Prevalence, Attitudes, and Factors Motivating Conscientious Objection toward Reproductive Health among Medical Students

Abstract

Objective We have evaluated the prevalence of and the motivating factors behind the refusal to provide reproductive health services and the ethical knowledge of the subject among medical students from the Escola Bahiana de Medicina e Saúde Pública, in the state of Bahia, Brazil.

Methods The present cross-sectional study involved 120 medical students. A questionnaire was utilized. The dependent variables were students' objections (or not) regarding three clinical reproductive health cases: abortion provided by law, contraceptive guidance to an adolescent without parental consent, and prescription of emergency contraception. The independent variables were age, gender, religion, ethical value, degree of religiosity, and attendance at worship services. Ethical knowledge comprised an obligation to state the reasons for the objection, report possible alternatives, and referral to another professional. Data were analyzed with χ² tests and t-tests with a significance level of 5%.

Results Abortion, contraception to adolescents, and emergency contraception were refused by 35.8%, 17.5%, and 5.8% of the students, respectively. High religiosity (p < 0.001) and higher attendance at worship services (p = 0.034) were predictors of refusing abortion. Refusal to provide contraception to adolescents was significantly higher among women than men (p = 0.037). Furthermore, 25% would not explain the reason for the refusal, 15% would not describe all the procedures used, and 25% would not refer the patient to another professional.

Conclusion Abortion provided by law was the most objectionable situation. The motivating factors for this refusal were high commitment and religiosity. A reasonable portion of the students did not demonstrate ethical knowledge about the subject.

Resumo

Objetivo Avaliar a prevalência e os fatores motivadores da recusa em prestar serviços de saúde reprodutiva, bem como o conhecimento ético do tema, entre estudantes de medicina.

Métodos Estudo transversal, envolvendo 120 estudantes de medicina. Aplicou-se um questionário cujas variáveis dependentes foram a existência ou não de objeções quanto à condução de três casos clínicos sobre saúde reprodutiva: o abortamento previsto em lei, a orientação contraceptiva a uma adolescente sem consentimento dos pais, e a prescrição de contracepção de emergência. As varáveis independentes foram: idade, gênero, religião, valor ético, grau de religiosidade e frequência a cultos religiosos. Os conhecimentos éticos pesquisados foram a obrigação de expor os motivos da objeção, relatar as alternativas possíveis e encaminhar a paciente a outro profissional. Os dados foram analisados pelo teste do χ2 e pelo teste-t, com nível de significância de 5%.

Resultados O abortamento foi recusado por 35,8% dos estudantes, a contracepção aos adolescentes por 17,5%, e a contracepção de emergência por 5,8%. A alta religiosidade (p < 0,001) e uma maior frequência a cultos (p = 0,034) foram os preditores identificados no caso do abortamento previsto em lei. A recusa da contracepção aos adolescentes foi significativamente maior entre as mulheres (p = 0,037). Entre os estudantes, 25% não explicariam o motivo da recusa, 15% não descreveriam todos os procedimentos e 25% não fariam o encaminhamento da paciente para outro profissional.

Conclusão O abortamento previsto em lei, foi a situação mais objetada. Os fatores motivadores a esta recusa foram o alto comprometimento e maior religiosidade. Uma parcela razoável dos alunos não demonstrou ter conhecimentos éticos sobre o tema.

Keywords

legal abortion - adolescence - reproductive rights - medical education - women's health

Descritores

aborto legal - adolescência - direito reprodutivo - educação médica - saúde da mulher

Contributors

Darzé O. I. S. P. and Barroso Júnior U. contributed with the project and the interpretation of data, the writing of the article, the critical review of the intellectual content, and the final approval of the version to be published.

• References

• 1 Chavkin W, Leitman L, Polin K. . for Global Doctors for Choice. Conscientious objection and refusal to provide reproductive healthcare: a White Paper examining prevalence, health consequences, and policy responses. Int J Gynecol Obstet 2013; 123: S41-S56 . Doi: 10.1016/S0020-7292(13)60002-8
• 2 American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 385 November 2007: the limits of conscientious refusal in reproductive medicine. Obstet Gynecol 2007; 110 (05) 1203-1208 . Doi: 10.1097/01.AOG.0000291561.48203.27
• 3 Nordberg EM, Skirbekk H, Magelssen M. Conscientious objection to referrals for abortion: pragmatic solution or threat to women's rights?. BMC Med Ethics 2014; 15: 15 . Doi: 10.1186/1472-6939-15-15
• 4 World Health Organization. Safe Abortion: Technical and Policy Guidance for Health Systems. 2^nd ed. Geneva: WHO; 2012
• 5 Zampas C. Legal and ethical standards for protecting women's human rights and the practice of conscientious objection in reproductive healthcare settings. Int J Gynaecol Obstet 2013; 123 (Suppl. 03) S63-S65 . Doi: 10.1016/S0020-7292(13)60005-3
• 6 Strickland SL. Conscientious objection in medical students: a questionnaire survey. J Med Ethics 2012; 38 (01) 22-25 . Doi: 10.1136/jme.2011.042770
• 7 De Zordo S. O173 Obstetricians-gynecologists' attitudes towards abortion and conscientious objection in Italy. Int J Gynaecol Obstet 2012; 119: S321 . Doi: 10.1016/S0020-7292(12)60603-1
• 8 Seoane JA. [The perimeter of the medical conscience objection]. In Dret 2009; (04) 1-21
• 9 Herranz G. La objeción de conciencia en las profesiones sanitarias. Una defensa pacífica de las convicciones morales. Scr Theol. 1995; 27: 545–563. https://dadun.unav.edu/bitstream/10171/13165/1/ST_XXVII-2_05.pdf . Accessed October 21, 2017
• 10 International Covenant on Civil and Political Rights: adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966, entry into force 23 March 1976, in accordance with Article 49. https://www.ohchr.org/Documents/ProfessionalInterest/ccpr.pdf . Accessed November 14, 2017
• 11 Magelssen M. When should conscientious objection be accepted?. J Med Ethics 2012; 38 (01) 18-21 . Doi: 10.1136/jme.2011.043646
• 12 Brock DW. Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?. Theor Med Bioeth 2008; 29 (03) 187-200 . Doi: 10.1007/s11017-008-9076-y
• 13 Figo Committee For The Ethical Aspects Of Human Reproduction And Women's Health; International Federation of Gynecology and Obstetrics. Ethical guidelines on conscientious objection in training. Int J Gynaecol Obstet 2015; 128 (01) 89-90 . Doi: 10.1016/j.ijgo.2014.10.005
• 14 Minerva F. Conscientious objection in Italy. J Med Ethics 2015; 41 (02) 170-173 . Doi: 10.1136/medethics-2013-101656
• 15 Heino A, Gissler M, Apter D, Fiala C. Conscientious objection and induced abortion in Europe. Eur J Contracept Reprod Health Care 2013; 18 (04) 231-233 . Doi: 10.3109/13625187.2013.819848
• 16 Oliveira da Silva M. Reflections on the legalisation of abortion in Portugal. Eur J Contracept Reprod Health Care 2009; 14 (04) 245-248 . Doi: 10.1080/13625180903053740
• 17 Hoge DR. A validated intrinsic religious motivational scale. J Sci Study Relig 1972; 11: 369-376 . Doi: 10.2307/1384677
• 18 Madeiro A, Rufino A, Santos P, Bandeira G, Freitas I. [Conscientious objection and legal abortion: medical students' attitudes]. Rev Bras Educ Med 2016; 40: 86-92 . Doi: 10.1590/1981-52712015v40n1e02382014
• 19 Darzé OI, Azevêdo BK. [Competences acquired during medical training and the opinions and attitudes about abortion]. Rev Bras Ginecol Obstet 2014; 36 (01) 5-9 . Doi: 10.1590/S0100-72032014000100003
• 20 Roe J, Francome C, Bush M. Recruitment and training of British obstetrician–gynaecologists for abortion provision: conscientious objection versus opting out. Reprod Health Matters 1999; 7: 97-105 . Doi: 10.1016/S0968-8080(99)90010-1
• 21 Rodríguez-Calvo MS, Martínez-Silva IM, Soto JL, Concheiro L, Muñoz-Barús JI. University students' attitudes towards Voluntary Interruption of Pregnancy. Leg Med (Tokyo) 2012; 14 (04) 209-213 . Doi: 10.1016/j.legalmed.2012.02.002
• 22 Wheeler SB, Zullig LL, Reeve BB, Buga GA, Morroni C. Attitudes and intentions regarding abortion provision among medical school students in South Africa. Int Perspect Sex Reprod Health 2012; 38 (03) 154-163 . Doi: 10.1363/3815412
• 23 Schwarz EB, Luetkemeyer A, Foster DG, Weitz TA, Lindes D, Stewart FH. Willing and able? Provision of medication for abortion by future internists. Womens Health Issues 2005; 15 (01) 39-44
• 24 Curlin FA, Lawrence RE, Chin MH, Lantos JD. Religion, conscience, and controversial clinical practices. N Engl J Med 2007; 356 (06) 593-600 . Doi: 10.1056/NEJMsa065316
• 25 Trussell J, Guthrie KA. Talking straight about emergency contraception. J Fam Plann Reprod Health Care 2007; 33 (03) 139-142 . Doi: 10.1783/147118907781004859
• 26 Montanari Vergallo G, Zaami S, Di Luca NM, Marinelli E. The conscientious objection: debate on emergency contraception. Clin Ter 2017; 168 (02) e113-e119 . Doi: 10.7417/CT.2017.1991
• 27 Tilahun FD, Assefa T, Belachew T. Predictors of emergency contraceptive use among regular female students at Adama University, Central Ethiopia. Pan Afr Med J 2010; 7: 16
• 28 Brasileira de Pediatria S. Federação Brasileira das Sociedades de Ginecologia e Obstetrícia. Contracepção e ética: diretrizes atuais durante a adolescência. Adolesc Saude. 2005; 2: 6-7
• 29 Uberoi D, Galli B. A recusa dos serviços de saúde reprodutiva por motivo de consciência na América Latina. SUR 2016; 13: 105-116
• 30 Diniz D, Madeiro A, Rosas C. Conscientious objection, barriers, and abortion in the case of rape: a study among physicians in Brazil. Reprod Health Matters 2014; 22 (43) 141-148 . Doi: 10.1016/S0968-8080(14)43754-6
• 31 Conselho Federal de Medicina. Resolução CFM No 1.811, de 14 de dezembro de 2006. Estabelece normas éticas para a utilização, pelos médicos, da Anticoncepção de Emergência, devido a mesma não ferir os dispositivos legais vigentes no país. http://www.portalmedico.org.br/resolucoes/cfm/2006/1811_2006.htm . Accessed May 24, 2017
• 32 World Health Organization. Emergency Contraception. Fact Sheet No. 244. 2012. http://www.who.int/mediacentre/factsheets/fs244/en . Accessed May 24, 2017
• 33 Ministério da Saúde. Secretaria de Ciência, Tecnologia e Insumos Estratégicos. Departamento de Ciência e Tecnologia. PNDS 2006: Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher: Relatório . Brasília, DF: Ministério da Saúde; 2008. http://bvsms.saude.gov.br/bvs/pnds/img/relatorio_final_pnds2006.pdf . Accessed June 20, 2017
• 34 World Health Organization. Adolescent Pregnancy: Issues in Adolescent Health and Development . Geneva: WHO; 2004
• 35 Oliveira-Campos M, Nunes ML, Madeira FdeC. , et al. Sexual behavior among Brazilian adolescents, National Adolescent School-based Health Survey (PeNSE 2012). Rev Bras Epidemiol 2014; 17 (Suppl. 01) 116-130 . Doi: 10.1590/1809-4503201400050010