Providers of reproductive
health services struggle daily with ethical decisions that can have profound
consequences for the well-being of their clients.
Serving adolescents,
HIV-positive clients, and women whose partners are violent or who oppose
contraception are among the many ethical issues that reproductive health
service providers routinely face. So, too, is balancing pressures to help
reduce population growth with clients’ rights to make contraceptive
decisions freely.
There is no correct
approach that fits every case. At the very least, the ethical delivery of
reproductive health services must begin with providers carefully considering
the possible consequences of their actions, based upon three
well-established cornerstones of medical ethics: respect, beneficence, and
justice (see "Human
Research Must Protect Participants"). And providers should remember
that clients make the final decisions about the services they receive.
Not uncommonly,
however, providers face situations in which these ethical principles are in
conflict with each other. For example, respecting the confidentiality, and
thus privacy, of clients is considered to be the ethical duty of all health
professionals. However, providers may feel that disclosing confidential
information is ethically correct in order to maintain societal norms or
protect the health of the public at large.
Adolescents
As with all clients,
adolescent clients’ specific circumstances should be carefully considered
when providing reproductive health services. For example, particular care
must be taken in the case of a young adult who wishes to be sterilized,
since the procedure is permanent. Sterilization is inappropriate for young
teenagers, and thorough counseling is needed for young adults who are older,
in their early 20s. Studies show that up to 20 percent of women sterilized
at a young age (younger than 25 years old, in one study) later regret this
decision.1
Providers should
respond to adolescents’ requests for reversible contraceptive services
with courtesy, while maintaining confidentiality. Research has demonstrated
that adolescents are more likely to seek such services from providers they
feel they can trust and from providers who respect their right to privacy.2
"Youth are sensitive to the idea that the information they share about
their sexual behavior will not be held in confidence, but instead will be
shared with their parents or other adults," says Dr. Cindy Waszak, an
FHI senior scientist with expertise in adolescent reproductive health.
"They feel they lack control, that their behavior will be particularly
scrutinized and judged by adults, and they realize that the consequences of
such information being disclosed may be severe.
"They have good
reason to be concerned," she adds. "Many providers do not see
adolescents as having the same rights as adults, and may be reluctant to
serve them without parental consent, even when policies spell out the right
of adolescents to receive non-permanent contraception or treatment for
sexually transmitted infections (STIs) without such consent. Many providers
either deny services to adolescents or fail to provide confidentiality
because they sincerely worry that freely making contraceptive methods
available to adolescents will encourage them to be sexually active, although
research indicates that this is not the case.3 Finally, many
providers choose to deny the fact that adolescents are sexually
active."
However, the decision
not to provide reproductive health services to adolescents in a confidential
setting can cause far more harm than good. "Providers need to ask
themselves whether they are providing the best possible care to their
clients, regardless of age," says Dr. Waszak. "An adolescent who
is turned away or whose reproductive health information is not held in
confidence may well end up with an unplanned pregnancy, STI, or ostracism
from parents or others in the community. Any of these outcomes can have
life-long adverse consequences for an adolescent."
In cases where the
law, administrative policies, or guidelines require parental consent for
certain reproductive health services, the provider must follow the law.
However, the provider can recommend options that do not require disclosure,
such as buying condoms at a pharmacy rather than getting pills at a clinic.
Also, the provider can either encourage the client to talk with her or his
parents or offer to talk to the parent and adolescent together.
"Providers also
need to keep in mind that some girls are in situations in which they find it
difficult, if not impossible, to refuse sex," says Dr. Waszak. "In
such cases, it is important for providers to respect an adolescent’s
courage and resolve even to seek reproductive health services. It is
unethical for providers to turn away or betray the confidence of adolescents
who have made such an effort to get help."
HIV-positive
clients
Many clients who are
HIV-positive or have other STIs do not know they are infected. In many
settings, testing is unavailable. In others, clients who suspect they are
infected may be reluctant to be tested. They may fear receiving a positive
test result, particularly if treatment is unavailable. They also may worry
that a positive test result will not remain confidential, leading to severe
social consequences.
Confidential and
anonymous HIV testing services are slowly becoming available, and providers
should promote the use of such services, most experts agree. (In
confidential testing, a person’s identity is known but test results are
kept confidential. In anonymous testing, the identity of the person being
tested is not recorded or required.)
"People who learn
that they are not infected will be encouraged to maintain their HIV-negative
status," says Dr. Eric van Praag, an FHI expert on HIV/AIDS care and
support services. "Meanwhile, those who learn they are infected will
become aware of the urgent need to adopt safe sexual behaviors to avoid
infecting others, receive contraceptive counseling that takes their HIV
status into account, and be actively referred for medical care and social
support if needed. Pregnant women can receive treatment to reduce the risk
of transmission of HIV to their unborn children. A diagnosis also allows
infected individuals to obtain appropriate counseling and to plan for the
future, anticipating how to care for surviving children and to make
wills."
In Kenya, Tanzania,
and Trinidad, a study conducted by a group that included FHI and involved
some 4,200 people between 1995 and 1998 showed that HIV counseling and
testing reduced risky behaviors associated with the sexual transmission of
HIV. Over six months, individuals receiving HIV counseling and testing were
more than twice as likely to report declines in unprotected intercourse with
non-primary partners than individuals who received only basic information
about HIV transmission and correct condom use. Self-reported behavioral
changes were confirmed by STI incidence rates. However, the study showed
that clients were reluctant to disclose test results for fear of
stigmatization and discrimination.4
Their fears are
well-founded in most settings. In developing countries, people usually
depend on their families and communities for support and care. But, where
stigmatization is associated with HIV/AIDS, disclosure can lead not only to
rejection by family members, but loss of work and friends, physical and
sexual assaults by male partners, and even deadly attacks.5
The Joint United
Nations Programme on HIV/AIDS and the World Health Organization (WHO), which
jointly provide surveillance of the global HIV/AIDS and STI epidemic, have
stated that all such surveillance programs "should have policies that
protect the privacy of patients and the confidentiality of disease control
data."6 Furthermore, health care providers are bound by
their profession to maintain the confidentiality of client information. And
many do so.
However, positive test
results often are disclosed, either carelessly or on purpose. Reports of
such breaches have come from many countries. For example, HIV/AIDS reporting
is supposed to be confidential in Sri Lanka, but some people have reported
being stigmatized after their HIV status was carelessly disclosed and became
publicly known against their wishes. Some health staff in Sri Lanka have
been accused of demanding money from people who tested positive in exchange
for not disclosing their HIV status to the community.7
A small study in
Russia concluded that confidentiality is not well understood by physicians.
"There is little evidence that principles of confidentiality have
received much consideration," the researchers concluded. For example,
even at sites promising anonymous HIV testing, little effort was made to
conceal patient identity on laboratory or insurance forms.8
Even well-intentioned
providers sometimes disclose confidential information about HIV status. They
argue that the confidentiality afforded infected people may jeopardize the
well-being of uninformed, healthy partners. By guarding such deadly secrets,
some providers fear that they may lose the trust of the community.
These concerns are so
acute that partner notification against client wishes – although usually
qualified by a long list of conditions – has been accepted in some
countries. In the United Kingdom, for example, the doctor who believes an
HIV-positive patient has not informed his or her sexual partner (and cannot
be persuaded to do so) may notify the partner, but must be prepared to
justify such a decision. In Thailand, where husband and wife are legally
considered to be the same person, either must be informed of their
spouse’s HIV status.9
"In general,
however, if a client is not ready to disclose his or her HIV-status to
anyone, there is little a provider can do except repeatedly discuss with the
client when and how to disclose and to whom," says FHI’s Dr. van
Praag. Notably, HIV counseling and testing services have been developed in
Uganda, Rwanda, and other African countries to facilitate partner
communication about HIV status. FHI researchers in Kenya and Tanzania found
couple HIV counseling to be more difficult than individual counseling, but
more likely to reduce high-risk sexual behaviors.10
Despite the ethical
duty of health professionals and reproductive health providers to care for
HIV-infected patients or clients, some do not fulfill this obligation. In
India, for example, 22 of some 100 doctors interviewed said they did not
treat patients with STI complaints. "It is most regrettable that the
medical profession, which should be the first to offer care and support to
HIV-infected people, actually discriminates against them and rejects
HIV/AIDS patients in India," researchers concluded.11
Discrimination against
HIV-positive patients not only threatens their well-being, but can also
jeopardize the safety of other health professionals. Dr. María Eugenia González,
an obstetrician and gynecologist at the General Hospital of Mexico in Mexico
City, recalls how staff there could have been endangered because a woman in
labor lied about her HIV status to gain admission to General Hospital, after
being denied admission to other hospitals because of her HIV-positive
status. "By the time she reached our hospital she was desperate for
medical attention," says Dr. González, chosen for a research
fellowship under FHI’s Fellowship in Con-traceptive Technology Research.
"Immediately after being admitted, she gave birth." Although
General Hospital routinely uses precautions to protect staff from HIV
infection, staff at some hospitals might not be as careful if they did not
know a patient was HIV-positive.
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Harm from partners
Women are more likely
to be injured, raped, or killed by a current or former partner than by any
other person. In reliable, large-scale studies, results indicate that
between 16 percent and 52 percent of women have been physically abused by a
partner. Surveys in a number of countries show that from 10 percent to 15
percent of women report being forced to have sex by their intimate partner.12
Common as it is,
domestic violence often remains hidden. The spouse was the aggressor in
three of every four reported cases of abuse among 179 women using health
services in Santo Domingo, Dominican Republic. Yet, half of the interviewed
women who had suffered physical or emotional abuse – with over
three-quarters of those experiencing sexual abuse – said they had told no
one about the violence before being interviewed for the study on violence.13
"Many abused women never tell," said L.J. Payán of PROFAMILIA’s
Santo Domingo clinic, where many of the women were interviewed.
Why should
reproductive health providers consider it their ethical obligation to help
clients who are victims of domestic violence?
"Violence is a
reproductive health issue," says Donna McCarraher, an FHI research
associate who has investigated intimate partner violence in Bolivia.
"It can endanger pregnant women, and directly jeopardize the use of
family planning and STI prevention and treatment. Also, for many women who
are abused, health workers are the main and often the only contact for
support and information." (See "Responding
to Victims of Domestic Violence" for how providers can help.)
Meanwhile, a married
woman’s life and health also can be seriously threatened if her spouse
vetoes her use of family planning services. In many countries, providers
need to follow spousal authorization requirements that are found in laws,
regulations, clinic guidelines, and national ministry of health regulations.
However, some providers require spousal consent simply because they fear
that not getting such authorization will defy cultural values and bring
reprisals against them.
Studies conducted in
Kenya, Botswana, Burkina Faso, Senegal, and Tanzania by the Population
Council found that some providers reported imposing more restrictions on
contraceptive use than required by policy or service protocols. Spousal
consent is not required for provision of combined oral contraceptives,
condoms, intrauterine devices (IUDs), injectables, or Norplant in these
countries. But, depending on the method and country, from 6 percent to 57
percent of some 2,000 providers in the studies still required it as of 1998.
"For all countries, the level of spousal consent requirements for
condoms is discouraging, particularly since many of these regions have a
high prevalence of HIV and other sexually transmitted diseases," the
study researchers observed. In Kenya, for example, 41 percent of some 444
providers reported restricting condoms without spousal consent,
"suggesting an unwillingness to recognize the frequency of HIV
transmission within married couples or a fear that the women would use the
condoms in extramarital relationships."14
In the absence of
legal requirements for spousal consent, providers have an ethical obligation
to allow women to make independent decisions about contraception. The right
of couples and individuals to decide freely on the number and spacing of
their children has been repeatedly recognized throughout the world as a
matter of principle: in 1974, at the World Population Conference in
Bucharest; in 1984, at the Mexico City World Population Conference; and, in
1994, at the International Conference on Population and Development in
Cairo. Furthermore, courts of several countries have held that spousal veto
practices violate principles of personal privacy and autonomy and the right
to health care. Courts in general agree that one partner may not compel the
other to reproduce.15
Pressure
FHI and many other
international health organizations believe that pressuring clients to use
contraception is ethically wrong. Most countries uphold this position.
Nevertheless, there
have been efforts in some countries to curtail rapid population growth,
which can strain resources and lower the quality of life for all. For
example, doctors may be offered incentives to meet quotas for IUD insertions
and consequently pressure women to accept this method. Women in indigenous
regions where language and cultural barriers exist between health providers
and patients may be particularly vulnerable to pressure to use
contraception.16
Clients’
contraceptive preferences also may be overridden when providers –
believing they know what is best – make decisions on behalf of clients.
"One must remember that, in some settings, women themselves may prefer
providers to make reproductive health decisions for them," says Dr.
Irina Yacobson, an FHI assistant medical director who conducts contraceptive
technology training for developing country providers. "In fact, they
may feel that a provider who is supposed to know what is best for them –
yet still does not make a decision for them – simply does not care.
Ideally, though, a provider should explain to the client that, while the
provider knows what methods the woman can use, only the woman will know,
based on her personal circumstances, what method is best for her."
In general, providers
of contraception – particularly long-acting methods – should offer
methods without pressure as part of a wider menu, offering removal upon
request of such methods as IUDs and the Norplant implant.
– Kim Best
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