Conscientious objection emerged as a means to allow people to refuse to participate in military service due to personal beliefs. It has expanded to also allow health care professionals to refuse to provide reproductive health care, and in particular abortion care [1,2,3]. However, the assumption that conscience-based refusals need to be accommodated in abortion care has recently been challenged [4,5,6]. Some contend that it is unethical to deny people access to health care on the basis of non-verifiable personal, non-evidence based beliefs and that when health care professionals choose their profession they are agreeing to the professional obligation to serve their patients, unlike mandatory military service [7].
It has been argued that conscientious objection may be used for reasons other than conscience, such as avoiding the stigma of providing abortion care, avoiding participating in care where one has limited training, and to reduce one’s workload [3, 8]. In Latin America, there is the idea of a “double discourse” where in public, individuals such as health professionals, uphold the prevailing, highly restrictive cultural norms, whereas in private, their views are much less conservative [9]. This “double discourse” might compel health professionals in Latin America to publically declare themselves as objectors, even if not in accordance with their private views. Studies have shown that widespread use of conscientious objection can limit access to abortion care, particularly for those living in rural areas [10, 11]. In an effort to preserve people’s access to abortion care, international professional organizations have provided guidance aimed at ensuring that the rights of the health professional are balanced with those of the patient seeking abortion [5, 12,13,14]. It is also widely accepted that health professionals have the professional responsibility to treat patients seeking post-abortion care, irrespective of their personal views about abortion [15].
In 2017, Chile lifted its complete ban on abortions, permitting abortions: 1) to save a woman’s life, 2) for lethal fetal anomalies, and 3) due to rape [16]. The current law requires that all people seeking an abortion be given information about social and financial support services, referrals to a willing provider, and offered psychological support services. The health professional’s role in the abortion procedure is not yet clearly defined. Only physicians are legally allowed to provide an abortion, yet midwives often care for the patient. In the case of medication abortion, physicians write the prescription and midwives might inform and give the patient the prescription. Abortions can only take place in hospitals or clinics with high risk obstetric units, not private practices, even though abortion is not a high risk procedure. All personnel present during the abortion procedure, including physicians, midwives, anesthetists, and nurses can claim conscientious objection refusals. Objecting providers must register as objectors, offer patients information and referrals to a non-objecting provider, and if a non-objecting provider is not available, provide abortion care in the case of a life-threatening emergency [17]. When registering as an objector, the provider must first notify the hospital or clinic director in writing before they can object to an abortion procedure and they must indicate for which of the three legal grounds (i.e. abortions to save a woman’s life, lethal fetal anomaly, or rape) they object. Registration must occur before a patient requests the abortion. The hospital or clinic director must honor the objecting provider’s status. The goal of the registry is to facilitate referral practices by documenting the number of providers willing to do a procedure in each facility. The law does not allow conscience-based refusal claims for pre-abortion (diagnosis) or post-abortion care. A recent survey indicates that 47% of ob-gyn physicians working in the 69 public hospitals designated to provide abortions claim conscientious objection to care for women seeking abortions due to rape, 27% claim refusals for abortions due to fetal anomalies, and 20% claim refusals to save a woman’s life [18]. Midwives represent 21% of people registered as objectors to participating in abortions due to rape, 18% of objectors for abortions due to fetal anomaly, and 12% of objectors for abortions to save the woman's life [19].
Like other countries in Latin America, Chile allows private, but not public institutions to claim objector status [17]. Chile’s Catholic University “Pontificia Universidad Católica”, which houses the country and region’s top medical school and includes a wide network of hospitals and health centers, became the first institution to claim objector status at the institutional level. While claiming themselves objectors at the institutional level does not preclude them from training health professionals in abortion care, they have not indicated that legal reform would result in changes to their existing curriculum. Furthermore, in interviews with medical and midwifery school faculty, most of those working at religiously-affiliated universities described strong support for the use of conscientious objection at the institutional and individual level and did not believe their curriculum needed to change in response to legal reform [20]. However, a recent survey of medical and midwifery university students from both religiously-affiliated and secular universities found that most support recent abortion decriminalization, believe their university should train medical and midwifery students to provide abortion care, and are interested in becoming trained to provide abortion services [21, 22]. The current study, builds on these findings by assessing these same students’ support for the use of conscientious objection in abortion care.
