Ethical and legal approaches to ‘the fetal patient’

The concept of fetuses being 'patients' can serve a benign protective, cautionary purpose, alerting healthcare providers and pregnant women to the implications that medical treatment can have for fetuses. The concept allows women to provide the children they intend to deliver with the care they consider appropriate. A negative effect occurs, however, if healthcare providers decide to treat pregnant women according to providers' own views of the best interests of fetuses, and compromise patients' care and self-determination without their informed consent. Some activists advocate rights of fetuses for the purpose of limiting pregnant women's self-determination. Recognition that fetuses have legitimate interests, rather than rights, is common, and opens a way to balancing various competing interests without compromising patients' rights to decide on their medical care. Courts of law generally favor this approach, and tend to allow few limits on women's choice of indicated medical care while pregnant.

Achieving transparency in implementing abortion laws

National and international courts and tribunals are increasingly ruling that although states may aim to deter unlawful abortion by criminal penalties, they bear a parallel duty to inform physicians and patients of when abortion is lawful. The fear is that women are unjustly denied safe medical procedures to which they are legally entitled, because without such information physicians are deterred from involvement. With particular attention to the European Court of Human Rights, the UN Human Rights Committee, the Constitutional Court of Colombia, the Northern Ireland Court of Appeal, and the US Supreme Court, decisions are explained that show the responsibility of states to make rights to legal abortion transparent. Litigants are persuading judges to apply rights to reproductive health and human rights to require states' explanations of when abortion is lawful, and governments are increasingly inspired to publicize regulations or guidelines on when abortion will attract neither police nor prosecutors' scrutiny.

Respecting adolescents' confidentiality and reproductive and sexual choices

Adolescents, defined as between 10 and 19 years old, present a growing challenge to reproductive health. Adolescent sexual intercourse contributes to worldwide burdens of unplanned pregnancy, abortion, spread of sexually transmitted infections (STIs), including HIV, and maternal mortality and morbidity. A barrier to contraceptive care and termination of adolescent pregnancy is the belief that in law minors intellectually mature enough to give consent also require consent of, or at least prior information to, their parental guardians. Adolescents may avoid parental disclosure by forgoing desirable reproductive health care. Recent judicial decisions, however, give effect to internationally established human rights to confidentiality, for instance under the Convention on the Rights of the Child, which apply without a minimum age. These judgments contribute to modern legal recognition that sufficiently mature adolescents can decide not only to request care for contraception, abortion and STIs, but also whether and when their parents should be informed.

Reproductive health and public health ethics

Individuals' reproductive choices are private matters, but sexual conduct and pregnancy impose significant public health burdens. Ethical principles of public health are distinguishable from principles applied in modern bioethics. Bioethical principles have been developed at the clinical or microethical level, affecting relations among individuals, whereas pubic health ethics applies at the population-based or macroethical level. Resolution of issues, for instance of consent to healthcare interventions and preservation of privacy, is different in public health practice from in clinical medicine. Public health aspects of human reproduction concern reduction of maternal mortality and morbidity, particularly in resource-poor countries, and the contribution to high rates of each of unsafe abortion, most prevalent where abortion laws are restrictive. Further aspects of public health ethics concern limited access to contraceptive services, the spread of sexually transmitted infections (STIs), including HIV, causes of infertility, especially due to STIs, and responses to each of these concerns.

Acquiring human embryos for stem‐cell research

Human tissue engineering and regenerative medicine may be considerably advanced by embryonic stem-cell research and cell line development, to provide preventive means, cures and treatment strategies for a range of debilitating conditions and injuries. Research may result in embryos from which stem-cells are derived losing viability, which offends some religious convictions. The different status religions and laws may attribute to embryos serves different purposes and results from different approaches. Neither need depend on, nor impose itself on, the other. Embryos surplus to IVF patients' needs may be donated to research with appropriate consent. In some circumstances, it may be ethical to ask patients to make their fresh embryos available for research. Prohibitions against deliberately creating embryos for research purposes are common, but not universally adopted, and are being challenged. Women who donate ova require information about risks, which for women considering donation for research may not be balanced by compensating benefits.

Legal and ethical issues in telemedicine and robotics

Modern medical concerns with telemedicine and robotics practiced across national or other jurisdictional boundaries engage the historical, complex area of law called conflict of laws. An initial concern is whether a practitioner licensed only in jurisdiction A who treats a patient in jurisdiction B violates B's laws. Further concerns are whether a practitioner in A who violates a contract or treats a patient in B negligently incurs liability in B, A, or both, and, if treatment lawful in A is unlawful in B, whether the practitioner commits a crime. Judicial procedures are set by courts in which proceedings are initiated, but courts may decline jurisdiction due to inconvenience to parties. If courts accept jurisdiction, they may apply their own substantive legal rules, but may find that the rules of a conflicting jurisdiction should apply. Cross-border care should not change usual medical ethics, for instance on confidentiality, but may mitigate or aggravate migration of specialists.

Emergency contraception, abortion and evidence-based law

Courts and legal tribunals increasingly decline to serve as religious or moral guardians, and require social evidence to support litigants' claims. Recent cases on emergency contraception and abortion are examined to show how judicial interpretations can take account of evidence of the impact that different understandings of the law will have for how ordinary people can plan their lives and reproductive choices. In an emergency contraception case, an interpretation was rejected that would have criminalized choices that millions of decent, law-abiding physicians, pharmacists and women routinely make. In an abortion case, three judges unanimously rejected a government ministry's defence of compliance with the law because the ministry had failed to investigate the needs within its jurisdiction for legal clarity, lawful services, and its responsibility to women returning from having lawful procedures elsewhere. In both cases, litigants prevailed who showed factual evidence that their claims better promoted reproductive health and choice.

Conflict of interest: Legal and ethical aspects

Conflicts of interest arise when those who owe conscientious duties to others appear to have personal interests that might tempt them to subordinate those duties to their self-interest. Conflicts of interest are distinguishable from conflicts of commitment, which arise when individuals bear two or more mutually exclusive duties to others. If persons in conflicts of interest favor their self-interest, they may violate binding legal duties such as fiduciary duties. Conflicts arise when, for instance, medical practitioners refer their patients to other practitioners in exchange for payments (fee splitting), and when they gain secondary incomes such as from testing patients' samples in laboratories in which they hold ownership or investment interests. Financial dealings with commercial sponsors may place researchers in apparent conflicts of interest with research subjects. When conflicts of interest are unavoidable, they may be resolved by appropriate disclosure.

Caring for victims of sexual abuse

Recognizing sexual abuse to be universal, in stable as well as disordered societies and directed predominantly but not only against younger women, this article first considers legal definitions of sexual abuse and the forensic evidence health care providers may be expected to gather. It explores the impact on victims of historic definitions of rape, and legal reforms to dispense with proof of sexual penetration. The WHO 2003 guidelines for medico-legal care for victims of sexual violence are noted, which emphasize the need for physical and psychological care of victims. The guidelines show that goals of treating victims and retaining forensic evidence can create a clinical dilemma. Ethical issues concern management of this dilemma, probing whether patients' psychological disturbance may have roots in past sexual abuse, and the conduct of appropriate research. It concludes that much sexual abuse is symptomatic of women's sexual subordination and disregard of their human rights.

Sex selection: Treating different cases differently

This paper contrasts ethical approaches to sex selection in countries where discrimination against women is pervasive, resulting in selection against girl children, and in countries where there is less general discrimination and couples do not prefer children of either sex. National sex ratio imbalances where discrimination against women is common have resulted in laws and policies, such as in India and China, to deter and prevent sex selection. Birth ratios of children can be affected by techniques of prenatal sex determination and abortion, preconception sex selection and discarding disfavored embryos, and prefertilization sperm sorting, when disfavored sperm remain unused. Incentives for son preference are reviewed, and laws and policies to prevent sex selection are explained. The elimination of social, economic and other discrimination against women is urged to redress sex selection against girl children. Where there is no general selection against girl children, sex selection can be allowed to assist families that want children of both sexes.

Adolescents and consent to treatment

Adolescents, defined by WHO as 10 to 19 years old, can give independent consent for reproductive health services if their capacities for understanding have sufficiently evolved. The international Convention on the Rights of the Child, almost universally ratified, limits parental powers, and duties, by adolescents' "evolving capacities" for self-determination. Legal systems may recognize "mature minors" as enjoying adult rights of medical consent, even when consent to sexual relations does not absolve partners of criminal liability; their consent does not make the adolescents offenders. There is usually no chronological "age of consent" for medical care, but a condition of consent, meaning capacity for understanding. Like adults, mature minors enjoy confidentiality and the right to treatment according to their wishes rather than their best interests. Minors incapable of self-determination may grant or deny assent to treatment for which guardians provide consent. Emancipated minors' self-determination may also be recognized, for instance on marriage or default of adults' guardianship.

Obstetric fistula: the challenge to human rights

Obstetric fistula can be explained to result from different causes. These holes in the tissue wall between the vagina and bladder and/or rectum are most prevalent in resource-poor countries, attributable to prolonged obstructed labour and absent or inaccessible remedial prenatal services. Obstructed labour is often due to small pelvic size, resulting from women's youth and premature childbearing and/or malnutrition. Poverty at national health-service and family levels often predisposes pregnant populations to suffer high rates of fistula. Global estimates showing up to 100,000 new cases each year and 2 million affected girls and women are probably gross underestimates. Fistula devastates lives of sufferers, who are often expelled by husbands and become isolated from their families and communities. Failures of states to provide prenatal preventive care (including medically indicated cesarean deliveries) and timely fistula repair violate women's internationally recognized human rights, especially to healthcare in general and reproductive healthcare in particular.

Preimplantation genetic diagnosis and ‘savior siblings’

From its emergence, preimplantation genetic diagnosis (PGD) has been opposed by religious, feminist, and disability-rights advocates. PGD has developed, however, to extend beyond genetic diagnosis of embryos to diagnose chromosomal abnormalities. Evidence shows that PGD is safe, children born after in vitro fertilization (IVF) and PGD having no higher rate of birth defects than children of normal pregnancies. Laws may accommodate PGD directly or indirectly, but some prohibit PGD totally or except to identify sex-linked genetic disorders. When children suffer severe genetic disorders and require stem-cell transplantation, compatible donors may be unavailable. Then, IVF and PGD of resulting embryos may identify some whose gestation and birth would produce unaffected newborns, and placental and cord blood from which stem-cells compatible for implantation in sick siblings can be derived. Ethical issues concern conscientious objection to direct participation, discarding of healthy but unsuitable embryos, and valuing savior siblings in themselves, not just as means to others' ends.

Safe abortion: WHO technical and policy guidance

In 2003, the World Health Organization published its well referenced handbook Safe Abortion: Technical and Policy Guidance for Health Systems to address the estimated almost 20 million induced abortions each year that are unsafe, imposing a burden of approximately 67 thousand deaths annually. It is a global injustice that 95% of unsafe abortions occur in developing countries. The focus of guidance is on abortion procedures that are lawful within the countries in which they occur, noting that in almost all countries, the law permits abortion to save a woman's life. The guidance treats unsafe abortion as a public health challenge, and responds to the problem through strategies concerning improved clinical care for women undergoing procedures, and the appropriate placement of necessary services. Legal and policy considerations are explored, and annexes present guidance to further reading, international consensus documents on safe abortion, and on manual vacuum aspiration and post-abortion contraception.

Dimensions of informed consent to treatment

Modern law approaches patients' consent to treatment not only through liability for unauthorized touching, namely criminal assault and/or civil (non-criminal) battery, but also through liability for negligence. Physicians must exercise appropriate skill in conducting procedures, and in providing patients with information material to the choices that patients have to make. The doctrine of informed consent serves the ethical goal of respecting patients' rights of self-determination. Information is initially pitched at the reasonable, prudent person in the patient's circumstances, and then fine-tuned to what is actually known about the particular patient's needs for information. Elements to be disclosed include the patient's prognosis if untreated, alternative treatment goals and options, the success rate of each option, and its known effects and material risks. Risks include medical risks, but also risks to general well-being such as economic and similar reasonable interests. Consent is a continuing process, not an event or signed form.

Ethics in medical information and advertising

This article presents findings and recommendations of an international conference held in Cairo, Egypt in 2003 concerning issues of ethical practice in how information is provided to and by medical practitioners. Professional advertising to practitioners and the public is necessary, but should exclude misrepresentation of qualifications, resources, and authorship of research papers. Medical institutions are responsible for how staff members present themselves, and their institutions. Medical associations, both governmental licensing authorities and voluntary societies, have powers and responsibilities to monitor professional advertisement to defend the public interest against deception. Medical journals bear duties to ensure authenticity of authorship and integrity in published papers, and the scientific basis of commercial advertisers' claims. A mounting concern is authors' conflict of interest. Mass newsmedia must ensure accuracy and proportionality in reporting scientific developments, and product manufacturers must observe truth in advertising, particularly in Direct-to-Consumer advertising. Consumer protection by government agencies is a continuing responsibility.

Ectopic pregnancy and emergency care: ethical and legal issues

Ectopic or tubal pregnancy presents a medical emergency that requires prompt treatment in order to contain risks of maternal death and morbidity, including loss of future fertility. Medical circumstances involving individual patients and resources of the prevailing health care system will determine the options and means of treatment. Termination of ectopic pregnancy does not constitute or directly implicate abortion. Any practice of deliberately delaying treatment of reliably diagnosed ectopic pregnancy, on non-clinical grounds, until rupture of the fallopian tube has occurred or is imminent, in order to justify termination of the ectopic pregnancy on grounds of saving the patient's life, is unethical and illegal. Those who undertake or counsel deliberate delay of medically-indicated treatment can be charged with criminal offences and civil (non-criminal) liability, and medical professional misconduct. On reliable diagnosis, prompt treatment to remove ectopic pregnancy is legally justified, and ethically and legally required.

Medical errors: legal and ethical responses

Liability to err is a human, often unavoidable, characteristic. Errors can be classified as skill-based, rule-based, knowledge-based and other errors, such as of judgment. In law, a key distinction is between negligent and non-negligent errors. To describe a mistake as an error of clinical judgment is legally ambiguous, since an error that a physician might have made when acting with ordinary care and the professional skill the physician claims, is not deemed negligent in law. If errors prejudice patients' recovery from treatment and/or future care, in physical or psychological ways, it is legally and ethically required that they be informed of them in appropriate time. Senior colleagues, facility administrators and others such as medical licensing authorities should be informed of serious forms of error, so that preventive education and strategies can be designed. Errors for which clinicians may be legally liable may originate in systemically defective institutional administration.

Challenges of ethical research in resource-poor settings

The disparity in resources between economically developed and developing countries presents ethical concerns when commercial sponsors of studies and investigators propose to conduct them with subjects in developing countries. Vulnerable people may be recruited into studies of little health benefit to themselves or their communities and, under undue inducements, may accept disproportionate risks. Reproductive health studies may present women with undue risks. Guidelines have been developed to protect exploitable populations in resource-poor settings, although guarding their right to make informed and voluntary choices poses special challenges. Guidelines pay special attention to pregnant women as research subjects, and may approve and even require their enrollment in studies of products not known to be harmful. Placebo-controlled studies are addressed in contexts where no recognized treatments are routinely accessible. The structure and functions of research ethics review committees present difficult challenges, but they may be mitigated by enlightened international collaboration.

Female genital cutting (mutilation/circumcision): ethical and legal dimensions

The practice better described as female genital cutting (FGC) is of long standing in some communities, and has spread to non-traditional countries by immigration. It is of varying degrees of invasiveness, often including clitoridectomy, but all raise health-related concerns, which can be of considerable physical and/or psychological severity, and compromise gynecological and obstetric care. The practice is not based on a requirement of religious observance, although parents usually seek it for their daughters in good faith. It is directed to the social control of women's sexuality, in association with preservation of virginity and family honor. FGC is becoming increasingly prohibited by law, in countries both of its traditional practice and of immigration. Medical practice prohibits FGC. In compromising women's health and negating their sexuality, FGC is a human rights abuse that physicians have a role in eliminating by education of patients and communities.

Patient care and the health-impaired practitioner

The risk of HIV-infected or otherwise impaired practitioners infecting or injuring their patients is very low, but is of proper concern to patients, practitioners and healthcare facilities. Practitioners' general legal and ethical duties to protect patients includes protection against their own liability to present risk of harm. Healthcare facilities have similar duties of care to protect patients, for instance by proper selection and management of personnel, but may also bear indirect or vicarious ('no fault') legal liability for injuries due to the negligence of the personnel they engage. Impaired practitioners should disclose their status to licensing and health facility authorities. They are entitled to non-discriminatory employment opportunities, but may be licensed and approved to practice under conditions that appropriately protect patients. When impaired practitioners practice within such approved conditions, modern courts hold that they have no legal duty to volunteer disclosure of their status to their patients.

Human rights and HIV-positive women

Recent court decisions, for instance in South Africa and Latin America, have held states bound to respect and serve HIV/AIDS patients' human rights to indicated and available medical care. HIV/AIDS is estimated to affect over 36 million people worldwide, including 16.4 million women of reproductive age. In the last 20 years, nearly 58 million people have been infected. This article reviews national responses to mounting concern with the HIV/AIDS pandemic, particularly in China, India and Africa, medical professional responses, notably by the World Medical Association, and international guidelines on human rights responses. These pay special attention to patients' rights to be treated without discrimination. It addresses national and international approaches to advancing HIV prevention, treatment and research on which UNAIDS and the UN High Commissioner for Human Rights have collaborated. Special issues in clinical care concern abortion services for HIV-positive women, breastfeeding and patients' involvement in research.

Human rights to safe motherhood

Each year an estimated 515000 women die of complications of pregnancy and childbirth, 7 million more suffer serious health problems and 50 million suffer adverse health effects. Over 98% of deaths occur in resource-poor countries. However, poverty alone neither justifies nor necessarily explains death rates. The Inter-Agency Group for Safe Motherhood, composed of six leading international agencies, has identified major medical causes of unsafe motherhood, and their origins in medical and health system failures, and in the failures of social justice that underlie them. These include women's 'inadequate education, low social status, and lack of income and employment opportunities.' This paper addresses the role of human rights to redress inequities that condition unsafe motherhood, and identifies five critical rights the observance of which would facilitate safe motherhood. These are women's rights to life, to liberty and security of the person, and to health, maternity protection and non-discrimination.

The legal status of emergency contraception

Emergency contraception (EC), an intervention within 72 h of unprotected intercourse, dates back approximately 30 years, to the Yuzpe method. Recent development of a second generation of 'morning after,' better called 'emergency' contraceptives, has raised claims that they are abortifacient. These claims are largely rejected in medical, legal and much religious reasoning. Pregnancy is usually ascribed to the postimplantation period; means to prevent completion of implantation do not terminate pregnancy. An alternative attack on EC has arisen under South American laws that protect human life 'from conception.' The chance of conception from a single act of unprotected intercourse is very low, in view of limited times of fertility during menstrual cycles. The protection of a woman's life is not suspended during pregnancy. Risks to women's interests are more credible than the chance of conception having occurred. The claim to prohibit EC to protect embryonic life from conception is therefore problematic.

Origins of the desire for euthanasia and assisted suicide in people with HIV-1 or AIDS: a qualitative study

BACKGROUND

Euthanasia and assisted suicide, and policies to address them are the subjects of contentious debate in many countries. However, the question of why people desire euthanasia or assisted suicide has not been coherently answered. We aimed to answer this question in a specific group of patients.

METHODS

We did a qualitative study of 32 people with HIV-1 or AIDS, who were enrolled in the HIV-1 Ontario Observational Database at Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. We elicited participants' experiences of deliberation about euthanasia or assisted suicide, and the meaning of these experiences with in-depth, face-to-face interviews. We analysed our data with grounded theory methods.

FINDINGS

Participants' desire for euthanasia and assisted suicide were affected by two main factors: disintegration, which resulted from symptoms and loss of function; and loss of community, which we defined as progressive diminishment of opportunities to initiate and maintain close personal relationships. These factors resulted in perceived loss of self. Euthanasia and assisted suicide were seen by participants as means of limiting loss of self.

INTERPRETATION

These determinants of desire for euthanasia or assisted suicide in people with HIV-1 or AIDS have implications for the debate on these practices, and development of policies to regulate them.

Assisted reproduction developments in the Islamic world

A November 2000 workshop organized by the International Islamic Center for Population Studies and Research, Al-Azhar University, Cairo, considered use of assisted reproduction technologies (ART) in the Islamic world. The workshop reinforced a 1997 recommendation that a Standing Committee for Shari'a Medical Ethics be constituted to monitor and assess developments in ART practice. Among issues the workshop addressed were equitable access to services for infertile couples of modest means, and regulation of standards of equipment and personnel that ART centers should satisfy to gain approval to offer services. Acceptable uses of preimplantation genetic diagnosis were proposed, and follicular maturation research in animals, including in vitro maturation and in vitro growth of oocytes, was encouraged, leading to human applications. Embryo implantation following a husband's death, induced postmenopausal pregnancy, uterine transplantation and gene therapy were addressed and human reproductive cloning condemned, but cloning human embryos for stem cell research was considered acceptable.

The management of severely malformed newborn infants: the case of conjoined twins

The birth of 'Siamese' twins in August 2000 whose parents refused to consent to surgery for separation required English courts to decide whether the twins could lawfully be separated despite that refusal when one twin would certainly die as a direct surgical result. The Court of Appeal unanimously upheld the trial judge's decision to authorize surgery, taking account of principles of family law, criminal law and human rights law. Parental duties to the viable twin were found consistent with the justification of allowing, without intending, natural death of the non-viable twin. The right to human dignity of both twins supported the justification of separation surgery. The decision did not elevate physicians' choices over parents', but subjected both to the law. The hospital was found entitled to bring the case to court, but not obliged; it could have declined surgery in conformity with the parents' wishes.

Bioethics for clinicians: 24. Brain death

Brain death is defined as the complete and irreversible absence of all brain function. It is diagnosed by means of rigorous testing at the bedside. The advent of neurologic or brain death criteria to establish the death of a person was a significant departure from the traditional way of defining death and remains ethically challenging to some. We review the ethical, cultural, religious and legal issues surrounding brain death and outline an approach to establishing a diagnosis of brain death in clinical practice.

Reproductive health services and the law and ethics of conscientious objection

Reproductive health services address contraception, sterilization and abortion, and new technologies such as gamete selection and manipulation, in vitro fertilization and surrogate motherhood. Artificial fertility control and medically assisted reproduction are opposed by conservative religions and philosophies, whose adherents may object to participation. Physicians' conscientious objection to non-lifesaving interventions in pregnancy have long been accepted. Nurses' claims are less recognized, allowing nonparticipation in abortions but not refusal of patient preparation and aftercare. Objections of others in health-related activities, such as serving meals to abortion patients and typing abortion referral letters, have been disallowed. Pharmacists may claim refusal rights over fulfilling prescriptions for emergency (post-coital) contraceptives and drugs for medical (i.e. non-surgical) abortion. This paper addresses limits to conscientious objection to participation in reproductive health services, and conditions to which rights of objection may be subject. Individuals have human rights to freedom of religious conscience, but institutions, as artificial legal persons, may not claim this right.

The scope and limits of conscientious objection

Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses' conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.

Law and ethics in conflict over confidentiality?

Ethical principles that require the preservation of patients' confidential information are reinforced by principles found in several areas of law, such as law on contracts, negligence, defamation and fiduciary duty. However, laws sometimes compel disclosures of medical confidences, and more often may justify or excuse disclosures. Legally contentious issues concern patients' confidences regarding possible unlawful conduct, such as pregnancy termination, and the risk of spread of HIV and other infections. This article reviews the various legal bases of the duty of confidentiality, and legal challenges to the ethical obligation of non-disclosure. It addresses the justifications and limits of exchange of patients' health information among healthcare professionals and trainees, and considers legally recognized limits of confidential duties, and the scope of legitimate disclosure. An underlying theme is how to determine whether physicians are ethically justified in employing the discretion the law sometimes affords them to breach patients' expectations of confidentiality.

Recognizing adolescents' 'evolving capacities' to exercise choice in reproductive healthcare

All countries (except Somalia and the USA) have adopted the UN Convention on the Rights of the Child, which usually applies to individuals aged under 18 years. The Convention requires governments to 'respect the responsibilities, rights and duties of parents [or others acting as parents] ellipsis in a manner consistent with the evolving capacities of the child'. Many adolescents gain capacity to make decisions for themselves concerning reproductive and sexual health services, and to decide issues of confidentiality. Immature adolescents must be given usual protections. The Convention sets a legal limit on parental power to deny capable adolescents reproductive and sexual health services. The question whether an adolescent is a 'mature minor' must be decided by health service providers independently of parental judgment. The specific duties of government and health service providers to implement adolescent rights regarding their reproductive and sexual health needs are examined.

Voluntary and involuntary sterilization: denials and abuses of rights

Laws that allow competent persons to make free and informed decisions for sterilization serve their entitlements to reproductive choice. Laws that allow others to consent to sterilization of disadvantaged persons who cannot freely consent risk oppression and denial of human rights. Laws that prohibit competent persons' choices for their own sterilization are comparably oppressive and violative of human rights to decide whether and how often to have children. Whether laws approach sterilization as a procedure done for patients, or to patients, is often ambivalent. Details of laws may indicate their liberating and oppressive potential. Programs offering inducements to persons to be sterilized may assist those who are disadvantaged to achieve their goals, but may appear to coerce those who, through poverty or dependency, cannot resist the inducement.

The FIGO study group on women's sexual and reproductive rights. International Federation of Gynecology and Obstetrics

In October 1998, the FIGO Executive Board established a Study Group on Women's Sexual and Reproductive Rights to develop specific details regarding observance, enforcement and advancement. At its inaugural meeting in April 1999 the Study Group reviewed international and national progress in respect of such rights. International initiatives had achieved considerable progress towards specification and monitoring of rights, particularly through the committee receiving reports of national compliance under the Convention on the Elimination of All Forms of Discrimination Against Women. National progress was more mixed. While some countries had improved women's sexual and reproductive rights, many had not, and rights in some had regressed. The Study Group considered actions available to FIGO member societies to advance rights in their countries, how advancement of rights might be pursued in countries in general, and initiatives that FIGO itself might undertake and facilitate to protect and promote women's sexual and reproductive rights.

Some ethical and legal issues in assisted reproductive technology

The potential and actual applications of reproductive technologies have been reviewed by many governmental committees, and laws have been enacted in several countries to accommodate, limit and regulate their use. Regulatory systems have nevertheless left some legal and ethical issues unresolved, and have caused other issues to arise. Issues that regulatory systems leave unresolved, or that systems have created, include disposal of embryos that remain after patients' treatments are concluded, and multiple implantation and pregnancy. This may result in risks to maternal, embryonic and neonatal life and health, and the contentious relief that may be achieved by selective reduction of multiple pregnancies. A further concern arises when clinics must (or choose to) publicize their success rates, and they compete for favorable statistics by questionable patient selection criteria and treatment priorities.

Human rights and abortion laws

Human rights protections have developed to resist governmental intrusion in private life and choices. Abortion laws have evolved in legal practice to protect not fetuses as such but state interests, particularly in prenatal life. National and international tribunals are increasingly called upon to resolve conflicts between state enforcement of continuation of pregnancy against women's wishes and women's reproductive choices. Legal recognition that human life begins at conception does not resolve conflicts between respect due to women's reproductive self-determination and due to prenatal life. Human rights protect healthcare providers' claims to conscientious objection, but not at the cost of women's lives and enduring health.

International developments in abortion law from 1988 to 1998

OBJECTIVES

In 2 successive decades since 1967, legal accommodation of abortion has grown in many countries. The objective of this study was to assess whether liberalizing trends have been maintained in the last decade and whether increased protection of women's human rights has influenced legal reform.

METHODS

A worldwide review was conducted of legislation and judicial rulings affecting abortion, and legal reforms were measured against governmental commitments made under international human rights treaties and at United Nations conferences.

RESULTS

Since 1987, 26 jurisdictions have extended grounds for lawful abortion, and 4 countries have restricted grounds. Additional limits on access to legal abortion services include restrictions on funding of services, mandatory counseling and reflection delay requirements, third-party authorizations, and blockades of abortion clinics.

CONCLUSIONS

Progressive liberalization has moved abortion laws from a focus on punishment toward concern with women's health and welfare and with their human rights. However, widespread maternal mortality and morbidity show that reform must be accompanied by accessible abortion services and improved contraceptive care and information.

Reproductive health and legal duties of medical confidentiality

This article discusses the reasons for, and the dimensions of, the obligations the law imposes on health care practitioners to keep confidential the information they obtain about their patients in the course of the therapeutic relationship, with particular reference to issues of reproductive health.

Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment

Demands by Patients or their Families for treatment thought to be inappropriate by health care providers constitute an important set of moral problems in clinical practice. A variety of approaches to such cases have been described in the literature, including medical futility, standard of care and negotiation. Medical futility fails because it confounds morally distinct cases: demand for an ineffective treatment and demand for an effective treatment that supports a controversial end (e.g., permanent unconsciousness). Medical futility is not necessary in the first case and is harmful in the second. Ineffective treatment falls outside the standard of care, and thus health care workers have no obligation to provide it. Demands for treatment that supports controversial ends are difficult cases best addressed through open communication, negotiation and the use of conflict-resolution techniques. Institutions should ensure that fair and unambiguous procedures for dealing with such cases are laid out in policy statements.