The perception of health professionals regarding legal abortion

Abstracts

The present study examined the knowledge and the perception of health professionals of the "Hospital Materno Infantil de Brasília" (Mother and Child Hospital of Brasilia) that do not deal directly with legal abortion services as the ethical aspects involved in the Programa de Interrupção da Gestação Prevista em Lei (PIGL - Legal preganancy interrupetion Program - PIGL). The study used a qualitative-quantitative method for which the results showed ignorance about the service and the procedures necessary for the service on the part of these. It was observed that moral, cultural and religious issues exert strong influence on the perception of the theme by health professionals who deal indirectly with the issue. The study points to the lack o PIGL diffusion associated to the stigma and prejudice involved in the theme as the main causes of this situation, indicating the continuing need for ethical training of professionals in order to qualify the care of women who use the Reference Service for Pregnancy Interruption Where Applicable by Law.

Abortion; Abortion, legal; Sexual violence; Ethics, professional; Bioethics

Este estudo analisou o conhecimento e a percepção dos aspectos éticos envolvidos no Programa de Interrupção Gestacional Prevista em Lei, por parte de profissionais de saúde do Hospital Materno Infantil de Brasília que não lidam diretamente com os serviços de abortamento legal dessa instituição. Utilizou-se método quantiqualitativo, cujos resultados indicaram desconhecimento por parte desses profissionais quanto ao funcionamento e aos procedimentos necessários ao serviço. Observou-se que as questões de cunho ético, moral, cultural e religioso exercem forte influência sobre a percepção do tema pelos profissionais da saúde que lidam indiretamente com ele. O estudo aponta como principal causa desse quadro a falta de divulgação do Programa associada ao estigma e ao preconceito presentes nessa temática, indicando a necessidade de capacitação ética contínua dos profissionais, como forma de qualificar o atendimento às mulheres que recorrem ao serviço de referência para interrupção de gravidez nos casos previstos em lei.

Aborto; Aborto legal; Violência sexual; Ética profissional; Bioética

El presente estudio analizó el conocimiento y la percepción de los profesionales de la salud del Hospital Materno Infantil de Brasília que no lidian directamente con los servicios de aborto legal en relación a los aspectos éticos involucrados en el Programa de Interrupción de la Gestación Prevista en la Ley (PIGL). Se utilizó una metodología cuali-cuantitativa, cuyos resultados indicaron un desconocimiento por parte de estos profesionales acerca del funcionamiento y de los procedimientos necesarios para el servicio. Se observó también que ciertas cuestiones de cuño ético, moral, cultural y religioso ejercen una fuerte influencia en la percepción del tema por parte de los profesionales de la salud que lidian indirectamente con el tema. El estudio señala como principal causa de este cuadro la falta de divulgación del PIGL asociada al estigma y el prejuicio implicados en la temática, indicando la necesidad permanente de capacitación ética de los profesionales como forma de brindar calidad a la atención de mujeres que utilizan el Servicio de Referencia para la Interrupción del Embarazo en los Casos Previstos en la Ley.

Aborto; Aborto legal; Violencia sexual; Ética profesional; Bioética

It's well known that abortion, a serious public health problem, is present in the Brazilian society, and it is a topic that generates much discussion, both for the defence of its legalisation as well as for the continuation, partial or unrestricted, of its prohibition ¹. Despite the fact that the academic background of health professionals includes various approaches to the subject, the influences of ethical, moral, socio-economic, political, cultural and religious issues end up bringing difficulties to the debate. As a theme discussed in the field called "bioethics of persistent situations"², abortion provides reflections on women's autonomy over their bodies, the view of health professionals before such decisions and also reflections on the ethical-political implications for public health.

Although the word "abortion" is commonly used to indicate termination of pregnancy, from a technical point of view, one should differentiate it, in Brazil, from the portuguese word “abortamento” : while the latter is the act of abortion, the former is the product. Thus, according to criterion of the World Health Organis ation adopted by Brazil³, the “abortamento” is characterised by the termination of pregnancy up to the 22nd week of pregnancy, provided that the product of conception - the abortion (or abortus) itself - weighs less than 500 grams. The causes which trigger natural abortion are varied and, for the most part, remain undetermined. However, many pregnancies are interrupted by personal decision of the woman, including cases where the pregnancy results from sexual violence.

Violence against women, like abortion, is a problem that integrates the list of persistent situations of bioethics, of which sexual assault is one of the most cruel and persistent manifestations of violence , considering that it’s a practice carried out unscathed across all of human history. On the one hand, in its pandemic dimension, it affects women, teenagers and children indiscriminately; on the other, in the form of symbolic and moral violence, terrorises, in particular, women’s imagery, causing vulnerabilities and a constant sense of insecurity ⁴. The results of this violence are in the form of impacts to the reproductive, physical and mental health of the victims. About 30% of these teenagers and women contract sexually transmitted diseases, and the risk of unwanted pregnancy affects up to 5% of them, aggravating an already traumatic situation. Such consequences allow to categorise sexual violence as a public health issue and a serious violation of human and reproductive rights ⁵.

The Brazilian Penal Code ⁶, in order to protect the sexual dignity of the victim, considers rape a crime against sexual liberty (Article 213). In recent years, the care for victims of sexual violence has received attention from political, social and judicial sectors. These mobilisations resulted in the creation of support services to women who were victims of sexual and domestic violence, as well as the creation of legal instruments such as the recent Maria da Penha Law ⁷ which allows a more humanised care of these women.

In an attempt to ensure the reproductive and sexual rights of women, defined in international agreements and confirmed in the existing national legislation, Brazil, through the Ministry of Health, published in 1999 the technical norm "Prevention and treatment of injuries resulting from sexual violence against women and teenagers"⁴, in order to ensure the right to legally interrupt pregnancy through the services of the Sistema Unico de Saude ( abbreviated as SUS in Brazil - Unified Health System ). It is important to stress that the scope of this norm is to fulfil the specific purposes of the National Policy for Integral Attention to Women's Health and its action plans.

This norm has been an indispensable instrument for the issue of sexual violence to be definitely incorporated into the health sector and for the society to begin to discuss the issue of abortion in a broader way, since it represents a milestone to guarantee the rights acquired by women by allowing the rescue of their dignity in the face of a pregnancy which results from rape.

In Brazil, although abortion is considered a crime, there are two cases mentioned in the Penal Code itself as exceptions which are not punishable (Article 128, sections I and II). Namely: 1) when pregnancy brings risk to the mother's life; 2) when the pregnancy results from rape and the abortion is preceded by consent of the mother, or, if legally unable, by her legal representative ⁶. There is also the case of foetus diagnosed with anencephaly, which became not punishable by a recent decision of the Supreme Federal Court ⁸.

In this context, it was created in 1996 the SOS Woman-Abortion Programme, planned in Law, of the Asa Sul Regional Hospital ^9,10, currently Mother and Child Hospital of Brasilia (HMIB), linked to the State Secretariat of Health of the Federal District (Abbreviated as SES / DF in Brazil) and considered a national reference in this type of care. As a result of the prejudice and stigma still persistent when using the word "abortion", from July 2013, the initial name of the service was changed to Pregnancy Termination program as provided by Law (Abbreviated as PIGL in Brazil) ¹¹.

There were 65 services in Brazil, until 2012, able to handle cases of abortion as provided by law. They were distributed in 26 states ¹². According to a document from the Ministry of Health⁴, the Ordinance MS / GM 1508/2005 determined that the police criminal report (Abbreviated as BO in Brazil) ceased to be required for access to the services offered by the program. A practical effect desired by this norm was to minimize the embarrassment and the difficulty that many women faced before going ahead with the procedure.

HMIB was also the first hospital in the Federal District to introduce the Program of Research, Assistance and Surveillance of Violence (Abbreviated as PAV in Brazil) - known as Violet Program - which provides humanised assistance to women who were victims of all forms of violence, whether physical, psychological or sexual. The program complies with the Law 12.845 / 2011 ¹³, which provides for the mandatory and comprehensive care of people in situations of sexual violence. This law says in its Article 1 that hospitals from the national health system must assist victims of sexual violence in an absolute way, treated as an emergency and using a multidisciplinary team in order to control and treat the physical and psychological consequences deriving from the violence suffered including, among different services, the practice of prevention of pregnancy and, if appropriate, abortion, which is performed after being forwarded by the PIGL (abbreviation, in Portuguese, of Pregnancy Termination program as provided by Law) . Despite the criticism of certain groups of the society ¹⁴ about the regulation of this normative act ¹⁵, the program represents an advance of humanised care and the rights of women who are victims of sexual violence.

This study aimed to identify the knowledge and awareness of the ethical aspects involved in the program of pregnancy termination, as provided by law, by health professionals from the Mother and Child Hospital of Brasilia (abbreviated as HMIB in Brazil) who do not deal directly with the services of legal abortion from that institution. The study attempted to present a view from observers close to the concrete reality of cases of pregnancy resulting from rape, which are the core of this study.

Method

This is a quantitative-qualitative study of the exploratory-descriptive type, which follows a stratified sampling method, involving health professionals of the HMIB (Mother and Child Hospital of Brasilia - abbreviated as HMIB in Brazil). As inclusion criterion, were considered professionals belonging to the categories as provided by Art. 7 of the ordinance 485/2014 of the Ministry of Health, which provides for the care service offered to people in situations of sexual violence within the SUS (Unified Health System - abbreviated as SUS in Brazil)¹⁵. As exclusion criteria, health professionals working in the PIGL or those not covered by the categories as provided for by Art. 7 of the Ministerial Ordinance were not included. A survey was conducted in the human resources department of the HMIB in order to identify those professionals.

The sampling added up to 177 health professionals, including physicians, social workers, psychologists, pharmacists, biochemists, nurses and nurse technicians, all of them working at the HMIB and without direct links to the PIGL (Pregnancy Termination program as provided by Law - abbreviated as PIGL in Brazil).

The participants were addressed individually in their own health institution during working hours, making sure that no service or hospital care were stopped or postponed. On that occasion, presented to the professionals was the Free and Informed Consent Term (abbreviated as TCLE in Brazil) and then a self-report questionnaire with questions structured in two parts. Within the first part, it was intended to collect data in order to characterise the sociodemographic profile of the participants. The second part consisted of closed-ended questions and multiple choice questions, which helped to identify the knowledge and the perception of health professionals about the ethical aspects involved in the referral services for pregnancy termination in cases provided by law. The filling out time was about 20 minutes.

The data obtained from the closed questions of the questionnaire were statistically analysed, and the options for the open answers were classified and analysed qualitatively, according to the methodology described by A.C.Gil¹⁶ The global analysis of the quantitative-qualitative results was based on the theoretical approach ofpersistent situations in bioethics ², focusing specifically on its implications for public health. The guiding question for the discussion of this article was: Would you participate in the Pregnancy Termination Program as provided in Law or other referral services involving abortion? The study focused on the discussion about the reasons why respondents would not accept to take part in the program.

The project was approved by the ethics on research committee of the State Secretariat of Health of the Federal District (abbreviated as CEP / Fepecs in Brazil) and of the Faculty of Health Sciences at the University of Brasilia (abbreviated as CEP / FS / UNB in Brazil). The research was conducted between September and November 2014. The data collection tool is available in the Appendix of this article.

Results and discussion

Sociodemographic profile

This survey was conducted with 177 HMBI (abbreviation, in Brazil, of Mother and Child Hospital of Brasilia) health professionals: 32 gynaecologists/obstetricians (18.1%), 3 GPs (1.7%), 5 social workers (2.8%), 9 psychologists (5.1%) 8 pharmacists / biochemists (4.5%), 68 nurses (38.4%) and 52 nurse technicians (29.4%). Of the respondents, 115 (65%) reported that they never participated in a pregnancy termination service in cases as provided by law; 10 (6%) had participated before ; 50 (28%) said that currently they work in services for pregnancy termination as provided by law, and 2 of them (1%) declined to answer the question.

In relation to this data, it is worth noting that the PIGL (Abbreviation, in portuguese, of Pregnancy Termination program as provided by Law) installed on the HMIB has a permanent staff of six professionals who were previously excluded from the study sample. The discrepancy between this exclusion criterion and the high number of professionals who said that they work in the said referral service for termination of pregnancy provided by law will be analysed in detail in subsequent topics.

As to gender, it was found that 159 participants were female (89.8%); 14 were male (7.9%), and 4 of them (2.3%) refused to answer the question. In terms of age, 10 were between 18 and 24 years old (5.6%); 69 between 25 and 35 years old (38.9%); 75, between 36 and 50 years old (42.4%); 22 were 51 years old or older (12.5%), and one of them refused to answer (0.6%).

Regarding religious orientation, 54.2% said they were Catholics (96); 27.1%, Protestants or Evangelicals (48); 10.2%, Spiritualists (18); 1.7% reported being both Catholics and Spiritualists (3); 4.5%, agnostics / atheists (8), and 2.3% of other religions (4). With regard to the degree of academic education, it was found that 67 professionals do not have post graduation lato or stricto sensu (37.9%); 96 have specialisation (54.2%); 11 have masters degrees (6.2%), and 2 have a doctorate (1.1%). One participant did not answer the question (0.6%).

Knowledge about the PIGL

Research on the knowledge of the existence of PIGL (Pregnancy Termination Program as provided by Law - abbreviated as PIGL in Brazil) in the institution revealed that 85 (48%) respondents reported that they know the program; 43 (24.3%) said they know it partially; 46 (26%) reported that they did not know it, and 3 (1.7%) declined to answer the question. However, of the 128 professionals who said they knew all or part of the program, only 21 (16.5%) said they had referred to the PIGL a patient who requested (or would request) information about the availability of abortion services in the institution. Although the questionnaire does not allow to evaluate these data as a result of any moral restraint on the part of those professionals, their responses clearly show a high level of unawareness about the program than the one presented in the self-assessment (socio-demographic profile).

Such lack of knowledge is more explicit when one considers the discrepant results found in the characterisation of the sample, in which 28% of participants reported, wrongly, that they currently participate of the PIGL, reminding that the only 6 HMIB professionals who do work in the program had been previously excluded from the study. These data support the hypothesis that, even among those who reported knowing the PIGL an important part was actually unaware of its role and specifics.

On the other hand, this discrepancy could, maybe, be due to the fact that these professionals possibly identify themselves as working in the program, since the HMIB is considered a national reference both on caring for women victims of sexual violence and procedures of legal abortion as well. The proof is that we came across a significant number of professionals who often call the PIGL Violet program or Program of Research, Assistance and Surveillance on Violence (abbreviated as PAV in Brazil), which are integrants of the Centre of Studies and Programs in Care and Surveillance on Violence (abbreviated as Nepav in Brazil) of the SES / DF¹⁷, created to service victms of violence, who could later be forwarded to the PIGL. Another possibility relates to the fact that some professionals, in their everyday activity, participate in routines that include the service of incomplete or spontaneous abortions.

It should be clarified that, according to information from the SES / DF provided to the mixed Parliamentary Inquiry Committee of the Senate which investigated the situation of violence against women in Brazil ¹⁸, the flow of health care to women and teenagers in situations of violence in the HMIB begins with a friendly welcome, qualified listening, anamnesis and risk assessment ; whereupon the woman, teenager or child is sent to the various hospital departments , including the service for termination of pregnancy as a result of sexual violence.

Thus, it is considered that the referral to the hospital programs such as program Violet, for example, does not misinterpret the PIGL. What is needed, in fact, is to make it visible in the hospital which requires, on the part of public managers, measures aimed at its better exposure throughout the hospital staff.

Practice in the PIGL and justifications for refusal

When positioned themselves regarding the possibility of acting on a referral service for pregnancy termination in cases provided by law or in any other case involving abortion, the majority - 113 (63.8%) - said that they would not participate , while 60 (33.9%) reported that they would participate, and 4 (2.3%) declined to answer the question.

To the question about whether the professional would participate or not in a referral service involving abortion, has been added the question of subjective nature asking the participant to justify the position if he or she had given a negative answer to the previous item. With this open question - which guides this article - it was intended that participants cast their opinions, even though they consisted of complex fragments about their stance of not acting on the program of the institution or any other service with the same purpose, due to the influence of moral, religious, ethical, emotional, cultural issues that are part of our society.

The number of justifications to this item was considerable. Given its diversity and complexity, the answers were coded on keywords to classify the reasons for the rejection, bringing out the subjectivity of each employee: "Stigma", 1 (0.9%); "No opinion", 3 (2.7%); "Morality", 5 (4,4%); "Inviolability of life", 10 (8.8%); "Religious", 19 (16.8%); "Emotional" 20 (17.7%); "Professional", 20 (17.7%); "Conscientious objection", 22 (19.5%), and 13 (11.5%) did not answer. Despite religion being a particularly significant factor in people’s decision-making , because it is an important aspect of our culture, as observed by Faúndes Barzlatto ¹⁹, in this qualitative analysis the religious argument was found in only 19 of the 113 professionals who stated that they would not act in a voluntary pregnancy termination. In any case, as will be presented in following topics, the religion factor (especially Protestants and Evangelicals) is significant in correlation with the view that opposes abortion rights in any situation and is in favour of convincing a woman who is pregnant because of a rape to go ahead with the pregnancy.

Regarding the justifications, it is worth noting that one of the participants reflected that he or she would not take part in the program for reasons related to the accuracy of information provided by the victim: "Because in some cases of sexual violence I believe that some patients give false information, so I do not know if I would like to participate and judge these cases. " This speech confirms the weight of mistrust and suspicion ²⁰ as relevant in the conduct of a health professional dealing with women seeking care for abortion in cases provided by law.

The existing referral services in hospitals should offer post-rape pregnant women all the support to decide whether or not to terminate their pregnancy. Social workers, psychologists and doctors, through interviews with the patient , can compare the gestational age with the date of the sexual crime event. On the other hand, a woman seeking the referral service saying that she was raped has credibility; this way, the team should assume she is saying the truth.

The purpose of health care provided by the state is to secure this right to the victim, and it is not the competence of health professionals to give a premature judgment about the information provided by the victim, which could aggravate the implications resulting of the criminal act. In a study with 82 health professionals from five referral services for legal abortion, being one from each region of the country, Diniz et al 20 found, in interviews, that the word of the woman was not enough to set the veracity of the violence suffered. The authors also note that most services of legal abortion are structured to reproduce the mistrust of health professionals about the narrative of the victim.

Reflection on the following transcribed speech allows to look also at the unwillingness of a professional who wants to avoid the possibility of being stigmatised in the workplace: "I like to work on cesareans and elective surgeries, and the colleague who works in the area of legal abortion is not well seen by other colleagues." This statement indicates that the negative dimension of abortion reproduces a stigmatising perspective both for the women who have experienced abortion and for the professional who executes it.

It is worth mentioning that, according to Godoi and Garrafa ²¹, the article 11 of Universal Declaration on Bioethics and Human Rights (abbreviated as DUBDH in Brazil)) ²²links the principle of Non-discrimination and Non-stigmatisation to the principle of human dignity, human rights and fundamental freedoms, which is why no one should suffer any embarrassment or be belittled on any grounds under penalty of having their dignity violated. Although here we are not trying to equate or even to compare the alleged suffering of the woman who aborts with the professional that executes it, it is worth noting that all those involved in the abortion, even legal, seem to be vulnerable to different processes of stigmatisation and discrimination.

In fact, Soares ²³found in her study that the difficulty of finding health professionals willing to act on legal abortion services is a major obstacle to the establishment of this type of care in the hospital network. According to the author, these difficulties are caused by several factors, such as : Lack of information, on the part of health professionals, about the existing legislation on legal abortion; the strong influence of ethical and religious values ​​on these professionals who, most of the time, can not detach their professional practice from their personal conceptions and values; the repudiation of being branded as "abortionists” (an approximation to the word “aborteiros” in Brazilian Portuguese).

In reinforcement, it should be mentioned the improvement of public policies for the promotion, within the hospital network, of discussions on the difficult and sensitive issue of abortion. Such debates may favor the change of attitude on the part of hospital staff, leading them to unlink moral precepts to professional practice and to recognise that human rights and the dignity of women must be respected at all times, so that, when dealing with situations of pregnant women victims of sexual violence, these professionals may face minor discomfort and embarrassment in performing the abortion.

Ethical and legal competence and knowledge about use of the police report

The survey identified that 56 health professionals from the HMIB (abbreviation, in Brazil, of the Mother and Child Hospital of Brasilia) had already participated in courses, lectures or workshops where ethical or legal aspects of abortion were discussed. It was established, however, that among these participants of the study, only 5 (8.1%) knew the documentation required from women for legal abortion services, and that many of them still believed the presentation of the police report to be indispensable (known as “boletim de ocorrencia - BO” in Brazil) by the victim.

It is exceedingly important to note that, to perform an abortion in the hospital network in case of pregnancy by sexual violence, no document proving the crime is necessary, considering the lack of legal support in this matter, since the technical norm "Prevention and treatment of injuries resulting from sexual violence against women and teenagers” , edited by the Ministry of Health, removed the requirement of a police report in such cases 4. It should also be noted that the exemption of the police report does not imply that the victim should not be guided by health professionals to take the appropriate legal steps in order to punish her aggressor; but , if she decides not to pursue legal action, she can not have her rights restricted.

Thus, one can envision that the purpose of this legal norm is to preserve the individual interests of these women who do not want to expose their suffering before the police. Moreover, if the doctor is mislead by the patient and performs the legal abortion procedure, he will be immune from punishment, since this situation configures the presumed decriminalising provided by Article 20, § 1 of the Penal Code ⁶.

Religious orientation and disagreement about the right of voluntary termination of pregnancy

It was found that 27.1% (48) of all respondents agree with the right of voluntary termination of pregnancy; 37.9% (67) partially agree; 23.7% (42) disagree; 4.6% (8) partially disagree; 5.6% (10) have no opinion , and 1.1% (2) did not answer whether they agree or disagree with the right.

With regard to the correlation between religious orientation and total or partial compliance with the right to voluntary termination of pregnancy, it was observed that 45.8% of Catholics, 41.7% of the Protestants and 38.9% of Spiritualists are favourable to termination only in cases of rape, life threat to the mother and the foetus is incompatible with life. Among the 25 professionals who position against abortion rights at any time, 14 (56%) say they are Catholics; 10 (40%), Protestant or Evangelical, and 1 (4%), Spiritualist. These data confirm, once again, Soares’ analysis 23, which indicated the influence of religiosity in the professional practice.

Regarding the professional attitude to convince a post-rape pregnant woman to carry out the pregnancy, 116 (65.5%) said they did not consider this attitude correct, while 48 (27.1%) said it is the right option, and 13 (7.4%) declined to answer the question.

Among the 48 professionals who agree with this attitude of persuasion, 24 (50%) declare themselves Catholics; 17 (35%), Protestant or Evangelical, and 7 (15%), Spiritualists. Although in this case the absolute number of Catholics was higher, the number of Evangelical or Protestant professionals in favour of persuasion was relatively more significant considering that of the 96 Catholics, only 24 (25%) were positioned in favour of persuasion, whereas, among the 48 evangelicals, 17 (35%) agreed with this stance.

Professional field and knowledge about conscientious objection

The questionnaire also allowed to observe the relationship between knowledge of the right to conscientious objection and the professional area. From the compiling of the data, it was established that only 4 (2%) participants revealed knowledge about the right to conscientious objection, when they marked simultaneously the following statements: the right to conscientious objection does not fit in the case of need for abortion because of risk of life for women and the right to conscientious objection does not fit into legally allowed abortion in the absence of another doctor to perform it.

It was noted that 12 (6.8%) professionals had chosen to respond only to the first statement, and 10 (5.6%), only to the second. It was noticed, too, that 38 (21.5%) of them only noted that the objection of conscience is a right of the professional and can be claimed at any time, while 59 (33.3%) did not know when asked about this right.

It is known that conscientious objection is provided in various normative acts or professional codes substantiated by the Federal Constitution, with the aim of protecting the individual in situations contrary to their moral principles. However, this right is not absolute when there is damage to the health of others. Thus, the right to conscientious objection has limits and it is not possible for professionals to invoke it in situations of urgency , namely: risk of death of pregnant women; Abortion legally permitted; absence of another professional to perform the abortion; possibility of women suffering health injury or damage due to the omission of a professional, and complications from unsafe abortion ⁴ Accordingly, Diniz highlights:

In terms of public health policies, my provocation is to understand the conscientious objection as a dispositive to protect feelings, which can be secured by administrative measures of interim accommodation to health services. Yes, I dare to redescribe the conscientious objection disposition as a protection setting, but not as an absolute right when it threatens health needs. ²⁴.

The data revealed in our research corroborate the study of Camargo et al as well. ²⁵, The study concluded that health professionals have little knowledge about the use of conscientious objection in the context of legal abortion in Brazil. It was also noted that the link between conscientious objection and legal abortion is scarcely addressed by academic authors, and these, when they do, establish a connection only with professional codes of ethics, in particular of the areas of nursing and medicine . Moreover, the authors of the study suggest the inclusion of the term "conscientious objection" as a controlled descriptor in order to expand research on the subject.

Área profissional e qualificação profissional

Regarding the investigation of specific qualifications of professionals working directly for the PIGL, 79.1% (140) said they were in favor of qualification, 18.1% (32) were against it and 2.8% (5) did not answer . Of the suggestions made by participants in favor of qualification, the following stood out: training workshops, training, courses, training or knowledge in psychology, ethics, bioethics, law, social work, nursing, medicine, obstetrics, human rights.

It is also appropriate to note the opinion of two of the professionals, who mentioned, respectively, "Adequate knowledge of legislation, training in how to meet the patient without judgment or prejudice, as well as training in psychological support" and "Qualification for humanised care that takes into account the wishes of the woman". It is worth noting in this regard that one of the Ministry of Health scopes is to seek to promote qualified and humanised attention to women in abortion situations, and among the basic principles for achieving that goal are equality, liberty and the dignity of the human being, having the assurance that victims will have access to health care ³. For the professional, the humanised care involves a conduct of disregarding their moral, cultural, religious convictions, as well as other aspects that may influence the care of the patient; that is, your attitude should be guided above all by impartiality (justice).

The statements of these participants are consistent with principled bioethics, according to which we must respect the autonomy of woman in relation to her life and her body; fully aim to her wellness, maximising it and minimising the damage (beneficence), and avoid any damage that causes suffering (non-maleficence). To Faúndes and Barzelatto¹⁹ the principles of non-maleficence and beneficence trigger a chain of events, including the rejection of any restriction to the access to abortion services and bureaucratic acts that make it inaccessible to the patient.

Final considerations

The analysis of the survey results made it clear that , although it had originated in 1996, abortion for referral service to the HMIB (abbreviation , in Brazil, of Mother and Child Hospital of Brasilia) in the cases provided by law remains little known and poorly publicised, both among users of the health service and the general population as well as among health professionals as a result of an outdated view about abortion, which ultimately discriminates and makes women vulnerable. Although in this study the religious beliefs of professionals have been correlated to stigmatising attitudes about legal abortion services, namely, the tendency of professionals with Christian orientation to state that they would not act in the PIGL (Pregnancy Termination program as provided by Law - abbreviated as PIGL in Brazil) and would agree to persuade a woman who is a rape victim to continue with the pregnancy, contributes negatively to this question the fact that the health professionals themselves appear to suffer the consequences of stigma and prejudice associated with abortion.

To this framework is added the lack of knowledge of other health professionals about the structure and functioning of the PIGL in the HMIB, observable in the fact that most of the study participants mistook this service with others offered by the hospital, especially those designed to focus on violence, such as the Violet Program and the Program of Research, Assistance and Surveillance on Violence, to which pregnant women victims of rape turn to in cases of violence and only when necessary refer these women to the PIGL. It is noteworthy that the PIGL not only provides assistance to pregnant women rape victims, but to all cases in which the abortion is permitted by law, namely high-risk pregnancies to women and proven cases of foetal anencephaly.

Given this result, we indicate not only the need for greater institutional and technical disclosure of the pregnancy termination services in cases provided by law, but also the creation and consolidation of spaces for dialogue and debate to encourage the proper reflection on the morality of abortion between different groups in the society. Although it was not the objective of this study to propose such solutions it can be argued that bioethics constitute a potentially propitious space of dialogue between managers, health professionals, users of hospitals, social movements, educators, media - in short, of all the various groups that make up the social fabric and, dialectically, promote and are victims of stigmatisation processes, vulnerability and violations of women’s sexual and reproductive rights.

Annex

Semi-structured questionnaire

Referências

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• Aprovação CEP Fapecs/SES/DF CAEE 34524414.0.0000.5553
• Work produced under the Program of Post Graduation in Bioethics and the UNESCO Chair of Bioethics at the University of Brasília, Brasília / DF, Brazil

Publication Dates

• Publication in this collection
  May-Aug 2015

History

• Received
  13 Feb 2015
• Reviewed
  7 June 2015
• Accepted
  12 June 2015