Conscientious Objection and Termination of Pregnancy (TOP) in South Africa
By Angie Vorster
In my psychotherapeutic work with undergraduate medical students ethical issues and moral dilemmas frequently arise as topics for exploration. Individual moral prerogative versus services enshrined in the South African constitution frequently present professional challenges, particularly to healthcare students and providers in the public healthcare service system. The Choice on Termination of Pregnancy Act of 1996 ensures every woman in South Africa’s right to access legal and safe abortion services upon request in the first twelve weeks of pregnancy. Socio-economic and other grounds for abortion are conceded from 13 weeks gestation until the 20th week of pregnancy. First trimester abortions may be performed by registered medical practitioners or by appropriately trained registered midwives, while second trimester abortions necessitate the services of a registered medical practitioner. Ngwena (2003) provides an extensive exploration of the dichotomy between legal and constitutional rights to accessing termination of pregnancy (TOP) services in South Africa, versus health care providers’ attitudes toward these services. Open hostility toward women seeking TOP, as well as the health care workers facilitating such services; have been observed frequently, both in literature, as well as anecdotally. Conversely there are also reports of healthcare workers being coerced into assisting with, and performing TOP services, against their will.
The Choice on Termination of Pregnancy Act does not address healthcare workers’ right to conscientious objection. However the constitution allows for the right to freedom of conscience, and as with all rights, there are limitations. Healthcare providers are required to provide women seeking TOP with the necessary information and appropriate referral. The woman’s life and health are legally regarded as primary to that of her foetus and consequently there is a professional and legal prerogative to prevent harm to, or loss of, her life which further challenges the right to conscientious objection to assisting with such reproductive health services. Although South Africa may have one of the most liberal legal stances regarding abortion, a vital lack of specific legislation within the Choice on Termination of Pregnancy Act regarding conscientious objection, places both service delivery, as well as the right to personal moral autonomy, in jeopardy. Harries, Cooper, Strebel and Colvin (2014) go so far as to state that the right to conscientious objection in South Africa competes with the constitutional rights to reproductive autonomy. In real terms this translates to women having legal protection to access TOP up to 20 weeks gestation, without necessarily having practical access to such services. Of course limited resources and various socio-economic and socio-political factors influence access to primary healthcare services. However one such factor that is potentially amenable to alteration is the attitude and willingness of healthcare providers to discuss, refer, perform and treat TOP requests, procedures and complications. Harries at al. (2014) found the following factors regarding conscientious objection that affect service delivery: among medical healthcare providers there is a lack of knowledge regarding relevant legislation as well as the legal rights and responsibilities of both patient and healthcare worker. There is also a confounding lack of formalisation of the registration of conscientious objection.
My anecdotal observation of the lack of TOP education and training in medical and nursing school curricula in South Africa has been explored and confirmed by Smit, Bitzer, Boshoff and Steyn (2009). Consequently the recommendation can be made that all training of medical students and nursing students should include content related to the legal and ethical requirements and obligations related to TOP. This would serve to address the limitation of access to primary healthcare services enshrined in the constitution, currently being provided by a relatively small cohort of healthcare workers.
My personal recommendation would be to ensure that there are enough opportunities created within the teaching/learning space to allow for discussions surrounding social justice issues. Such discussions should be facilitated by individuals familiar with, and non-partisan to, issues related to reproductive health, feminist health psychology, and legislation in this regard, ethical guidelines as well as individual moral decision-making frameworks. In this manner our medical and nursing students would be empowered to develop informed personal stances toward issues central to their future professions within the South African healthcare system.
References:
Harries, J., Cooper, D., Strebel, A., & Colvin, C. J. (2014). Conscientious objection and its impact on abortion service provision in South Africa: a qualitative study. Reproductive health, 11(1), 16.
Ngwena, C. (2003). Conscientious objection and legal abortion in South Africa: delineating the parameters. Journal for Juridical Science, 28(1), 1-18.
Smit, I., Bitzer, E. M., Boshoff, E. L. D., & Steyn, D. W. (2009). Abortion care training framework for nurses within the context of higher education in the Western Cape. Curationis, 32(3), 38-46.