The WHO’s Updated Abortion Care Guideline and Its Implications for Member States

The World Health Organization (WHO) recommends that babies should be killed up until the moment they emerge from the birth canal, without delay, whenever a pregnant woman requests it. Through its updated abortion care guideline released in 2022, the WHO expects all Member States to implement this policy.

This article is not about whether the WHO’s policy is right or wrong, but the process used to reach its conclusions, and what this tells us about it as a legitimate global health advisory body.

Dealing with a difficult topic

It is important to say awkward things sometimes, when these things are true. When we become polarized, we can start to believe that stating something consistent with ‘the other party’ can be worse than telling lies to support our preferred stance. This demeans us and does not help anyone. There are few issues that polarize (Western) society more than abortion. 

I am tied to neither side of the abortion debate. As a medical practitioner, I have taken part in surgical abortions, helping women to stop a pregnancy that they decided they did not want to continue. I have also assisted some hundreds of women to deliver babies.

I have been with tiny premature babies of just 20 weeks gestation when they died. I have gently cradled a very premature child of my own, fully human in my hands. He saw light and felt hunger, pain and fear, his outstretched hand the size of my thumbnail. He could have been killed in many places if he had not happened to be born early.

Many thousands of girls and women also die excruciating deaths each year from septic, unsafe abortions performed because safe abortion is outlawed or inaccessible. The introduction to the WHO guideline notes that 3 of 10 pregnancies end in abortion and nearly half of these are unsafe for the mother, nearly all these being in low-income countries. I have lived in a Southeast Asian country where several thousand women are thought to die from this each year. These young and agonizing deaths mostly cease when abortion is legalized.

Philosophically, I believe in the equality of all human beings and in the concept of bodily autonomy – no one has the right to interfere and control another’s body. We own and must control our bodies, not because someone grants us this right, but because we are humans. This applies to medical procedures as it does to torture. As it applies to our own body, it applies to all others.

However, because there is good and bad in the world –nurture and harm – the interpretation of this fundamental truth is not simple. At times we may need to kill another’s body. We do this in war, for example, to stop a country being invaded and its people tortured, raped and killed. But we also uphold the right of conscientious objectors who decline to kill because of their religious or moral beliefs.

So there is no simple right and wrong when it comes to the act of abortion, only a right or wrong in the intent. As humans we need to face such truths fearlessly because truth is intrinsically better than lies, and simplifications of complex issues are frequently lies. In interpreting the same truths, we may reach different actions. We need to recognize that life is full of hard choices, always harder for some than others, and we all have different experiences to inform them.

An anecdote

A wise friend was once discussing the issue of abortion with people who, with good intentions, held vigils outside abortion clinics to dissuade women from entering. He recounted the words of a woman who had an abortion at such a clinic: “What she needed was someone to be with her and support her after she had left by the back door, not someone accosting her on the way in”.

Like much that life throws at us, dealing with abortion primarily requires truth, understanding and compassion, not dogma.

The WHO position on abortion, and what it means

The WHO released its Abortion care guideline in early 2022, updating previous publications on the social, ethical and medical aspects of abortion into one volume. As a ‘guideline’ rather than a recommendation, the WHO expects the document to be followed by the 194 Member States that make up the World Health Assembly. The WHO, of course, does not have power to enforce guidelines, but ‘guideline’ in the WHO lexicon is an instruction with which countries should abide. 

To ensure an evidence-base, guideline development is supposed to involve a wide range of experts and stakeholders who gather to weigh evidence, using this to carefully formulate ‘best practice.’ The process should be transparent, and the data traceable. A department within the WHO oversees this process, ensuring that the guideline reflects the Organization’s principles and way of working.

The WHO’s guideline recommends unequivocally that abortion be performed on request of a pregnant woman, at any time during pregnancy up until delivery, without any delay that may potentially cause the pregnant woman distress.

Recommend against laws and other regulations that restrict abortion by grounds abortion is available when carrying a pregnancy to term would cause the woman, girl or other pregnant person substantial pain or suffering …

Remarks:

iv. health grounds reflect WHO’s definitions of health and mental health (see Glossary); 

[A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity]

[Mental health: A state of well-being in which every individual realizes their own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community]

Gestational age limits delayed access to abortion, especially among women seeking abortions at later gestational ages… Gestational age limits have been found to be associated with…increased rates of maternal mortality and poor health outcomes.

The evidence also showed that grounds-based approaches that require fetal impairments to be fatal for abortion to be lawful frustrate providers who wish to support patients and leave women no choice but to continue with pregnancy. Being required to continue with a pregnancy that causes significant distress violates numerous human rights. States are obligated [emphasis added] to revise these laws to make them compatible with international human rights law. 

Put another way (but exactly the same meaning), the WHO’s official position is that a woman may kill an unborn embryo or baby soon after conception, or when it is entering the birth canal during labor, and it is the health profession’s role to do this without delay upon request. 

The WHO’s logic in arriving at its conclusion is deeply flawed, and can only be reached by adopting a specific view of humanity that is inconsistent with that of most Member States. It is therefore an illegitimate position, if the WHO works for all of its Member States and not for narrow, unrepresentative interests.

In its lack of inclusivity, the guideline demonstrates a growing culture within international health that is deeply troubling and dangerous. This culture relies on a denial of reality to achieve a pre-ordained result. It deliberately misuses human rights norms to force a particular worldview on others – a form of cultural colonialism and quite the opposite of the community-driven and anti-colonialist ideals around which the WHO was formed.

The WHO’s human rights justification

The WHO justifies its position on abortion by citing what it considers relevant human rights norms and law. It holds that there is no choice but to allow abortion, as refusing or delaying abortion, such as through a requirement for counselling, could potentially distress the pregnant woman. 

When offering and providing counselling, it is essential to apply the following guiding principles: 

• ensure that the individual is requesting the counselling and make it clear that counselling is not required;

In causing distress, her human right to be free from ill-health (in this case psychological pain) has been infringed, based on the definition of health – physical, mental and social well-being – in the WHO’s Constitution. This weak argument requires disagreement with another person’s views to constitute a violation of that person’s rights. Society could not function on this basis. 

In establishing the required evidence-base for maintaining its incongruous position, the WHO has to consider only risk and no benefit. 

The studies also showed that where women requested an abortion and were denied care due to gestational age this could result in the unwanted continuation of pregnancy … those who presented at 20 weeks’ gestation or later. This outcome can be viewed as incompatible with the requirement in international human rights law to make abortion available when carrying a pregnancy to term would cause the woman substantial pain or suffering, regardless of pregnancy viability.

The studies used by the WHO do not however only record negative outcomes of delays through required counselling, but note that women also considered that legally-required delays and counselling could be positive, with some opting not to have an abortion as a result. 

If the WHO recognized any requirement for counselling, it would have to recognize that practitioners withholding counselling would be putting informed consent in jeopardy, and in some cases babies (“pregnancy tissue”) would be lost when an informed woman, on reflection, may have preferred to keep it. Informed consent is at the basis of modern medical ethics and an internationally-accepted human right. 

The WHO recognizes in the document that “States must ensure that informed consent is provided freely, safeguarded effectively, and based on complete provision of high-quality, accurate and accessible information.” Incongruously, it then considers that the rights of that woman are violated if the abortion is delayed in order to ensure that information, and time for reflection, are provided.

The human in ‘human rights’

At no place in the document is the definition of ‘human’ discussed. The WHO’s argument for abortion requires absolute acceptance that human rights do not apply in any form prior to birth. The only human rights acknowledged in the document are those of the pregnant woman, with disputable subsidiary rights of providers. Discussion of fetal (unborn baby) rights is absent. The Universal Declaration of Human Rights does not specify a time that dividing cells become human, creating uncertainty for the Guideline’s argument. 

Defining ‘human’ is difficult. It may be argued that the lack of independence, or ability to express thoughts to others, prevents the application of human rights to a fetus. This claim would require dependent adults or children who cannot articulate their thoughts to be considered sub-human, such as people severely mentally or even physically disabled, and those who are comatose. This is a position previously adopted by fascist and eugenic regimes that believed in a hierarchy of human worth. It would be unfitting for the WHO.

The only intrinsic difference between the baby within and without the womb apart from geography is the umbilical cord. Suggesting the functioning of this fetal organ, comprised solely of fetal tissue, somehow prevents the rest of the fetus from being a sentient being would require redefinition of ‘sentient.’ For the last few months within the uterus, when it could readily survive outside, it has its own unique and complete human DNA, a beating heart and independent movement. Some mothers will say it responds to familiar sounds. If removed from the uterus, it displays sensations of pain and distress, hunger, an ability to cry, respond to stimuli, recognize light, shapes and sounds, and drink milk. If this sentient being is not human, what is it?

Any recognition of humanness of the WHO’s ‘pregnancy tissue’ requires an acceptance of two persons in the woman – fetal relationship (i.e. two potential victims). The human rights basis of the WHO’s guidelines would then require one to be considered subservient to the other. This would require a rewriting of the human rights agreements on which the panel based its determination (a hierarchy of human worth).

Alternatively, it can be decided that the rights to life of one can be infringed to benefit the other. We do this in war, we may do it in triage at the scene of an accident. We also do this sometimes in pregnancy. It involves recognizing hard and unpleasant choices, as it involves putting value on potential harm to the woman versus harm to the second person in the equation. This approach would fit with human rights conventions, but would disallow an approach that relies solely on a dogma that claims the pregnant woman’s welfare is the only relevant concern. The failure of the WHO to recognize the potential of two humans with attendant rights in a pregnancy smells like cowardice. Their argument is flawed.

Pregnancy tissue or person?

The Guideline manages the definition of the unborn by avoiding the use of the term ‘baby’ anywhere in its 120 pages – itself quite a feat of drafting for an abortion guideline. The term ‘pregnancy tissue’ is used most frequently, to describe the growing mass within the uterus:

Pregnancy tissue should be treated in the same way as other biological material unless the individual expresses a desire for it to be managed otherwise. 

However, if the fetus happens to be born at 28 weeks, the WHO considers it a fully-fledged human. It is recorded in human death statistics, and the WHO provides guidance on how to support its health and welfare elsewhere. The WHO’s 2022 Recommendations for care of the preterm or low-birth-weight infant state: “The care of preterm and LBW infants is a global priority.” To kill it once out of the birth canal is murder in most countries – an ultimate violation of human rights.

For the WHO’s entire human rights argument to be valid, the definition of a human must therefore rely entirely on geography – inside or outside the uterus. The WHO must hold that at some moment during the final stage of labor, the ‘pregnancy tissue’ is suddenly transformed into an entirely different entity – from irrelevant tissue to a full person with the rights and immeasurable worth that this implies. 

If this guideline is followed, my 28-week baby became human not through any intrinsic value or worth, but because the drugs suppressing labor became ineffective. If these drugs had worked, the WHO holds that my child could have been subsequently killed as one might excise an annoying tumor. From pregnancy tissue to “global priority” depends, in the WHO’s eyes, on a matter of seconds and centimeters. Whether a live abortion ‘product’ is a global priority or pregnancy tissue is not discussed – the assumption is that the intent to abort changes the status of the erstwhile human to irrelevance.

Conscientious objection and health providers

The guideline considers removing the right to conscientious objection of the provider (this “may” be necessary), where this will delay an abortion. This is a fascinating contrast to the emphasis on avoiding any risk of emotional harm or stress to the pregnant woman. Rights apply here to the pregnant woman, but not to other involved humans. 

Recommend that access to and continuity of comprehensive abortion care be protected against barriers created by conscientious objection.

Rights of the provider to follow their own cultural or religious belief may be overridden “if no alternative provider is available.” 

If it proves impossible to regulate conscientious objection in a way that respects, protects and fulfils abortion seekers’ rights, conscientious objection in abortion provision may become indefensible.

Providers are not classed as equal humans; their rights are subservient. If we are to believe that ‘stress’ is a legitimate harm from which the pregnant woman must be protected as a human right, then this must also apply to stress caused to a provider who is forced to act against their conscience. We are faced with at least two beings whose rights must be weighed together. The WHO’s simplistic human interpretation again seems to fall apart. 

The guideline committee did appear aware of this dilemma, and resorted to EU human rights law to support their case (though legal arguments may question its fit with the Universal Declaration on Human Rights). The right to conscientious objection in other instances is strongly protected in international law. Whilst the guideline quotes sections of this EU law, it fails to elucidate contrary arguments. French human rights law takes a contrary view and upholds the rights of such a medical or nursing practitioner to object; recognizing the issue of forcing a practitioner to act in a way they consider wrong, It explicitly notes the inherent moral difficulty of setting rules in this area. 

The rights of parents and minors

The rights of parents or guardians are recognized in regard to decisions on medical procedures for minors in most WHO Member States, whilst being more widely questioned in some Western cultures. The Guideline considers only one view throughout, that young age is no limit to consent. Practitioners therefore have a duty to maintain confidentiality for a pregnant girl who requests an abortion and prefers her parents to be unaware.

 “Recommend that abortion be available on the request of the woman, girl or other pregnant person without the authorization of any other individual, body or institution.”

This is a complicated area, and there are strong arguments for protecting confidentiality, as there are for parental involvement in consenting to medical procedures for children under their protection. The WHO considers only one specific Western view to be legitimate and therefore superior, and supposedly holding that contrary views (e.g. in Islamic, South Asian, East Asian or most Christian communities) to be illegitimate and inappropriate. 

The WHO, inclusivity, and cultural colonialism

In formulating a guideline on an issue critical to human rights and values, the world might expect the WHO to consider the rich diversity of its cultural, religious and societal life. This is not evidenced within the document’s 150 pages. The drafting committee generically noted such opinions and cultures are important in the introduction:

The needs of all individuals with respect to abortion are recognized and acknowledged in this guidance,

and further;

WHO guidelines systematically incorporate consideration of the values and preferences of end-users of the recommended or suggested interventions into the process of developing the guidance.

Those formulating the guidelines were seemingly unaware that such values and preferences may lead to differing opinions regarding the killing of an unborn baby.

The WHO states that a global survey was conducted, followed by a meeting with participants from 15 (of 194) Member States. Either no one in this ‘inclusivity’-driven process raised any objection, or those in charge of the process considered such opinions so inferior to their own as to be unworthy of record. If cultural colonialism needs definition, this act of imposing one’s values on others through an apparent belief in the superiority of one’s own views seems an excellent example.

 The world does not need to return to colonialism

The WHO, heavily sponsored by private vested interests, is not the population-oriented organization it was 75 years ago. Along with the Covid-19 response, this guideline demonstrates the extent to which the WHO has regressed to a narrow Western-derived worldview that many in the West would find appalling. It seeks to impose this on others, considering alternate approaches unworthy of serious discussion.

Whatever one’s views on abortion, the flaws in the WHO’s human rights arguments, and its clear avoidance of diversity of opinion, suggest an organization focused on dogma rather than evidence. 

Abortion is a morally complicated area. Policy must be based on compassion and respect for all of humanity. To impose one’s views on others irrespective of evidence and without respect for alternate opinion is a form of fascism. The WHO may have a place in advising on safety of a medical procedure, but not in pontificating over moral rights and wrongs. It is not there to tell people how to live their lives, but to support them with the tools to do so.

Countries currently considering whether to grant greater powers to the WHO would do well to question whether the organization is compatible with their culture, ethics and beliefs. The abortion guideline is a reflection of the WHO’s growing unfitness to lead global health.