The Rcn and Abortions: The 'Conscience' Clause ca. 1995-1999

Introduction:

At no time has the Rcn made a policy statement on the rights or wrongs of abortion. The decision as to whether or not an abortion should be performed is a medical one. The role of the nurse is the undertaking of the nursing care of the woman receiving medical treatment. The need for nursing care obviously exists but it must always be remembered that nurses hold personal views and beliefs too, as do all members of the public and nurses have the same rights as other citizens. The general public holds differing views on the rights and wrongs of abortion and nurses are no different. Some will choose to undertake the nursing care of persons under going abortion and others will not. It is the recognition of the right of nurses to 'choose' that has caused the Rcn concern for many years.

In January 1972, in submitting evidence to the Committee on the Working of the Abortion Act (Lane Committee), the Rcn stated:

"The policy of the Rcn on this matter is that the decision to perform an abortion is a medical responsibility but where nurses are involved in the procedure, their FREEDOM TO DETERMINE WHETHER OR NOT THEY ARE PREPARED TO PARTICIPATE SHOULD BE RECOGNISED. The principle applies to any issue which may involve a matter of conscience or religion; a nurse should not be required to perform any action or to assist in any procedure which is against her conscience or beliefs."

Any nurse has the right to refuse to take part in abortions on grounds of conscience. Provisions are contained in Section 4 of the Abortion Act which reads:

4. (1) Subject to sub-section (2) of this Section, no person shall be under any duty, whether by contract or by any statutory or other legal requirements, to participate in any treatment authorised by the Act to which he has a conscientious objection: provided that in any legal proceedings the burden of proof of conscientious objection shall rest on the person claiming to rely on it.

(2) Nothing in sub-section (1) of this Section shall affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.

It is quite clear, therefore, that a person who has a conscientious objection may LEGALLY REFUSE to participate in treatment authorised by the Act OTHER THAN in cases where such treatment is in what amounts broadly to an emergency when the treatment is necessary to save life or prevent grave permanent injury to the physical or mental health of the pregnant woman.

Interpretation of the problems arising from the 'Conscience' Clause

As early as 1995, the DHSS acknowledged the concern of nurses that the Clause (Section 4 (2)) was open to differing interpretations. In a paper giving guidance to professional officers, the DHSS stated:-

Section 4 (2) exists in the regulations primarily to obviate the delay which might occur in an emergency if before treatment could be carried out, the statutory requirement of the signed agreement of the need for treatment by a second doctor be obtained. It cannot therefore be taken as the exclusive indication of those cases where the conscience clause can be revoked... a nurse is capable of reaching a considered view as to what is a medical necessity. The onus would be on a nurse who is sought to rely on the conscience clause to show that she did sincerely hold a conscientious objection to participating. Once she had done that, the onus would then be on anyone who sought to deny her right to show that the abortion had been necessary to save life or to prevent grave permanent injury.

It is the view of the Rcn that in normal circumstances any conscientious objection to participation in abortions would be conveyed to and documented by nursing management. Trained nurses on gynaecological wards, in abortion units and in theatres would work there through choice. Situations may arise when wards and theatres are staffed by relief nurses who have not been counselled and who have not informed nurse management of any conscientious objection to participation in abortions. Technically problems should not arise since ward intakes and theatre lists will be known in advance and nurse management will be in a position to determine whether the relief staff might object or not. The nurses too should state their case and alternative arrangements will need to be made by management. Nurses not so prepared, have the right to refuse to participate in treatment authorised by the Act OTHER THAN in cases falling under Section 4 (2) of the Act.

It is reiterated here that even under Section 4 (2), the nurse can rely on the conscience clause on reaching a considered view as to what is a medical necessity. On stating the objection, and documentation of the objection is advised, the onus is on management to make alternative arrangements.

Another problem is interpretation that has arisen as to whether the conscience clause covers pre-operative and post-operative care. The legal opinion as outlined in the DHSS paper mentioned is that:

'This does include pre-operative nursing care because unless provisions of the Act are complied with such care will constitute aiding and abetting an offence under the law. On the other hand, the legal view is that post-operative nursing care is not covered by the conscience clause because it is not treatment authorised by the Act.'

It is the view of the Rcn that nursing care is a continuous process and that therefore nurses who object to participation in abortion treatment should be facilitated by nurse management to non-participation in that continuous process.

Abortion by non-surgical methods

When an abortion is carried out by a surgical technique it is the operating department nurses who are most closely involved. Non-surgical methods of abortion bring a new dimension to the nursing requirements of the patient because the nurse is involved with the care throughout the procedure, from admission, during the abortion, and after, until her transfer home.

All nurse learners and all nurses seeking appointment to a gynaecologic and/or theatre suite where abortions are carried out, require sympathetic handling. This will involve counselling and careful explanation of all aspects of abortion that includes the law and the conscience clause. These nurses are required to be given the opportunity to contract out and this decision should be noted. It is the view of the Rcn that nurse learners may 'change their minds' following clinical experience and the continuous counselling process should not be denied to them.

Whilst conscientious objectors have rights, women seeking abortions have rights too. A doctor who objects should ensure that advice for the pregnant woman is available and this may require widening of the conscience clause.

Other comments of the Rcn

Distress can be caused to patients and staff when patients in hospital for sub-fertility investigations are nursed in wards with patients admitted for abortion. This should not happen and the reasons in terms of standards of care are obvious.

Family planning advice should be provided as an integral part of the abortion treatment. Increasingly family planning nurses (specialist nurses) are undertaking duties in gynaecological wards and midwifery units, but the service is by no means available everywhere. Many family planning nurses are only employed on a sessional basis for clinic sessions.

The Specified period after which an abortion may not be carried out

According to the provisions of the Infant Life (Preservation) Act 1929, a foetus is viable after 28 weeks of pregnancy have passed. Medical termination of pregnancy can take place therefore if two registered medical practitioners are of the opinion -

1) that the continuance of the pregnancy would involve risk to the life of the pregnant woman or of injury to the physical or mental health of the pregnant woman, or any existing children of her family, greater than if the pregnancy were terminated; or

2) that there is a substantial risk that if the child were born it would suffer from such a physical or mental abnormality as to be seriously handicapped, up until the 28^th week of pregnancy.

In 1972, the Rcn called for a definite period to be specified after which abortion should not be carried out except to preserve the life of the mother. The Rcn felt that 12 weeks would be reasonable, but realised this could only be achieved if adequate facilities were available and if preventive measures were seriously entered into. This has not occurred.

In 1978, the Rcn Society of Primary Health Care Nursing recognised that considerable advances had been made in the detection of severe foetal abnormalities in utero. The Society also expressed concern over the increase in numbers of 'schoolgirl' mothers and expecially those who emotionally denied pregnancy and sought advice late in pregnancy. The Society therefore conc1uded that in order to meet the needs of women carrying severely handicapped foetus's which could only be detected later in pregnancy, and facilitate their right to choose an abortion or not, the specified period of time should not be too restrictive. The Society is of the view that the period of time should be a matter of medical advice to the legislators.

For mid-trimester abortions Prostaglandin E2, marketed under the name Prostin E_2, is used when the pregnancy is advanced to sixteen weeks or more. The procedure is carried out in hospital. A premedication drug is given to the patient who will be examined in the operating theatre where a self-retaining catheter is inserted into the cervix above the level of the internal os. A test dose of Prostin E₂ is given to the patient who is observed for any adverse reaction. Prostin is then administered at a rate of about 100 micrograms per hour, either by infusion_, or by pump. Observation of the patient's pulse and blood pressure are made throughout the procedure. Approximately six hours after the commencement of Prostin the infusion is ceased and Cyntocinon or a similar drug is given. After this stage the catheter will leave the cervix and the products of pregnancy can be seen and removed.

The ward nurse's involvement will include taking a nursing history for the patient so that the nursing needs can be identified and planned. A definite relationship between the nurse and the patient will have been forged and the nurse in conjunction with the other members of the team will be responsible throughout the patient's stay for carrying out any nursing procedures, as well as contributing to her emotional support. Apart from the short visit to the operating theatre for the insertion of the catheter, the patient will be present in the ward throughout the procedure. It must be reiterated that a nurse who wishes not to be involved with the care of a patient undergoing an abortion should make her views known as described above.

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Another problem is that of the nurse learner. The Lane Committee recommended that abortion cases should be nursed in special units staffed by trained nurses where no nurses in training should work, and the Rcn has always supported this. The need for special units is even more apparent today as medical advances have brought about a higher incidence of induction of labour and 'normal' delivery of the foetus. Midwifery and possibly paediatric nursing skills are required in adequately providing appropriate care.

Such units rarely exist and the majority of abortions are carried out in gynaecologica1 wards to which nurse learners are allocated for experience. Such wards are often lacking in midwifery expertise or close communications with midwifery and paediatric units.

If nurses in training are to be allocated to wards in which patients undergoing an abortion are cared for, the students require preparation, counselling, sympathetic handling and careful explanation of the provisions of the Abortion Act. Nurse learners must, of course, be given the opportunity to contract out of participation in abortion treatment on grounds of conscience.

Finally, the Rcn is aware that there is a reluctance on the part of some nurses to exercise their right to contract out on conscientious grounds because they consider that to do so would increase the pressure on their colleagues by adding to their workload.

Conclusions

The Rcn concludes that the conscience clause requires some strengthening, any objection there might be to participation in abortion treatment should be specified so that pressure to undertake work that is against moral, religious and ethical beliefs, for example, would be largely negated. In order to offer the highest standards of care and at the same time assist to alleviate the stress on nurse learners and conscientious objectors, abortions should be carried out in special units or wards.