Catherine Reilly reports on the ongoing tension between the right to healthcare access and to freedom of conscience
A conscientious objection to participating in termination of pregnancy (ToP) services among a “cohort” of anaesthesiologists was raised in HSE reports throughout 2024.
The Department of Health was advised of “reported concerns re conscientious objection” among anaesthesiologists in one hospital. The quarterly reports from the HSE National Women and Infants Health Programme (NWIHP) noted “ongoing engagement” with the unidentified hospital and separately with the College of Anaesthesiologists of Ireland (CAI). The hospital had commenced ToP services. The NWIHP quarterly reports, which covered all programme activities, were released by the Department under Freedom of Information law.
Act
The Health (Regulation of Termination of Pregnancy) Act 2018 commenced in January 2019. It legalised abortion up to 12 weeks of pregnancy once a three-day waiting period is met. It also permits termination beyond 12 weeks in limited circumstances.
Some 10,033 terminations were notified in 2023. Most (9,876) took place under the ‘early pregnancy’ provision. The majority occur by way of oral medications. However, some women require or may prefer an elective surgical termination.
According to the HSE, on its last review, seven maternity hospitals/units were providing elective surgical ToP (ie, at patient request). In addition, four units were providing manual vacuum aspiration. The HSE spokesperson said all 19 maternity hospitals/units now provide medical ToP services.
They said key barriers to surgical ToP included logistical and infrastructural challenges; and workforce constraints, including availability of theatre staff and conscientious objection. Conscientious objection was “not confined to a single specialty and is provided for under the Act”.
According to the Department’s spokesperson some new consultant roles in obstetrics/gynaecology have explicitly included a requirement to participate in elective ToP. They did not make any comment regarding anaesthesiologists.
“Regarding consultant obstetrics and gynaecology positions, applications are reviewed and approved by the Clinical Director of the NWIHP before submission to the consultant applications advisory committee,” they said.
“Some consultant roles explicitly include ToP services, particularly where the position involves leading the service. Others incorporate ToP services as part of broader responsibilities outlined in the job description. For consultant posts funded by NWIHP to lead local ToP services, approval is contingent on explicit participation in the service as a funding condition. For non-ToP-specific roles, NWIHP recommends that candidates be informed of the scope of services provided at the site, including ToP. This does not override their right to conscientious objection.”
Rights and responsibilities
Conscientious objection is covered in section 22 of the Act. It states that doctors, nurses, and midwives are not obliged to “carry out” or “participate in carrying out” a termination if they hold a conscientious objection. An exception applies where there is an immediate risk to the life of the pregnant woman or of “serious” harm to her health and where a termination is “immediately necessary” to avert this risk.
In non-emergencies, doctors, nurses, and midwives with a conscientious objection “shall, as soon as may be, make such arrangements” for the transfer of care of the woman to enable her to access the ToP.
A general section on conscientious objection is contained in the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (2024).
It states doctors may refuse to provide, or to participate in carrying out, a lawful procedure, treatment or form of care which conflicts with their moral values, subject to certain conditions with which they have a duty to comply.
Doctors with a conscientious objection must inform their employer, colleagues, and the patient as soon as possible. They must give the patient enough information to enable them to transfer to another doctor to obtain the required treatment; make such arrangements as may be necessary to enable the patient to obtain the required treatment; and not mislead or obstruct a patient’s access to the lawful procedure, treatment or form of care based on their conscientious objection.
In referring a patient and/or facilitating their transfer of care, doctors must make sure that this is done in a safe, effective, and timely manner. In an emergency, doctors must provide the care and treatment their patient needs.
Concerns raised
Mr Martin McCormack, CEO of the CAI, said the College was aware that the NWIHP had engaged with “a number of stakeholders” on access to ToP services.
In February 2024, continued Mr McCormack, the NWIHP Director contacted the CAI to raise concerns regarding “hospitals where unanimous conscientious objection among anaesthesiologists had reportedly prevented the provision of surgical ToP services”. [The HSE stated the matter related to “unanimous or significant” conscientious objection and did not specify a number of hospitals].
Mr McCormack understood the issue related to elective rather than emergency interventions. He told the Medical Independent it was “important to note” that the legal and ethical provisions for conscientious objection do not extend to emergency care where the life or health of the patient is at risk. “Anaesthesiologists are expected to provide appropriate care in such circumstances, irrespective of personal beliefs.”
He confirmed the management of ToP is incorporated into the CAI’s specialist training programme for anaesthesiology.
In response to the matter raised, he said the NWIHP and the RCPI jointly hosted a webinar in October 2024 to “explore the legal obligations” of doctors under current legislation. Dr Terry Tan, Consultant Anaesthesiologist and CAI Council member, presented at this webinar, outlining the role of anaesthesiologists in the management of surgical ToP and the ethical responsibilities involved in responding to complications requiring emergency care. The link was circulated to all Fellows of the CAI as an educational resource.
Mr McCormack added: “As the professional body representing anaesthesiologists in Ireland, the CAI affirms that the right to conscientious objection is protected in law. The College’s position is clear: It would be both unlawful and unethical to compel any anaesthesiologist – whether in a new appointment or currently in post – to participate in [non-emergency] ToP services contrary to their sincerely held beliefs. Should such a requirement arise, the College would strongly oppose it.
“At the same time, the College supports the principle of safe and lawful access to healthcare services. The Medical Council’s Guide to Professional Conduct and Ethics requires that any doctor who conscientiously objects to a procedure must ensure the patient is referred to another practitioner who can provide the service. We acknowledge that this referral obligation remains a matter of ongoing professional debate.
“The College maintains that the development of clear clinical pathways, appropriate training, and robust supports for healthcare professionals who conscientiously object are all essential to ensure safe, high quality care for patients, and to uphold professional standards.”
The CAI acknowledged the “significant service challenges” that can arise in units where provision is limited. However, resolving these issues “must take place within a framework that upholds the legal rights and professional autonomy of individual doctors”.
“The College would strongly oppose any move to impose participation in termination services as a condition of employment for anaesthesiologists.”
Mr McCormack added the College remained available to engage constructively with the NWIHP, the Department of Health, and other stakeholders to support access to services “while safeguarding the professional and ethical responsibilities of our Fellows and trainees”.
O’Shea review
The issue of conscientious objection was highlighted in an independent review of the operation of the Act. The review, commissioned by the Department and published in April 2023, was conducted by barrister Ms Marie O’Shea.
Conscientious objection was a “significant” factor in the uneven geographic distribution and number of providers, it stated. “The HSE has attributed conscientious objection as being a major factor in the roll out and development of services in the hospital setting. There is a relationship between GPs’ willingness to provide and lack of hospital support.”
In addition to conscientious objection, theatre access and resourcing challenges were also identified as key factors limiting access to surgical ToP.
The review noted changes made to consultant recruitment processes after at least two NWIHP-funded positions were filled by consultants who subsequently stated a conscientious objection. “To try to prevent this recurring, the HSE NWIHP Director confirmed that in 2022, the provision of funding approval for five additional posts was conditional upon the recruiting hospitals making it clear through advertising that candidates would be expected to contribute to elective termination of pregnancy as part of their practice.”
The review referenced “uncertainty” among those involved in the recruitment process as to the lawfulness of making provision of ToP a contractual condition or of asking candidates whether they were willing to provide and/or lead the provision of services.
It stated that freedom of conscience, thought and religion were internationally protected human rights, but these rights were not “absolute”.
“Of note, Article 9 of the European Convention on Human Rights, which protects people from being unfairly discriminated against on the basis of their thought, conscience and religion, is subject to such limitations as may be prescribed by law and are necessary in a democratic society in the interests of, inter alia, health, for the protection of rights and freedoms of others.
“Arguably, the State could, by amending section 22 [on conscientious objection], place on a statutory basis the employing hospital’s obligation to accommodate conscientious objection except in circumstances where it is necessary to uphold the right to healthcare.
“This would require the hospital employer to be cognisant of the need to balance both rights in the recruitment process. The hospital would have to be able to show that it did not have the critical mass of existing employees to perform the duties and sustain the service.”
The review also recognised the importance of all staff feeling respected and psychologically safe in the workplace.
“Whilst research informing this review reports providers of abortion services feeling varying degrees of disapproval or ostracism from non-providing colleagues, it would appear from the preliminary observations of the CORALE study [led by Trinity College] that non-providers also describe experiencing stigmatisation in the workplace if they were perceived as being out of step with the dominant ethos.
“In some instances, hospital staff with conscientious objections perceived that they were being accused of ‘not caring about women’ by colleagues because it was known that they were not willing to provide the service.”
Its recommendations around conscientious objection also included the development of Ministerial guidelines to provide “clarity” as to the obligations of conscientious objectors and training on “conscientious objection and values clarification” in hospitals. More generally, the review also made recommendations to enhance surgical termination, such as ensuring protected time for healthcare professionals who want to engage in competency-based training.
‘Legislative explainer’
The Department spokesperson stated the O’Shea review made a range of recommendations, “most of which are operational in nature and are focused around increasing access to services.”
“Significant progress has been made in this regard,” according to the Department.
They added that the national ToP service improvement group is developing a “legislative explainer” as part of “ongoing efforts” to enhance service provision.
‘Doctors must recognise power differential in the consultation’
There are 453 providers of termination of pregnancy (ToP) services in community healthcare, a rise of over 50 in the past three years, according to the Department of Health.
Nenagh GP Dr Brian Kennedy is a member of START (Southern Taskforce on Abortion and Reproductive Topics). START is a national group run by GPs who offer unplanned pregnancy services, including ToP, and operates as a peer support network for providers.
Dr Kennedy has a special interest in sexual and reproductive health and justice. He has authored a thesis on Ireland’s enabling environment for abortion care (a mixed methods systematic review of pertaining literature).
He noted that the My Options freephone helpline links women directly to providers. This helps to protect patients from difficult encounters and possible stigma or rejection. However, in these circumstances, doctors with conscientious objection are less likely to encounter women seeking ToP. According to Dr Kennedy, this potentially reinforces stigma associated with the service and may limit the opportunity for such doctors to reflect further on their position. He believed all healthcare professionals should receive training in respectful communication around abortion care – even if they object to providing ToP.
Dr Kennedy acknowledged that the Act makes provision for conscientious objection. However, he said this legal provision does not allow doctors to “abdicate their responsibility to women who need an abortion”.
“They must recognise the power differential in the consultation and refer the woman to help.”
For all practical purposes, this means giving them the number for MyOptions at the very least, he said.
“The other issue with conscientious objection is that sometimes it is invoked as a ‘convenience’ objection by overrun healthcare providers who don’t have capacity to take on the service rather than holding moral or ethical objections,” he stated.
Conscientious objection has “practical implications” in terms of access, particularly in areas with “patchy” provider uptake. He said marginalised groups are disproportionately affected in this regard. ToP services have often relied on “individual champions”, thereby posing a risk of burnout, gaps, and attrition in services. However, Dr Kennedy noted this issue has improved nationally.
He advocates for a “universal exposure to abortion education” in undergraduate curricula across healthcare disciplines. He also proposes that “values clarification training” is essential for all healthcare professionals, not just potential providers. He said this training is highly endorsed by studies to help healthcare professionals explore and express their stance. It would also serve to differentiate between lawful objection and referral and unlawful obstruction.
It is also important to have “explicit” clinical guidance on conscientious objection that is endorsed by professional bodies. This guidance should “clarify referral duties and delineate acceptable professional boundaries for objectors”.
Legal reforms around the area could include defining the limitations of conscientious objection within hospitals. This would place an obligation on hospitals to have measures in place to safeguard provision despite the conscientious objection of individual staff. He said values clarification was especially important to identify willing providers so that expansive solutions are in place (eg, making sure rotas are staffed appropriately). Dr Kennedy also suggested the appointment of formal GP clinical leads for ToP.
According to Dr Kennedy, conscientious objection and conscientious provision can coexist as “moving complementary parts” of an enabling environment. A “nuanced approach” that respected conscience rights while ensuring timely and compassionate access to abortion care was “both possible and necessary”.
Conscience rights
Dr Catherine O’Donohoe, GP in Co Wexford, does not provide ToP services on grounds of conscientious objection. However, she emphasised that her door is open to all patients and their autonomy is respected. Dr O’Donohoe said she was very conscious of her role as a GP in a rural area.
Over the years, a number of women have presented to discuss ToP. “In my experience many women self-refer directly to the My Options HSE service and supports. Where they have linked in firstly with myself, it can reflect being unsure of where to access abortion, or uncertainty in the decision.
“Foremost in my concern for the attending woman will be her concerns and wellbeing. In addition to any necessary clinical care and support that is needed, I will explain that I have not opted-in to provide abortion and if required, provide My Options information (usually in the form of provided leaflet). For the woman who is unsure of the stage of her pregnancy, I will refer for the dating scan, this being also a requirement for clinical antenatal care.”
In regard to women with an unplanned pregnancy, Dr O’Donohoe said she highlights counselling available via My Options and may also reference “practical supports” available through the pro-life Gianna Care (Dr O’Donohoe said she references the fact Gianna Care has a pro-life ethos and said it is not a resource she would generally suggest to a woman who has decided to seek a ToP).
In terms of enabling the transfer of care to access ToP: “I provide [patients] with all the relevant information [ie, My Options resource], because I mightn’t necessarily know myself what GPs around me might be providing it. In fact, there would be several parts of the country where there are very few.”
The GP said she does not know of any colleagues who would try to obstruct a patient and any such action is a breach of patient autonomy. Within the GP community, she believed there was a “general professional respect across the board” among providers and non-providers with conscientious objection.
According to the O’Shea review of the abortion legislation, the Irish College of GPs indicated it would facilitate members to attend “values clarification” workshops.
Dr O’Donohoe said she had no knowledge of these workshops. “It
would be important that professional autonomy for the clinician with a conscientious objection is not in
any way intentionally or unintentionally, directly or indirectly, undermined.”
More broadly, Dr O’Donohoe said it was unclear how many women do not proceed with ToP after the first visit with a providing GP. She said it appeared to be a substantial number from the available data.
“We don’t have any idea from a medical perspective, are there any additional supports that these women need?”
She added while the focus following the O’Shea review partly centred on removing the three-day waiting period, this failed to recognise the women who did not proceed with ToP and were glad to have continued the pregnancy.
ICGP
The Irish College of GPs delivers education on ToP services annually –
with one or two workshops held every year in different regions.
In early 2024, a survey of GP trainees was conducted to assess learning needs in this area. Based on the results, the College developed a blended learning module which was launched in September 2024. This consists of an online module and live webinar with the subject experts. A total of 400 GP trainees attended the live webinar and 499 trainees completed the module online.
A College spokesperson told the Medical Independent (MI): “All of this education looks specifically at cases that initiate and mediate break-out session conversations on values clarification and addresses legal obligations without breaching a medical practitioner’s values.”
In February 2025, the College amended a ‘quick reference guide’ on ToP to align with the updated model of care. A guide for non-providers has been available since December 2022.
The latter guide states GPs are under no obligation to provide ToP. It highlights Medical Council ethical guidance requiring doctors to enable patients to transfer to another doctor to access the service.
“Signposting is as simple, in most cases, as giving the MyOptions helpline phone number 1800 828 010 or directing the woman to a doctor who provides an early medical abortion service,” states part of the summary.
A Medical Council spokesperson told MI: “The [ethical] guide makes allowance for the doctor to conscientiously object to engaging in or providing certain medical procedures. However, the guide is equally strong on making a referral to another service or making the necessary arrangements to enable a patient to obtain the required treatment. Providing the MyOptions phoneline, website, or pamphlet may not necessarily satisfy the criteria defined in this part of the guide if this doesn’t enable the patient to obtain the required treatment.”
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