Conscience-based refusal in reproductive medicine

This paper includes explanation of the legal principle of conscience-based refusal in reproductive medicine, analysis of legislation, politics and practice regarding refusal of health care services provision on conscientious grounds in the Republic of Croatia, and indicating the problems in legislation and practice which enables malpractice of this right thus violating the right of each patient to access lawful medical care in a timely manner.

 The Republic of Croatia does not have uniformed and standardized procedure of refusing to provide relevant services for reasons of personal conscience, there is no systematic data collection on professionals' refusals to provide standard reproductive services as well as its effect on the quality of health care. Lack of monitoring from the side of the Ministry of Health and tolerance for institutionalized conscience-based refusal represents public-health problem which, finally, results in limited access as well as legal and medical insecurity for women. Women who request abortion are stigmatized in the society, they are facing with disapproval or humiliation in health care facilities, and they can also be exposed to unnecessary waiting periods, additional costs and discrimination. The paper presents legislation and practice of conscience-based refusal in Spain, in which the legislator and the profession are working on development and implementation of standards so that conscience-based refusal could not affect the access and the quality of health care services. In Norway, unlike in Croatia, the dignity and the autonomy of women is in the first place. Conscience-based refusal is not allowed in several European countries, and in Croatia there are some people who question the expansion of conscience-based refusal to professional sphere.

 Considering the findings of this research, and in order to regulate conscience-based refusal in a way that it does not hinder the availability of legal health care, it is necessary to adopt and implement standards that would clearly articulate the state's obligation which guarantees that conscience-based refusal in practice does not obstruct access and availability of lawful medical care in a timely manner, to ensure supervision and monitoring of practice as well as to seek responsibility of those who do not respect the standards. Only individuals have conscience, not legal entities or other collective bodies. Public health care institutions cannot refuse provision of legally prescribed health care services; they are obliged to hire enough staff who is willing to provide all services of reproductive health. It is necessary to determine under which conditions conscience-based refusal is possible, to regulate the procedures and prohibit conscience-based refusal in situations when patient's life or physical/mental health is endangered. Conscientious based refusal can be claimed only by providers involved in direct provision of services, it has to be specific and correspond to concrete actions. In case of conscientious refusal, patients' should get timely service by another provider and therefore have no additional inconveniences and costs. Additionally, women's dignity and their independence in decision-making have to be respected.The standard curriculum and teaching programs for health care professionals should incorporate information about humane way of notifying patient about professionals' refusals to provide reproductive health service, as well as to ensure that students of medicine learn about performing services that they may need to provide in the case of emergency.