World Medical Association
Revisione della
Dichiarazione di Oslo
sull'aborto terapeutico (2006) della WMA
Appendice "C"
Politica sull'aborto del gruppo di lavoro (PAGL)
Dichiarazione di Oslo sull'aborto terapeutico (2006)
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Politica sull'aborto del gruppo di lavoro (ottobre 2017)
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PREAMBOLO
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1. La WMA richiede al medico di mantenere il
rispetto per la vita umana.
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Eliminato
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1. L'aborto come indicazione medica
si riferisce a un'interruzione di gravidanza per motivi di
salute, in conformità ai principi della medicina basata su
evidenze e della buona pratica clinica.
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2. L'aborto è una questione medica tra il paziente e il
medico. L'atteggiamento verso l'aborto è
una questione di
convinzioni personali e di coscienza che vanno rispettate.
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2. Le circostanze che portano gli
interessi di una madre in conflitto con gli interessi del
suo bambino non ancora nato
creano un dilemma e sollevano la
domanda circa la legittimità di interrompere o meno la
gravidanza.
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3.
Le circostanze che portano gli interessi di una
donna in
conflitto con gli interessi del suo feto non ancora nato
possono
creare un dilemma circa la legittimità di interrompere o meno la
gravidanza.
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3. La diversità di risposte in
tali situazioni è dovuta in parte alla diversità di
atteggiamenti verso la vita del
bambino non ancora nato.
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La diversità di risposte in tali situazioni è dovuta in parte
alla diversità di atteggiamenti verso la vita del feto, dovuti a
motivi di cultura, religione e tradizione.
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È una questione di convinzioni personali e di coscienza
che vanno rispettate.
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(Spostata al preambolo 2; significatio cambiatio)
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RACCOMANDAZIONI
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4. Non è compito della professione medica stabilire
gli atteggiamenti e le regole di uno stato o di una comunità
sull'argomento, ma è nostro dovere tentare di tutelare i
nostri pazienti e di salvaguardare i diritti del medico in
seno alla società.
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4. I medici dovrebbero essere consapevoli delle
leggi, delle norme e dei requisiti di segnalazione sull'aborto.
Leggi, norme, standard e pratiche cliniche nazionali sull'aborto
dovrebbero promuovere e proteggere la salute delle donne e i
loro diritti umani, il loro consenso informato volontario, la
loro autonomia decisionale e la loro riservatezza e privacy. Le
associazioni mediche nazionali dovrebbero richiedere che la
politica sanitaria nazionale rispetti questi principi.
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5. Di conseguenza, se la legge permette l'aborto
terapeutico, la procedura deve essere eseguita da un medico
competente in strutture approvate dall'autorità competente.
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5. Laddove la legge consente l'aborto
come indicazione
medica, la procedura dovrebbe essere eseguita da un medico
competente o da un altro operatore sanitario nel rispetto dei
principi della medicina basata su evidenze e della buona pratica
medica in una struttura approvata che soddisfa gli standard
medici necessari.
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6. Devono essere rispettate le
convinzioni di entrambi medici e pazienti.
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7. I pazienti con convinzioni
morali devono essere adeguatamente sostenuti e deve essere
fornita loro l'assistenza medica e psicologica necessaria.
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6. Se le convinzioni del medico non gliconsentono
di consigliare o praticare un aborto, può tirarsi indietro
pur garantendo la continuità dell'assistenza medica da parte
di un collega qualificato.
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8. Un medico ha il diritto
all'obiezione di coscienza nei confronti dell'aborto, ma tale
diritto non deve permettergli di ostacolare o negare l'accesso
all'aborto legale perché ciò ritarderebbe l'assistenza alle
donne, mettendone a rischio la salute e la vita stessa. In tali
casi, il medico deve affidare la donna a un professionista
disposto e qualificato sull'aborto o a un'altra struttura
sanitaria di facile accesso, in conformità al diritto nazionale.
Qualora ciò non fosse possibile, il medico obiettore, deve
praticare l'aborto sicuro o eseguire qualsiasi procedura si
renda necessaria per salvare la vita della donna ed evitare che
riporti problemi di salute gravi.
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9. I medici devono lavorare con la
società affinché nessuna donna perda la vita perché i servizi di
aborto terapeutico non sono disponibili, anche in circostanze
estreme.
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C2.1.1 None of the responding members recommended deletion of the
requirement that physicians "maintain respect for human life."
Clause 1: Definition
1. Medically indicated abortion refers to
interruption of pregnancy due to health reasons, in accordance with
evidence-based medicine principles and good clinical practice.
C2.2.1 Denmark suggested the need for a definition of
"therapeutic" abortion (Appendix
"B", Comment), and Netherlands
thought the policy should be about "elective" abortion (Appendix
"B", 2.5.2).
Norway also emphasized the importance of "elective" abortion (Appendix
"B", B2.4.1-2).
Discussion reported by
the Associate Members (Appendix
"B", B2.3.1), France's insistence that the document
must be understood to be about "therapeutic" abortion (Appendix
"B", B2.8.4).
C2.2.2 Clearly, the obligations of physicians with
respect to the provision of therapeutic services are different from their
obligations concerning the provision of elective services. This probably
explains the comments and recommendations of Denmark, Netherlands, the
Associate Members and France.
C2.2.3 It appears that the
Working Group originally drafted a definition of "therapeutic abortion," but
changed the
term to "medically indicated abortion" during a last minute meeting before
the draft was presented to Council.12 "Medically indicated" can refer
to either therapeutic or elective abortions, so it obscures the difference
between them (Appendix "E", E4.).
C2.2.4 The failure to distinguish between therapeutic
and elective abortion obstructs proper consideration of ethical issues and
significantly impedes efforts to find ways to accommodate patient access to
services and physician freedom of conscience (C2.3.13).
Clause 2: Abortion as a medical act
2. Abortion is a medical matter between the patient
and the physician. Attitudes toward abortion are a matter of individual
conviction and conscience that must be respected.
C2.2.5 The first sentence of this new statement appears
to be the result of an American suggestion (Appendix
"B", B2.9.1). The Working Group
excluded the AMA's qualifying conditions, including reference to the
physician's clinical judgement.
C2.2.6 The 2006 Declaration stresses the need to
respect individual conviction and conscience concerning "the life of the
unborn child." The Secretariat Revision urges respect for conviction and
conscience concerning "respect for human life." The WGAP
- emphasizes respect for individual conviction and conscience
concerning abortion (another American recommendation);
- states that abortion "is a medical matter between the patient and
the physician."
C2.2.7 The "patient" - singular - would appear to be
the mother. The WGAP thus excludes the empirically verifiable view that
abortion concerns two individuals, and the philosophical view that abortion
concerns two patients. This is prejudicial to physicians who, holding such
positions, factor the life of the unborn child/fetus into their ethical
calculations.
C2.2.8 The assertion that abortion is a "medical
matter" is absolute, implicitly overriding any contrary assertion, again to
the prejudice of physicians who disagree. It implies, for example, that
sex-selective abortion is a purely "medical matter," which potentially puts
the WGAP at odds with the WMA Resolution on Female Foeticide.25
Clause 3: No maternal relationship
3. Circumstances where the interest of a woman is in
conflict with the interests of her unborn fetus may create a dilemma as to
whether or not the pregnancy should be deliberately terminated. The
diversity of responses to such situations is due in part to the diversity of
attitudes towards the life of the fetus, for various reasons including
cultural, religious and traditional.
C2.2.9 The 2006 Declaration and Secretariat
Revision refer to the dilemma that can arise when the interests of the
"mother" and "unborn child" conflict. The WGAP
- replaces "mother" with "woman" and "unborn child" with "unborn
fetus."
C2.2.9 This effectively erases the concepts of
maternity and maternal relationship, as well as the equal humanity of mother
and child. Opposition to abortion for reasons of conscience frequently
depends upon arguments that employ such concepts, so the change is
disadvantageous for physicians holding such views.
C2.2.10 The British Medical Association was the only
responding member that suggested replacing "unborn child" with "fetus"
(though not consistently) and none suggested deleting the term "mother."
France's deletion of the entire clause that mentioned mother and unborn
child did not reflect an intention to erase the concepts of maternity and
maternal relationship, but was motivated by its insistence to make clear
that the document concerned only "therapeutic" abortion.
C2.2.11 The 2006 Declaration and Secretariat Revision
both state that the diversity of responses to the possibility of abortion
arise from diversity of attitudes toward the life of the unborn child/fetus.
The proposed policy
- states the diversity arises "for various reasons including cultural,
religious and traditional."
C2.2.12 Again, the WGAP erases the unborn child/fetus,
substituting a list of variables that many would describe as non-rational,
if not irrational. While the list is not technically exhaustive, the absence
of reference to science, philosophy, and medical ethics is noteworthy. The
change reflects the recommendations of Norway (Appendix
"B", B2.4.1), which held that a
right to "elective" abortion is more important than the life of the
fetus/unborn child.
Clause 4: Law and social policy
4. Doctors should be aware of local abortion laws, regulations and
reporting requirements. National laws, norms, standards, and clinical
practice related to abortion should promote and protect women's health and
their human rights, voluntary informed consent, and autonomy in
decision-making, confidentiality and privacy. National medical associations
should advocate that national health policy upholds these principles.
C2.3.1 The proposed policy introduces a new clause asserting that
doctors must be "aware of local laws regulations and reporting
requirements." It does not state that they must abide by them. This
formulation may reflect Swedish influence, since the Swedish Medical
Association clearly implied that law was irrelevant to whether or not
abortion should be performed (Appendix
"B", B2.10) (SR Recommendation 5).
C2.3.2 The
2006 Declaration and Secretariat Revision avoid giving direction on social
or legal norms. The WGAP
- insists that social norms and regulations
concerning abortion "should promote and protect women's health and their
human rights," informed consent, autonomy and "confidentiality and privacy";
- urges national medical associations to advocate for health policies
consistent with such goals;
- makes no reference to adequate prenatal,
obstetric or maternal health care, nor to advocating health policies that
ensure such care is available (See C2.3.19).
Clause 5: Technical
standards for abortion practice
5. Where the law allows
medically-indicated abortion to be performed, the procedure should be
performed by a competent physician or other health care worker in accordance
with evidence-based medicine principles and good medical practice in an
approved facility that meets necessary medical standards.
C2.3.3 This clause satisfactorily incorporates comments from
responding members. It recognizes that abortion can be provided by
health care workers who are not physicians, something suggested by the
British. In other respects it more thoroughly articulates the
corresponding provision in the 2006 Declaration and Secretariat
Revision.
Clause 6: Convictions of doctors and patients
6. The
convictions of both the doctors and the patient must be respected.
C2.3.4 The WGAP
- states that the convictions of both doctors and "the
patient" must be "respected", but
- does not require that the convictions of
both be accommodated.
C2.3.5 This new clause may reflect Korean
influence, since Korea commented that both doctors' and patients' right
should be respected, and Korea was part of the Working Group (Appendix
"B", Comment).
C2.3.6 As the French response demonstrates, "respect
for convictions" does not necessarily refer to religious or moral
convictions and is not equivalent to respect for freedom of conscience
(Appendix "B", B2.8).
C2.3.7 The
use of "respected" rather than "accommodated" is significant and unhelpful,
since (as demonstrated in Canada) some medical regulators claim that they respect the beliefs of physicians, even as they demand that
they do what they believe to be wrong - including referral for euthanasia.26
Clause 7: Patients with moral convictions
7. Patients with moral
convictions must be supported appropriately and provided with necessary
medical and psychological treatment.
C2.3.7 A new clause requires
that "patients with moral convictions must be supported appropriately and
provided with necessary medical and psychological treatment." Since all
patients have moral convictions, and all most be provided with necessary
medical and psychological treatment, the statement is either redundant or
meaningless. None of the responding associations made a recommendation to
this effect.
Clause 8: Physician freedom of conscience
8.
Individual doctors have a right to conscientious objection to providing
abortion, but that right does not entitle them to impede or deny access to
lawful abortion services because it delays care for women, putting their
health and life at risk. In such cases, the physician must refer the woman
to a willing and trained health professional in the same, or another easily
accessible health-care facility, in accordance with national law. Where
referral is not possible, the physician who objects, must provide safe
abortion or perform whatever procedure is necessary to save the woman's life
and to prevent serious injury to her health.
C2.3.8 The 2006
Declaration and Secretariat Revision state that physician whose convictions
preclude performing an abortion "may withdraw while ensuring the continuity
of medical care by a qualified colleague." This does not require
facilitation of the procedure by referral or other means, while ensuring
that the patient continues to receive medical care.
C2.3.9 The WGAP
completely replaced this protection of conscience provision with the new
Clause. However, none of the responding WMA members stated that objecting
physicians should be compelled to refer for abortions, although Sweden
(which would have entirely suppressed physician freedom of conscience with
respect to abortion) might approve of the new WGAP provision.
C2.3.10 The
WGAP
C2.3.11
The WGAP continues:
- "In such cases, the physician must refer the woman
to a willing and trained health professional in the same, or another easily
accessible health-care facility, in accordance with national law."(Emphasis
added.)
C2.3.12 The context clearly indicates that the objecting physician is
expected to personally and directly arrange for the abortion to be provided
by someone else. Many objecting physicians would find this unacceptable
because they believe that doing so would make them morally complicit in an
immoral act.
C2.3.13 On the other hand, the italicized phrase
is significant because it can be understood to mean that referral is
required only in the case of therapeutic abortions, when the health or life
of the woman is at risk. As the Royal Dutch Medical Association observed,
this is rare and usually uncontroversial. An unknown number of physicians
who object to elective abortion would be willing to refer a patient for an
abortion necessary to save her life.
C2.3.14 The Working Group failed to address the distinction between
therapeutic and elective abortion, which was the subject of the Dutch
comment and reflected in comments by others as well . As a result, this section of the WGAP is ambiguous and will
exacerbate rather than resolve controversies associated with physician
freedom of conscience (Appendix
"E").
C2.3.15 Finally, when
referral is not possible, WGAP states that objecting physicians "must
provide safe abortion or perform whatever procedure is necessary to save the
woman's life and to prevent serious injury to her health." (Emphasis added.)
This requirement was suggested by the British Medical Association (Appendix
"B", B2.7.4).
C2.3.16 This implies that every physician must be capable of performing an
abortion, presumably at any stage in pregnancy, which, in turn, implies that
all physicians, including objecting physicians, must train to perform
abortions. This statement alone, if accepted, would be sufficient to force
all objecting physicians out of medical practice.
Clause 9:
Availability of "therapeutic abortion services"
9. Physicians must work
with society to seek to ensure that no woman loses her life because
therapeutic abortion services are unavailable, even in extreme
circumstances.
C2.3.17 This is the verbatim text of a statement
recommended by the British Medical Association (Appendix
"B", B2.7.6).
It is not clear that the retention of "therapeutic" rather than "medically indicated" is
deliberate, or if it
reflects the hasty last-minute revisions that occurred just before the
document was presented to the Council (I.2.9).
C2.3.18 "Extreme circumstances" is not explained. Since
loss of life is itself extreme, it would seem 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.
C2.3.19 Once
more (C2.3.2), there is no reference to the need for adequate prenatal,
obstetric or maternal health care, nor to advocating health policies that
ensure such care is available. This seems consistent with the fact 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.