Ethical Issues

Ethical issues regarding reproductive health services in both public and private health care settings were discussed extensively at at Seminar on Reproductive Health, Reproductive Rights & Abortion. Below is a summary of the discussions to guide thinking around this are:

Seminar on Reproductive Health, Reproductive Rights & Abortion

Sunday, 20 December 2009; Auditorium Permata, Ambulatory Care Centre, Hospital Tengku Ampuan Rahimah (HTAR), Klang, Selangor
Organised by Department of Obstetrics & Gynecology, HTAR; Family Health Development Division (FHDD) MOH and Reproductive Rights Advocacy Alliance Malaysia (RRAAM)

Objectives:

  • Discuss issues and challenges of abortion care and services for doctors and nurses within reproductive health services in both public and private health care settings including the latest medical technologies;
  • Address misconceptions on the legality or abortion as well as ethical concerns; and
  • Advocate for increased access of women to abortion care and services to better meet women’s needs and fulfill Malaysia’s policy agreements to reproductive rights and women’s rights.

G. SESSION 4: Challenges for the Public Sector in Providing Quality, Affordable and Ethical Abortion Services as Part of Reproductive Health Services.

i. O&G Specialist Services in Hospitals

Before beginning his talk, Dr Hj Mohamad Farouk Abdullah noted that the questions asked thus far were the same that have surfaced from their roadshows, indicating the need for continuing their work in educating medical professionals on this issue.

He said it was important for him to state that the abortion services in public hospitals is of high quality and affordable, meets the conditions for quality, affordability and ethics.

Firstly, he clarified that public hospitals do provide TOP services, since the medical profession tends to be schizophrenic and sometimes does not see the whole range of terminations they perform – eg. inducing preeclampsia at 36 weeks; inducing uncontrolled eclampsia at 34 weeks; conducting elective Caesarean section; over foetal anomaly, on a woman with congenital heart disease in her first trimester, etc. Their clients are from OSCC, peripheral health clinics, gynaecology clinics and those with post-abortion complications. The providers are HO, MO, specialists and consultants, and nursing and administration staff.

The techniques used are D&C, suction and curettage, MVA and medical agents (but limited; one of the challenges to address for comprehensive care). They do not have RU486 because it’s not registered in Malaysia; nor misoprostol because it’s not indicated for TOP. But there are others, prostaglandin.

He said the first challenge to address is ignorance, as demonstrated in the questions asked in this seminar. Ignorance is not a crime, but continued ignorance despite being informed with the facts is wrong. We need to know what is legal, what we owe the public and we need to educate women on their rights to health services.

Where the law concerns, Section 312 of the Malaysian Penal Code says “a medical practitioner” can perform termination. As for what “good faith” constitutes, if he were to bring a 16-year-old girl he impregnated, asking the doctor to perform an abortion on her, the doctor’s decision would not be in good faith. But if the girl herself comes and the doctor can show there is a doctor-patient relation, documenting that an assessment has been done, with indications checked and consent obtained, then that is good faith. On the three conditions for pregnancy, he said public hospitals have conducted abortions as cited earlier, including underage rape cases from OSCC, evoking the mental health clause. Harking back to questions raised earlier about involving a psychiatrist, he said previous speakers have differentiated between a psychiatric patient and a mental status (which a doctor can assess). However, for those working in hospitals that have psychiatrists, they can consult one if they cannot form an opinion on their own as per the usual peer consultation.

The next challenge is to ensure that, following non-directive counseling, women have access to abortion services within the public health sector in accordance with local laws. He stressed that nothing asked of medical practitioners in this seminar is illegal. Health care services have an obligation to provide such services as safely as possible. Often, the worst-case scenario of being sued is raised, yet the reverse can also happen – i.e. the hospital can be sued by patients or their family for breaching the law by failing to provide health care as per their duty.

Also there is a need to study, analyse and understand national laws and policies in order to encourage provision of abortion services to the fullest extent permissible. As well, advocate for laws that recognise the rights of women to obtain safe abortions. While the present law is fairly good, as Mr Radha revealed, there were attempts to amend it to make it easier for doctors to decide, especially in respect of contraceptive failure and foetal anomaly. In his department, he makes it easy for the doctors by mandating every pregnancy to be discussed with a group of consultants, making it educational for all as well.

The other challenge is ignorance about the legality of abortion, which is commonly perceived as a criminal offence as perpetuated by a few unscrupulous doctors who overcharge for such services.

Also, with regard to conscientious objection, they must ensure that health care providers don’t impose their moral/religious/cultural convictions regarding abortion on women seeking such services at public hospitals. Dr Farouk said he’s a Muslim who believes he is a good Muslim and does his best to be one. However, the public hospitals in this country are not Islamic hospitals, nor Buddhist or Christian, etc. and those serving in hospitals will have different cultural/moral standings. A patient may not share the same moral/religious conviction and she has a legal right to that service. Those with a conscientious objection have an obligation to inform patients of their rights and to refer them to others who can provide the service they asked for. In the UK, doctors are asked to sign a form indicating such convictions; if there is, a locum has to be engaged to do it. If it were an Islamic hospital, then the hospital is free to act in accordance with its principles, but until that happens, and Dr Farouk assures all that public hospitals will continue to serve all regardless of backgrounds, the service must be made available; otherwise a patient can take them to court for breach of duty.

When it comes to rape survivors who become pregnant from it, the challenge is to restore their right to choice, since the choice about her body has been taken away by the rape. Thus, to further impose our beliefs on women from the OSCC – since there are people with agendas everywhere – is wrong. We need to empower them in making a choice, support them and their decision, and provide them with care as per our duty, free of encumbrances. The options at OSCC, because not all pregnancies happen in desirable conditions are: keeping the baby (even among rape survivors); foster care/ adoption; TOP (which is where public hospitals play their role).

Another challenge is maintaining confidentiality of health care providers (eg. the labeling of “abortionist” for those who would provide the service) and women patients (we need to curb our admittedly human trait of gossiping about other people in trouble). Medical professionals must honour the code of professional ethics which safeguards clients’ confidentiality while working within the laws of the country, as part of the obligation to provide safe and reliable post-abortion care.

Also problematic is the lack of access to agents for medical TOP. Misoprostol is available and widely used, but MOH hasn’t responded to their request for access. Dr Farouk noted that, despite Malaysia having enough women in positions of power – including in the MOH, on top of a vibrant women’s ministry headed by a woman minister – to make a difference in ensuring that laws, policies, personnel are women-friendly, more needs to be done in preparing and implementing norms and guidelines that define the minimum quality in abortion care, and the steps to ensure sufficient public sector services, staffing and supplies, including WHO-endorsed technologies.

Next, training of professionals and continuing education of health professionals as is being done to some extent in this seminar. As stated by the ICPD Agreement signed by Malaysia: In circumstances where abortion is not against the law, health systems should train and equip health providers and take other measures to ensure safe and accessible abortion, with additional measures to safeguard women’s health. The ICPD Agreement was signed 15 years ago; yet what has been done by the elected people in power? This is where we come in. We need to engage with politicians and those in power to ensure treaties are implemented locally.

ICPD+5 found the following results that need to be addressed:

  • Medical education curriculum in 3 main local universities with regard to abortion laws does not reflect current status, which has serious implications on future practitioners’ practices.
  • There is no practical training on abortion services for undergraduates; some content in post-graduates.
  • Other private universities: situation unknown; needs assessment.

Harking back to conscientious objections, he revealed that he has had devout Muslims crying over a necessary abortion, thinking they were going against the religion/law although the fatwa allows it based on Muslim jurisprudence. To personalise the issue, he said everyone should think about their daughters – though they may have been brought up in the best possible way, they could still be victims of unwanted pregnancies. His own family of three daughters gives him a personal reason to continue this reproductive health crusade.

The findings show that:

  • Access to legal abortion in government hospitals is lacking – obviously not a priority concern.
  • 1989 amended law is still largely unknown – owing to apathy and ignorance, which means continued violation of women’s reproductive rights.
  • Work with authorities governing curriculum medical review.
  • Promote continuing education in reproductive rights.

On medical curriculum review, it must address the low contraceptive prevalence rate and barriers to family planning access, introduce reproductive rights, explain the legality of abortion accurately, teach all abortion methods, and include training in all other components in provision of good quality, ethical, reproductive health service.

On reproductive rights, Dr Farouk is reminded of another controversy – contraception. The prevalent view is that it should be for married people only – which he finds silly because they’re meant for sexually active people, which not many married people are, compared with single women.

He said reproductive rights encompass: having (legal) choices (pre- and post-pregnancy); choice; involvement in decision making (in consultation with others; not the women’s alone to make); and support for the choices made.

He concluded by saying:

  • Abortion care is a medically required service that must be provided in the public sector. It is a critical component of public health programmes, or many may risk lives to obtain unsafe, illegal abortions.
  • In the last maternal mortality report, there were no deaths due to abortion but that’s not the situation next year because of a recent case.
  • Abortion is not an elective procedure: outcomes are inescapable and time sensitive. Any delay increases medical risks to women.
  • Legal access to abortion is a constitutional right.
  • Almost all abortion-related deaths are preventable if performed by qualified people using correct techniques and openly, as allowed by the law.

ii. MOH Policy and Guidelines

Dr Rachel Koshy, Principal Assistant Director of Department of Family Health, Ministry of Health, began by pointing to the reality that not every pregnancy is welcome, yet abortion is such an emotional subject (from religious, cultural and social perspectives) that no one from her department was willing to replace her boss, who had to go overseas, to give this talk.

She stressed that abortion occurs in all groups of income and all countries regardless of level of development. WHO estimates there are 45 million unintended pregnancies terminated annually; 19 million in unsafe conditions. According to Dr Choong, out of the latter figure, 70,000 die. Half a million women die of pregnancies. In Malaysia, there are no figures on abortion, but maternal death is less than 5% of total death, mostly due to septic abortion.

There are no guidelines on TOP from MOH. A few years ago there was an enthusiastic taskforce group set up to develop them, but it died out. Dr Koshy said it needs to be resuscitated now as they can’t hide the problem anymore. The taskforce should consist of the Division of Family Health Development, medical practice and development personnel, and others. The guidelines must address these aspects: risk in abortion, as also found in all surgical procedures; compulsory counseling; consent; post-abortion care; and – most important for doctors – a patient’s death should not be a criminal offence. The guidelines must be tested, go through many levels, and finally be approved by religious authorities before being presented to the DG, complete with statistics to show it’s a public health issue.

MOH and other health sectors have done a lot in terms of provision of RHS. But there are new areas to tackle – they need to develop strategic approaches to come up with guidelines so that all hospitals are on same page, have the same voice and patients feel safe with them.

 


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