INTRODUCTION

Conscientious Objection (CO) arises in the military as an opportunity to refuse to participate in compulsory military service for moral or religious reasons. In the health field, the OC describes the ability of service providers to refuse to carry out certain activities -such as the Voluntary Interruption of Pregnancy (IVE)- due to generating conflicts regarding their beliefs. At this point, there is a problem between the rights of people to receive health care and the health team to act following their conscience⁽¹⁾.

The literature indicates that CO is used to limit access to abortion, ceasing to provide this care⁽²⁾, and maybe misused and put women's health care at risk as rights holders. In addition, international and human rights organizations have identified the use of CO to deny access to abortion services, requesting countries to protect their entry from the limits established between a democratic rule of law and the current ethical guidelines concerning health and the needs of vulnerable people⁽³⁾.

Chile modified the abortion law in August 2017, going from prohibiting all abortions to allowing them under three grounds: (C1) due to risk to the life of the woman, (C2) lethal malformation of the fetus, and (C3) pregnancy resulting from a violation. There was no existing regulation regarding the exercise of CO⁽⁴⁾. However, law 21,030 was amended to allow health institutions and a wide range of clinical and non-clinical health personnel to request CO^(4),(5). In this sense, any private institution can refuse to provide abortion services; if an institution requests CO, its health professionals are not authorized to offer abortion services, regardless of their position.

Nevertheless, to ensure that CO does not impede access to legal abortion or postabortion care, objecting providers must register by notifying their institution's authority, referring all women seeking a legal abortion to a non-objecting provider. In this context, the CO has played a dominant role during the implementation of the law, given the proportion of officials who are conscientious objectors^(4),(6). Regarding the institutional CO, according to official information as of January 2019, in Chile, only seven health establishments have declared objections; one for C3, and the others object on all grounds⁽⁴⁾.

As of October 2022, of 1,338 gynecologists-obstetricians hired in the 29 Chilean public health services, 15% are objectors for C1, 23% for C2, and 43% for C3. Regarding the health team members related to the IVE, of 924 anesthesiologists (March 2022), 11% objected to C1, 14% to C2, and 21% to C3. Of the non-medical professionals, 9% objected to C1, 12% to C2, and 16% to C3. Regarding the technical personnel who work inside the pavilion, 10% object for C1, 11% for C2, and 13% for C2⁽⁶⁾. This national percentage distribution for 2022 maintains similar trends compared to 2019⁽⁷⁾. In addition, the literature has managed to problematize the issue of CO at the individual level, raising arguments that emphasize medical-religious, conservative discourses, reasons other than morality, or lack of trained health providers.

In Chile, this is worrying since it could generate inequalities because the CO can limit women's timely and effective access to the benefits guaranteed in Law 21,030. At the international level, the same tensions regarding the implementation of this public policy impact health processes; where although the regulations recognize the exercise of CO in the field of health, it is necessary to articulate two-way protection so that it is legitimate and coherent, for one hand, and ensure women's right to health, on the other. These restrictions raise questions about access to legitimate benefits for specific groups, considering the objectives of medicine, public health, and the fulfillment of the rights and interests of women in conflict, highlighting the commitment of health teams to care for the well-being, sexual and reproductive health of women, opening the way to the construction of the concept of biological citizenship.

With this background, the objective of this article is to analyze the arguments that are at stake in the CO in the context of IVE from the point of view of those who provide health care, as well as the elements that come into conflict in terms of public health; contributing to the public debate on CO, based on the main theoretical components described in recent literature.

MATERIAL AND METHOD

This study is a six-step integrative review of the literature. This type of review allows for summarizing the information available regarding the subject matter through analyzing various studies⁽⁸⁾.

Method: 1) identification of the problem 2) determination of the search strategy and determination of inclusion and exclusion criteria 3) definition of the information to be extracted from the selected studies/categorization of studies 4) evaluation of the studies included in the integrative review 5) interpretation of study results and 6) presentation of the review/synthesis of knowledge⁽⁸⁾. For the development of this stage, the work is carried out through a data analysis matrix and the elaboration of descriptive Tables.

The question guided the review: What are the arguments and critical issues at stake in the CO in the context of IVE, from the point of view of those who provide health care that affects public health between 2018-2022?

Regarding the eligibility criteria:

Inclusion criteria (IC): Scientific journal; full text online; the central relationship between CO, abortion, reproductive rights, caregivers, and public health policies; critical or documentary analysis articles; studies with qualitative, quantitative methodological approach and case studies.

Exclusion criteria (EC): methodologically incomplete articles; articles in a language other than Spanish, English, or Portuguese; papers with references to CO among other main professionals; essays; letters to the editor.

The search period was in October and November 2022, searching for studies between 2018 and 2022, in Spanish, English, and Portuguese, in the PUBMED, WoS, LILACS, and SciELO databases, with detailed search strategies in Table 1.

Table 1. Search path by database, October, and November 2022. 

For data selection, the modified PRISMA⁽⁹⁾ methodology (Figure 1) was used to delimit the final texts and present the data⁽⁸⁾: Step 1: articles published from 2018 to 2022. Step 2: detailed reading of the title and summary of the articles, selecting according to CI and CE. Step 3: identification of final articles. Step 4: categorizes texts into three thematic areas: 1) Characteristics of CO in the health team AND How does CO affect public health?; 2) The advisability of proceeding to a regulation of the exercise of CO; and 3) Challenges regarding CO. Finally, a thematic analysis of Minayo was developed, categorizing the findings with a qualitative-narrative synthesis of the results⁽⁸⁾.

Source: Own elaboration based on Hutton et al.

Figura 1: Diagrama de flujo PRISMA que resume el proceso de selección de estudios. 

RESULTS

Characterization of the studies

Of the 55 documents found, 30 met the search criteria. Finally, 25 completed the criteria (Figure 1. PRISMA Diagram) and are presented in Tables 2 and 3. The descriptive analysis (Table 2) highlights 32% of the publications were made in 2020, followed by 2018; 36% are critical analyses of the literature, followed by qualitative studies; 24% were carried out in Chile, and 32% were obtained from PUBMED.

Table 2: Analysis matrix of selected articles. 

Table 2 (cont.): Analysis matrix of selected articles. 

Table 2 (cont.): Analysis matrix of selected articles. 

Table 2 (cont.): Analysis matrix of selected articles. 

Table 2 (cont.): Analysis matrix of selected articles. 

Table 2 (cont.): Analysis matrix of selected articles. 

Table 2 (cont.): Analysis matrix of selected articles. 

Table 3. Qualitative - descriptive synthesis of the texts. 

Source: self-made.

DISCUSSION

It is inferred that the different categories highlight the interest of the research community in characterizing CO with arguments associated with its characteristics, how it affects public health, the convenience of proceeding with a regulation of the exercise of CO among the health team, and the challenges that the literature highlights, in terms of CO.

CONCLUSIONS

This study managed to answer the guiding question, highlighting that despite the heterogeneity found in the reasons for taking advantage of the CO -from Catholic fundamentalism to work overload- or providing IVE, it continues to be a decisional and deliberative process that it must take into account many individual aspects that are constrained or driven by disparate legal regulations around the world, which rarely take into account how the context in which reproductive health care is provided will affect the practice of CO.

Even so, perspectives of the power of contemporary medical knowledge on female bodies are maintained, which are necessary to transform by enhancing reproductive autonomy in general, to allow women to enjoy life as integral social beings, which, among other things interests, you can choose your reproductive future.

However, the final reflection is that this reproductive right is often disrespected and limited in its ethical validity, being justified by norms, interrelated with gender, tradition, religion, social condition, age, and education, by gender inequalities, due to social and historical norms, which give others the power to control women's decisions about sexual, reproductive, and maternity behavior. In this, recognizing the advisability of proceeding to a regulation of the exercise of CO in the field of public health is beneficial since it guarantees the rights and duties of the users of the health systems, provides legal certainty to objectors and care centers of health, and establishes when the CO responds to the exercise of ideological and religious freedom protected by legal bodies, limiting the crossroads that underlie decision-making.