Part 2 of 3. Read Part 1 here.

Contributed by Ma. Olivia Hubilla-Tripon

The paper below was written when the controversial RH Bill had not yet been passed as ongoing debates were at its peak. The RH Bill was finally passed into law in December 2012 but has not been implemented to date, pending the Supreme Court’s ruling on its constitutionality after an indefinite restraining order.

In population ethics, a framework of ethical principles underpinned in internationally accepted treatises and declarations is commonly applied into national policymaking.16 Thus, this research aims to provide an ethical reflection on the 3 Philippines’ struggle for a national family planning policy and its compliance with the ICPD Programme of Action and the UN MDGs. (The author analyzed the family planning provisions of the consolidated version of House Bill 4244 according to ethical principles. With permission from the author, here is an excerpt from his thesis:)

From the International Conference on Population and Development to the Millennium Development Goals:
An Ethical Reflection on the Philippines’ Family Planning Policy*

By Jose Sebastian Manguiat, M.D.

Introduction
As signatory to the ICPD and the MDGs, the Philippines made attempts to formulate a more specific and comprehensive national population policy to help achieve thetime-bound commitments. In 1999, the first version of a proposed comprehensive reproductive health bill was filed in the Philippine Congress. Since then, the bill has seen several revisions but has yet to be enacted into law. As of this writing, a consolidated version of the bill, i.e., House Bill No. 4244, is currently in the interpellation process at the House of Representatives.7(Republic Act 10354 “The Responsible Parenthood and Reproductive Health Act of 2012 was finally enacted into law in December 2012.)

The Philippine reproductive health bill needs to be addressed, as the specificity of a national family planning policy presents an obvious ethical dilemma when health parameters continue to show an unmet need for family planning services.12 The ethical problem is made more apparent as thousands of Filipino women continue to die due to preventable complications related to childbirth, i.e., in 2005 the UN estimated that 230 Filipino women die per 100,000 live births.13 The 1994 ICPD agenda stresses universal access to a full range of safe and reliable family planning methods and related reproductive services at the primary healthcare level by 2015.14However, the 2010 Philippines Progress Report on the MDGs revealed that these targets as well as the reduction of maternal mortality rates (i.e., 52 deaths per 100,000 live births by 2015) are least likely to be achieved by the Philippines.15 It is thus imperative that disagreements regarding the family planning provisions be urgently resolved to realise the ICPD and MDG targets that the Philippines agreed to attain in the next four years.

The ICPD and the MDGs
During the 1994 ICPD in Cairo, Egypt, 179 countries adopted a 20-year,113-page Programme of Action that emphasises the interconnectedness of population and development.1, 14 While not a legal document, the section on Reproductive Rights and Reproductive Health (Chapter VII) has had the most significant political and moral influences. The concept of reproductive rights was not recognised as a newly-created human rights principle, but the explication of reproductive self-determination was arguably the most significant contribution of the consensus with regard to reproductive health.17 Six years after the Cairo conference, world leaders at the UN Millennium Summit formulated eight time-bound MDGs with targets and measurable indicators aimed to reduce extreme poverty by 2015.2

Recognising that development is a multidimensional process, the MDGs, specifically MDG5 (i.e., improving maternal health), further substantiated the ICPD’s initiativeto shift the focus of population policies towards a rights-based approach.3 Initially, MDG5 only had a demographic target of reducing the maternal mortality ratio by three quarters between 1990 and 2015, and two indicators: maternal mortality ratio and proportion of births attended by skilled health personnel. In 2007, upon the recommendations of the UN Inter-Agency and Expert Group on MDG Indicators, a second target was added to MDG5, i.e., “Achieve, by 2015, universal access to reproductive health.” 3

The Philippine Reproductive Health Bill
In 1999, House Bill No. 8110, entitled “The Integrated Population and Development Act of 1999” was filed at the 11th Congress when the Philippines had a population of 75 million.6 In the last decade, its most recent version, House Bill No. 4244, has reached the public interpellation phase at the House of Representatives. Meanwhile, the population has increased by a projected 20 million in 2010.23

It should be noted that House Bill No. 4244 does not seek to legalise modern contraceptives — most of these are currently available as over-the-counter products in the Philippines. As with the ICPD and MDG5 objectives, what the bill seeks to change is to universalise access to the widest possible range of family planning services which will be subsidised by the government. Intuitively, this provision will benefit the poor who cannot afford the services, especially women who directly suffer the consequences of ineffective or lack of family planning methods.

The most influential opposition to the Philippine reproductive health bill comes from the uncompromising stance of the Catholic Church against modern contraceptives, which dates back to the 1968 encyclical Humanae Vitae.22

Ethical Mapping: The ICPD, MDGs and the Philippine Reproductive Health Bill
To identify the ethical underpinnings of the family planning provisions, a comparison of the three documents was done,using an ethical mapping scheme. For the ICPD Programme of Action, aside from the official 1994 document,14 three succeeding official outcomereports from the United Nations Population Fund were reviewed and relevant updates and recommendations were included. For the MDGs, the most recent list of targets and indicators as well as the latest progress reports (2009 and 2010) were used.32–36

No major inconsistencies are noted. This is not surprising, especially since the bill has adopted the ICPD definition of reproductive health, that is, the “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity, in all matters relating to the reproductive system and to its functions and processes.” 7, 14

While the three documents share common principles and goals, the accurate translation of the international agendas into a national policy has been challenging. Using the principles of informed free choice, beneficence and justice that are shared by the three documents, potential ethical issues are identified and are further analysed in the context of the family planning provisions of the Philippine reproductive health bill.

Reproductive Freedom: Informed Free Choice
The primary ethical underpinning highlighted in the three documents is that of reproductive self-determination and the promotion of reproductive health and rights (Table 1).26, 41–43 The provision of ensuring universal access to reproductive health, specifically to a full range of safe and reliable family planning methods without coercion, upholds the principle of informed free choice (see Table 2, Basis for Family Planning Provision).14 However, while this provision protects the rights of patients, the rights of healthcare providers also need to be protected. The bill assures that healthcare providers may refuse nonemergent consults if requested services are inconsistent with their “ethical or religious beliefs”; however, it is interesting that this provision is placed under the Prohibited Acts section of the bill (Section 28) and recognizes that valid reasons for refusing of providing reproductive healthcare services are exceptions rather than the rule.(tables may be seen in the full version of the paper)

The MDG documents do not discuss such situations, and the ICPD recommends referral only when services are not available. Understandably, this provision is specific to the context ofthe Philippines where Catholicism continues to be a major contributing factorin the provision of family planning services, coupled with persistent culturalnorms supporting large family sizes.44 Thus, it has been challenging to identify which “ethical or religious beliefs” are considered as legitimate reasons for refusing provision of family planning services.A strong referral process must be ensured so that provision is not significantly hindered by differences in personal beliefs.

The role of healthcare providers becomes more critical with the repositioning of reproductive health as part of primary healthcare,reclassifying family planning supplies as essential medicines.7

Beneficence: Alternative Methods and Safety Issues
A look into the principle of beneficence has identified the need to add a provision in the current reproductive health bill regarding follow-up care and treatment of patients who may experience side effects due to contraceptives. Other safety concerns raised stress the need to ensure that both natural and modern contraceptive methods are promoted without bias, as deemed acceptable by patients and as approved by the local FDA.

Justice: Unmet Needs and Resource Allocation
With less than five years remaining to achieve the objectives of the ICPD and the MDGs, related health parameters in the Philippines have been discouraging. For instance, the United Nations Development Programme (UNDP) noted that the Philippines will unlikely meet the target reduction in maternal mortality rate of 52 deaths per 100,000 live births in 2015.15According to the 2011 Family Health Survey, maternal mortality rate in the country went up to 221 deaths per 100,000 live births in 2010, from 162 deaths in 2006.53

Another parameter that highlights the current inefficiency of family planning programmes is the remaining unmet needs of Filipino couples. According to the 2006 Family Planning Survey, while Filipino women across all socioeconomic classes desire fewer children and express their interests in modern contraceptives, 50.6% of women of reproductive age (15 to 49 years) practice traditional and/or modern family planning methods.12 In the same survey, the unmet need for family planning (i.e., number of women who do not want to get pregnant but are not using any form of contraception) was estimated at 15.7% for all women of reproductive age and 32% for teenagers. The linkbetween unwanted pregnancies and abortion rates is also related to unmet reproductive health needs,48and thus strengthens the argument to allocate resources to family planning services.

In summary, the continuing unmet need for family planning services, the persistence of grim health parameters and the decreased international support for family planning programmes amidst problems associated with scarce resources complicate the application of the principle of justice in the Philippine setting. Despite the bill’s adherence to this principle and its consistency with the recommendations of the ICPD and the MDGs, resource allocation is foreseen as a dividing issue at the implementation level. Nevertheless, as Macklin aptly emphasised, implementation barriers do not stem solely from limited resources, but also from a “lack of political will” and “the indifference of men in power to death and disease among unempowered women.” 8

Situating the National Debate within the ICPD and MDG Framework
Religious fundamentalism and women’s discrimination are depicted as significant obstacles in the implementation of family planning policies in the Philippines.11 However, it is the influence of the Catholic hierarchy on national policies that continues to be the strongest opposition to progressive family planning programmes. This is perhaps rooted in the 1987 Philippine constitution, which may be the only one in the world that explicitly mandates the protection of the life of the unborn from conception.55 Despite these conflicts, the strength of House Bill No. 4244 and the two international documents is the presence of what Macklin requires as a normative minimum — that of cultural and ethical relativism8 or toleration.10 While not claimed to be an ethical principle, it is a necessary prerequisite in the analysis of reproductive health policies that are bound to have ethical controversies due to social, cultural and religious differences.8

The framework used in this article may be extended beyond the family planning provisions of the reproductive health bill. House Bill No. 4244 contains other controversial sections related to sexual health (e.g. adolescent sexuality, age-appropriate reproductive health and sexuality education, reproductive health for patients with HIV/AIDS) that encounter similar disagreements due to cultural and religious differences. Thus, while the ethical framework suggested avoids a direct confrontation with many issues potentially rooted from these differences, the minimum requirement of moral toleration may help the assessment of the bill to proceed while facilitating religious and cultural accommodation. Such an approach may help policymakers arrive at an ethically sound assessment of the Philippine reproductive health bill.

Concluding Remarks
The policy analysis in this study is insufficient to recommend an absolute position regarding the Philippine reproductive health bill since only the family planning provisions were reviewed. Nevertheless, a framework using ethical principles underlined in international documents may help evaluate family planning policies amidst unresolved conflicts arising from cultural and religious differences. In this reflection, the ICPD and MDG agendas were appropriate documents to use for such a framework, because both conform to internationally recognised human rights standards.

Based on the family planning provisions, House Bill No. 4244 is ethically consistent with the principles emphasised in the ICPD Programme of Action and the MDGs. Although potential ethical problems are identified, these are foreseen to occur at the implementation process once the bill is enacted into law, and are thus insufficient to deter the approval of the bill itself. As signatory to both international documents, the Philippines may apply this framework in analysing the currently proposed reproductive health bill in its entirety to identify ethical issues that have not been emphasised in the current national debate. Such an approach will not only demonstrate international commitment to objectives previously agreed upon, but it may also assist legislators in arriving at an ethically sound consensus while ensuring sensitivity to cultural and religious particularities.

*published in the Asian Bioethics Review, vol. 5 no. 1, 2013 (First Prize in the ABR Prize 2012)
(Abstract and full text may be accessed at the Archives section of the Asian Bioethics Review website at www.asianbioethicsreview.com)

Part 2 of 3. Read Part 1 here. Part 3 is here.