Guidance on Conscientious Objection to Abortion for Healthcare Workers in Northern Ireland

I’m sure you’re wondering where you stand if you don’t want to be a part of abortion in your workplace.

I’ve read through the guidance from the UK Government, the recent RCGP guidance, looked at the GMC guidance and considered the NMC guidance on consciencious objection in an effort to think through the implications and to try and distill the advice into a straightforward guide for those who object to being involved with abortions.

Let’s look first at the legal situation in Northern Ireland:

• Sections 58 and 59 of the 1861 Offences Against the Person Act have been removed. This is what criminalised procuring an abortion, either for the woman or for another person performing the abortion, whether surgically or medically.
• Abortion is still illegal for a child “capable of being born alive” (over 28 weeks) according to section 25(1) of the 1945 Criminal Justice Act (Northern Ireland), unless it’s to save the life of the mother.

There is no restriction or guidance on abortion under 28 weeks. There is no advice on what constitutes a reasonable request for an abortion; there is no guidance on how a patient requesting an abortion should be assessed; there is nothing in law about prevention of women being coerced into an abortion; there is nothing to prevent abortion for fatal foetal abnormality, or for non-fatal abnormality; there is nothing to prevent sex-selective abortion of male or female babies. There is nothing to advise on the nature of the surgical technique – partial birth abortions are not barred, where the child is partially delivered and then killed. There is nothing to advise on what should happen to a child who survives an abortion and is capable of being resuscitated.

That’s a whole lot of nothing.

So where do we stand?

Let’s break it down for each category of worker that might be affected

1. General Practitioners – what do I do when a woman walks in and asks for an abortion?
   1. This bit is simple – there is no service in Northern Ireland at present, or over the next few months, which will provide abortion for the vast majority of requests (unless it’s an emergency to save the life of a mother)
   2. So then what? The advice from the Government is to give them the number for the Central Booking Service in England to arrange this themselves. If your conscience allows you to do that, go ahead. I won’t be offering the number – it’s freely available on the Internet.
   3. At this point, there are options that the Government does not mention. Firstly, let’s make sure the patient is pregnant. Offer a urine pregnancy test. If it’s positive, offer a scan (if you have an ultrasound machine). Offer to ring the Early Pregnancy Clinic in the local hospital and book her an early appointment. Offer her the details for Life NI, a charity based on the Lisburn Road, Belfast, who offer a wide range of pro-life counselling and resources, and have some excellent printed material – consider getting some of their printed resources to have in your consulting room/bag.
   4. Are there concerns here for GPs? Not yet. We can’t be forced to treat these women, and we can’t be forced to refer them on because there is no NI service for abortion. Yet. There’s always the chance that a rogue GP could start prescribing abortion pills, claiming some form of ‘competence’ based on previous UK experience, but that would not be through official channels.
   5. Locum and sessional GPs – if you are contracted for a session’s work, then you see everything that comes through the door. Perhaps it’s time to start being a bit more prescriptive about what you will see and what you won’t see? Perhaps it’s time to start writing to Practice Managers stating that there are a some limitations to your services, based on ethical considerations, and stating clearly what your views are, but also providing work arounds for the practice, so that they know how and when to offer alternative services.
2. Hospital Doctors
   1. So, what will the Obstetricians amongst us do when our Antenatal Clinic patient asks us for an abortion at 16 weeks? There doesn’t seem to be anything stopping a ‘competent’ hospital doctor performing an abortion in NI. I would expect someone over the next few weeks to be the test case and to start pushing the envelope. What if your patient asks for you to refer them to this doctor? Can you refuse? At the moment, because this is not an official NHS service, I believe that you can refuse to refer. Once an official service has started – the GMC guidelines would state that you cannot refuse. Is there any leeway here? I would backtrack a couple of steps. The GMC guidance states that we should first of all “adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient“. So firstly – don’t panic. Take the time to listen, patiently working out what this person’s holistic needs are. Then examine them. That means do an Ultrasound, and do it well. Encourage the patient to look at the screen, talk them through everything that’s going on in that baby’s body at that point. Reason with them. After that? If your conscience won’t allow you to refer, then my advice is go with your conscience.
   2. So, the Anaesthetics SpR is doing their usual gynae list. Only this time there’s an abortion on it. What do you do now? If it has got to this stage, then you’ve missed the boat. If your boss doesn’t know that you object to abortions, then you’re going to end up in a difficult situation. Take it back a couple of steps and have that conversation before it becomes an issue. Will NIMDTA support you? Who knows? Will your boss support you? They have to. Tell people about your conscientious objections in advance. If you leave it until you’re faced with the situation, then GMC says you have to refer to a colleague. Best not to let it get that far.
   3. Paediatricians/Neonatologists – you might be involved in assessing babies with abnormalities within the womb. If you are, I take my hat off to you, I don’t how you do it. Whenever a pregnant woman discovers that her child has Downs, or a cleft palate, or tetralogy or spina bifida, and asks for an abortion, what do you do? Again, because there is no NI service, I believe that you are within your rights not to refer, even if there is a local Obstetrician starting to take an interest in this work. The Central Booking Office number is freely available online. I’m sure that I don’t need to tell you how to be compassionate in these awful situations.
3. Nursing Professions
   1. Midwives – what happens when your antenatal patient asks you for assistance in procuring an abortion? What do you say, what can you do? Do you have to comply? Again, as there is no locally provided service in NI, then there is no duty for you to refer. There is a freely available number for the Central Booking Office available online, which is a self-referral service, and does not require your input. But, how about if one of your Obstetrics colleagues is starting to take an interest in providing this service on an ad-hoc basis? Again, unless this is a formal service, agreed and implemented, there is no automatic right to avail of it, and no compulsion for you to refer. What should your approach be? You don’t need me to tell you that it should be compassionate and caring, both for mother and child. Can you challenge your medical colleagues on their actions and stance on abortion? Of course! Should you have your dissenting voice noted by your managers and by your department? Of course! I would advise notifying people in writing today, or as soon as possible, and Midwives for Both Lives have a template letter on this subject.
   2. Nursing staff – whether you are on a gynae ward, in theatre, recovery, or a general medical ward, there is a fair chance that you will be asked to care for someone about to have an abortion, or someone who has just had an abortion. What if you are unhappy about this? Do you have any right to refuse? In this area, preparation is key. You must let your line manager know that you absolutely refuse, on grounds of conscience, to be involved in this work. There’s no point in springing this on someone just as a patient lands in front of you – that’s not giving your team appropriate time to work around you – make it as easy as possible for your colleagues to allow you freedom of conscience. But do you have any statutory right to object on grounds of conscience? Sadly, there is no right for Nurses, Midwives, HCAs to opt out of work on the grounds of conscience. The NMC guidance only has exclusions for the 1967 Abortion Act, which is UK legislation. There is no provision for Northern Ireland. You may remember the case of the Glasgow Midwives in 2014, who were seeking to opt out of supervising staff who would be performing abortions – the Supreme Court ruled that, as they were not involved in the ‘hands-on’ procedure, they had no right to opt out, which is distressing. However! This legislation only applies to the rest of the UK – not to Northern Ireland. The bottom line is – there is no opt-out for Nurses, Midwives, HCAs in the legislation for NI; but this has not been tested in court.

I want to say a little about healthcare staff in training too – the implications are worrying if we think through them. They are at a delicate stage of their training – what if attendance at an abortion becomes a compulsory part of medical student training? What if an attachment at an abortion clinic becomes a compulsory part of nursing student training? What if, as a trainee doctor, your supervisor disagrees with your stance on abortion? There is potential for all of these situations, and many more, to put student and trainee healthcare workers at a disadvantage, to affect the completion of their training, and perhaps prejudice their chances of obtaining future work.

My suggestion to students is this – write to the Dean of your Faculty, stating your beliefs, and ask for a concrete reassurance that you will be allowed to act in accordance with your firmly held beliefs, in a manner that will not prejudice your current training, or your progress to completion of your course. Trainee doctors – write to the Northern Ireland Medical and Dental Training Agency and ask for the same reassurance. Get it in writing, put pressure on these agencies to recognise your concerns.