, moral, or religious grounds healthcare services that they might otherwise have a legal or employer-mandated obligation to provide. Second, there are laws directed at forcing healthcare workers to provide services to which they might have ethical, moral, or religious objections. Both types of laws are rarely comprehensive, but instead target: (1) certain types of healthcare providers, (2) specific categories of healthcare services, (3) specific patient circumstances, and (4) certain conditions under which a right or obligation is triggered. For the sake of clarity, I have grouped recent legal developments concerning conscientious refusal into eight categories: 1. Abortion: right to refuse 2. Abortion: duty to provide 3. Contraception: right to refuse 4. Contraception: duty to provide 5. Sterilization: right to refuse 6. Fertility, HIV, vaccines, counseling 7. End-of-life measures: right to refuse 8. Comprehensive laws: right to refuse.

National bioethical legislation and guidelines for biomedical research in the Islamic Republic of Iran.

Rapid advances in biomedical science and technology, which have revolutionized medicine and health-care services in different societies, have been associated with inevitable ethical challenges. Undoubtedly, these innovations could lead to irreversible disasters if they are not limited by appropriate regulations. Substantial attempts have been made in the Islamic Republic of Iran to establish a structured approach for identifying, analysing and resolving ethical issues in clinical practice. Given the consensus of religious and scientific scholars, some laws recently approved by the parliament include the Deceased and Brain-Dead Patients Organ Transplantation Act (2000), Embryo Donation to Infertile Spouses Act (2003) and the Therapeutic Abortion Act (2005). National guidelines for ethical assessment and supervision of research proposals have also been compiled by the authorities. This paper reviews the main endeavours made in bioethics legislation in the Islamic Republic of Iran.

The therapeutic exception: abortion, sterilization and medical necessity in Costa Rica.

Based on the case of Rosa, a nine-year-old girl who was denied a therapeutic abortion, this article analyzes the role played by the social in medical practice. For that purpose, it compares the different application of two similar pieces of legislation in Costa Rica, where both the practice of abortion and sterilization are restricted to the protection of health and life by the Penal Code. As a concept subject to interpretation, a broad conception of medical necessity could enable an ample use of the therapeutic exception and a liberal use of both surgeries. The practice of therapeutic sterilization has been generalized in Costa Rica and has become the legitimate way to distribute contraceptive sterilization. In contrast, therapeutic abortion is very rarely practiced. The analysis carried out proposes that it is the difference in social acceptance of abortion and sterilization that explains the different use that doctors, as gatekeepers of social morality, make of medical necessity.

Palatable truth.

Parents can be devastated when a scan reveals their expected baby has a cleft palate. Nurses working in this specialist field can offer support and practical information to help parents cope.

Intention and responsibility in double effect cases.

I argue that the moral distinction in double effect cases rests on a difference not in intention as traditionally stated in the Doctrine of Double Effect (DDE), but in desire. The traditional DDE has difficulty ensuring that an agent intends the bad effect just in those cases where what he does is morally objectionable. I show firstly that the mental state of a rational agent who is certain that a side-effect will occur satisfies Bratman's criteria for intending that effect. I then clarify the nature of the moral distinction in double effect cases and how it can be used to evaluate the moral blameworthiness of agents rather than the moral status of the acts. The agent's blameworthiness is reduced not by his lack of intention but by his desire not to bring about the side-effect, and the 'counterfactual test' can be used to determine whether he desires the effect in acting. In my version, the DDE has its rationale in virtue ethics; it is not liable to abuse as the traditional version is; and it makes more plausible distinctions when applied to standard examples.

Nurses' attitudes toward pregnancy termination in the labor and delivery setting.

OBJECTIVE: To examine nurses' attitudes toward pregnancy termination in the labor and delivery setting and the frequency of nurse refusal to care for patients undergoing pregnancy termination. DESIGN: Nonexperimental, descriptive study. SETTING: Six central and northern California hospitals, including Level 1, 2, and 3 facilities. PARTICIPANTS: Seventy-five labor and delivery registered nurses. METHOD: Anonymous survey with visual analog scales. RESULTS: Ninety-five percent of the nurses indicated they would agree to care for patients terminating a pregnancy because of fetal demise, 77% would care for patients terminating a fetus with anomalies that were incompatible with life, and 37% would care for patients terminating for serious but nonlethal anomalies, with a significant drop in agreement as gestation advanced. Few nurses would agree to care for patients undergoing termination for sex selection, selective reduction, or personal reasons. Nurses both accepting and refusing patient care assignments were criticized by coworkers. CONCLUSION: Clear guidelines should be established on how to handle nurse refusal to care for patients terminating pregnancy in advance. Open discussions should be encouraged between staff and management to minimize criticism.

Teorías bioéticas, protección de la vida y ley natural / Bioethics theories, the protection of life and natural law

La bioética principialista de Beauchamp y Childress se ha hecho con un lugar preeminente en la Bioética actual. No obstante, presenta algunas carencias teóricas importantes: falta de elaboración de algunos conceptos, tendencia al relativismo moral, etc. Entre los múltiples posicionamientos éticos alternativos actuales desde los cuales cubrir tales carencias, pensamos que el más adecuado es la teoría de la ley natural. Esta ofrece una reflexión argumentada sobre el bien y los bienes humanos y sobre su relación con los principios morales generales. Desde tales bienes, dicha teoría sostiene la existencia de acciones que son siempre maleficentes, esto es, acciones intrínsecamente y universalmente malas. El artículo aplica la teoría de la ley natural a temas relacionados con la protección de la vida humana (aborto, eutanasia, legítima defensa y manipulación genética)

Principlist Bioethics by Beauchamp and Childress has reached a prominent status in contemporary Bioethics. Nevertheless, it includes some important theoretical problems: some lacks when defining some concepts, a tendency to ethical relativism, etc. Among the ethical alternative approaches from which such problems can be solved, we think that the most appropiate is the Natural Law theory. It offers a reasoned reflection on the concept of good and on human basic goods and their relation with moral general principles. From such goods, this ethical theory supports the existence of actions that are always maleficent acts, that is, intrinsically and universally evil acts. The article applies the Natural Law theory to issues related to the protection of human life (abortion, euthanasia, self-defense and genetic manipulation)

[Terminations of pregnancy for maternal indications in the Paris area: a retrospective multicenter study in the period between the 2001 French law on termination of pregnancy and the new bioethics law]. / Interruptions médicales de grossesse pour motifs maternels : étude rétrospective multicentrique des indications dans la période entre la loi sur l'interruption de grossesse de 2001 et la nouvelle loi de bioéthique.

OBJECTIVE: To analyze the reasons for terminations of pregnancy (TOP) in cases of "severe jeopardy of the woman's health" beyond the limit of 14weeks, performed under the 2001 French law on abortion which extended these indications, until a new bioethics law was promulgated in 2011. METHODS: A retrospective observational study of all TOP performed for maternal indications (excluding premature membrane rupture), following a medical decision, from 2001 to 2010 in four academic maternity units in northern Paris. RESULTS: One hundred and three patients were included. The incidence was approximately 1 per 1000 births. The mean gestational age at the time of the TOP was 21.5weeks (range 7.7-34.7); 7% occurred before 14weeks and 35% after 24weeks. Indications were: (1) maternal diseases (22%), (2) psychosocial indications (21%) in majority multiple drug addictions, (3) psychiatric indications (21%), (4) obstetrical complications (mainly preeclampsia) before fetal viability (20%) and (5) rape (16%) mostly on minors. In 16% of cases, several indications were associated. CONCLUSION: TOP for maternal indications remains exceptional, including for psychosocial indications. Our findings suggest that the French law on TOP was not misused in these centers to permit abortion on demand beyond the limit of 14weeks.

El aborto como un bien social / Abortion as a social good / L'avortament entès com un bé social

Se analiza al aborto como un bien social examinando las distintas miradas que tiene la sociedad con respecto al aborto y sus leyes. Se critica la posición de los distintos actores sociales con respecto a la posición de la Iglesia o la posición de aquellos que están a favor de la vida. Estos no deberían estar influenciados por sus creencias personales sino por la necesidad de la población y la de políticas públicas. Se analiza la necesidad de despenalización del aborto por motivos de salud pública y de dignidad de las mujeres

Abortion is analyzed as a social good. This article considers the different views society has regarding abortion and its regulation. The positions of different social actors are criticized, when related to the view of the Catholic Church or prolife positions, for social actors should not be influenced by their personal beliefs but by the requirements of public policy and people's needs. The need of de-penalizing abortion is defended based on public health and women's dignity

S'analitza l'avortament com un bé social des de les diferents mirades que té la societat pel que fa a l'avortament i les lleis que ho regulen. Es critica la posició dels diferents actors socials pel que fa a la posició de l'Església o la d'aquells que estan a favor de la vida. Aquests actors no haurien d'estar influenciats per les seves creences personals sinó per les necessitats de la població i de les polítiques públiques. S'estudia la necessitat de despenalitzar l'avortament per motius de salut pública i de la dignitat de les dones

Caso Esperancita: hacia un estándar legal mínimo de aborto terapéutico en el Sistema Interamericano de Derechos Humanos / Esperancita Case: towards a minimum legal standard on therapeutic abortion in the Interamerican System of Human Rights / Cas Esperancita: cap a un estàndard legal mínim d'avortament terapèutic en el Sistema Interamericà de Drets Humans

El presente artículo describe la estrategia jurídica utilizada en el caso de Rosaura Almonte (Esperancita) vs. República Dominicana ante la Comisión Interamericana de Derechos Humanos. Se argumenta que el artículo 4 de la Convención Americana de Derechos Humanos (CADH), que consagra el derecho a la vida, establece que los Estados, en cumplimiento de sus obligaciones, deben permitir como mínimo el aborto terapéutico. A partir de un análisis de los métodos de interpretación establecidos en la Convención de Viena sobre Derecho de los Tratados y su aplicación en el Sistema Interamericano de Derechos Humanos, resulta admisible establecer que el artículo 4 de la CADH protege la vida y salud de la mujer embarazada cuando se encuentren en riesgo

This paper describes the legal strategy used in the case of Rosaura Almonte (Esperancita) vs. the Dominican Republic before the Inter-American Commission on Human Rights. This argues that Article 4 of the American Convention on Human Rights (ACHR), which enshrines the right to life, establishes that States, in compliance with their obligations, should allow at least therapeutic abortion. Indeed, based on an analysis of the methods of interpretation established in the Vienna Convention on the Law of Treaties and their application in the Inter-American System of Human Rights, it is admissible to establish that Article 4 of the ACHR protects the life and health of the pregnant woman when they are at risk

El present article descriu l'estratègia jurídica utilitzada en el cas de Rosaura Almonte (Esperancita) vs. la República Dominicana davant la Comissió Interamericana de Drets Humans. S'argumenta que l'article 4 de la Convenció Americana de Drets Humans (CADH), que consagra el dret a la vida, estableix que els Estats, en compliment de les seves obligacions, han de permetre com a mínim l'avortament terapèutic. A partir d'una anàlisi dels mètodes d'interpretació establerts en la Convenció de Viena sobre Dret dels Tractats i la seva aplicació al Sistema Interamericà de Drets Humans, resulta admissible establir que l'article 4 de la CADH protegeix la vida i salut de la dona embarassada quan es trobin en risc

Políticas públicas de aborto en transición: de las consejerías pre y post aborto a las interrupciones legales del embarazo en el Área Metropolitana de Buenos Aires / Abortion policy in transition: from pre and post abortion counseling to legal interruptions of pregnancy at Metropolitan Area of Buenos Aires / Polítiques públiques d'avortament en transició: de les conselleries pre i post avortament a la interrupció legal de l'embaràs a l'Àrea Metropolitana de Buenos Aires

En este artículo, analizamos la transición desde el modelo de consejerías pre y post aborto hacia la implementación de las interrupciones legales del embarazo (ILE) en el Área Metropolitana de Buenos Aires. Mientras el primer modelo se enmarca en el paradigma de la reducción de riesgos y daños, la implementación de las interrupciones legales del embarazo resignifica como un derecho las causales de no punibilidad contempladas en el Código Penal argentino de 1921, a saber: la causal violación y la causal salud. En este trabajo, analizamos en qué contexto se produce esta transición, cuáles han sido los factores que han contribuido y qué diferencias supone este cambio de modelo

In this paper, we analyze the transition from pre and post abortion-counseling model to the implementation of legal interruptions of pregnancy (ILE, for its Spanish initials) in the Metropolitan Area of Buenos Aires. Whereas the first model is framed in the paradigm of risk and harm reduction, the implementation of legal interruptions of pregnancy resignifies as a right the cases of non-punishable abortion included at the Argentine Penal Code of 1921, namely: cases of rape and cases of maternal health or life risk. In this paper, we analyze in which context this transition takes place, which factors have contributed and what differences this change of model implies

En aquest article analitzem la transició des del model de conselleries pre i post avortament cap a la implementació de la interrupció legal de l'embaràs (ILE) a l'Àrea Metropolitana de Buenos Aires. Mentre el primer model s'emmarca en el paradigma de la reducció de riscos i danys, la implementació de la interrupció legal de l'embaràs estableix com un dret els supòsits de no punibilitat contemplades en el Codi Penal argentí de 1921, a saber: el supòsit de violació i el supòsit de salut. En aquest treball, analitzem en quin context es produeix aquesta transició, quins han estat els factors que hi han contribuït i quines diferències suposa aquest canvi de model