Abortion in Northern Ireland: could conscientious objection impact patient care?

Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on twitter: @drricharmitage

Abortion was decriminalised in Northern Ireland (NI) in October 2019, and the Abortion (Northern Ireland) Regulations 2020 came into effect in March 2020. The legislation allowed NI women to access abortion in their home country. While the Abortion Act 1967 legalised abortion on multiple grounds in England, Wales and Scotland, it had not previously extended to NI, although NI women were able to access abortion elsewhere in the UK, and could receive funding to access such services from 2017.  The arrival of abortion services in NI coincided with that of COVID-19 and the associated impacts on social contact and access to healthcare, thereby complicating the analysis of relevant data.  However, data suggest that around 600 ‘expected’ abortions in NI women in 2020 did not take place.¹  Possible explanations to account for these ‘missing abortions’ include: 1) the unwanted pregnancies never came into existence; 2) NI women accessed abortions outside NI; 3) NI abortion services were disrupted by COVID-19; and 4) NI women in need of abortion services were unaware of their local availability and were restricted from traveling elsewhere in the UK to access them.¹  An additional potential explanatory factor is the conscientious objections (COs) of NI healthcare professionals (HCPs) to participation in abortion, which may have at least partially contributed to the reported data that suggest these statistically ‘missing’ abortions.

The debate regarding the extent to which COs ought (if any) to be accommodated in the healthcare profession continues,² with views ranging from conscience absolutism (that COs should always be accommodated) through a variety of compromise positions (that COs should be accommodated under specific circumstances) to conscience incompatibilism (that COs should never be accommodated).³  The applied relevance of this debate is determined by the nature of the procedure in question and the political, social, legal, economic and religious context of the country and health system in which the CO arises with regard to that procedure.

The new legal framework for abortion in NI mirrors the same statutory protection as under the Abortion Act 1967, meaning that, absent any emergency, HCPs are not obligated to participate in the clinical delivery of an abortion.⁴  This therefore represents a compromise position regarding the accommodation of COs, which obligates the objecting HCP to refer the patient to a colleague who holds no such objection.  The context, however, is a less than unanimous embrace of these legislative changes, including amongst NI HCPs themselves, who in large numbers vocally opposed abortion liberalisation in 2019.⁵  While the current landscape of NI HCP attitudes regarding CO to abortion is unknown, high levels of conscientiously objecting HCPs at least temporarily threatened the successful roll-out of the country’s abortion services,⁶ suggesting the prevalence of HCPs holding such objections is substantially higher in NI than in England, Scotland and Wales.⁷

It has previously been noted that access to abortion services is substantially impeded when the concentration of HCPs holding relevant COs rises, including in the Sicily, Lazio and Basilicata regions of Italy where the prevalence of gynaecologists with a CO to the procedure reached 80%.⁸  With regard to NI, while any CO that compromises the quality, efficiency, or equitable delivery of a service would not be legally accommodated, the practical implications for patient care of a CO (and subsequent clinical referral, potentially to services in England) may be substantial and significantly impact the number of abortions provided. This is because the issue is raised in a setting of nascent abortion services, amongst HCPs with a potentially high prevalence of CO, during widespread travel restrictions imposed by COVID-19.  Accordingly, the CO status of NI HCPs regarding abortion should be urgently surveyed, and the results used to inform the scope and limits of CO in the country, and to appropriately optimise public health messaging, to ensure access to abortion services is secured for women who need them.

References

1. R Armitage. Abortion in Northern Ireland: Decriminalisation, COVID-19 and recent data. The Lancet Regional Health Europe 01 April 2022; 15, 100349. DOI: 10.1016/j.lanepe.2022.100349
2. Special issue on Conscientious Objections. Journal of Medical Ethics April 2017; 43(4).
3. Wicclair MR, Conscientious Objection in Health Care: An Ethical Analysis (Cambridge University Press 2011)
4. E Rough. Abortion in Northern Ireland: recent changes to the legal framework. House of Commons Library. 15 March 2022 https://researchbriefings.files.parliament.uk/documents/CBP-8909/CBP-8909.pdf [accessed 30 April 2022]
5. M Connolly and C Smyth. Abortion: Hundreds of healthcare workers oppose new law. BBC 26 September 2019. https://www.bbc.co.uk/news/uk-northern-ireland-49831856 [accessed 30 April 2022]
6. M Wall. ‘Conscientious objections’ delaying roll-out of abortion services. The Irish Times 29 October 2019. http://www.irishtimes.com/news/ireland/irish-news/conscientious-objections-delaying-roll-out-of-abortion-services-1.4065217 [accessed 30 April 2022]
7. N Emmerich. After abortion’s arrival in Northern Ireland: Conscientious objection and other concerns. Clinical Ethics 20 April 2020; 15(2): 71-74. DOI: 10.1177/1477750920920549
8. F Minerva. Conscientious objection in Italy. Journal of Medical Ethics 2015; 41(2): 170-173.

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