How Italy's "Conscientious Objector" Doctors — De Facto — Limit Abortion Rights
Italy decriminalized abortion in 1978, but the law allows for doctors to conscientiously object. And so many do that it makes it difficult for many women to access health care when they need it most, with some turning to unsafe abortions.
COSENZA — At the Annunziata Civil Hospital in this southern Italian city, every single gynecologist is a conscientious objector. So pregnancy termination is possible only twice a week here when the visiting doctor who performs the procedure is present.
“More than six months after the resignation of the only non-objector gynecologist at Annunziata, the service is still lacking and is proceeding in fits and starts," explain the activists of the FEM.IN collective, who met with the hospital's administrative director in December and made them promise to hire two more doctors and guarantee the service in the area.
The hospital is not an isolated case in Italy. According to a Ministry of Health report from 2022, 64.6% of Italian gynecologists were conscientious objectors in 2020, a rate slightly lower than 2019, while 44.6% of anesthesiologists and 36.2% of non-medical staff object to performing pregnancy terminations.
This means that 45 years after the passage of the law that decriminalized abortion in Italy through the third month of pregnancy, the "objection" rate among physicians and health care professionals is so high that it makes the termination of pregnancy effectively impractical in many areas of the country.
Women who want to get an abortion struggle to find information, have to wait a long time, or are forced to travel to another region to have the operation.
Church and state
The Luca Coscioni Association's Mai Dati report, edited by Chiara Lalli and Sonia Montegiove (which became a book in 2022), shows that the situation is even worse in some parts of the country because the data in the ministerial report are not up to date.
According to the report, there are 72 hospitals in Italy where the percentage of conscientious objectors among their health care staff is between 80 and 100%. In fact, there are 22 hospitals and four counseling centers that consist of 100% objectors among all healthcare staff.
According to Michele Mariano, a doctor, most colleagues are objectors “because those who perform abortions do not advance in their careers... In Italy, there is the Church, and as long as the Vatican dictates the law, the problem will always be there. And then, it’s because the majority of public opinion — and colleagues — considers those who practice abortion as people to be cast aside, second-class gynecologists, who do something bad."
Also Marina Toschi, a gynecologist, says that gynecologists who perform the procedures often find themselves doing only abortions, with a very high workload, without adequate remuneration and suffering the stigma that is still attached to these operations.
“The real objectors are the medical directors and the general directors who do not apply the law," Toschi continues. According to her, there is also a shortage of health personnel: “Gynecologists, in general, are few and there should be more hiring of non-objector doctors,” she adds.
There is also a problem with professional training: “There is a lack of training on the topic of abortion, but also on contraception. These topics are still a big taboo in Italian universities, especially Catholic universities. There is little or no teaching at universities on how to use drugs such as misoprostol (an abortifacient drug) or how to insert IUDs for contraception, even though they are indicated by the World Health Organization (WHO) as the best contraceptives,” Toschi continues.
As evidence of this, “the Ministry of Health's guidelines requiring abortion pills (Ru486) to be administered in Counseling Centers [the Italian state-funded version of Planned Parenthood] have not been adopted by many regions partly due to lack of training of providers.” This is why, according to activists from the Marche collective Sisters on the Block, many women are still forced to travel to other regions such as Emilia Romagna for abortions.
You have to be very motivated to continue to be a non-objector.
Irene Cetin, professor of obstetrics and gynecology at the University of Milan and head of the gynecology department at the Buzzi Hospital in Milan, notes that for many gynecologists, the problem is related to the workload and the repetitiveness of pregnancy termination operations: “As a head doctor, I can assure you that the organizational problem arises when in a department there is a rate of more than 50% of doctors who are objectors. In that case, the work for non-objectors becomes relevant. Dealing only with abortions is penalizing from a professional point of view also because it is an easy operation."
According to Cetin, who is a non-objector physician and a member of the Italian Society of Gynecology and Obstetrics (Sigo), in the Italian healthcare system, "you have to be very motivated to continue to be a non-objector, especially if you work in a facility where the objectors are the majority."
The conscientious objectors
Paolo Rollo, an objector physician and head of the gynecology ward at Cannizzaro Hospital in Catania, argues that the conscientious objection of the majority of the doctors in his department does not prevent the hospital from providing the pregnancy termination service regularly. Rollo, a gynecologist since 1985, believes it is right that there is an article in the Italian law allowing doctors not to perform abortions for personal and ethical reasons.
“There should be no stigma, neither on objectors nor on non-objectors. What is important is that the service is guaranteed. This is what the state asks of us,” says Rollo, according to whom there are no waiting lists at his hospital for those who want to have an abortion within the time limits set by law.
“We have a non-objector doctor on contract for three years to ensure the service of the termination of pregnancy in our department. There is no waiting list, women can come to the clinic on Thursdays, even without a reservation,” he says. For the chief physician, there should be no hospitals that do not guarantee this service, even in the case where all the doctors in the department are objectors because the medical directors should intervene and use ad hoc contracts to carry out this type of operation.
He argues that there is also an age issue on conscientious objection: “Younger gynecologists are almost all non-objectors because culturally they perceive abortion differently. While the old guard has personal reasons, often related to ethical-religious motivations.”
At Niguarda Hospital in Milan, there are eight non-objectors out of 22 physicians. “There have been times when I had only two non-objectors, but even under these conditions it is possible to guarantee the service,” says Mario Meroni, head of the hospitals' gynecology department and a conscientious objector. Like Rollo, he suggests that chiefs and medical directors should collaborate with consultants in these cases and enter into agreements with other hospitals to fully implement Law 194.
A map of facilities
Every year dozens of testimonies and complaints arrive to the associations concerned with the full application of the law, such as the Free Italian Association of Non-Objecting Gynecologists for the Application of Law 194 (Laiga).
“Although 1978 Law 194 was adopted 45 years ago, clear, public and transparent information has never been provided on how to access voluntary termination of pregnancy services and especially on which hospitals one can go to in order to get one,” Laiga explains.
“This is particularly problematic given that the very high rate of conscientious objection leaves women at the mercy of fate at a time when we need to act quickly to stay within the gestational limits of the law. Women often go by hearsay, turning to objector personnel and wasting precious time,” continues Laiga, which on its website offers a map of Italian facilities where voluntary termination of pregnancy can be performed.
Politics and health care
Filomena Gallo, a lawyer and secretary of the Luca Coscioni Association for the freedom of scientific research, explains that “the first thing to do would be to open the data, update it, make it known and available, to have a current snapshot of the situation at the regional level and for each facility. But this is not there at the moment."
According to Gallo, in every facility where there are too many objector doctors, open competitions for doctors should be held, providing for 50% non-objectors and 50 percent objectors, as was done at St. Camillo Hospital in Rome.”
Many such competitions, however, are blocked by politics. In Liguria, in northwest Italy, for example (where there are 59 non-objecting doctors out of 123), such a proposal was rejected by the center-right majority in the regional council on Jan. 31.
The Luca Coscioni Association receives dozens of complaints every year from women who even run into objector pharmacists refusing to give them the morning-after pill, which is a contraceptive.
Gallo explains that “it is illegal for pharmacists to declare themselves objectors.” However, the lawyer continues that women who initially file a complaint about the lack of service often do not go through the legal process.
San Camillo-Forlanini Hospital in Rome, Italy
A law with many limitations
The right of doctors, anesthesiologists and healthcare personnel not to perform the termination of pregnancy through objection is guaranteed by Italy's Article 9 of Law 194, introduced after a long parliamentary debate, which decriminalized abortion in Italy within the first trimester of pregnancy and under certain conditions for the woman.
“At that time, decriminalizing abortion meant a radical change in the practice of public hospital doctors. Therefore, this article was inserted to allow objection to those who had chosen to do those professions before the introduction of the law and who had moral issues with it. Doctors were allowed to continue practicing their profession even though their duties had changed,” explains Caterina Botti, professor of moral philosophy and bioethics expert at La Sapienza University in Rome.
According to Botti, the principle of conscientious objection is strongly linked to the structure of the law, which is the result of great political compromises and conceives abortion not as a “practice of women's freedom,” on par with other legal traditions, but as a “health practice to protect women's health.”
Botti explains that abortion, according to the wording of Italian law, is not a woman's choice, but “a doctor’s duty to protect the woman’s health, which is why health care personnel are allowed to object, that is, to not fulfill that duty for ethical reasons.”
Forty-five years after its approval, one cannot understand this formulation of the law unless one considers that at the time “it was the result of great negotiations between parties that were very reluctant to decriminalize the termination of pregnancy,” decriminalization that had been discussed without result since 1971.
But according to Botti, that article providing for conscientious objection “could be overcome. Today, those who choose that profession know that among their duties is that of performing abortions. Those who do not want to do so could choose another profession, another specialization, or operate outside the national health service."
Professor of bioethics and history of medicine Chiara Lalli, has a similar viewpoint. “Conscientious objection should not be allowed by law,” Lalli writes. “It is often used as a battering ram to oppose individual rights enshrined in law; doctors who do not want to perform abortions for reasons of conscience come directly and personally into conflict with the women who request that service."
“Admitting that a physician can invoke conscientious objection is a form of paternalistic moralism."
"It is rooted in the idea that the physician is the holder of the truth or a truth stronger than ours and therefore also knows what is good for us and decides accordingly,” Lalli continues. “A physician cannot choose to be a doctor and then exercise this power to impose their own worldview and to shirk their duties,” she concludes.
Mirella Parachini, a gynecologist, radical activist, vice-president of the International Federation of Abortion and Contraception Practitioners (Fiapac), and one of the founders of the Luca Coscioni Association, does not agree. According to Parachini, the conscientious objection can coexist with the right to abortion.
“I am not against conscientious objection because it is present even in countries where abortion is accessible, such as France and the United Kingdom. Allowing conscientious objection presents organizational problems, but it can be reconciled with ensuring quick access: it should be the facility that does not provide abortion care to inform the woman and even book her the procedure in facilities where abortion is practiced." According to Parachini, an incentive system, including economic incentives, for non-objecting physicians could be set up to favor the implementation of the service.
There is one aspect, finally, that according to the gynecologist should give us pause for thought: “The number of abortions has been steadily decreasing in Italy since 1978 when the law was passed. Instead, clandestine abortions remain stable, according to the ministerial report, and are estimated at between 15,000 and 20,000 per year. This figure... hides an increase in the percentage of clandestine abortions in areas where abortion is less accessible.”
This is another point that should push institutions to ensure that the both the spirit and letter of the law is enforced throughout the country.