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J R Soc Med. 2004 January; 97(1): 43–44.
PMCID: PMC1079274

Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law

‘... The focus of legal activism for women’s rights should be less about the development of new laws and conventions, and rather more on education and creating a familiarity with and regular use of already existing instruments in the every-day situations of women’s lives’1

Writing in 1994—the year of the International Conference on Population and Development in Cairo at which he chaired the main committee—Dr Fred Sai, the Ghanaian academic and advocate for women’s rights and health, focused on what various instruments of reproductive rights had actually achieved for women. The most comprehensive statement of women’s legal rights, the Convention on the Elimination of All Form of Discrimination Against Women (CEDAW), was by then 15 years old and had already had more reservations placed against its articles than any other international convention. And Sai quoted the economist Marilyn Waring who had ruefully observed ‘despite all the instruments and conventions, women’s rights are still considered “social” rather than “civil” or political, conditional on custom and religion rather than universal’. Abuses of those rights, Waring noted, were therefore regarded as private concerns and not matters for state intervention.

All this prompted Sai to suggest that, in view of the widespread failure of top-down legal change, a more bottom-up strategy might be appropriate. He continued, ‘There is little doubt that one of the most important keys to solving these difficulties... is education’. In the same year, in a WHO publication coinciding with Cairo,2 Dr Rebecca Cook argued that the more people there are who understand what human rights treaties have to say about women, health, and equity, the more such treaties can be used as a lever to improve the health of women in countries that have signed them. With two other experts, Dr Cook has now surveyed the scene in Reproductive Health and Human Rights.3

At the Cairo conference, 179 countries formally agreed that population and development were linked and recognized that individuals’ needs and rights in sexual and reproductive health and the empowering of women were crucially important in enhancing development and reducing poverty. One output of Cairo was an ambitious 20-year programme of action. So at ‘Cairo plus 10’ what has happened on the ground? Regrettably, the integrated approach to population issues, including sexual and reproductive health, has been fragmented. Whereas Cairo acknowledged that sexual and reproductive health, HIV/AIDS, and poverty are closely linked, several key development agencies have entirely extracted the more controversial aspects from the projects they are prepared to fund. Excluded, for example, are projects aimed at safe abortion and promotion of condoms for safe sex. As a result, many non-governmental organizations (NGOs), being heavily reliant on aid-agency money, have followed suit. In the USA, George W Bush inaugurated his Presidency in 2001 by reinstating a Reaganesque policy now known as the ‘global gag rule’. This antiabortion funding policy has had widespread ramifications, effectively preventing foreign NGOs that receive funds from the US Agency for International Development (USAID) from using even their own non-US funds to provide comprehensive reproductive health services. Since USAID remains the world’s largest donor of family planning assistance—$446.5 million in 2003 alone—hundreds of NGOs in almost 60 countries have found themselves caught in this web of double jeopardy: either they remove any abortion-related health services from their programmes or they will see their funds dwindle dramatically. And on top of that, in June 2003 the US House of Representatives refused to reinstate the US contribution to the United Nations Population Fund (UNFPA), the world’s largest international reproductive health organization. The emphasis of many aid agencies now is on the care and treatment of HIV/AIDS. Even in the more liberal political climate of the UK, the latest reorganization of the Department for International Development has split sexual and reproductive health and HIV/AIDS into different teams. The concept of sexual and reproductive health rights (SRHR) has, not for the first time, become a political football kicked into touch by personal prejudice.

All the more timely that Cook, an expert in human rights law, Bernard Dickens, an authority in medical and health law and ethics, and Mahmoud Fathalla, an internationally prominent reproductive health specialist, have come together to analyse the medical, ethical, legal, and human rights aspects of sexual and reproductive health. It is easy to get carried away by the powerful rhetoric of rights and to forget that implementable rights are essentially a creature of law.4 Margaret Somerville made a telling point when she observed that, although rights are a powerful tool in a society the legal system of which recognizes them, ‘they are in danger of being totally ignored in a society that is not “rights based”’. Consequently she argued for the importance of seeking the implementation of the content of those rights even where they are not legally recognized. This broad objective is shared by Cook et al. Their aim is to help individuals in disparate health-related disciplines understand the ways in which medicine, ethics, and law, including human rights law, can interact to improve reproductive and sexual health. That help is sorely needed: as Cook et al. note, ‘reproductive health is often compromised not because of lack of medical knowledge, but because of infringements of women’s human rights. Powerlessness of women is a serious health hazard’.

A large section of the book is devoted to fifteen case-studies illustrating practical dilemmas regularly encountered in impoverished settings. These range from sexual assault and emergency contraception to counselling and caring for an HIV-positive woman. This emphasis on practical application in everyday situations is what really matters to women. As Nafis Sadik, former Executive Director of the United Nations Population Fund and Secretary-General at Cairo, notes in her foreword, this book is both an academic text and a training tool. She also takes the opportunity to remind readers that ‘the greatest single difference between women in rich countries and women in poor ones is in their reproductive health status’. The case-studies are well constructed and illuminating. Each describes the medical, ethical, legal, and human rights aspects before turning to the practical approaches according to clinical duty and the obligations of healthcare systems. For example, one study, set in a country with a high rate of population growth, relates to involuntary female sterilization in a governmentrun hospital serving an impoverished community. The study advises Dr T, a hospital doctor faced with carrying out the edict, how he can invoke his ethical duty of respect for the patient’s autonomy and what he can do if he finds himself threatened with disciplinary action. As it happens, this theoretical example echoes recent events in Peru. In August 2003, the Peruvian government finally signed an agreement before the Inter-American Commission on Human Rights (IACHR) that is set to improve women’s access to family planning and reproductive healthcare. The agreement was the direct outcome of an international legal battle against Peru after the death of a woman in 1998 from the complications of forced sterilization, at a time when the government was actively pursuing a coercive sterilization policy. After legal redress in Peru failed, a case was filed with the IACHR in 1999. Although agreement was reached in 2002 whereby Peru would modify its discriminatory legislation and policies, the then health minister refused to sign. His resignation in the summer of 2003 brought about a swift and satisfactory conclusion.

I confess to a vested interest in all of this. I am a trustee of an NGO, International Family Health, that remains committed to an integrated approach to sexual and reproductive health despite the increasingly challenging funding environment. Can this approach make a difference? When one sees faith-based organizations coming together in Africa to address reproductive health and HIV/AIDS issues pragmatically, or a successful peer-led programme of education among low-income women and young people, there has to be hope. And despite the post-Cairo disappointments, Cook et al. strike the right chord when they say ‘at least the silence has finally been broken on sensitive but vital issues in reproductive health—we have discovered that sex is a three, not a four-letter word’.

References

1. Sai F. Adam & Eve and the Serpent. London: International Planned Parenthood Federation, 1994
2. Cook RJ. Women’s Health and Human Rights. Geneva: World Health Organization, 1994
3. Cook RJ, Dickens BM, Fathalla MF. Reproductive Health and Human Rights: Integrating Medicine, Ethics, and Law. Oxford: Clarendon Press, 2003. [554 pp; ISBN 0-19-924133 p/b;£19.99]
4. Somerville MA. The right to health: a human rights perspective. In: AIDS, Health and Human Rights. Lyons: Fondation Marcel Mérieux, 1993

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press