World Medical Association
Revision of WMA Declaration of Oslo on Therapeutic
Abortion (2006)
12 December, 2017
Introduction
This commentary has been prepared at the request of an Associate
Member of the World Medical Association for the use of WMA Associate and
Constituent Members, and members of national physicians' associations
that are Constituent WMA Members. The original WMA documents quoted and cited
herein are available on the WMA website.
Full Text
Almost all members of the World Medical Association (WMA) were satisfied
with a minor revision of the WMA’s 2006 Declaration of Oslo on
Therapeutic Abortion circulated for comment in 2016. Nonetheless, a WMA
Working Group has proposed a new abortion policy (WGAP). A WMA Associate
Member has asked the Protection of Conscience Project to review the policy.
The WGAP has serious adverse implications for physicians who, for reasons
of conscience, refuse to provide abortion. The 2006 Declaration states that
they "may withdraw while ensuring the continuity of medical care by a
qualified colleague." This ensures continuity of care without requiring
facilitation of abortion by referral or other means. The provision was
unchanged in the Secretariat Revision and acceptable to almost all WMA
members.
In contrast, the WGAP requires objecting physicians to refer patients for
abortion, even if they believe that referral is unethical. It is incoherent
to assert that physicians are ethically obliged to do what they believe to
be unethical, and many objecting physicians consider referral unacceptable.
The WGAP requirement is not supported by the returns from even the
handful of members who commented on the Secretariat Revision. Only one
suggested a minor revision, and none recommended compulsory referral.
Further, to force objecting physicians to facilitate what they believe to
be unethical or immoral procedures would be inconsistent with other WMA
statements and policies that explicitly prohibit physicians from doing so.
Moreover, as demonstrated by developments in Canada, the WGAP provides a
precedent for compelling unwilling physicians to refer for other morally
contested procedures, including euthanasia, assisted suicide. It can also be
cited to support demands that physicians personally perform such procedures.
Finally, the Working Group ignored or failed to notice the distinction
between therapeutic and elective abortion drawn to its attention by
responding WMA members. The distinction is essential to identifying a
physician’s ethical and professional obligations concerning abortion.
However, the WGAP is ambiguous on this point, and controversial because it
can be cited to support the claim that physicians must provide or refer for
elective abortions.
The WGAP should be rejected. It is subversive of physician freedom of
conscience concerning abortion in the short term, and euthanasia and
assisted suicide in the long term. On the other hand, the 2006
Declaration could be safely reaffirmed with the update to Clause 5
proposed by the Working Group.
I.1.1 The World Medical Association (WMA) is
comprised of 115 national medical associations (constituent members)1 that
are "broadly representative of the physicians in their countries," which are
"not subject to, or controlled by, any office or agency of government."2
I.1.2 In
addition, individual physicians may become associate members. The associate
members form a group analogous to a national association. They may
vote in an Annual Associate Members Meeting and, through their chosen
representatives, participate (but apparently not vote) in the WMA General
Assembly.2 As will be seen, the associate members' group may also be
consulted by standing committees and the WMA executive about policy
development.
I.1.3 The WMA is organized in six regions: Africa,
Asia, Europe, Latin America, North America and the Pacific.3 Its working
languages are English, Spanish and French.
I.1.4 The WMA Council is the executive of the
organization, the members of which are elected every two years by the WMA
General Assembly. Members of the Council are drawn from the six WMA regions.3
The Council meets twice yearly, in the spring and in autumn. After the
Council meeting in autumn, delegations from all constituent members assemble
in the General Assembly, "the supreme decision-making body of the WMA."4
I.1.5 The WMA has three standing committees: Medical Ethics, Finance
and Planning, and Socio-Medical Affairs.3
I.1.6 The Secretary General of the WMA is the chief executive officer
of the organization and the head of the Secretariat, full time
administrators in Ferney-Volataire France.3
I.2.1 The WMA has an annual policy review process.
In April, 2016, the Council decided that the 2006 WMA Declaration of Oslo on
Therapeutic Abortion should be reaffirmed with minor revisions. In October,
the Secretariat submitted a draft revision of the Declaration for
consideration by the Council (Secretariat Revision - SR).5 With one exception, the revisions were purely
editorial (Appendix "A").
I.2.2 The 2006 Declaration observed that a
conflict may arise between the interests of a mother and her unborn child in
some circumstances, raising the question of abortion (Clause 2). It
acknowledged a "diversity of responses" in such situations was partly due "to the diversity of attitudes towards the life of the unborn child,"
adding, "This is a matter of individual conviction and conscience that must
be respected." (Clause 3)6
I.2.3 The Secretariat did not change the text of
these clauses, but moved and recombined them in such a way that, in the
Secretariat Revision, "This is a matter of individual conviction and
conscience that must be respected" (Recommendation 2) was made to refer, not
to "the life of the unborn child," but to the requirement that physicians
"maintain respect for human life."(Recommendation 1)5
I.2.4 This change was subtle and not inconsistent
with the original, since "respect for human life" can pertain to the lives
of both mother and unborn child. In its new position, "respect for
conviction and conscience" about "respect for human life" may have been
intended to avoid attributing greater importance to the life of the unborn
child.
I.2.5 In any case, this was the only modification
of any significance. The substance of the 2006 Declaration remained
intact in the Secretariat Revision (Appendix "A").
In October, 2016, the Council decided to circulate the Secretariat Revision to WMA members for
comment.7
I.2.6 The Secretariat Revision was returned with
comments from 15 of 116 members (115 constituent members and the associate
members' group), which suggests that the
overwhelming majority of associations were satisfied with the document. Of
the 15 associations that offered comments, only four suggested significant
revisions (Appendix "B"). However, because of
"controversies of opinions" reflected in the
returns from these associations, the Secretariat suggested that the Council
should appoint an individual or group to further discuss revisions to the
Declaration.5
I.2.7 The Medical Ethics Committee met in April,
2017. 18 members were present.8 Dr. Heidi Stensmyren of the Swedish Medical
Association was elected chair. It was decided to refer the Secretariat
Revision to a working
group consisting of volunteers from Australia, South Africa, Canada,
together with committee facilitator, Professor Vivienne Nathanson. Dr.
Stensmyren encouraged others to participate.9
I.2.8 The working group (ultimately consisting of representatives from South
Africa, Australia, Denmark, Korea, and Dr. Joseph Heyman, Chair of Associate
Members)10 reported back to the Medical Ethics Committee in October, 2017. Of
the 18 Ethics Committee members present, most had been at the previous
meeting.11 The working group chairman, Dr. Seleao Mametja of the South African
Medical Association, provided an oral report and submitted the group’s draft
revision [Working Group Abortion Policy (WGAP)].
I.2.9 Dr. Mametja said that the working group had
met just before the meeting of the Medical Ethics Committee "and proposed
additional adjustments to the document" as well as a change of the name of
the document from "therapeutic abortion" to "medically indicated abortion."
The Ethics Committee recommended that the WGAP be circulated to WMA members
for comment.12
I.2.10 The WGAP was circulated to national associations for feedback
at the end of November. Responses from the national associations were
requested by 12 February, 2018.10
I.2.11 It would seem that feedback received by 12
February will provide the basis for the next report on the WGAP, which will
presumably be made at the Council Meeting in April, 2018. The Council could,
at that time, recommend that the WGAP be adopted and put the document on the
agenda for the General Assembly, which meets on 3-6 October, 2018 in
Reykjavik, Iceland.7
I.2.12 From 2-4 October the WMA will hold a major
ethics conference in Reykjavik in conjunction with the General Assembly. It
will be open to the public. Belgium, Brazil, Canada, Comité Permanent des
Médecins Européens (CPME13), Denmark, Japan, Kuwait, Netherlands, Turkey,
South Africa, Spain, and the Chair of the Medical Ethics Committee have
volunteered to participate.14 A website for the conference is already active.15
I.2.13 The usual Scientific Session of the General
Assembly is to be replaced by the second day of the ethics conference, which
"will focus on important topics for the WMA."15 This would provide an ideal
opportunity to convince delegates to adopt new policies on
abortion and euthanasia.
II.1 The overwhelming majority of WMA members -
100 out of 116 - appear to have been satisfied with the Secretariat Revision. Further, the Working Group was formed because of "controversies"
among the handful of WMA members who did comment on the Secretariat
Revision (Appendix "B").
II.2 These circumstances do not suggest a need for a radical change of
policy concerning a controversial issue. However, the Working Group
does propose a radical change to WMA policy (Appendix "C").
II.3.1 Clause 6 of the 2006 Declaration,
carried over unchanged in Clause 5 of the Secretariat Revision, states:
If the physician's convictions do not allow him or her
to advise or perform an abortion, he or she may withdraw while ensuring the
continuity of medical care by a qualified colleague.
II.3.2 This does not imply that a physician is obliged to facilitate abortion by
referral or other means. It has been the Project’s experience that objecting
physicians are quite willing to continue medical care for the patient that
does not include abortion, or to arrange for a colleague to do so.
II.3.3 In contrast, the WGAP requires physicians who refuse to
provide abortion for reasons of conscience to refer patients to someone who
will, even if they believe that referral is unethical because it makes them
morally complicit in what they believe to be gravely wrong. In short, the
WGAP relies upon the incoherent premise that there can be an ethical
obligation to do what one believes to be wrong.
II.3.4 Many objecting physicians, accepting the concept of
vicarious moral/ethical responsibility, believe that they can be morally
responsible for acts committed by another person. Hence, an undetermined number
of physicians who object to abortion for reasons of conscience (either in
principle or in a particular case, such as sex selection) would also object to
facilitating abortion by referral.
II.3.5 Among the fifteen responding members, 12
left the protection of conscience clause intact (SR Recommendation 5), and
one (the American Medical Association) recommended only minor clarifications
of the provison. Neither the French nor the British
indicated an intention to suppress physician freedom of conscience in relation to elective
abortions. Only one medical association in the world - Sweden - clearly
sought the suppression of physician freedom of freedom of conscience in
relation to all abortions (Appendix "B").
II.3.6 In sum, the requirement
for referral introduced by the Working Group cannot be justified by reference to the
returns from the fifteen responding members.
II.3.7 The concept of vicarious moral/ethical responsibility,
which makes referral unacceptable for many objecting physician, is
accepted by the World Medical Association. It is applied in the Statement on Organ and Tissue Donation16 and its
resolutions prohibiting physician participation in capital punishment,17,18
torture and interrogation.19 All of these prohibit physicians from even
indirectly facilitating conduct by others that contradicts
principles of medical ethics.
II.3.8 The point here is not that abortion is morally
equivalent to capital punishment or torture, but that one who believes that
X is wrong does not act unreasonably by refusing to facilitate X. If it is reasonable for the WMA to accept and
apply this principle, it is equally reasonable for objecting physicians to
do so, and to refuse to facilitate abortion by referral or other means.
II.3.9 Moreover, the Declaration of Geneva
explicitly states that physicians must practise medicine "with conscience
and dignity,"20 and the WGAP itself asserts that
"individual conviction and
conscience [about abortion] . . . must be respected" (Clause 2). The WMA
would contradict the Declaration of Geneva were it to respect the
consciences of physicians willing to refer for abortion, while overriding
the consciences of those unwilling to do so. This would amount to a
policy of discrimination based on ethical orientation.21 The Canadian Medical
Association has dealt squarely with this issue in an eloquent submission to
a Canadian medical regulator:
For the majority of physicians who will choose not to
provide assistance in dying, referral is entirely morally acceptable; it is
not a violation of their conscience. For others, referral is categorically
morally unacceptable; it implies forced participation procedurally that may
be connected to, or make them complicit in, what they deem to be a morally
abhorrent act. In other words, referral respects the conscience of some, but
not others.22
II.3.10 Notice that this submission concerned mandatory
"effective
referral" for euthanasia and assisted suicide. What most national
associations probably do not realize is that forcing physicians to
facilitate abortion is preliminary to forcing them to facilitate euthanasia,
assisted suicide or any other morally contested procedure. The reasoning
used to justify the former is also used to justify the latter. This is
abundantly clear from the Canadian experience (Appendix
"D").
II.3.11 Moreover, most constituent and associate members of the WMA
probably do not realize that, ultimately, forcing objecting physicians to
refer may not satisfy those who demand that physicians participate in
morally contested acts. Once it is accepted that objecting physicians can be
compelled to refer for morally contested procedures, it can be
argued that they should be compelled to perform them, since referral
makes them complicit in the act in any case. Those unwilling to personally
provide abortion and euthanasia should not become physicians. Once more,
this is demonstrated by the Canadian experience (Appendix
"D").
II.4.1 The Working Group either ignored or did not
recognize an issue raised explicitly by the Netherlands and implicit in the
comments of other responding associations: the distinction between
"therapeutic" and "elective" abortion (Appendix
"E", E1.).
II.4.2 A therapeutic abortion to be one performed to
save women’s lives or to prevent serious, permanent injury to them (Appendix
"E", E2.). An elective abortion is one performed for socio-economic or
other reasons, including birth control (Appendix
"E", E3.).
II.4.3 Replacing "therapeutic" with "medically
indicated" is not helpful because the terms are not equivalent. "Medically
indicated" can refer to both therapeutic and elective abortions. The WGAP
would, if adopted, mean quite different things in different parts of the
world, and would be used to justify coerced provision or referral for
elective abortions, notably those provided for birth control (Appendix
"E", E4.).
II.4.4 This is significant because the majority of
abortions in North America and the United Kingdom (and probably in other
developed countries where the procedure is widely available) are not
therapeutic. They are overwhelmingly elective abortions performed for the
purpose of birth control (Appendix
"E", E5, E6.).
II.4.5 However, there is a significant difference
between an act of birth control by contraception and an act of birth control
by killing an embryo/fetus/unborn child. It is reasonable for women and
their physicians to incorporate this into their moral reasoning, even if
they ultimately arrive a different conclusions concerning the moral
acceptability or need for elective abortion. The killing of her
embryo/fetus/unborn child may be particularly important or advantageous for
a woman making the request. It does not follow, however, that reasons
she finds sufficient to justify her own acts are sufficient to compel
physicians who think differently to kill her embryo/fetus/unborn child, or
to punish them if they refuse (Appendix
"E", E7.).
II.4.6 Granted the profound impact of pregnancy and
childbirth on a woman and the need to respect her bodily and personal
integrity and moral agency, objecting physicians have an equal claim to
protection from violation of their bodily and personal integrity and moral
agency (
Appendix "E", E8.).
II.4.7 Attempts to suppress physician freedom of
conscience with respect to abortion frequently employ the paradigm of
"therapeutic" abortion. That is: it is said that physicians must be
compelled to provide or refer for all abortions because abortions are
performed only to save the life of the mother or to prevent serious
permanent injury. This is the premise underlying the WGAP demand for
referral. As returns comments from the Netherlands and others indicate, the
premise is demonstrably false.
II.4.8 A physician’s ethical and professional
obligations to provide elective procedures cannot be reasonably construed as
being identical to their obligations to provide emergency medical treatment.
It is disingenuous to purport to "balance" physician freedom of conscience
with patient access to abortion without taking this into account.
II.4.9 Unfortunately, the Working Group did not take
this into account, and, moreover, replaced the existing protection of
conscience provision with a passage that is ambiguous on this very point (C2.3.13).
Hence, its policy is likely to cause more controversy because it is likely
to be used to force physicians to provide and facilitate elective abortions
for non-medical socio-economic reasons and birth control (Appendix
"E", E9.).
III.1.1 The deletion of the requirement that physicians
maintain respect for human life was not suggested by any member of the WMA
outside the Working Group (Appendix
"C", C2.1).
III.2 Clauses 2-3:
Abortion as a medical act / no maternal relationship
III.2.1 The assertion that abortion is a "medical
matter" admits no exceptions. Hence, the paragraph implies that
sex-selective abortion is a purely "medical matter," contradicting the
WMA Resolution on Female Foeticide (Appendix
"C", C2.2.5-8).
III.2.2 Consistent with the deletion of the requirement
for respect for human life, the WGAP now requires respect for attitudes to
abortion, not (as in the 2006 Declaration) to the life of the
unborn child/fetus, or (as in the Secretariat Revision) to human life. This
is a subtle but significant change (Appendix
"C", 2.2.6).
III.2.3 The statement that abortion concerns only the
"patient" (singular) and physician effectively excludes the view that
abortion concerns three individuals, or that a physician treating a pregnant
woman has two patients. Replacing the terms "mother" and "unborn child" with
"woman" and "fetus" erases the concepts of maternity and maternal
relationship, as well as the equal humanity of mother and child (Appendix
"C", C2.2.9-12).
III.3.1 While suggesting advocacy by physicians and national associations
concerning abortion, the paragraph makes no reference to adequate prenatal,
obstetric or maternal health care, nor to advocating health policies that
ensure such care is available (Appendix
"C" C2.3.1-2).
III.4.1 This clause satisfactorily incorporates
comments from responding members. It recognizes that abortion can be
provided by health care workers who are not physicians, and more thoroughly
articulates the corresponding provision in the 2006 Declaration (Appendix
"C", C2.3.3).
III.5 Clause 6:
Convictions of doctors and patients
III.5.1 While this new clause affirms that the
"convictions" of both a doctor and patient must be "respected," this is not
equivalent to an affirmation that moral, ethical, or religious convictions
must be respected, nor to an affirmation that freedom of conscience and
religion must be accommodated (Appendix
"C", C2.3.4-7).
III.6 Clause 7: Patients
with moral convictions
III.6.1 The new clause states that "patients with moral
convictions"must have appropriate support and "necessary medical and
psychological treatment." None of the responding members made a
recommendation to this effect. Since all patients have moral convictions,
and all most be provided with necessary treatment, the statement is
redundant or meaningless (Appendix
"C", C2.3.7).
III.7 Clause 9:
Availability of "therapeutic abortion services"
III.7.1 It appears that this statement is intended to
ensure that abortion service is made a priority during famines, droughts,
natural and man-made disasters and in war zones.
III.7.2 While the clause urges advocacy to ensure that
no woman dies because of lack of therapeutic abortion services, no
comparable advocacy is urged with respect to the need for adequate prenatal,
obstetric or maternal health care, nor to advocating health policies that
ensure such care is available.
III.7.3 Granted the importance of preserving the lives
of pregnant women, it is remarkable that, among the many policies,
declarations and resolutions produced by the World Medical Association,
there is not a single one devoted to the provision of prenatal and maternal
health care, and the sole document concerning obstetric care is the
Declaration on Therapeutic Abortion (Appendix
"C", C2.3.17-19).
III.8.1 Clauses 4, 5, 7 and 9 do not appear to be
problematic from the perspective of freedom of conscience, although the
advocacy recommended in Clauses 4 and 9 is clearly biased in favour of
abortion.
III.8.2 Clause 6 is misleading because it actually does
not require that freedom of conscience be accommodated, and it is
contradicted by the demand for compulsory referral in Clause 8.
III.8.3 The deletion of the requirement to respect
human life and the addition of clauses 2 and 3 do not directly affect
freedom of conscience. However, taken together with the new demand to
respect attitudes toward abortion (rather than life), the changes are
prejudicial to the position of physicians who hold that abortion involves
two individuals/patients, who acknowledge that pregnancy involves a maternal
relationship, or who insist that the lives of both the woman and her unborn
child/fetus have the same value in ethical calculations.
III.8.4 Hence, the general tenor of the WGAP
demonstrates a bias in favour of abortion and against the exercise of
freedom of conscience by physicians who refuse to participate in abortion
for reasons of conscience. This bias must also be considered in assessing
the impact of Clause 8, which is directly concerned with freedom of
conscience.
III.8.5 Note that the Working Group’s elimination of
respect for human life and replacement of evocative words like "mother" and
unborn child" with the minimally demanding technical terms "fetus" and
"pregnant woman" did not produce an unbiased document. It simply changed the
bias.
IV.1 The WGAP is a radical revision of the 2006
Declaration of Oslo on Therapeutic Abortion not called for by the
overwhelming majority of WMA members. It demonstrates a general bias in
favour of abortion and against physician freedom of conscience. The demand
for mandatory referral is not supported by the comments of the few members
who commented on the Secretariat Revision of the Declaration.
IV.2 The Working Group claims that physicians are
ethically obliged to facilitate abortion by referral, even if they believe
that doing so is unethical or immoral. This claim is incoherent, since there
can be no ethical obligation to do what one believes to be wrong.
IV.3 To force objecting physicians to facilitate what
they believe to be unethical or immoral would contradict the Declaration of
Geneva. It would also be inconsistent with WMA statements concerning organ
and tissue donation, capital punishment, torture and interrogation, all of
which prohibit physicians from even indirectly facilitating conduct by
others that contradicts principles of medical ethics. Finally, adopting the
WGAP would signal the support of the WMA for discrimination based on ethical
orientation.
IV.4 The distinction between therapeutic and elective
abortion is essential to identifying a physician’s ethical and professional
obligations concerning the procedure. The Working Group not only failed to
acknowledge the distinction, but replaced the existing policy with a passage
that is ambiguous on this very point. Hence, the WGAP, if adopted, would
likely cause more controversy, since it would usually be applied in order to
compel physicians to facilitate elective abortions for the purpose of birth
control.
IV.5 Forcing physicians to facilitate abortion is
preliminary to forcing them to facilitate other morally contested
procedures, including euthanasia, assisted suicide, and, ultimately, to
personally providing such services. This would drive many physicians from
medical practice and close the medical profession to many religious
believers and others whose philosophy of medicine reflects a traditional
Hippocratic approach.
V.1 The WGAP should be rejected. It is subversive of
physician freedom of conscience concerning abortion in the short term, and
euthanasia and assisted suicide in the long term.
V.2 On the other hand, the 2006 Declaration
could be safely reaffirmed with the update to Clause 5 proposed by the
Working Group. which is clearly supported by the returns from the handful of
WMA members who commented on the Secretariat Revision.