Reproductive health care is a part of general health care. There are, however, special considerations which set it apart from general health care. Reproductive health care providers deal with mostly healthy people, they often have to take into consideration the interests of more than one “client” at the same time, they deal mostly with women and they have to deal and interact with society. These special considerations have ethical, legal, and human rights implications.
1. Dealing with healthy people
Reproductive health care providers respond to needs of healthy subjects, related to their physiological sexual and reproductive functions (including the prevention of unwanted pregnancy and the prevention of sexually-transmitted infections). This has several implications.
Different from other disciplines in medicine, reproductive health care is more health- oriented than disease-oriented. Promotive and preventive health care are major components of reproductive health care.
giver-recipient relationship to a more participatory type of health care. Counseling is the description for a good part of reproductive health care. There is no other field of medicine in which participation of the „patient‟ in health care decisions is as much desired and practiced. The ethical principle of respect, a minimal standard for ethical conduct, includes autonomy of capable persons. While in other fields of medicine, patients are required to give their informed consent to the treatment proposed by the health care provider, freely and without undue pressure or inducement, in the case of reproductive health care, clients have to make informed choices and decisions.
The risk/ benefit ratio is different when a drug or device is used for a healthy subject, to prevent a condition which may or may not happen, from what it is when a drug or device is used by a person suffering from a disease which in itself carries a risk. The risk/ benefit ratio is also different from another aspect. Often, very large numbers of people are involved in receiving a treatment, so that rare adverse effects assume more importance. Safety and efficacy of drugs and devices are regulated by government agencies, and are subject to laws of product liability. Reproductive health products, in terms of regulation and law, are seen as different from products developed and marketed to treat patients with diseases.
In dealing with healthy people, the temptation to over-medicate for normal life events would be resented, but in reproductive health care of women it has often been accepted, sometimes without valid scientific evidence, by the health profession.
2. Dealing with more than one “client”
Different from other health professionals, reproductive health care providers often deal with, or have to take into consideration, more than one “client” at the same time. This other party to a treatment decision could be a woman‟s male partner, or her fetus. The interests of the different parties may coincide and may diverge, or even conflict. Beneficience, the ethical duty to do good and maximize good, underpins the provision of much medical treatment and health care. As will be discussed in chapter 4, beneficience poses an ethical challenge when what one person seeks as beneficial for herself may have adverse implications for others.
3. Dealing mostly with women
Providers of reproductive health care deal mostly with women, who have often been subordinated to their societies‟ needs and have been under-valued. Providers, who are mostly men, should set a male model in respecting women and treating them as equals. They must not only respect women, but also be sensitive to their concerns and perceptions. The profession must encourage and promote the participation of women in their health care, and be sensitive to their perspectives. Respect for women should be shown in providing them with confidentiality, privacy and access to all information they need to make well-informed decisions about their health. It is true that a majority of women in many parts of the world are illiterate, but they are fully capable of making sound decisions. An illiterate person in a rich society is a person who, in spite of the opportunity, cannot read and write. In poor societies, illiterate persons are those who were not given the opportunity to read and write. Poor people have a very narrow safety margin for error in making decisions about their lives and, consciously or subconsciously, they know that. Women, literate or illiterate, rich or poor, given the information and the right to choose and decide, will make the right decisions for themselves and their families, and for the community at large.
As explained by the General Recommendation on Women and Health of the Committee on the Elimination of Discrimination Against Women, lack of respect for confidentiality of women seeking reproductive health care can deter women from seeking advice and treatment and thereby adversely affect their health and well-being (see Part III.6.b., para. 12(d). Women will be less willing, for the reason of unreliable confidentiality, to seek medical care for diseases of the genital tract, for contraception or for incomplete abortion and in cases where they have suffered sexual or physical violence.
Women have been excluded from historical sources of moral authority, and under-represented in learned professions of medicine and law, and in legislative assemblies. The voices of women, and their perspectives, have often not been taken into consideration in laws, policies and regulations governing sexual and reproductive health care for women.
4. Dealing with society
Reproductive health care providers have to deal and interact with their society at large. No society has ever been neutral about sexual and reproductive issues. No other health profession has to deal with such emotionally charged health issues as sexuality and abortion. As new health technologies develop, new issues arise for which society may or may not be well prepared. Enforcing perceived interests of the society may violate women‟s human rights. Fertility control is a case in point.
D. Shortcomings in the performance of the reproductive health care system
Health reforms, commonly referred to as health sector reform, have been taking place in many countries over the last decade. This has been in response to a general dissatisfaction with the performance of the system. In countries which have undergone structural adjustment, the main drivers have been constraints on government expenditure and donor conditionalities. In economies in transition, health systems are being reconstructed as a response to economic liberalization and the need to move away from command and control management models. In general, there has been a rethinking of the role of governments, moves towards decentralization, emphasis on cost recovery, and an expanded role of the private sector. The impact of health sector reform on reproductive health services is a matter for concern, 4 and its human rights implications are discussed in chapter 6.
A well-functioning system should respond adequately to the health care needs of the population. In spite of major expansions and improvements in health care and development, health care systems have been unable to meet the health needs of large segments of the world population. Shortcomings of health care systems vary from country to country and even within the same country. Among those that need to be addressed are an imbalance in available services, inefficient utilization, and lack of responsiveness to women‟s expectations and perspectives.
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