CLINICAL
ETHICS
Abortifacient drugs: ethico-legal issues Issued by the Royal College of Nursing Ethics and Nursing Committee Chair: Steve Wright RGN, RENT, Dip.N, RNT, DANS. MSc.
It is conceivable that an oral medicine capable of terminating pregnancy will become available for use in this country. Such a drug will pose significant moral and legal dilemmas for nurses who may find themselves embroiled in situations where they are uncertain of how to reconcile their consciences with statutory law and the requirements of their employ ers. The RCN Ethics and Nursing Committee offer some guidance on how nurses should act under such difficult circumstances.
At the 1989 Royal College of Nursing Con gress there was discussion about the role of the nurse in the use of abortifacient drugs. Con cerns were raised about the care that the nurse can give to someone who is prescribed the drug, and the moral and legal position of nurses. Abortifacient drugs offer an alternative to surgical termination of pregnancy. The drug under discussion was RU486, which has not yet been licensed for use in this country. RU486 is a steroid which can be used up to the ninth week of pregnancy to block the proges terone receptors in the lining of the uterus. This causes the lining to be shed, and the interruption of any pregnancy. Prostaglandins are given two days later to make the uterus contract and expel the contents. Bleeding normally begins within a day and lasts for 10-12 days.
Ultra-sound scan After eight to ten days an ultrasound scan is performed to ensure that termination of preg nancy is complete. Results from clinical trials indicate that this is effective in 95 per cent of cases. Although the oral abortion pill RU486 is not in use in this country, other abortifacient drugs such as prostaglandin pessaries are widely used. Indeed the majority ol abortions are now carried out in the ward and take a number of hours from initiating the process to aborting the fetus. The new drug is intended by its manufac turers to be administered to women who fulfil the requirements of the 1967 Abortion Act. An application for a product licence has been submitted by Roussel-Uclaf to the Medicines 36 Nursing Standard March 6/Volume 5/Number 24 1991
Control Agency and a decision on the granting of a licence is still some way off. Its usage will be confined specifically to those hospitals and clinics approved and licensed under the Act for the legally sanctioned termination of pregnancy. It will be administered only under medical supervision. It will not be available for general sale, nor on a family doctor's prescription. In most cases the treatment will involve attendance at an out-patient clinic. France was the first country to approve the use of this drug, in 1988. A month after it had been officially approved it was withdrawn from the French market; the company had received threats against its personnel and threats of an international boycott. The Min ister for Health insisted that the company (Roussel-Uclaf) continue production and the drug is now in general use there. There are a substantial number of health care professionals who have religious or other personal objections to abortion. Legislation within this area reflects this reality. The 'conscience clause', section four of the Abor tion Act 1967, provides that ‘no person shall be under any duty, whether by contract by statutory or other legal requirement, to parti cipate in any treatment authorised by this Act to which he has a conscientious objection, provided that in any legal proceeding the burden of proof of conscientious objection shall rest on the person claiming it'. But the conscience clause does not relieve a person of 'any duty to participate in any treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman'. It is clear from the House of Lords decision in a case in 1981 (1), that nurses have the protection of the Abortion Act when they accept delegated instructions from a registered medical practitioner and carry out the treatment in accordance with his or her directions. The practitioner should remain in charge throughout. The protection of the conscience clause is only given to those nurses who 'participate in any treatment'. But can these words be applied to administering the abortion drug and caring for the women afterwards? In the past the clause was tested (2) by a secretary
CLINICAL ETHICS
Involvement in abortion procedures can cause emotional crises for some nurses.
who refused to write a letter referring a patient to a consultant about a possible termination. Both the Court of Appeal and the House of Lords accepted the health authority’s argu ment that the words 'participating in treat ment' referred to 'actually taking part in treatment administered in a hospital or their approved place ... for the purpose of termi nating pregnancies’.
Burden of proof
References 1. Royal College of Nursing of the United Kingdom versus Department of Health and Social Security (1981). 2. Janaway versus Salford Health Authority (1988).
The advice that the College would give is that administering an abortifacient drug is clearly ’participating in any treatment' and a nurse who had a conscientious objection and could discharge the burden of proof should not be required by his or her employer to carry out this procedure. Caring for women who are bleeding after wards is not as straightforward. The bleeding might occur even if the fetus had not been expelled and the abortion had not been concluded. If the treatment involved com pleting the abortion, then this would seem to be 'participating in treatment’ according to the Act. If the fetus has already been expelled and
the bleeding followed the completion of the abortion procedure then it is more likely that the nurse having a conscientious objection could not claim that he or she was 'participat ing in any treatment’. In any event, the conscience clause does not apply where the treatment is necessary to save life or prevent grave permanent injury to physical or mental health. This situation may well apply where a woman patient is bleeding afterwards and a nurse would be ill-advised to try and claim the protection of the clause where there was an emergency and no other nurse was available. In summary, nurses could refuse to ad minister abortifacient drugs but almost cer tainly could not refuse to care for women who are bleeding after their administration. The safe advice must be not to claim protection of the conscience clause in this second instance, unless the employer is clearly in a position to provide other nursing staff immediately. On the other hand, a reasonable employer, having been satisfied in advance that a nurse has grounds for claiming the protection of the conscience clause, should take steps to avoid the nurse being put in such an awkward situation. March 6/Volume 5/Number 24 1991 Nursing Standard 37
ETHICS
Abortifacient drugs: ethico-legal issues Issued by the Royal College of Nursing Ethics and Nursing Committee Chair: Steve Wright RGN, RENT, Dip.N, RNT, DANS. MSc.
It is conceivable that an oral medicine capable of terminating pregnancy will become available for use in this country. Such a drug will pose significant moral and legal dilemmas for nurses who may find themselves embroiled in situations where they are uncertain of how to reconcile their consciences with statutory law and the requirements of their employ ers. The RCN Ethics and Nursing Committee offer some guidance on how nurses should act under such difficult circumstances.
At the 1989 Royal College of Nursing Con gress there was discussion about the role of the nurse in the use of abortifacient drugs. Con cerns were raised about the care that the nurse can give to someone who is prescribed the drug, and the moral and legal position of nurses. Abortifacient drugs offer an alternative to surgical termination of pregnancy. The drug under discussion was RU486, which has not yet been licensed for use in this country. RU486 is a steroid which can be used up to the ninth week of pregnancy to block the proges terone receptors in the lining of the uterus. This causes the lining to be shed, and the interruption of any pregnancy. Prostaglandins are given two days later to make the uterus contract and expel the contents. Bleeding normally begins within a day and lasts for 10-12 days.
Ultra-sound scan After eight to ten days an ultrasound scan is performed to ensure that termination of preg nancy is complete. Results from clinical trials indicate that this is effective in 95 per cent of cases. Although the oral abortion pill RU486 is not in use in this country, other abortifacient drugs such as prostaglandin pessaries are widely used. Indeed the majority ol abortions are now carried out in the ward and take a number of hours from initiating the process to aborting the fetus. The new drug is intended by its manufac turers to be administered to women who fulfil the requirements of the 1967 Abortion Act. An application for a product licence has been submitted by Roussel-Uclaf to the Medicines 36 Nursing Standard March 6/Volume 5/Number 24 1991
Control Agency and a decision on the granting of a licence is still some way off. Its usage will be confined specifically to those hospitals and clinics approved and licensed under the Act for the legally sanctioned termination of pregnancy. It will be administered only under medical supervision. It will not be available for general sale, nor on a family doctor's prescription. In most cases the treatment will involve attendance at an out-patient clinic. France was the first country to approve the use of this drug, in 1988. A month after it had been officially approved it was withdrawn from the French market; the company had received threats against its personnel and threats of an international boycott. The Min ister for Health insisted that the company (Roussel-Uclaf) continue production and the drug is now in general use there. There are a substantial number of health care professionals who have religious or other personal objections to abortion. Legislation within this area reflects this reality. The 'conscience clause', section four of the Abor tion Act 1967, provides that ‘no person shall be under any duty, whether by contract by statutory or other legal requirement, to parti cipate in any treatment authorised by this Act to which he has a conscientious objection, provided that in any legal proceeding the burden of proof of conscientious objection shall rest on the person claiming it'. But the conscience clause does not relieve a person of 'any duty to participate in any treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman'. It is clear from the House of Lords decision in a case in 1981 (1), that nurses have the protection of the Abortion Act when they accept delegated instructions from a registered medical practitioner and carry out the treatment in accordance with his or her directions. The practitioner should remain in charge throughout. The protection of the conscience clause is only given to those nurses who 'participate in any treatment'. But can these words be applied to administering the abortion drug and caring for the women afterwards? In the past the clause was tested (2) by a secretary
CLINICAL ETHICS
Involvement in abortion procedures can cause emotional crises for some nurses.
who refused to write a letter referring a patient to a consultant about a possible termination. Both the Court of Appeal and the House of Lords accepted the health authority’s argu ment that the words 'participating in treat ment' referred to 'actually taking part in treatment administered in a hospital or their approved place ... for the purpose of termi nating pregnancies’.
Burden of proof
References 1. Royal College of Nursing of the United Kingdom versus Department of Health and Social Security (1981). 2. Janaway versus Salford Health Authority (1988).
The advice that the College would give is that administering an abortifacient drug is clearly ’participating in any treatment' and a nurse who had a conscientious objection and could discharge the burden of proof should not be required by his or her employer to carry out this procedure. Caring for women who are bleeding after wards is not as straightforward. The bleeding might occur even if the fetus had not been expelled and the abortion had not been concluded. If the treatment involved com pleting the abortion, then this would seem to be 'participating in treatment’ according to the Act. If the fetus has already been expelled and
the bleeding followed the completion of the abortion procedure then it is more likely that the nurse having a conscientious objection could not claim that he or she was 'participat ing in any treatment’. In any event, the conscience clause does not apply where the treatment is necessary to save life or prevent grave permanent injury to physical or mental health. This situation may well apply where a woman patient is bleeding afterwards and a nurse would be ill-advised to try and claim the protection of the clause where there was an emergency and no other nurse was available. In summary, nurses could refuse to ad minister abortifacient drugs but almost cer tainly could not refuse to care for women who are bleeding after their administration. The safe advice must be not to claim protection of the conscience clause in this second instance, unless the employer is clearly in a position to provide other nursing staff immediately. On the other hand, a reasonable employer, having been satisfied in advance that a nurse has grounds for claiming the protection of the conscience clause, should take steps to avoid the nurse being put in such an awkward situation. March 6/Volume 5/Number 24 1991 Nursing Standard 37
