Abortion and Public Health Ethics
Abstract and Keywords
There is an ethical imperative to take public health action to eliminate the global problem of unsafe abortion. The moral obligation is dictated by the magnitude of the problem, the health inequities and social injustices that result from lack of access to safe abortion, the voices of women calling for action, and an international consensus recognizing unsafe abortion as a global health problem. The availability of public health interventions and the cost savings associated with fewer abortion complications reinforce the obligation to address unsafe abortion. Public health actions include reducing the need for abortion through family planning, providing safe abortion to the full extent of the law, managing abortion complications, and providing post-abortion care. These actions intersect with morality, religion, law, justice, and human rights. The public health community has a collective social and ethical responsibility to stand beside and behind women as they claim their human right to health.
(p. 403) Unsafe Abortion: A Global Public Health Challenge
Unsafe abortion has been described as a preventable pandemic (Grimes et al., 2006). Each year, approximately 25 million abortions worldwide meet the World Health Organization (WHO) definition of “unsafe abortion”: they are performed either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards, or both (WHO, 2017). Importantly, unsafe abortion and illegal abortion are not synonyms. Illegal abortion involves terminating, or attempting to terminate, a pregnancy when doing so is against the law. Illegal abortion is often, but not always, unsafe. In many countries where abortion is illegal, for example, private physicians may perform safe abortions for wealthy patients who can afford their high medical fees (Warriner, 2006). Also, not all legal abortions are safe. Some developing countries have liberalized their abortion laws, but because their health care systems are inadequate to meet the demand for abortion, women in those countries may go to medically unqualified abortionists for the procedure (Warriner, 2006).
The public health rationale for addressing unsafe abortion was first highlighted in 1967 by the World Health Assembly, which declared that “abortions and . . . high maternal and child mortality constitute a serious public health problem in many countries,” warranting international action (WHO, 1967, 25). In addition to the public health justification for addressing unsafe abortion, there is an ethical imperative to do so as well. The moral obligation is dictated by the magnitude of the health problems caused by unsafe abortion (in terms of prevalence, mortality, and morbidity), the health inequities and social injustices that poor women experience when they cannot access safe abortion, the many women who have called for action, and an international consensus—including (p. 404) statements and guidelines from the WHO—that recognizes unsafe abortion as a global public health problem. The availability of affordable and appropriate public health interventions, coupled with the cost savings from fewer abortion complications, reinforce the ethical imperative to prevent unsafe abortions.
Magnitude of the Problem
The global prevalence of unsafe abortion is staggering. A 2017 study supported by the WHO and the World Bank, among others, reported that each year between 2010 and 2014, approximately 25 percent of all pregnancies globally ended in an induced abortion, which accounts for an estimated 56 million induced (safe and unsafe) abortions each year worldwide during that time period (WHO, 2017; Ganatra et al., 2017). Of those induced abortions, more than 25 million met the WHO definition of unsafe abortion, and almost all of these (97 percent) occurred in developing countries (WHO, 2017).
When performed safely, induced abortion can be markedly safer than childbirth. Even in a developed country like the United States, the risk of death associated with childbirth is reported to be approximately fourteen times higher than that with safe induced abortion; similarly, the overall morbidity associated with childbirth exceeds that associated with safe abortion (Raymond and Grimes, 2012).
Unsafe abortion, however, is a significant factor in maternal morbidity and mortality. The major life-threatening complications resulting from unsafe abortion are hemorrhage, infection, and injury to the genital tract and internal organs. In developing countries, about 7 million women are admitted to the hospital each year for complications related to unsafe abortion (WHO, 2017; Singh and Maddow-Zimet, 2016). Complications of unsafe abortion are also responsible for approximately 47,000 pregnancy-related deaths each year, accounting for 4.7–13.2 percent of all maternal deaths (Say et al., 2014). Because stigma and fear of punishment may deter reliable reporting, particularly following illegal abortion procedures, deaths and disabilities resulting from unsafe abortion are probably underestimated. In addition, unsafe abortion can have major emotional, social, and financial costs for women and their families.
Inequity, Injustice, and Women’s Voices
Public health ethics has always concerned itself with equity and social justice in population health. At the global level, unsafe abortion is a glaring inequity. In developed regions, it is estimated that 30 women die as a consequence of unsafe abortion for every 100,000 abortions performed; that number rises to 220 deaths per 100,000 unsafe abortions in developing regions, and 520 deaths per 100,000 unsafe abortions in sub-Saharan Africa (WHO, 2017). Mortality from unsafe abortion disproportionately affects women in Africa. While the continent accounts for 29 percent of all unsafe abortions, it sees 62 percent of unsafe-abortion-related deaths (WHO, 2011b).
(p. 405) Within countries in which abortion is legal but highly restricted, unequal access to safe abortion can result in socially unjust outcomes. While “[u]nsafe abortions threaten the lives of a large number of women” and represent “a grave public health problem,” the Fourth World Conference on Women in Beijing in 1995 noted that “it is primarily the poorest and youngest [women] who take the highest risk” (UN, 1996, para. 97). Abortions that meet safety requirements can become the privilege of the rich, while poor women have little choice but to resort to unsafe abortions. Young adolescent girls are especially vulnerable to unsafe abortions, because they may delay the procedure to later in their pregnancies, when there often are more legal restrictions on the procedure and fewer skilled providers offering safe abortion (Woog et al., 2015).
Recognizing the inequity and injustice associated with unsafe abortion, women at the Beijing Conference called upon “[a]ll governments and relevant intergovernmental and non-governmental organizations . . . to strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public health concern” (UN, 1996, para.106, k).
In 1994 the world government community at the United Nations International Conference on Population and Development recognized unsafe abortion as a major public health concern (UNFPA, 1994, para. 8.25). A decade later, the World Health Assembly adopted a global reproductive health strategy in which eliminating unsafe abortion is a key component (WHO, 2004). The strategy is stated to be “grounded in international human rights treaties and global consensus declarations that call for the respect, protection, and fulfilment of human rights” to health, including “the right of women to have control over, and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, . . . the right of access to relevant health information, and the right of every person to enjoy the benefits of scientific progress and its applications” (WHO, 2012, sec. 1.2). To realize these rights, and to save women’s lives, the WHO strategy calls on the international community to address the programmatic, legal, and policy aspects of providing safe abortion worldwide.
Preventing Unsafe Abortion: The Practical and Economic Rationale
The ethical imperative to address unsafe abortion is further bolstered by practical and economic considerations. A variety of public health actions, including effective contraception services, provision of safe and legal induced abortion, timely management of complications, and provision of post-abortion care are feasible steps toward preventing almost every death and disability caused by unsafe abortion (WHO, 2017).
(p. 406) One of the ethical challenges in public health is the rationing of limited resources for different health and disease conditions. In countries that face competing demands for the limited resources their health systems can afford, safe abortion is rarely, if ever, a top priority, and unsafe abortion is thus more likely to become a public health problem. Treating complications of unsafe abortion is costly and can overwhelm health systems in low-income countries (WHO, 2012). For example, estimates suggest that the total annual cost to the health system in the developing world for management of serious, post-abortion medical complications that require hospitalization lies between $375 and $838 million, with a central estimate of around $500 million (Vlassoff et al., 2008). If the millions of women who currently receive no treatment from a health system for serious, post-abortion complications were to do so, approximately $375 million more would be required each year to cover their care. The cost of long-term morbidities, mainly infertility and chronic reproductive tract infections, may cost many billions of dollars annually. In addition, estimates suggest that women and their families may pay $600 million in out-of-pocket expenses, and developing countries may face economic losses of more than $400 million each year from lower productivity caused by unsafe abortion.
Against this background, it is important to emphasize that safe abortion services are a cost-saving measure. For example, unsafe abortion was estimated to cost the Mexico City health system $2.6 million in 2005, prior to the legalization of abortion (Levin et al., 2009). Although studies to document cost savings are needed, it was estimated that with access to safe abortion, the system could potentially save $1.7 million annually, by shifting abortion management from emergency in-patient procedures to routine outpatient procedures as well as use of medical abortion (Levin et al., 2009). Eliminating unsafe abortion would result in significant savings that health systems could then conserve and redirect to other urgent public health needs.
Abortion at the Intersection of Morality, Religion, Law, and Human Rights
Abortion has been, and continues to be, a controversial topic in reproductive health (Cook, Dickens, and Fathalla, 2003). The ethical obligation of public health to eliminate unsafe abortion must, therefore, consider the ways in which abortion intersects with morality, religion, law, and human rights.
The public debate on the moral status of the human embryo and fetus, as a person requiring protection independent of the mother, remains, and probably will remain, unsettled (Araujo et al., 2015; Catlin, 2015). Some people believe the fetus lacks personhood status until birth, while others believe it warrants protection as a person from the moment of conception. This debate can have a potential impact on public health policy, which led the American Public Health Association (APHA) to issue a statement (p. 407) renouncing the adoption or misapplication of laws to recognize fetuses as independent of pregnant women (APHA, 2013).
Although world religions have not been silent on the question of induced abortion, there is not a unanimous view shared by all religions. Religious perspectives on induced abortion range from very conservative to more permissive, with leniency—where allowed—more likely for early-term abortions (Maguire, 2016). There can also be a variety of views within individual religious traditions. From a public health perspective, institutionalized religions may influence laws and policies limiting access to abortion (Marecek, Macleod, and Hoggart, 2017).
Because abortion laws and policies vary by country, any global public health efforts to stem unsafe abortions must consider the legal context in which unsafe abortions are occurring. At the start of the twentieth century, abortion was illegal in almost every country of the world. During the second half of the twentieth century, as a part of the social movement for women’s rights, countries that otherwise prohibited abortion began to enact laws that allow abortion on specified grounds. Currently, the exceptions for which abortion is allowed vary widely by country, and may include risk to the woman’s life; risk to her physical and, sometimes, mental health; pregnancy resulting from rape or sexual abuse; serious fetal anomaly; social and economic reasons; and permission by request. The permissibility of abortion on each of those grounds also varies greatly between regions. For example, recent studies report that abortion is permitted upon request in 65 percent of developed countries but only 14 percent of developing countries, and for economic and social reasons in 75 percent of developed countries but only 19 percent of developing countries (Berer, 2017).
Where abortion is not against the law, abortion access may still be restricted by legally introduced procedural barriers, such as mandatory and biased counseling requirements, waiting periods, third-party consent and notification requirements, limitations on the range of permissible abortion methods, and limitations on public funding (Finer and Fine, 2013). In June 2017, to enhance global and country-specific efforts to address unsafe abortion, the WHO Human Reproduction Programme, in collaboration with the Population Division of the United Nations Department of Economic and Social Affairs, launched the open-access Global Abortion Policies Database (Human Reproduction Programme, 2017). The database is a tool that tracks evolving abortion policies by country and is intended to inform policymaking and advocacy to eliminate unsafe abortion.
When prohibitions and restrictions on abortion threaten women’s lives and conflict with their individual liberty, human rights violations may occur. Recognizing women as competent and conscientious decision makers in their own lives, one legal view places abortion as one procedure within a spectrum of services to which women should have safe access as a matter of human rights and social justice (Cook and Dickens, 2003). Abortion policies should be geared to respecting, protecting, and fulfilling the human rights of women (WHO, 2012). Offering access to safe abortion also recognizes women as competent and conscientious decision-makers in their own lives. A tension in public health ethics may occur, however, when abortion policies appear to contravene human rights, which can occur in two ways.
(p. 408) The first way in which abortion policy can conflict with human rights is when action for a real or perceived public good conflicts with individual liberty. For example, population growth is a legitimate concern, and the state may make voluntary, safe pregnancy termination an option for women. However, human rights “red lines” are crossed when women are forced to terminate wanted pregnancies, as was reported in China during the implementation of its “one-child policy”—a government mandate in effect from 1979 through 2015 to limit families to one child in order to restrain population growth (Howden and Zhou, 2014). Human rights were similarly abridged under the authoritarian leadership of Nicolae Ceauşescu in Romania where women were forced to do the opposite under his population-promoting policies; that is, they were compelled to keep unwanted pregnancies for the public good, because the fetus was considered the socialist property of the state, and women who resorted to abortion were viewed as deserters and betrayers (Hord et al., 1991).
The second way in which abortion policy can conflict with human rights is when individual liberty conflicts with a perceived public good, as in the case of sex-selective abortion. The availability of ultrasounds and other technologies has enabled parents to detect the sex of a fetus during prenatal screenings. In cultures where son preference prevails, parents may arrange to abort female fetuses. This can result in gender imbalances in the population, which is of increasing concern in some South Asian, East Asian, and Central Asian countries (Fathalla, 1994; WHO, 2011a). The individual liberty to choose sex-selective abortion not only reflects the persistent, low status of women and girls, but it also results in a female deficit that may have damaging effects on societies.
Public Health Actions
Inaction Is Not an Ethical Option
Inaction, by denial or neglect, is not an ethically justifiable response to the global tragedy of unsafe abortion. Denying or neglecting a major health problem does not take it off the ethical radar screen. Whether or not it is wanted by society, abortion is needed by women. They have needed it throughout human history, and they have often risked their health or lives in the process. The oath of Hippocrates, which has at times been taken by those who become physicians, includes an injunction against abortion: “I will not give to a woman a pessary to cause abortion.” However, Hippocrates himself, writing in 400 bce, could not ignore the reality that women nevertheless resort to abortion, often with serious consequences to their health:
When the woman is afflicted with a large wound as a consequence of abortion, or the womb is damaged by strong suppositories, as many women are always doing, doctoring themselves, or when the fetus is aborted and the woman is not purged of the afterbirth, and the wound inflames, closes and is not purged, if she is treated promptly she will be cured but will remain sterile.
(Cited in McLaren, 1990, 28)
(p. 409) In developed countries, the global public health problem of unsafe abortion may be neglected because it is considered to be only a problem of the poor. In developing countries, the problem may be neglected because it is perceived as a woman’s issue in societies where women are undervalued. It is an inconvenient truth that many “women are not dying because of untreatable conditions . . . [t]hey are dying because societies have yet to make the decision that their lives are worth saving” (Fathalla, 2006, 409).
Four Components of an Ethical Public Health Strategy
The growing international consensus, as adopted by the United Nations General Assembly, is that unsafe abortion can, and should, be dealt with through a public health strategy with four components: reducing the need for abortion by provision of family planning services, making safe abortion services available to the full extent of the law, offering quality services for management of post-abortion complications, and providing post-abortion care to help avoid repeat abortions (UNFPA, 1999).
Reducing the Need for Abortion
Making contraceptive information and services available, accessible, and affordable can reduce women’s need for abortion (Bongaarts and Westoff, 2000). In the United States, the availability and appropriate use of affordable, effective, and safe contraception has been associated with decreasing numbers of abortions (Chescheir, 2017). Data from countries in Eastern Europe and Central Asia, where induced abortion was once the main method for regulating fertility, show that when the use of modern contraceptive methods increased, the incidence of induced abortion decreased (Westoff, 2005). Rates of induced abortion are the lowest in Western Europe, where modern contraceptive use is high and abortion is generally legally available on request (WHO, 2012).
Although impressive gains have been made in contraceptive use worldwide, an unmet need for family planning continues to persist. Defined broadly, unmet need for family planning is “the number of women who want to avoid or postpone a pregnancy but are not using any method of contraception” (WHO, 2012, 23). The WHO (2017) estimates that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method. Women will continue to face unintended pregnancies as long as their family planning needs are not met.
Given the reality of gendered power relationships, women are often exposed to unprotected sexual intercourse. This dictates the need for backup methods that women can use in such instances to reduce the need for abortion. Methods for emergency contraception (often referred to as the “morning-after pill”) exist and can be used within a few days of unprotected sexual intercourse to prevent pregnancy. This “retroactive contraception” would also be suited to the particular needs of adolescents, where the decision to contracept may not be made before having sex. Emergency contraception is also greatly needed in refugee situations and cases of sexual assault (Fathalla, 2003). It is not enough that services for emergency contraception are made available. Although they (p. 410) cannot be a substitute for regular contraception, information about emergency contraception methods should be widely distributed. A multi-country analysis of the knowledge and use of emergency contraception highlighted the need to broaden the dissemination of information about this service (Palermo, Bleck, and Westley, 2014).
Although contraceptive use reduces the number of unintended pregnancies, it does not eliminate the need for access to safe abortion. Data from 2007 on contraceptive prevalence and the typical failure rates of contraceptive methods estimated that approximately 33 million women worldwide experience an accidental pregnancy while using contraception every year (WHO, 2012). Some of the accidental pregnancies are terminated by induced abortions, and some end up as unplanned births.
Where Abortion Is Not Against the Law, It Should Be Safe
In 1994 the Programme of Action of the United Nations International Conference on Population and Development stated that in “circumstances where abortion is not against the law, such abortion should be safe” (UNFPA, 1994, para. 8.25). At a Special Session of the UN General Assembly in June 1999, governments agreed that “in circumstances where abortion is not against the law, health systems should train and equip health-service providers and should take other measures to ensure that such abortion is safe and accessible” (UNFPA, 1999, para. 63, I, iii).
The legal status of abortion has “no effect on a woman’s need for an abortion, but it dramatically affects her access to safe abortion” (WHO, 2012, 17). Although laws vary widely by country, they generally permit abortion to save a woman’s life and (in the majority of countries) to preserve the woman’s physical and/or mental health, or on other grounds such as rape or incest and fetal impairment. Safe abortion services, including medication abortion, should be available and accessible for all women, to the full extent of the law. Patients and health care providers should be familiar with conditions where abortion is not against the law. Keeping this information hidden is not ethically justifiable.
The WHO provides and updates technical and policy guidance for safe abortion services (WHO, 2012; Fathalla and Cook, 2012). There is an ethical responsibility to provide safe abortion services within the limits of the law. Conscientious objection is allowable but should not be used to hide the fear of the stigma associated with abortion (Faúndes, 2017). It should be remembered that when women are denied access to legal, safe abortion services, they often resort to an unsafe abortion, and in many cases they suffer its consequences. As asserted by the Committee for the Ethical Aspects of Human Reproduction and Women’s Health of the International Federation of Gynecology and Obstetrics (FIGO, 2012, 29): “The primary conscientious duty of obstetrician–gynecologists is at all times to treat, or provide benefit and prevent harm, to the patients for whose care they are responsible. Any conscientious objection to treating a patient is secondary to this primary duty.” Pharmacists, too, where abortion is not against the law, cannot ethically justify denying women access to drugs used for medication abortion.
(p. 411) Access to Treatment for Abortion Complications
Health care providers are ethically obliged to provide life-saving medical care to any woman who suffers abortion-related complications, regardless of the legality of abortion in that locality. The WHO (2012) has developed technical and policy guidance for the provision of these services. From a public health perspective, the practice of extracting confessions from women seeking emergency medical care as a result of illegal abortion is not ethically acceptable. Such a practice puts women’s lives at risk because it prevents women from seeking care. It is also ethically objectionable for a state to conscript health care providers as police informants to report patients who have undergone abortion to relevant authorities. Not only does this practice create a conflict of interests, it also violates patient confidentiality, a central principle of medical ethics and professionalism (WHO, 2017).
Following an abortion, women should, at a minimum, receive information and be offered counseling that addresses post-abortion health care, including how to avoid a future abortion. All women should receive contraceptive information and be offered counseling for and methods of post-abortion contraception, including emergency contraception, before leaving the health care facility (WHO, 2015).
An Ethical and Social Duty for the Public Health Community
Abortion laws and policies impact women’s lives and health. The public health community has an ethical and social duty to educate legislators, policymakers, health administrators, and the public at large about any adverse health impact of such laws and policies. Examples of such collective public health action include the APHA’s statement “urging federal and state legislatures, law enforcement and judiciary bodies, election commissions, and health care providers to renounce any and all personhood claims or misapplications of child welfare laws that recognize fetuses as persons and infringe on women’s reproductive, constitutional, and human rights” (APHA, 2013), as well as the association’s position that “restricted access to abortion violates human rights, precludes reproductive justice, and demands public health intervention” (APHA, 2015).
There will always be ideological views opposed to any attempt to interrupt the establishment of pregnancy after an ovum has been fertilized, or even to any form of artificial contraception. Those views are entitled to full respect. They should not, however, be imposed on those who do not share them, nor should they be enforced to adversely impact women’s lives, rights, and health.
(p. 412) Unsafe abortion is a global public health problem requiring worldwide attention and the necessity of a multi-actor response. Members of the health profession should be among those at the forefront. Women trust their health and life to the health profession. They expect more than technicians and services to fix their diseased body, organs, and systems. They expect a health profession that stands beside them and behind them as they claim the human rights voiced by women when they gathered at the Fourth World Conference on Women in Beijing in 1995: “The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence” (UN, 1996, para. 96).
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