Revisiting the Role of Health Care Proxies in Reproductive Choice.

In an effort to protect patients' reproductive rights, many states prohibit health care proxies from serving as surrogate decision makers for pregnancy termination in patients who lack capacity. We explore the case of a 24-year-old developmentally delayed woman with intractable seizures and complex psychosocial needs who was found to be pregnant. Her older sister was her health care proxy and declared that an abortion would be in her best interest, medically and socially; the patient herself lacked capacity to make this decision. Legally, her sister's judgment alone was insufficient to move forward with the procedure. Here we describe our multidisciplinary medical, ethical, and legal review of this case and how, despite agreeing with the patient's sister, legal barriers hindered our ability to obtain an abortion for this patient. Her situation illustrates the unintended consequences of our current approach to surrogate decision making in pregnancy termination. It highlights the need to reconsider the role of health care proxies in reproductive-choice decisions and emphasizes the value of a holistic evaluation of patients' social circumstances.

Therapeutic abortion in Iran: an epidemiologic study of legal abortion in 2 years.

OBJECTIVES: Unsafe abortion is one of the most important causes of death and disability among mothers in countries where abortion is illegal. These conditions have changed since then. The present study has investigated the cases who were referred to the legal medicine organization to receive abortion permission. This country level secondary patient data analysis, investigated all the cases who were referred to the legal medicine centers of Iran for abortion permission during 2015 to 2017. RESULTS: From 21,477 applicants, 15,617 (72.71%) received permission including 14,367 (91.99%) for fetal abnormalities and 1250 (8.01%) for maternal diseases. The most common fetal abnormalities/disorders were nervous system malformations (26.4%), chromosomal abnormalities (18.4%) and of maternal diseases were circulatory system diseases (43.9%), neoplasms (13.4%) and genitourinary system diseases (9.9%). The most common reasons for not permission were lack of supplementary documents to prove (38.8%), not competency with the criteria (33.9%), and gestational age of more than 19 weeks (25.8%).

Termination of Pregnancy as a Means to Reduce Maternal Mortality in Pregnant Women With Medical Comorbidities.

The United States is the world's only developed country with a rising maternal mortality rate, with an increase of 26% between 2000 and 2014. Of the approximately 700 pregnancy-related deaths per year in the United States, nearly 30% are attributable to preexisting disease. Maternal-fetal medicine physicians are in a unique position-they are tasked with counseling patients regarding the risks of pregnancy in the context of their medical comorbidities. Individual physicians' opinions regarding the level of risk of death at which a termination of pregnancy would be considered "medically indicated" are highly variable and are influenced by where physicians are from, where they trained, and their knowledge regarding the safety of termination of pregnancy. Additionally, 43 states have legislated restrictions to abortion access that contain exceptions to protect women's life or health, but what constitutes a risk to a woman's life or health is not well-defined and appropriates medical terminology for political purposes. The current statements from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine advocate for safe, legal, and unobstructed access to pregnancy termination services. These statements attempt to remove health care providers' own biases regarding the exact risk level at which they would consider an abortion to be medically indicated. Because the risk of death from a first- or second-trimester termination is less than that of a traditional delivery, any medical problem that increases that risk of death could be considered an indication for counseling patients regarding the option of termination of pregnancy as a means to reduce mortality or morbidity.

The prevalence and the reasons of issuing permission for therapeutic abortion in department of forensic medicine, Kermanshah, Iran, during 2005 to 2010.

OBJECTIVE: The present study aimed to investigate the prevalence and the reasons of issuing permission for therapeutic abortion in department of forensic medicine, Kermanshah-Iran. RESULTS: There were a total number of 428 applications for issuing permits. The most common reasons of issuing permit for therapeutic abortion were fetal and maternal problems, specifically cerebral abnormalities (70.8%), and anencephaly (30.3%). Furthermore, 354 (82/7%) out of 428 applications were able to get the legal permit and 17.3% of the applications did not receive permission, which was mainly due to "the lack of maternal indication". Increased knowledge of physicians and clinical personnel on indications of therapeutic abortions and related regulations would lead to the implementation of strategies which prevent void referrals to the department of forensic medicine and a better execution of therapeutic abortion law. By improving the health condition of pregnant women who seek pregnancy termination, informing them about indications of therapeutic abortions, and developing proper strategies to make pregnant women more acquainted with legal cases of abortion, we can take a significant step towards helping pregnant women and promoting their health.

Prenatal Diagnosis in France: Between Regulation of Practices and Professional Autonomy.

Prenatal diagnosis (PND) was introduced in France in the 1970s on the initiative of medical researchers and clinicians. For many years the regulation of practices was self-imposed, decentralised and idiosyncratic. The advent of 'therapeutic modernity' in the 1990s gave rise to an ethical, legal and scientific framework designed to homogenise PND at a national level, with the creation of multidisciplinary centres (CPDPN) and the Agence de la biomédecine. This article first recovers the history of PND in France. It then compares the activities of two CPDPNs, using ethnographic fieldwork and by analysing national quantitative data compiled by the Agence. It argues that the official policy of nationally homogeneous practices is not born out in practice, at the local level. This lack of homogeneity is most apparent in the number of authorisations for pregnancy termination due to foetal malformation, which varies considerably from one centre to another. Rooted in local culture, this variation relates to organisational methods, decision-making processes and variable levels of tolerance towards the risk of disability. Foetal medicine practitioners, thus, maintain a certain amount of autonomy that is collective rather than individual and that is reflected in the particular 'identity' of a given centre.

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

Medical Emergency Exceptions in State Abortion Statutes: The Statistical Record.

This article attempts to determine, first, whether emergency exceptions in statutes regulating abortion have been abused and, second, whether the standard used in such an exception--subjective or objective--makes a difference in the reported incidence of such emergencies. A review of the statistical data supports two conclusions. First, physicians who perform abortions and have complied with state reporting requirements have not relied upon the medical emergency exceptions in state abortion statutes to evade the requirements of those statutes. Second, the use of an objective standard for evaluating medical emergencies ("reasonable medical judgment") has not been associated with fewer reported emergencies (per number of abortions performed) than the use of a subjective standard ("good faith clinical judgment"). Both of these conclusions may be relevant in drafting other abortion statutes including prohibitions (e.g., post-viability abortions).

Perspectives in Genetics and Sickle Cell Disease Prevention in Africa: Beyond the Preliminary Data from Cameroon.

Management of sickle cell disease (SCD) in Africa needs to be accompanied by various preventive strategies, including early detection via prenatal genetic diagnosis (PND). Contrary to Cameroonian doctors who considered termination of an affected pregnancy (TAP) for SCD in 36.1%, the majority of parents (62.5%) with affected children accepted TAP in principle. In practice, most women opted for TAP (90%), justified by a huge psycho-social burden. The ethical and legal challenges of PND prompted the need to explore the use of genetics for secondary prevention of SCD. In 610 Cameroonian SCD patients, the genomic variations in two principal foetal haemoglobin-promoting loci were significantly associated with foetal haemoglobin levels. In addition, the co-inheritance of a 3.7-kb α-globin gene deletion and SCD was associated with a late disease onset and possibly improved survival: there was a much higher allele frequency of the 3.7-kb α-globin gene deletion in SCD patients (∼ 40%) than in haemoglobin AA controls (∼ 10%). The data indicate the urgent need to develop and implement policy actions in sub-Saharan Africa on at least four levels: (1) the implementation of SCD screening practices and early neonatal follow-up; (2) the development and incorporating of socio-economic support to alleviate the burden of SCD on affected families; (3) the exploration of the appropriateness of the medical abortion laws for SCD, and (4) the development of national plans for genetic medicine, including research on genomic variants that affect the phenotypes of SCD, in order to potentially use them for anticipatory guidance.

Aborto terapéutico: ¿realmente existe? / Therapeutic abortion: is there really?

A propósito de la reciente promulgación de la Resolución Ministerial N.º 4862014/Minsa, que aprueba la guía técnica nacional para el aborto terapéutico, se ha generado un gran debate al respecto. Como un aporte a la discusión, se presenta una revisión sobre las definiciones y tipos de aborto, para luego centrarse en el denominado ‘aborto terapéutico’ y explorar las dificultades que existen para definirlo. Finalmente, se presentan algunas observaciones a esta Guía técnica emitida por el Minsa. Se concluye que el término ‘aborto terapéutico’ es anacrónico y contradictorio porque el aborto no es un tratamiento que asegure mejorar la salud de la mujer ni la del niño. El término apropiado debería ser ‘interrupción del embarazo por razones médicas’.

With regard to the recent enactment of the Peruvian Ministerial Resolution N.º 4862014/Minsa, which approves the national technical guide for therapeutic abortion, has generated considerable debate. A review of the definition and type of abortion and the focus on the socalled ‘therapeutic abortion’ is presented. This article explores the difficulties in defining it. Finally, some comments are presented to the Technical Guidance issued by the Minsa. We conclude that the term ‘therapeutic abortion’ is anachronistic and contradictory because abortion is not a treatment ensuring better health of the woman neither for the unborn child. The proper term should be ‘termination of pregnancy for medical reasons’.

[Therapeutic abortion, unjustified absence in health policy]. / Aborto terapéutico, ausencia injustificada en la política sanitaria.

Although abortion for health reasons is not considered a crime in Peru, the State does not allow its inclusion in public policy, thus violating women's right to terminate a pregnancy when it affects their health. When examining the article in the Criminal Code which decriminalizes this type of abortion, provisions are identified which protect women and set the conditions to offer this type of service. This document sets the debate about the arguments used by the Peruvian State for not approving a therapeutic abortion protocol which would regulate the provision and financing of therapeutic abortion in public services, and explains why this obligation should be complied with, based on the conceptual framework of "health exception" In addition, it presents two cases brought before the judicial court in which the Peruvian State was found guilty of violating the human rights of two adolescents to whom a therapeutic abortion was denied.

Aborto terapéutico, ausencia injustificada en la política sanitaria / Therapeutic abortion, unjustified absence in health policy

A pesar de que el aborto, por razones de salud, no es considerado un delito en el Perú, el Estado niega su inclusión en la política pública, con lo cual infringe el derecho de las mujeres a interrumpir un embarazo cuando este afecta su salud. Al examinar el artículo del Código Penal que exceptúa de delito a este tipo de aborto, se identifican atribuciones que protegen a las mujeres y establecen condiciones para ofertar dicha atención. En el presente documento se pone en debate los argumentos que el Estado Peruano viene usando para no aprobar el Protocolo de Aborto Terapéutico, con el cual se reglamentaria su oferta y financiamiento en los servicios públicos y se fundamenta por qué se debería cumplir con esta obligación, en base al marco conceptual de la “causal salud”. Se presentan, además, dos casos judicializados, en que el Estado Peruano ha sido encontrado responsable de violar los derechos humanos de dos adolescentes a quienes se les negó el aborto terapéutico.

Although abortion for health reasons is not considered a crime in Peru, the State does not allow its inclusion in public policy, thus violating women’s right to terminate a pregnancy when it affects their health. When examining the article in the Criminal Code which decriminalizes this type of abortion, provisions are identified which protect women and set the conditions to offer this type of service. This document sets the debate about the arguments used by the Peruvian State for not approving a therapeutic abortion protocol which would regulate the provision and financing of therapeutic abortion in public services, and explains why this obligation should be complied with, based on the conceptual framework of “health exception”. In addition, it presents two cases brought before the judicial court in which the Peruvian State was found guilty of violating the human rights of two adolescents to whom a therapeutic abortion was denied.

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.