“Conscientious Objection” in Reproductive Health Care is Immoral and Should Be Abolished

Updated July 2, 2018

The topic of “conscientious objection” (CO) in reproductive health care is a fascinating one that has given me much food for thought. My position on CO is fairly well-developed and I’ve written or co-authored a number of pieces about it. In this piece, I discuss or expand upon a few aspects that have come up in informal discussions with researchers and academics, mostly around philosophical and epistemological issues. 

First, my position on CO

“Conscientious objection” is the refusal by a health care professional (HCP) to provide a legal medical service or treatment for which they would normally be responsible, based on their objection to the treatment for personal or religious reasons.

The majority of so-called “conscientious objection” is exercised today in reproductive health care and is not really about protecting the right to conscience. It’s about a person in a privileged position of authority (there by choice) imposing their personal beliefs on a vulnerable other in a dependent position (not there by choice). That is, physicians have a monopoly on the practice of medicine, and they voluntarily entered a profession that fulfills a public trust. They know they have obligations to provide care to patients without discrimination, and that patients are completely reliant on them for essential health care and can’t go elsewhere. These factors make the exercise of CO in reproductive health care a violation of medical ethics and an abuse of HCPs' position of trust and authority. It is also discrimination because it mostly affects women and the LGBTQ community.

The entire argument for CO in reproductive health care fails once it’s understood that the “conscience” excuse is a subterfuge that justifies class privilege and the “right” to control others. “Conscientious objection” is a propaganda term, not much different than “pro-life” in the abortion debate. CO is actually “Dishonourable Disobedience." It’s really unfortunate that the medical and human rights communities have been bamboozled by the CO term to the extent that allowing CO in reproductive health care is now considered a “consensus” position. They’ve accepted an anti-choice term as the starting point, which is the reason things are in such a mess today in terms of rampant CO abuse around the world and the near-impossibility of regulating and controlling it.

For further information on my position, please check out my previously published articles on CO, summarized and linked at the bottom of this article. (Most are co-authored with my colleague Dr. Christian Fiala of Vienna, Austria.)

Is CO ever justifiable in health care?

There are some valid cases where an HCP may conscientiously refuse to provide a legal treatment that is requested by the patient, but this should be done in the context of honouring their professional obligations and medical ethics. Doctors can refuse treatment on the principle of “beneficence” or “non-maleficence” to ensure the patient is helped or at least not harmed. This only applies in limited circumstances, such as a patient who requests a risky experimental treatment, or a mentally disturbed patient who wants an unnecessary procedure such as an amputation.

We (Dr. Fiala and I) also support refusal by HCPs if they are asked to perform illegal or quasi-legal activities that injure people and violate their rights, such as torture or genital mutilation of children (including circumcision of male infants, which likely has no health benefits but has plenty of harms). Such practices are not legitimate medical treatments and are not requested or needed by the patient; therefore, ethical HCPs should conscientiously refuse to participate in them.

However, these types of refusals are not grounded in the individual personal or religious beliefs of HCPs, so they do not actually qualify as CO as we have defined it.  Virtually all 'personal' CO occurs in reproductive health care (or medical assistance in dying) and does not stem from professional ethics.

This means that  personal conscientious objection to a treatment that a patient requests has no valid place anywhere in health care. Treatment decisions by HCPs must be patient-directed, not self-directed, and must be based on evidence, medical ethics, and professional obligations. If the treatment is legal, within the HCP’s qualifications, requested by a mentally healthy patient, and primarily beneficial (which abortion is), there is simply no excuse to refuse.

Downie and Shaw give an example of a Jewish doctor refusing to operate on a patient with a swastika tattoo. Another example is an abortion provider who refuses to do an abortion on a patient who calls him a murderer and treats him with contempt. It may be easy to sympathize with these doctors' refusals, but they are still not true examples of CO, because where does it end? Individual doctors may have personal moral misgivings on a lot of different things, but in the end, doctors cannot morally judge others and abuse their position of trust and authority by citing CO. Their responsibility is to treat.

What about physician-assisted dying?  Canada's Supreme Court struck down the criminal laws prohibiting this practice in 2015. A fight has emerged, with Catholic hospitals refusing to comply with the requests of terminally-ill patients to end their lives, even to provide them with information. Instead, these hospitals have taken to transferring these patients to another hospital. Unfortunately, this inflicts grave psychological and physical harm on patients who are already in a frail and weakened condition. Public institutions like hospitals should of course have no right to CO, since this can only be an individual right. It also violates the conscience rights of HCPs working at Catholic hospitals who want to provide the objected-to service. It's especially frightening that Catholic hospitals often have a near-monopoly on palliative care, such as in Alberta. In my opinion, special legislation may be needed to force Catholic hospitals to provide assisted-dying services – as well as abortion care and other medically necessary care such as sterilization services. If they refuse, provincial governments should step in and find a legal way to take control of these hospitals and secularize them. It's a radical move, but should be justifiable on the basis that Catholic hospitals are publicly funded, yet are systematically violating patients' rights and dignity and endangering their lives. Further, it's not realistic to defund or close these hospitals, as they are often the only ones in a particular community.

Coming back to why CO is not justifiable in reproductive health care, another reason is because it tends to become too broadly used, with providers citing CO for reasons other than a supposed moral objection, such as stigma, distaste, fear, personal preference, money, etc. I say “supposed” moral objection because the evidence is overwhelming and conclusive that safe legal abortion saves women’s lives and benefits their health and that of their families. The vital public health interests in keeping abortion accessible (as well as contraception) decisively trump any supposed moral concern for fetuses. Actually, I think it can be shown quite persuasively, by citing evidence on anti-choice policies, laws, etc., that anti-choice beliefs in general are not motivated by the desire to “save babies” but by the desire to control women’s sexuality and childbearing role. So treatment refusals in reproductive health care really do come down to harmful gender discrimination (see more below), and are not true CO because they’re based on a false ethical framework. People often assume we should respect the conscience of objectors, but why? I personally have zero respect for their beliefs against abortion because they are illegitimate and harmful. Their "conscience" denies respect to women, violates their rights, and risks their health and lives – all of which is demonstrable, not subjective.

Most anti-choice HCPs would claim they’re motivated by “respect for unborn life” or whatever, but that raises the issue of how we can’t trust peoples’ stated justifications anyway, since one’s personal or religious beliefs cannot be verified or falsified on a rational basis, including how genuinely such beliefs are held. It is also inappropriate and impossible for courts or governments to "decide" whether someone's religious beliefs are valid or sincere. Therefore, one reason that allowing CO is a bad idea is because it leaves us unable to challenge peoples’ justifications – we have to accept them at face value regardless of the harms they may cause to patients.

That said, many personal or religious beliefs are indeed empirically false or unethical in light of scientific evidence or accepted human rights standards (such as the inaccurate belief that some forms of contraception are abortifacients). Any justification of CO should therefore not rely on what individual HCPs claim, but instead on a broader social recognition of the benefits of the treatment in general and the harms of refusal (or perhaps vice versa in some cases). This means that true CO can happen only in unique individual cases as described above, or in cases where the patient would be harmed more with the treatment than without it, or at least not helped (the beneficence or non-maleficence principle).

Finally, on a practical basis, it may be acceptable to tolerate false CO in some limited and temporary circumstances. For example, a hospital may find it has only one objector amongst a larger group of doctors. Rather than fire or transfer the doctor, the hospital might decide to accommodate the objector if it can ensure that no-one is harmed or inconvenienced by it (except perhaps the objector). This does not mean that CO is 'okay' – it's still inherently wrong in principle and should not normally be tolerated. However, private and contingent decisions to accommodate CO on a case-by-case basis could be made by particular institutions, which also reflects the practical reality that things cannot be changed overnight. Indeed, my recommendations for ending CO (below) adopt a long-term, incremental approach, that "grandfathers" in existing objectors. 

Is CO in reproductive health care really discrimination?

Because the vast majority of CO takes place in sexual and reproductive health care, and because this care involves biological gender and sexual aspects that differently affect women, men, and LGBTQ communities in a way that’s not true for most other forms of health care, refusals of treatment constitute discrimination on the basis of sex/gender or sexual orientation. I believe that discriminatory treatment is by definition harmful, and can never be justified by evidence or ethics.

Similarly, HCPs cannot generally refuse to treat black people, gay people, obese people, smokers, injured drunk drivers, or other groups they may disapprove of, because that would be harmful and discriminatory (even if some such groups are not specifically protected under anti-discrimination laws).

Some might claim that discriminating by refusing to treat a class of persons is different than refusing to do a particular treatment like abortion – therefore, CO in reproductive health care is not discrimination. Or at least, the discrimination is an unintended byproduct of the objection to the treatment, and so is too indirect or removed to really be discrimination. However, when that treatment is something only women and some transgender people need, then it is indeed discrimination because it has a discriminatory effect.

The legal definition of discrimination in Canada is not about intention, but effect. The Supreme Court of Canada has defined it as (emphasis added): “a distinction, whether intentional or not but based on grounds relating to personal characteristics of the individual or group, which has the effect of imposing burdens, obligations, or disadvantages on such individual or group not imposed upon others, or which withholds or limits access to opportunities, benefits, and advantages available to other members of society. Distinctions based on personal characteristics attributed to an individual solely on the basis of association with a group will rarely escape the charge of discrimination, while those based on an individual's merits and capacities will rarely be so classed.”

It should also be clear that when objectors are not allowed to refuse treatment, they do not suffer discrimination themselves – they are prevented from discriminating against others. HCPs are free to hold and practice their beliefs in private, but their agreement and obligation to fulfill a public trust means they can’t bring their beliefs into their work and impose them onto patients (as per the principle of “public accommodation”).

Should patients’ rights be “balanced” with providers’ rights?

It’s sometimes implied by CO supporters (academics and doctors) that patients and doctors are on some kind of equal footing, so each bear some responsibility in cases of refusals and we should “balance” their rights. For example, the provider should refer appropriately while the patient is “responsible” for going to another practitioner. Or, the provider and patient have an equal obligation to be “respectful” of diverse views and values. (These examples come from a private email conversation I had in July 2014 with Dr. Owen Heisler, Assistant Registrar of the College of Physicians and Surgeons of Alberta.)

But this is absurd. Patients have an unquestioned right to health care and are in a dependent position with their doctor, so they bear zero responsibility for any supposed moral conflict or its consequences. And the patient’s values are irrelevant – they are there simply to obtain a required medical service, which might even conflict with their own values. The responsibility for CO is 100% on the objector, who should bear the burden of any refusals. Currently however, all or most of the burden falls on the patient, while the objector rarely has to answer for it and often even benefits from the refusal (e.g., by avoiding stigma, or freeing time for more lucrative health care). The harm to patients of allowing CO always outweighs any harm to doctors of disallowing CO – if there even is any.

Organizations and professionals that support CO often confidently state that providers have a right to conscience and patients have a right to health care. (For example, here.)  But which is it? These two things are entirely incompatible because when a provider refuses treatment, the patient has lost their right to health care, period. Giving doctors a blanket right to refuse treatment on questionable CO grounds contradicts the whole purpose of medicine – to care for patients. It usually also violates the fundamental values and policies of the medical organizations that espouse CO, with all their noble talk about physicians’ commitment to patient care and interests, evidence-based medicine, comprehensive care, and so on. But if you allow CO, health care is no longer comprehensive, it’s no longer based on science and evidence, it’s no longer in the patient’s best interests, and doctors are no longer committed to any of the above.

Can we really prohibit CO?

The solutions proposed by the organizations and professionals who want to allow CO, but who are nevertheless well aware of its systemic harms, seem (to me) to be clear evidence of the inherent unworkability and contradiction of allowing CO in the first place. The general objective in these proposals (such as those by Global Doctors for Choice,  FIGO, ACOG, and members of ESC) is to limit the injustice of CO as much as possible by requiring objectors to refer appropriately, impart accurate information on all treatment options, treat patients respectfully, and in urgent situations, provide the treatment they object to if no-one else is around to do it. The problem is that such concessions don’t work very well in practice because they assume that objectors will be rational and agree to compromise their stance against a particular treatment at some point in the process. But why should they, when they’ve already been given the right to practice “faith-based” medicine? It’s impossible to draw a line between that and evidence-based medicine, because they have nothing to do with each other. 

It is difficult for me to understand how medical groups and professionals can clearly see the many problems with CO in reproductive health care, but instead of recognizing that it is fatally flawed, they just want to put band-aids on the serious (often intractable) problems caused by CO, and continue to insist there is a provider’s right to refuse treatment on the supposed basis of conscience. Frankly, I don’t see any reason for this other than to protect the power and privilege of doctors over patients. But doctors are public servants, basically. They are no longer the paternalistic figures whom patients should just defer to when it comes to important life decisions.

I believe that a general ban on CO in reproductive health care is not only the right thing to do, but also would be simpler and much more doable than trying to accommodate and regulate CO on an ongoing basis. Empirically-based criteria could be developed that would be ethical and fair to all parties, with no need to navigate subjective aspects such as trying to decide if an objector’s reasons are valid. It also does not involve “forcing” doctors to do abortions, which is a red herring fear about banning CO. Below is my suggested protocol for carrying it out on an incremental basis:

1. Disqualify objectors from entering certain disciplines at the medical school level (e.g., all Obstetrics/Gynecology applicants must be willing to provide abortions; all Ob/Gyn and family medicine applicants must be willing to prescribe birth control).
2. Offer guidance to objecting students in terms of acceptable disciplines or specialties where their objection won’t be a problem. 
3. At medical schools, provide compulsory training in contraception provision for all students in family medicine, and compulsory training in abortion techniques for all those in Ob/Gyn (and other things like vasectomies etc.).
4. Include the requirement to participate in abortion in job descriptions at the point of hiring. 
5. Require existing objectors to enroll in a Continuing Education course or Values Clarification workshop on the need for reproductive health care services (especially abortion) and why women request abortions. Expose them to patients requesting the services, educate them on the negative effects of CO on patients, and provide a clear understanding of their fiduciary duty to patients. This should decrease the number of objectors because many are arguably just misinformed, uncertain, or using the excuse of CO for the wrong reasons. 
6. For those who continue to object, assist them and incentivize them to move to other disciplines or areas where their objection won’t be a problem. 
7. Increase the burden on those who want to stay and continue objecting, with the goal of encouraging them to eventually transfer or quit. These measures would become mostly unnecessary over time as CO becomes rarer. For example, medical organizations could: 

a.      Require all remaining objectors to register so they can be monitored.

b.     Require all objectors to file a report every time they refuse services based on their moral or religious objections.

c.      Investigate any inadequate or problematic reports.

d.     Randomly conduct regular audits on objecting doctors.

e.      Discipline those who violate the policy, and develop a more robust disciplinary policy.

f.      Hold objectors financially liable for any harms done to patients.

g.     Prohibit existing objectors from working alone, especially in small communities where they are the only physician.

h.     Allow employers to prioritize hiring of non-objecting physicians.

i.       Pay objecting physicians less (a cut in wages for employed doctors, or a percent reduction in Medicare fees)

8.   To improve public accountability and transparency: 

j.       Medical organizations could make the complaint process easier for patients, including preventing the doctor from learning or discerning the complainer’s identity.

k.     Medical organizations could engage in public advocacy about the right to complain when doctors refuse care or referrals – e.g., create a brochure for doctors’ offices, publish an op-ed, write a position paper for their website, keep a permanent prominent link to it on their home page, etc.

l.       Governments could regulate public health systems to guarantee abortion provision, provide financial aid to hospitals to recruit abortion providers, engage in public education to reduce abortion stigma, implement buffer zones and various security measures to support doctors, and other initiatives.

Over time, such measures should reduce or eliminate the presence of doctors who refuse to deliver health care for which they would normally be responsible. 

Finally, it is crucial to point out that Sweden, Finland, and Iceland already do not allow CO – either it’s generally prohibited, or in the case of Iceland there’s so few objectors that requiring Ob/Gyns to participate in abortion care has not posed any problems. The assumption that CO is legitimate and must be allowed disregards the proven reality that it is indeed possible to disallow CO without any negative impacts on providers. They simply find other jobs or disciplines to work in, and they can be assisted (and even recompensed) to do so.

One might argue that these Nordic countries are a unique and unrepresentative case because they have high degrees of secularism and gender equality, and less abortion stigma. But isn’t that exactly the point? A strong commitment to secularism and gender equality makes CO unnecessary and even unthinkable, as it should be. And that’s really what our end goal should be – not trying to accommodate the ongoing oppression and stigmatization of women under the guise of “conscience.” CO is simply an ideological retaliation against laws that empower women, and it comes mainly from fundamentalist religion. It should not be defended or tolerated. 

(The End)

My previous articles on “conscientious objection”:

‘Dishonourable Disobedience’: Why Refusal to Treat in Reproductive Healthcare Is Not Conscientious Objection. Christian Fiala and Joyce H. Arthur. Woman - Psychosomatic Gynaecology and Obstetrics. December 2014 (first published online March 2014).

Synopsis: A comprehensive paper that uniquely delves into the underlying premises of CO to show that it is fundamentally contradictory and unworkable, and has nothing in common with the military CO from which it is supposedly derived. Current laws and practices in various countries around CO in reproductive health care show that it is frequently abused, with harmful impacts on women's health care and rights. CO in reproductive health is not actually Conscientious Objection, but Dishonourable Disobedience (DD) to laws and ethical codes. It should be dealt with like any other failure to perform one's professional duty, through enforcement and disciplinary measures.

Why We Need to Ban ‘Conscientious Objection’ in Reproductive Health Care. Joyce Arthur and Christian Fiala. RH Reality Check. May 14, 2014.

Synopsis: A criticism of the global consensus by secular medical and health organizations and human rights bodies that “conscientious objection” is a legitimate right of physicians. All such groups that accept CO simply assume without question that health care providers have a right to CO, while they contradictorily often devote considerable discussion and resources to documenting and trying to limit the systemic harms caused by the exercise of CO. Not a single statement, article, report, or study by any group that supports CO can cite any benefits of CO in health care, other than supposedly respecting clinicians’ “right” of conscience. But all groups fail to see that the term “conscientious objection” as applied to refusals of reproductive health care is fraudulent, and not true CO.

The CO debate: ‘Conscientious Objection’ is still dishonourable disobedience, Joyce Arthur and Christian Fiala. Bpas Reproductive Review. July 14, 2014.

Synopsis: A response to our critics, including Global Doctors for Choice. We paraphrase and respond to eight criticisms, most of which we feel ignored or misunderstood our position.

Doctors do not have the right to discriminate and deny basic health care. Joyce Arthur. Rabble.ca August 1, 2014.

Synopsis:  Policies and practice around “conscientious objection” in reproductive health care in Canada, and a summary of the “Dishonourable Disobedience” paper by Joyce Arthur and Christian Fiala to show what’s wrong with CO.

Christian doctors angry they can no longer abandon their patients.  Joyce Arthur. Rabble.ca. April 3, 2015

Synopsis:  A critique of anti-choice views on “conscientious objection”, including in particular the views of the Christian Medical and Dental Society of Canada, which is suing the College of Physicians and Surgeons of Ontario for enacting a policy requiring objecting doctors to refer patients to someone who can provide the services.

Submission #1 to the College of Physicians and Surgeons of Ontario (see No. 731). Joyce Arthur and Christian Fiala. July 31, 2014.

Synopsis: We ask the Ontario College to amend its policy to prohibit or at least strongly discourage the practice of conscientious objection for contraception and abortion services in particular. We also ask the College to implement monitoring and enforcement against those who disobey CO regulations, including disciplinary measures and financial and legal liability for any patient harms. We provide arguments against allowing any degree of CO in reproductive health care, on the basis that it is not genuine CO, is a violation of medical ethics and patients’ right to health care, and is discrimination on the basis of sex. We also provide arguments against the typical compromise that requires doctors to refer appropriately, because it is contradictory, unfeasible, and systematically abused.

Submission #2 to the College of Physicians and Surgeons of Ontario. Joyce Arthur. February 2015.

Synopsis:  The College’s new draft policy requires objecting doctors to make an “effective referral” to someone who can provide the service. I draw attention to the negative anti-choice reaction to this and the likelihood that most anti-choice doctors will flout the policy because they think referring makes them “complicit.” I urge the College to implement various suggested monitoring and enforcement measures, and to make the patient complaint process more accessible and confidential.

ARCC's Submissions to the Saskatchewan College of Physicians and Surgeons. Joyce Arthur. March to Aug 2015.

Synopsis: I critique the College’s draft "Conscientious Refusal" policy with similar arguments as in the above submissions to the Ontario College. (While the latter stuck to its “effective referral” policy, the Sask. College caved to anti-choice pressure and weakened its policy so that doctors only need to “make an arrangement” for the patient to see someone who can refer them to someone who can provide the service.)

Yes We Can!  Successful Examples of Disallowing ‘Conscientious Objection’ in Reproductive Health Care. By Christian Fiala, Kristina Gemzell Danielsson, Oskari Heikinheimo, Jens A. Guðmundsson, and Joyce Arthur. Feb 2015. European Journal of Contraception & Reproductive Health Care.  DOI: 10.3109/13625187.2016.1138458.

Synopsis: Three countries – Sweden, Finland, and Iceland – do not generally permit health care professionals in the public health care system to refuse to perform a legal medical service for reasons of CO when the service is part of their professional duties. We investigate the laws and experiences of these countries to show that disallowing CO is not only workable but beneficial for all involved.

Refuting Elard Koch’s errors and distortions

Note: This piece contains information supplementing my 2012 article: Anti-choice Researchers in Chile try to disappear illegal abortion - and  women who die from it. It has been updated several times since then, with Addendums appearing at the bottom. 

by Joyce Arthur

First published June 1, 2012 (links updated July 22, 2017)

The following refutes several egregious errors and falsehoods in Dr. Elard Koch's rebuttal to the Guttmacher Institute (published May 25, 2012 at PLOS ONE). 

Illegal abortions still common in Mexico

Koch grossly underestimates the number of abortions in Mexico by playing fast and loose with the facts. He wrongly compares Guttmacher’s previous estimated illegal rates for all of Mexico (between 700,000 and 1 million), to today’s officially reported legal rate for only Mexico City (just over 20,000 in 2011). Mexico City is the only area in the entire country where abortion on request is legal. Less than 20% of Mexicans live in the capital, and most women from other states would be too poor to be able to travel to the capital, which means they are still having unreported illegal abortions in their own communities. But even in Mexico City, legal access is still limited, leading many women there to continue resorting to illegal abortion. Further, only public sector abortions are counted in official numbers, not legal abortions done in the growing private sector.  

Increases in abortion after legalization to be expected

Koch complains that legalization causes an increase in abortions, but this reflects an anti-choice belief that denies the positive and obvious reasons for such increases. It also stems from Koch’s stubborn refusal to acknowledge the prevalence of illegal abortion. Common sense dictates that after legalization, reported legal abortions will begin to replace the previous non-reported illegal abortions. Since it takes time to ramp up services after legalization, of course numbers will increase for a few years as access improves. But if all goes smoothly and especially if contraception also becomes increasingly accessible, legal abortion numbers will eventually stabilize and start to go down. That pattern is now well-documented for most western countries.

Overreliance on official statistics and unwarranted dismissal of evidence that doesn’t fit anti-choice ideology

Koch’s trust in the accuracy of Chile’s maternal death registry is based on faith, not evidence. In a criminalized regime like Chile, there is good reason to believe that many healthcare workers misreport the cause of death when women die in hospital from complications of illegal abortion, since women themselves (or a family member) would be highly motivated to lie to medical personnel about what happened when they arrive at the hospital, to protect themselves from prosecution. Healthcare workers are required to report women who have illegal abortions. While many would likely not ask too many questions and record the complication or death as a result of spontaneous abortion (going along with the woman's story in other words), some women are still being turned in by health workers to face arrest and a possible jail sentence, at least they were as recently as 2007. A 2010 article on abortion in Chile by researchers Shepard & Becerra notes: “More than 99% of abortions are not reported at all, disguised as a different procedure, or reported as spontaneous abortions in public hospitals.” They state the reason for the latter: “To protect both women and hospital staff from prosecution, hospital patient data reported to the Ministry of Health do not differentiate between spontaneous and induced abortion.”

Guttmacher cited this Shepard & Becerra article in its Advisory Review, but Koch dismisses it, as well as another study in Spanish cited by Guttmacher. He refers to them as “mere opinions without any epidemiological evidence or quantitative data supporting such claims.” The context for that comment is a discussion of women's illegal use of misoprostol to induce abortions, in which Koch summarily dismisses the possibility that misoprostol might be contributing to a decrease in maternal mortality, again because of an alleged lack of hard evidence. However, self-use of misoprostol by women is an obvious and highly promising way to reduce abortion-related complications and deaths, because of its relative safety over other traditional clandestine methods. Further, Koch asserts that "no study currently exists to date, that seriously supports a decline in maternal mortality associated with the use of abortifacient drugs such as misoprostol in Chile," while ignoring studies from countries such as Brazil that demonstrate exactly that.

I believe that Koch's practice of rejecting out of hand any data sources he deems invalid reflects an ideological desire to cover up evidence of widespread illegal abortion. For one thing, he chooses to ignore official statistics that don’t fit his ideology. The above-noted Spanish study that he discards as “mere opinion” used the following official sources to determine maternal causes of death: “Clasificación internacional de enfermedades, traumatismos y causas de defunción, CIE-9” (International Classification of Diseases, Injuries and Causes of Death, ICD-9) and the “Anuarios del Instituto Nacional de Estadísticas de Chile” (Yearbooks of the Chile National Institute of Statistics). The latter is apparently the same (and only) source that Koch used for his PLOS ONE study. But based on those two sources, the Spanish study determined that abortion was the second-leading cause of maternal death in Chile between 1990 and 2000, with 19.1% attributed specifically to “induced illegal abortion”, 73.6% to “unspecified abortion,” and 6.2% to “spontaneous abortion.”  Note that these figures are from after 1989, the year Chile's abortion law was tightened to eliminate the exception to save the life of the woman. So even while Chile's maternal mortality rate was still declining in the 1990's, women were still dying from illegal abortion, which simply means that the decline would have been even steeper if abortion was safe and legal.

Koch has not explained why alternative methods of collecting data (besides his preferred statistical sources) on maternal deaths from illegal abortion should be considered entirely worthless. He has no grounds for totally dismissing them, since other ways must necessarily be found to measure the incidence of illegal abortion and resulting deaths and complications (which include for example, surveys of women, surveys of specific healthcare facilities, and interviews with healthcare workers). His dismissal of the data these methods produce amounts to a gratuitous slur against the hundreds of reputable scientists and researchers who spend large amounts of time carefully gathering, comparing, and adjusting such data under challenging circumstances.

Small numbers of pre-1989 legal abortions in Chile. 

Koch asserts that the pre-1989 abortion law in Chile, which allowed abortion only to save the woman’s life, was often interpreted liberally. Yet he can only cite a single documented case of 3,000 abortions being performed “on request” at one hospital in Santiago in 1973. In reality, liberal interpretations of the law did not appear to be common, and Koch himself explains that: "Flexible interpretation of the practice of ‘therapeutic’ abortion was progressively restricted and prosecuted until the definitive derogation of all types of abortion in 1989." A statement in the Koch et al study's AppendixS1 clarifies further: "It is documented that an undetermined number of elective abortions were conducted by several medical doctors utilizing the latter law [in force from 1967-1989], but this practice seemed to be strongly restricted after 1973 by the military government until the definitive derogation in 1989." (emphasis added)  Therefore, Koch has refuted his own conclusion that the 1989 abortion ban “meant a major transition from a partially restrictive to a fully restrictive law in practical terms,” because legal abortion was already very rare many years before 1989. In fact, this falsifies the central claim* in Koch et al’s PLoSONE study, as stated in the final two sentences of the conclusion: "Finally, prohibition of abortion in Chile did not influence the downward trend in the maternal mortality ratio. Thus, the legal status of abortion does not appear to be related to overall rates of maternal mortality." In reality, the new law would not have led to any noticeable difference in maternal mortality rates anyway. The number of reported legal abortions had already dropped to miniscule proportions by 1989, and the illegal abortion rate would have remained about the same as before.

It's also worth noting that since the pre-1989 law allowed abortions only to save the woman’s life and required the approval of two doctors, it’s highly unlikely that large numbers of Chilean women would have even attempted the process, let alone succeeded at it – especially poor, indigenous, uneducated, rural, and other marginalized women with few resources. Such common-sense considerations seem to be beyond Koch, because of his insistence on considering hard data and nothing else.

(* I call this the central claim because we hardly need a study to determine that declines in maternal mortality would be associated with higher education for women, improved access to health facilities and doctors, nutrition programs, clean water, skilled birth attendants, and similar factors. Such findings are already well-documented elsewhere and are pretty much self-evident. Therefore, I believe the authors' focus on those factors serves as a smokescreen to help conceal the study's true agenda, which is political and ideological - part of an anti-choice campaign to ensure that abortion stays criminalized throughout Latin America.)

**************

One of the most offensive things about Koch’s insistence that illegal abortion does not negatively impact women’s health is that it throws under the bus the most vulnerable groups of women who have little power or voice in society, and who resort to illegal abortion the most. But the most offensive thing of all is that, because maternal deaths from illegal abortion do appear to be quite low in Chile (compared to other developing countries), Koch seems to think it's acceptable that those few should be sacrificed unnecessarily under Chile's harsh criminal laws, and that the rest – anywhere from 40,000 to 200,000 a year according to various estimates – should continue jeopardizing their health and lives, not to mention arrest and imprisonment, and all the upheaval and psychological trauma that these things entail, just because they needed an abortion - an action taken by half of all women around the world to protect their lives, families, and futures. 

In my opinion, based on the above analysis and my published rebuttal, Koch's anti-choice advocacy as a privileged male academic in Chile is an irresponsible abuse of power that puts women's lives and health at risk – not just in Chile, but throughout Latin America wherever abortion is mostly illegal.

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Addendum, July 30, 2012:  Guttmacher has published a rebuttal to Koch et al's attack on Guttmacher's methodology for estimating the number of illegal, unsafe abortions in Latin American countries:   Summary   •   Detailed rebuttal   Guttmacher says: "The Koch et al. critique is characterized by pervasive distortions of Guttmacher's methodology, and their proposed alternative methodology is based on scientifically unsound and illogical assumptions and contains such serious errors that its results are not valid."

Addendum October 2012:  During the CEDAW review of Chile's record on women's rights, including questions to the Chilean delegation on its abortion laws, the Chilean delegation was disingenuous in its claim of a low mortality rate due to abortion, and greatly exaggerated the availability of contraception

On Oct 2, 2012, the UnitedNations Committee on the Elimination of Discrimination against Women (CEDAW)considered the combined fifth and sixth periodic report of Chile on how that country is implementing the provisions of the Convention on the Elimination of All Forms of Discrimination against Women. When questioned by CEDAW experts on its abortion legislation, the Chilean delegation claimed that "Therapeutic abortion was allowed in Chile, and could be carried out by a doctor if the woman’s life was at risk." (emphasis added) The word "could" is a grasping-at-straws hypothetical. In fact, no exceptions are allowed under the law and few doctors would dare risk prosecution by causing an abortion, even if unintended. Moreover, the claim that unintended abortion may occur in order to save a woman’s life rests on the immoral ideology that doctors must wait until a pregnant woman’s life or health is already put at risk or seriously compromised before she receives any healthcare that may endanger the fetus.

The Chilean delegation also claimed (paraphrased in the report): "Maternal mortality due to abortion only amounted to between six to ten women per year. Over 50 per cent of those deaths were due to identifiable causes, and 47 per cent were due to non-identifiable causes. In Chile abortion was illegal so any death due to abortion fell within that 47 per cent. The Government had passed a law to provide contraceptives, including emergency contraceptives, in order to ensure wider distribution guaranteed by law. Any person refusing to provide emergency contraceptives would be committing a criminal offence, and technical guidelines were distributed to health centres on how to help women who had had an abortion, relating to privacy and other related reproductive health services. Although abortion was criminalized there had been no sanctions in the reporting period."

The Chilean delegation is being disingenuous in its claim of a low mortality rate due to abortion. As explained previously, deaths from abortion are almost certainly underreported to at least some degree, while much of the morbidity from induced abortion would be hidden under the "unspecified abortion" loophole in order to protect patients and staff from prosecution. Regardless, even 6-10 deaths a year is 6-10 more than necessary, since these could all be eliminated if abortion was legal.

As for the alleged wide availability of contraception, that too turns out to be a hugely exaggerated claim. An April 2012 article from Chile's Santiago Times [no longer available online] quotes Dr. Beatriz Salgado, a general practitioner at the Department of Public Health at the Universidad de Valparaíso. She explained that sexual health is a taboo topic in Chile, and contraceptive methods are both expensive and often difficult to access. The article states: "In 2008 a constitutional court struck down attempts to make the distribution of the morning after pill free. Two years later Congress finally ruled that the morning after pill had to be freely distributed by the public health system, but young girls who need the pill must be accompanied by one of their parents. Many pharmacies still refuse to stock the morning after pill for religious or moral reasons." Dr. Salgado believes most of the decline in maternal mortality in Chile is due not to good contraceptive use, but because of increasing numbers of women successfully self-administering misoprostol.

Interestingly, the Chilean delegation claims that no one has been prosecuted for abortion during CEDAW's previous two-year reporting period (2010-2012). With at least 40,000 abortions a year (and as many as 200,000), either doctors and patients are becoming very adept at evading the long arm of the law, or Chile is no longer enforcing its criminal abortion law - maybe out of embarrassment after years of being pilloried in the international press for throwing women into jail? 

Addendum, December 14, 2012:  Guttmacher criticizes Koch for recycling his disproven claims about Guttmacher's methodology: Everything Old Is New Again—Debunked Criticism of Guttmacher Methodology Resurfaces 

Addendum November 13, 2014:  Rewire has published a "False Witnesses" series documenting anti-choice activists and researchers who have published false information designed to mislead the public, lawmakers, and the courts about abortion. One piece exposes Elard Koch for his "Signature Falsehood": That making abortion illegal does not result in more maternal deaths.  Rewire says: "The overwhelming evidence from reputable scientists and organizations, including the World Health Organization, is that there is a direct link between illegal abortion and higher maternal death rates."