How Conscientious Objection Laws Create Backdoor Abortion Bans in Europe

Across the continent, increasing numbers of medical professionals are refusing the procedure on ethical grounds

How Conscientious Objection Laws Create Backdoor Abortion Bans in Europe
Activists demonstrate for abortion rights in front of Berlin’s Brandenburg Gate on May 8, 2022. (Sean Gallup/Getty Images)

Kristina Haenel is a gynecologist working in a small family clinic in Gleissen, a quaint university town in the center of Germany. At 66 years old, she should be winding down and getting ready for retirement. Instead, she works in an increasingly stressful environment.

“We have a waiting list of two weeks for abortions,” she tells me over the phone. “We never had this in the past.” Just six years ago, she could book patients within a week. But now, delays mean some pregnant people need to have an abortion later in the pregnancy, which increases the risk of complications. Other times, it pushes them over Germany’s 12-week limit, forcing them to travel abroad.

No other clinicians in Haenel’s city or the surrounding 20 miles perform abortions. Even though Gleissen and the next closest city, Marburg, a university town of about 78,000 people, both have hospitals, their doctors perform them only in cases of fetus disability or medical emergencies. Both institutions cite “conscientious objection” laws, which allow medical professionals to abstain from carrying out procedures that might conflict with their religious beliefs. The German Association of Gynecologcal Practitioners states that the country’s trained OB-GYN doctors are under no legal or ethical obligation to perform abortion on demand and that, in some regions, women must “accept longer distances” if they need to access the procedure.

Abortion rights vary widely across Europe, though the region is generally considered lenient compared with the United States, where the Supreme Court’s overturning of Roe v. Wade last year upended five decades of abortion access. But in recent years, European abortion rights have been squeezed for a combination of political and religious reasons, leading the European Parliament to pass, in the summer of 2021, a resolution declaring abortion a human right. Though nonbinding, it was designed to urge countries belonging to the European Union to condemn “any attempt to limit access” to abortion and contraception services. It was largely viewed as being directed at heavily Catholic countries such as Poland, which allows abortion only in cases of rape, incest or when the woman’s life is in danger, and Malta, the only country in the bloc to have an all-out ban.

While most European countries recognize the right to an abortion on demand during the first trimester, the Croatian parliamentarian who authored the text said at the time that Europe was experiencing a “regressive agenda” when it came to women’s rights and emphasized that so-called “conscience clauses” allowing medical practitioners to withhold abortions endanger women’s lives.

In recent years, some countries have introduced these clauses, which allow doctors to refuse pregnant people the right to terminate if it contradicts the medical practitioner’s personal beliefs. Many experts argue that this situation is not an accident, but a deliberate tactic by social conservatives to restrict access. It has coincided with the mobilization of the Catholic Church, which is enjoying greater power and influence, especially in countries in eastern and southern Europe that were formerly socialist or communist, and where state religion mixes with notions of nationalism.

The recent upsurge in invoking these laws has effectively created back-door abortion bans in some countries where the procedure is legal, forcing many women to travel hundreds of miles in search of a provider. In Germany, 420 hospitals — almost a quarter of the country’s total — are run by Catholic organizations, meaning entire premises have blanket bans on providing abortions even if individual doctors themselves are not religious. The church’s power in medical institutions does not reflect the general population, where the numbers of those identifying as Catholics and Protestants are roughly evenly split, but less than 10% of whom attend church every week.

Furthermore, the procedure is not covered during standard medical training at universities — the reasoning being that some people will object for religious reasons.

Haenel is well-known in Germany because she led a campaign to change a Nazi-era law that banned doctors from advertising whether they provide abortions. The surrounding publicity led to an initial increase in calls to her clinic. (In 1933, shortly after Adolf Hitler assumed power in Nazi Germany, the law was brought in for “pure race” reasons. In 1938, Jewish women were allowed to have abortions but Aryan women were not.)

However, even though the advertising law was scrapped last summer, her patient numbers are still going up. Her small clinic, which is nestled in a converted 200-year-old house, sometimes receives inquiries from as far away as Bavaria — a heavily Catholic southwestern state some 125 miles away, which has some of the patchiest abortion provisions in the country. If the next available appointment is over two weeks away, Haenel will tell patients they need to go elsewhere.

“But then they come back after a week and tell us they can’t find one anywhere else,” she says, sighing.

The right to conscientious objection — refusing to follow a rule for moral or religious reasons — has always existed in institutionalized healthcare in some form, and many countries have clauses including it in their laws legalizing abortion. As Neil Datta, president of the European Parliamentary Forum on Sexual and Reproductive Rights (EPF), points out, forcing a doctor to perform an abortion when it flies against their beliefs does not serve the patient well. “You don’t want a doctor practicing on you if the doctor doesn’t believe in what they’re doing,” he tells me over Zoom. But the problem is that many European countries are not putting these laws into practice in a way that still safeguards access to healthcare.

International guidelines make clear that if a doctor is not willing to perform an abortion, then a patient should be directed to someone who is. Leah Hoctor, regional director for Europe at the advocacy nonprofit Center for Reproductive Rights, believes entire hospitals having blanket refusals on abortion provision may be a breach of international law.

“This isn’t in line with multiple international treaties, such as the Covenant on Economic, Social and Cultural Rights or the Convention on the Elimination of Discrimination Against Women,” she says, referring to U.N. treaties designed to ensure access to healthcare and equal rights for women, among other things. Last year, the World Health Organization said the current effect of conscientious objection laws is “a barrier to access to quality abortion care. … If it proves impossible to regulate conscientious objection in a way that respects, protects and fulfills abortion seekers’ rights, conscientious objection in abortion provision may become indefensible.”

Datta, from the EPF, who has carried out extensive research on what he calls “anti-gender movements” — ultraconservative groups that oppose women and LGBT+ people’s rights — believes this situation has been deliberately engineered. “For me, it’s very clear that conscientious objection is one of the first tools social conservatives will use to obstruct progressive laws they feel are unwelcome,” he says.

Powerful Catholic figures have repeatedly made statements calling for doctors to invoke conscientious objector clauses. In 2016, Pope Francis spoke of “the moral duty” of healthcare workers to refuse to perform abortions. The Italian Bishops’ Conference spoke out in 2017 against a hospital that had posted a job advert for non-objector OB-GYNs, saying it “distorts the structure of the … law that didn’t aim to induce abortion but to prevent it,” referring to the law passed in 1978 that legalized abortion in Italy. In Romania, where Orthodox Christianity is the dominant religion, the anti-abortion group Pro Vita published a guide in 2015 urging “the whole medical corps, especially gynecologists, to renounce ‘the barbaric practice of abortion,’ using their right to moral objection.” The group also offers legal support to doctors and pharmacists facing sanctions for claiming objector status.

These tactics appear to be working. Italy experienced a 12% increase in the number of conscientious objector gynecologists from 1997 to 2016, according to health ministry figures. In Croatia, which was formerly part of Socialist Yugoslavia, over 60% of doctors now claim conscientious objector status after a law was introduced in 2003, according to research by the Croatian daily newspaper Jutarnji.

According to Datta, the tactic was pioneered in Italy by the late politician and anti-abortion advocate Carlo Casini. He worked to promote conscientious objection in Italian hospitals from the 1970s onward and helped block legal challenges to it. Today, abortion provision in Italy has become so scarce that the country has been condemned by the Council of Europe. “We’ve then seen this [tactic] appearing in other countries where the anti-gender actors are getting organized,” says Datta. These places include Croatia, Romania and Slovakia. The shrinking number of abortion providers has led to mass protests — in May 2022, thousands took to the streets in Croatia after a woman was denied an abortion at 20 weeks after being told the fetus had a brain tumor and no chance of a normal life. A medical commission eventually approved a termination under public pressure.

Historically, the goal of medicine has been to provide care to those who are in need, which usually means sick. The Declaration of Geneva, established by the France-based World Medical Association in the aftermath of World War II, encourages graduating physicians to pledge that their patients’ health will be their “first consideration” — a modern take on the oath associated with the ancient Greek physician Hippocrates to do no harm. (It doesn’t specify if it means physical or mental health, or both.)

Through the centuries, when refusing to perform certain procedures, like abortion, sterilization and euthanasia, physicians have expressed their conscientious beliefs as reasons that prevent them from doing so.

When looking at the statistics for objecting doctors, it’s immediately clear that something doesn’t add up. According to the global pollster Ipsos, around 73% of Italians support abortion in at least some circumstances, such as in cases of rape or fetal disability, yet over 70% of doctors claim objector status. A similar number of Croatians support abortion, according to a poll by the broadcaster HRT, yet 60% of the country’s doctors are objectors. This suggests that many healthcare professionals may be objecting for reasons other than their personal beliefs.

Multiple experts I spoke to for this piece believe that when conscientious objection becomes widespread throughout the medical establishment, it creates an environment where many doctors feel immense pressure not to perform abortions, either because of stigma, or how it may affect their careers. One study published in the Global Public Health Journal in 2016 on the reasoning behind conscientious objectors’ choices found that doctors also considered abortion a “boring” procedure from a technical point of view, as it’s very simple. They worried that if they offered it, the shortage of other doctors would mean they end up spending their whole time performing it.

All these factors have led to a desperate and legally unnecessary situation around Europe where thousands of women need to travel out of their country to access safe abortions — even though the procedure is technically legal in the country in which they live.

Brezice sits in picturesque southern Slovenia. Its nearby wineries and thermal springs have made it a popular tourist destination. At the small hospital in its center, Splosna Bolnisnica, a different kind of visitor comes by. Around ten women a week travel from Croatia to access abortions here — the Croatian capital Zagreb is just 20 miles away, making it a relatively easy trip. The clinic even has a dedicated section on its website in Croatian and a price list for customers who are not covered by the Slovenian health insurance system.

According to the gynecologist Natasa Kocnar, the clinic first saw an increase in people traveling across the border in 2018 after word spread that early medical abortions, commonly known as the “abortion pill” — which are hard to access in Croatia — were available there. It is also cheaper — $220, compared to $330 in Croatia. “I see a lot of Croatian women express more guilt than Slovenian women,” says Kocnar over the phone, referring to the high stigma in Croatia of having an abortion. “They also say they feel good coming here because they have anonymity. The chance someone will recognize them and think something about them or say something about them is lower.”

According to Kocnar, conscientious objection is also allowed in Slovenia, but it doesn’t cause access problems. “There’s not one hospital in the country that cannot do the procedure,” she says. Even though both countries were once part of Socialist Yugoslavia, in which the right to choose was enshrined in the constitution, the Catholic Church has exerted increasingly more influence and power in Croatia’s medical institutions since the breakup of the republic in the early 1990s. Even on the buzzing streets of Zagreb, it’s common to see chapels built on hospital grounds.

It is impossible to establish the exact numbers of women who travel within Europe for abortions because no countries collect data on those leaving. Only one study, the European Abortion Access Project, which was carried out at the University of Barcelona with support from the European Research Council, has tried to gain a comprehensive picture. Researchers gathered data on foreign arrivals at clinics in the U.K., Spain and the Netherlands, interviewing multiple women. Team member Giulia Zanini says that the number is certainly in the thousands — one Dutch clinic she visited treats 3,000 visitors who come from abroad in one year alone.

Although some women interviewed by Zanini and her colleagues were from countries with outright abortion bans, such as Malta and Ireland (the study was carried out prior to Ireland’s repealing of the ban in 2013), she says they also encountered large numbers from Germany, France and Italy. “Usually, they were having to travel because they had reached the legal limit in their country,” she says — the U.K. and the Netherlands both allow abortion up to 24 weeks. And the reason the majority were over the limit was because they had been refused care in their home countries, sometimes under false pretenses or deliberate deception. “Doctors often don’t tell the patients that they are objectors,” Zanini says. “Rather, they act as gatekeepers. We saw again and again that people were refused information and weren’t referred to another service.”

Traveling abroad for an abortion can cost anything from $550 to well over double that, depending on the destination and how far along a pregnancy is. It causes extra stress and can make recovery from the procedure harder. Women and pregnant people may also face extra costs such as loss of earnings and additional childcare — across Europe, more than half of all those seeking an abortion have at least one child already, according to Abortion Support Network which helps women and pregnant people access abortions overseas.

Social conservatives’ interest in conscientious objection laws means that litigation to try to expand them has played out at the highest echelons of European lawmaking. Most famously, a Catholic midwife from Sweden — one of the few European countries that does not allow conscientious objection — brought a case in 2017 against her government to the European Court of Human Rights. She was supported by Alliance Defending Freedom (ADF), the powerful Christian law firm that played a role in the overturning of Roe v. Wade in the U.S. ADF did not respond to a request to comment for this piece. The court ruled in Sweden’s favor, stating that although the right to religious freedom is protected by the European Convention on Human Rights, it is not an absolute right and should not trump a patient’s right to healthcare.

Fred Matic, a Croatian member of the European Parliament who led the report on the effect of conscientious objection laws around Europe, told New Lines via email that this litigation tactic has also been used to restrict contraception access, giving examples of cases involving pharmacies in Spain, France, Malta and Croatia that successfully argued against providing emergency contraception and IUDs. He also says his research found that, in some cases, conscientious objector doctors are stopping pregnant people from accessing proper natal care by refusing to perform screening procedures that detect fetal health conditions, in case they lead to abortions.

“It is astonishing that we are allowing this when there is a right to access this type of medical care and medical products,” he says. “We are putting individual personal beliefs, often religious-based, before a patient’s right to health. It should worry us all deeply.”

Datta from the EPF says that even though organizations such as ADF have not achieved any major legal wins, the fact that they have managed to bring cases to the highest courts in Europe is an achievement by itself. “They want the holy grail of setting a legal precedent establishing that the right to religious freedom is a higher category of human rights than other rights,” he says.

As the problems created by conscientious objection have become better understood over the past few years, some countries are attempting to find solutions. Spain recently passed a law creating a public registry of conscientious objectors to try to ensure that professionals performing abortions are always available by highlighting abortion deserts. In France, President Emmanuel Macron has backed making abortion a constitutional right.

In Germany, Haenel believes abortion needs to be taught during medical school so that all doctors know how to perform it. “If they haven’t seen it performed, or it wasn’t a standard aspect of their training, they’ll always see it as something niche,” she says. “But it’s actually an everyday reality.”

Zanini from the European Abortion Access Project suggests that enabling midwives and nurses to perform abortions — as is already allowed in many countries, including the U.K. — could potentially create better access in countries such as Italy, where currently only doctors can perform them. “You don’t need a doctor if the procedure is done safely according to WHO protocols and there are no complications,” she says.

Datta, however, thinks there’s another, more simple answer.

“For me personally, the ideal solution is what they have in Sweden — that conscientious objection in this area is simply incompatible with a certain profession,” he says. “If your religious beliefs are very important to you, then that’s entirely legitimate, but perhaps you need to find a profession that actually suits you.”

This reporting was supported by the International Women’s Media Foundation’s Howard G. Buffett Fund for Women Journalists.

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