There are situations that cannot and should not be overlooked. Some situations must
always be remembered so mistakes are not repeated and we seek to be better as people,
professionals and citizens.
In August of this year, the case of a ten-year-old child in the southeastern region
of Brazil that became pregnant with her uncle who had abused her since she was six
was widely reported in the media. A child who lived in the company of her grandparents,
and could say nothing about the rapes she suffered, given the risk of losing those
who raised her. If she said anything, he [the uncle] would kill her grandfather. Four
years of violence and silence. Four years of stolen childhood, until the symptom of
abdominal pain caused her grandmother to take her to the hospital, where the pregnancy
was revealed. What to do?
In Brazil, abortion is allowed by the legal system when there is no other way to save
the pregnant woman's life; when the pregnancy results from rape; and in case of an
anencephalic fetus pregnancy. These three cases do not require a court order, although
an order to terminate the pregnancy had been issued by the Judge of the local Child
and Youth Court after a request from the Public Ministry. However, the hospital, an
accredited center for providing abortion care provided for by law in the region where
the child lived, did not comply with the sentence under the allegation of “technical
issues.”
This child and her grandmother were quickly taken to another referral center, this
time in the northeast region, and finally, amid a great turmoil caused by pro-life
and pro-choice movements, the abortion was performed by the hands of a competent and
dedicated professional.
As a doctor, I do not have the knowledge to analyze legal issues, although it was
clear that the Judiciary was present in this case and acted quickly to guarantee the
dignity of life, paying attention to a basic principle of the Statute of the Child
and Adolescent, which is their best interest, and protecting the right to health as
well as the physical and psychological wellbeing.
While voices argued that pregnancy should be continued as if by a child's “moral obligation,”
even though she had been abused and raped, others took the opposite position by defending
her life in a broader sense: the biological and biographical life of a weeping girl
in fear and pain while clung to a teddy bear. Fear and pain that would never be understood
by police, judges, prosecutors, doctors, family members and an entire angry population.
Note the teachings of legal experts on this issue: “Childhood pregnancy, by itself,
would already constitute a violation of a child's right. Would not the imposition
of continuing this pregnancy be a further violation of her rights [...]?” We are talking
about the pregnancy of “a ten-year-old girl, raped by someone from whom is expected
care and protection.”[1]
What about Medicine?
The reasons raised by the referral center in the southeastern region for not having
an abortion were that they followed the Ministry of Health guidelines that allow humanized
abortion up to twenty-two weeks of pregnancy and the fetus' weight of up to five hundred
grams. The law does not establish these limits. In this case, the fetus exceeded the
estimated five hundred grams by thirty-seven grams. Because of this difference, the
first referral center failed to comply with the court order. After all, is medicine
an exact science? To what extent can a single argument like this be useful for medical
decision making? Once abortion is permitted in specific cases, as provided by law,
it is necessary to investigate if care centers accredited for this purpose are fulfilling
their role.
In an article published in this issue of RBGO entitled “Conscientious objection to
legal abortion in Minas Gerais State”[2] the authors clearly revealed the imperfections of the program created by the National
Health System (Brazilian SUS) to assist patients in carrying out abortions provided
for by law and involving as complex situations as the case above. In the referred
work, data were collected from institutions accredited by the Health Department of
the state of Minas Gerais (SES/MG) to assist sexual violence victims in the state
(87 institutions). According to the results presented, although the services were
accredited for this purpose, 11% of them do not have doctors to provide legal abortion
and 31% do not provide specific training for this type of care. About 83% of patients
willing to have a legal abortion who sought these services did not have their request
responded. Of the reasons alleged for not having an abortion, the main one was the
religious conscientious objection on the part of doctors working at the institution
(57%).
The question of termination of pregnancy provided for by law is an unresolved situation
in Brazil. Where these pregnant women should be referred and who should serve them
are unanswered questions until today, as some hospitals refuse to perform these referrals
and many professionals claim conscientious objection to avoid the commitment to carry
out the interruption of pregnancy. How should doctors who will exercise conscientious
objection in services aimed precisely at the care of women victims of sexual violence
who seek abortion be accredited? When being a SUS professional and not working in
a private clinic, is such an objection possible? Would not this hiring model enable
the failure to comply with a legal determination in a biased way?
The conscientious objection foreseen in the Code of Medical Ethics is a right of doctors
who refuse to perform procedures or services that are inconsistent with their religious,
ethical, social, moral, and other convictions. Thus, pregnant women due to rape often
do not receive adequate care and use clandestine clinics to terminate the pregnancy,
thereby exposing themselves to potentially fatal risks, or continue with pregnancy,
although undesired.
In this sense, the Ministry of Health has published the Technical Norm for the Prevention
and Treatment of Diseases Resulting from Violence against Women and Adolescents, aiming
to contribute to the planning and execution of actions that improve the quality of
health care for the population suffering this type of offense. The Technical Norm
issued by the Ministry of Health in 2005 states that “With respect to abortion, the Brazilian Government is a signatory to United Nations
Conference documents that consider it a serious public health problem (Program of
Action of the International Conference on Population and Development held in Cairo
in 1994) and recommend that countries revise the laws penalizing the practice of unsafe
abortion, that is, which poses risks to the life and health of women (Action Plan
of the World Conference on Women held in Beijing in 1995). In this sense, it is necessary
to guarantee the quality and expansion of referral services for performing the abortion
provided for by law and to ensure that women who arrive at health services in the
process of abortion are treated in a humanized manner, with care appropriate technology,
thus avoiding the risk of illness and death”.[3]
To achieve these objectives, referral services were accredited by the SUS to provide
this assistance to victimized patients, supported by the state, represented here by
the institutions providing care. However, the issue of conscientious objection does
not seem to have been properly considered by the SUS when accrediting a service with
the premise to guarantee the performance of abortion provided for by law with quality
and safety hence, without objector medical professionals in the team. In the aforementioned
work, the authors reported that conscientious objection was the main cause of refusing
assistance to patients in the accredited services evaluated. However, even if they
were objectors, the patient embracement and clarification would be the professional's
duty, as well as referral to services where the procedure would be effectively performed
or else guarantee their care by another professional of the institution. Thus, the
need to alert the objector professional who performs the care of these patients, as
well as in all other medical situations when they should abstract from the motivating
convictions of their conscientious objection and guide their conduct and attitudes
for the benefit of patients, but never to their detriment or for shady purposes, as
established in the good principles of Hippocratic medicine.
The doctor-patient relationship is no longer vertical and has been built through dialogue.
“Of course, doctors are also a subject of this legal relationship, but their role
is to collaborate with the main subject, and not to treat him/her as an object of
rights. We cannot forget we live in a pluralistic society, with different cultural
currents, and the critical judgment to human values deserves to be observed.”[4]
The form of accreditation of referral centers of this nature should be revised by
the SUS. These aspects must be taken into account, whether in the selection of personnel
or in the choice of institutions hosting the services by prioritizing those synergistic
with the program purposes under penalty of setting up true obstetric violence by default.
The report on the Referral Centers of Minas Gerais published in this issue of RBGO
is only the “tip of the iceberg” of a wider and much more complex problem. The accreditation
of referral services without due care with the preparation of accredited institutions,
using political criteria for the allocation of scarce resources of the SUS will not
solve the problem nor will improve the system. Brazilian women will remain unassisted
most of the time. Recently proposed measures contained in Ordinance of the Ministry
of Health number 2.561 of September 23, 2020,[5] such as how to communicate the fact to the responsible police authority; preserve
possible material evidence of the crime of rape to be immediately handed over to the
police authority or official experts; and include the anesthesiologist in the multidisciplinary
health team, are just distracting measures to change the focus of the problem and
hinder the performance of health professionals truly involved with these issues. The
appreciation of already accredited institutions that adequately fulfill their mission
in a safe, professional and, above all, humanized way would be a better measure.
In demanding times, when right and left extremism are gaining ground, there must be
caution so we, medical professionals, do not make decisions based solely on our pre-understandings
and moral conceptions. The Hippocratic oath taken on the graduation of doctors must
always prevail: “I will not allow that considerations of religion, nationality, race,
political party, or social position come between my duty and my Patient.” In the case
of women and adolescents victims of sexual violence, the promotion of technical scientific
knowledge combined with the awareness of health professionals and the accreditation
of institutions truly engaged in this cause are the best options for the SUS toward
raising the quality of care and providing a definitive solution to this admittedly
serious public health problem in Brazil.
