Bioethics Training in Reproductive Health in Mexico

This is the pre-peer reviewed version of the following article: Gustavo Ortiz-Millán and Frances Kissling, “Bioethics Training in Reproductive Health in Mexico,” International Journal of Gynecology and Obstetrics 2020 (Nov): 151.2: 308-313, which has been published in final form at https://doi.org/10.1002/ijgo.13344. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.” A PDF of the final text, as published, will be freely accessible for 12 months after publication through Wiley Online Library: https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.13344. Bioethics Training in Reproductive Health in Mexico Gustavo Ortiz-Millán1,*, Frances Kissling2 Abstract Bioethical approaches to reproductive health have been of utmost importance for the last three decades in Mexico. As Mexican laws regarding abortion, assisted reproduction, and conscientious objection have been modified, a number of social actors with an interest in these areas have realized that they have to educate the different agents who take part in these procedures in a bioethical approach to reproductive health and rights. This strategy was first used in Mexico by the Catholic Church and many Catholic universities. Advocates, scientists and feminist organizations, as well as some public universities, have also realized that grounding in bioethics could strengthen health providers comfort with abortion. Bioethics is also a good framework for supporting the legalization of abortion and for more liberal laws regarding assisted reproduction. So, for the last few years, one of the priorities of these two sides has been to train healthcare personnel, lawyers, and members of ethics committees and members of Congress in the application of their respective bioethical perspectives. Synopsis After Mexican Catholic institutions reframed their theological teachings, particularly on reproductive health, as “bioethics”, a movement restoring secular bioethics now provides alternative sources of bioethics education. Key words Bioethics training; Reproductive Health; Abortion laws; Mexico 1. HOW BIOETHICS APPEARED IN MEXICAN DEBATES Bioethics training in reproductive health has been very important in Mexico for the last three decades, since ethical and legal debates have arisen during this time on a range of issues including abortion, infertility treatment, surrogacy, conscientious objection and gender ideology. Supporters of legal reproductive health services saw that legalizing abortion did not necessarily lead to its provision. The different actors involved in these debates have seen an opportunity through a bioethical frame, to influence, healthcare personnel, particularly obstetricians and gynecologists, to 1 National Autonomous University of Mexico, Mexico City, Mexico Correspondence Gustavo Ortiz-Millán, Institute for Philosophical Research, National Autonomous University of Mexico, Mexico City. E-mail: [email protected] 2 The Center for Health Ethics and Social Policy, Washington DC, USA * 1 Electronic copy available at: https://ssrn.com/abstract=3721686 provide these procedures. They also wanted to influence members of hospital ethics committees to decide more often to permit such procedures. Finally, they aimed at influencing lawyers, members of Congress and others who make public policy. In addition, once familiar with bioethical principles and how to apply them to reproductive health, these actors can also communicate more persuasively with the media and ultimately the general public. Accomplishing these goals required first basic education in the core principles of bioethics, and then training doctors and ethicists in teaching techniques to expand ethical knowledge throughout the hospitals in the states. Before the 1990s, there was very little public concern about ethical debates on reproductive health issues. The curriculum of medical schools did not include bioethics till the late 1980s when health care professionals started questioning the general ethics of medical practices such as problems with consent, confidentiality, and design of clinical trials. Liberals’ early advocacy approach regarding reproductive rights focused on the public health problems associated with illegal abortions and on matters of women’s human rights. They thought that framing abortion in moral or ethical terms would only strengthen the conservative discourse. Catholicism, the dominant religion in Mexico, regularly preached that abortion was immoral, and those supporters of legal abortion were not confident that they could mount a successful argument based on morality. Also, many women, particularly those in the feminist movement, tended to identify “morality” with “control.” It was not until bioethics became a well-established discipline that the idea of framing the issue of abortion in moral terms gained traction with the public and professionals in many fields. However, it has been hard to integrate the bioethical perspective into the discourse of the advocacy community. The trend towards bioethics was due to the constitutional recognition of the right to health protection in 1983, and then the promulgation of the General Health Law in 1984. This Law, and many others that derived from it, included regulations about medical malpractice, clinical research, and other issues that required ethical analysis. In 1989, the General Health Council, Mexico’s highest authority in health matters, created a Bioethics Study Group, which in 1992 gave way to the creation of the National Bioethics Commission (Conbioética). Conbioética’s goal is to promote public discussion on bioethics. It has also advanced the creation of hospital ethics committees as well as research ethics committees in public and private health care institutions, establishing guidelines to ensure their proper functioning. In fact, all hospitals are now legally obliged to have these committees.1 2. CULTURE WARS OVER ABORTION AND BIOETHICS Abortion has been prohibited in Mexico since the mid-19th Century, after the recently independent country established new penal laws that classified it as a crime (as opposed to a sin), allowing for abortion only when the life of the woman was in jeopardy. However, Mexico is a federal republic and each state has its own penal code, so abortion laws differ from state to state. Although abortion has been highly restricted by the penal codes of most states, Mexican laws changed gradually during the last third of the 20th Century to allow several exceptions for abortion. In all 32 2 Electronic copy available at: https://ssrn.com/abstract=3721686 states, abortion is permitted when pregnancy results from rape. In 24 states, abortion is legal when it threatens a woman’s life; in 16 when pregnancy poses a severe risk to a woman’s health; in 16 in the case of fetal malformations, and in two for socioeconomic reasons.2 3 Opposition to these changes was firmly rooted in the religious arguments put forward by the Catholic Church and the political power of the Church. Whenever a bill to legalize elective abortion in a state was presented, the Catholic Church’s hierarchy exerted its political influence and managed to defeat the bill. This was not easy as Mexico is a lay state and religious arguments carry limited weight. As abortion became an issue in many states, the Church understood that it needed additional arguments, preferably nonreligious ones. The increasingly pluralistic and secular field of study of bioethics from the 1970s questioned religious perspectives, which led to their marginalization within bioethics and undercut the prominent place religious perspectives had occupied on matters of morals. In response, various actors within the Catholic community from the Vatican to conservative theologians and philosophers adopted language and arguments in the more acceptable language of modern bioethics. In this way, their teachings would resonate with a more secular audience.4 5 Some Catholic universities started to look towards bioethics with the aim of justifying religious arguments with a more secular and scientific discourse on abortion, but also on topics such as euthanasia, brain death, medical ethics and stem cell research. They also drew on the discourse of human rights, claiming for instance that the fetus from conception was a rights bearing entity. These universities have adopted a personalist perspective on these issues. Personalism claims that personhood is the ultimate source of value; it emphasizes the unique dignity and the inviolability of the person. Personalists claim, for instance, that a person exists from conception and that abortion or any form of embryo manipulation or destruction is a violation of a person’s dignity.6 In 1992, Universidad Anáhuac (established in Mexico City by the Legionaries of Christ in 1964) founded the Institute for the Humanities in Health Sciences. In 2002, the Institute was turned into the Faculty of Bioethics, the first in the country, and also the first to offer a PhD in bioethics. This Institute was founded with the aim of advancing a personalist perspective of bioethics. Since its inception this university has trained hundreds of bioethicists able to transform Catholic positions against abortion and other “life” issues into a “nonreligious” bioethical frame. Other Catholic universities, belonging to or affiliated with the devout Opus Dei and Lasallian organizations (as well as some public universities), have followed their lead in training bioethicists in the same perspective. Even though Catholic bioethics is not monolithic and a lively debate between conservative and progressive views went on worldwide in the Church, the bioethics programs in Catholic universities in Mexico present only the conservative side. The bioethical curriculum in the Mexican Catholic universities overlooked the more open discourse prevalent in some European and US Catholic universities, which was debating issues such as when the fetus becomes a person and freedom of conscience. All these positions were basically ignored. At the same time, the women’s movement for reproductive rights in Mexico was developing an identity and arguments. The Information Group on Elective 3 Electronic copy available at: https://ssrn.com/abstract=3721686 Reproduction (GIRE), founded in 1993, joined by the Population Council and Ipas were more focused on a classic, secular rights approach with a strong emphasis on women’s agency and the health and human cost of unsafe abortion. Católicas por el Derecho a Decidir (CDD), founded in 1994, framed its arguments on Catholic liberation theology and provided arguments from theology that reinforced the right to decide and the Catholic concept of freedom of conscience. By the end of the 1990s, similarly to the Catholic Church, reproductive rights groups also realized their approach had limited appeal and they needed a values foundation. Research has shown that facts rarely change people’s minds.7 What motivates people to act in the public sphere is vision and values, the very heart of ethics. Marta Lamas, GIRE’s founder, recognized this approach as a missing element of abortion advocacy and set about activating the liberal bioethics community in favor of a values oriented approach, accessible to both religious and nonreligious people. In 2003, Lamas convened a number of scientists, physicians, lawyers and philosophers, who decided to create the Colegio de Bioética, an NGO dedicated to analyze the bioethical aspects of abortion, and also of assisted reproduction, euthanasia, organ donation, and the other bioethical interests (disclosure: OrtizMillán is a member of the Colegio de Bioética). One of the objectives of the Colegio would be to advise public institutions on the design, implementation and evaluation of public policies regarding bioethical issues with particular emphasis on abortion and reproductive health. Since its foundation, the Colegio de Bioética has been instrumental in arguing before state and federal congresses and the Supreme Court every time abortion, assisted reproduction and conscientious objection laws have been debated.8 Members of the Colegio have submitted amicus (i.e. friend of the court) briefs to courts in favor of the legalization of abortion and of strict regulation of the right to conscientious objection in health care. They have also occasionally provided training and education in bioethics to reproductive rights groups during this period. However, since the Colegio is an ethics policy and research organization, and not an educational institution, its impact on bioethics education has been limited. 3. MEXICO CITY’S ABORTION LAW REFORM AND CONSERVATIVE BACKLASH The progressive reproductive health community—advocates, physicians, lawyers and ethicists—had a major victory on April 24, 2007, when Mexico City’s Legislative Assembly liberalized the city’s law on abortion. Just a few weeks after the legislation passed, the office of the Attorney General and the National Commission on Human Rights—with the support of the conservative federal government—challenged the law at the Supreme Court, arguing that the abortion reform was unconstitutional since it was a violation of the human rights of the fetus. The bioethics community played a very important role in public hearings, which took place for the first time in the Court’s history. In these hearings, members of both the conservative and the liberal bioethics communities gave their expert opinions to the justices.9 10 At the end, the Supreme Court decided to uphold the law, ratifying its constitutionality and recognizing women’s reproductive rights.8 11 12 Contrary to the expectations of people who thought that this reform was going to be followed by similar reforms in other states once the Court upheld the law, there 4 Electronic copy available at: https://ssrn.com/abstract=3721686 was a conservative backlash in 20 states leading to the modification of local constitutions designed at “protecting the right to life from conception to natural death.” These reforms, although symbolically strong, had no consequences on access to abortion under the existing legal framework in the states nor on possible future attempts to legalize abortion, given that abortion was already illegal in those states. Since the Court upheld Mexico City’s abortion reform, Mexican congresses have seen a legal battle over reproductive issues on three fronts: fetal personhood laws, assisted reproduction, and conscientious objection in the provision of health services. Conservative politicians at state congresses have passed laws acknowledging the personhood of the “product of conception”, giving rise to juridical inconsistencies.13 14 Regarding assisted reproduction, federal senators and representatives have presented bills trying to restrict access to these techniques by prohibiting them for same-sex couples and single women, limiting the number of embryos that can be generated and frozen, prohibiting in utero “embryo reduction” techniques as well as the final disposal of frozen embryos. One of the few states where surrogacy is legally regulated is Tabasco, which modified its civil code in 1997. However, in 2016, the state congress decided to bar gestational surrogates from bearing children for foreigners and for same-sex couples. Some human rights organizations have opposed these modifications as a form of discrimination.15 Conservative politicians have also presented several bills in the national Congress to amend the General Health Law on the issue of conscientious objection. They hoped that if conscientious objection were widely permitted few health care personnel would provide services—not only for elective abortions but also for procedures already recognized by state laws on grounds of rape, fetal malformations or risk of maternal death. In fact, 88% of the physicians working in Mexico City’s hospitals at the time of the abortion law reform declared themselves conscientious objectors and refused to perform abortions, jeopardizing the whole program at its outset.16 Finally, in October 2017, the federal Congress approved a modification of the General Health Law, proposed by a member of a new evangelical party, recognizing an almost unrestricted right to conscientious objection, except when a person’s life is at risk or in medical emergencies. The National Commission of Human Rights has challenged the constitutionality of this law before the Supreme Court where the issue is yet to be discussed. 4. BIOETHICS EDUCATION AND ITS INFLUENCE While efforts continue in the advocacy community to expand the limited access to abortion that exists in the states, the fact is that access to abortion, where it is legal (see above) is often not available. Reforming the law has not by itself changed deeply held beliefs about “life” or about “motherhood” and women’s nature. As progressive ethicists and philosophers become more active in educating medical personnel service provision modestly improves and beliefs change. The dominant presence of conservative bioethics in the Catholic medical schools and universities and the relatively late inclusion of secular bioethics in the public universities are still obstacles to progress. A good example of the dominance of Catholic institutions’ outreach to hospital ethics committees is that they have trained many of their members. These 5 Electronic copy available at: https://ssrn.com/abstract=3721686 committees have been instrumental in obstructing the exercise of women’s reproductive rights. For example, in a recent case in Veracruz, a hospital ethics committee prevented access to a legal abortion to two girls who were raped, even though abortion is legal under this circumstance.16 The ethics committee went against a recent decision of the Supreme Court, which confirmed the constitutionality of a 2016 norm that establishes that hospitals do not require a court authorization, filing of a police report nor parental consent for minors over age 12 who seek an abortion because they were raped. Abortion care under these circumstances is defined as “emergency medical services.”18 The ethics committee argued that the state penal code allowed them to reject the abortion. Conbioética has tried to remain neutral in the battles over these topics— although in many cases Conbioética has co-sponsored some of the courses offered at Catholic universities. Similarly, the Mexican Associations of Ob-Gyn and its national Federation (FEMECOG) have avoided the topic of abortion. They have no position on the issue and their annual meetings are usually devoid of sessions on the topic. Where then can health professionals and advocates develop a progressive, woman-centered ethical perspective on reproductive health—especially issues as controversial as abortion and assisted reproduction? Several academic options exist. The Colegio de Bioética and faculty in those universities where a mainstream and scientific perspective dominates bioethics programs have played a minor role in training healthcare personnel in a more progressive bioethical perspective. The National Autonomous University of Mexico (UNAM), the only national university in the country, also started offering bioethics courses in the early 1990s and created its first graduate program on bioethics in 2002. Since 2008, several schools and research institutes have organized, along with the Colegio de Bioética, diplomas in bioethics as well as courses on reproductive health, addressed to professionals at different areas. In 2012, UNAM founded its University Program on Bioethics, which tries to cover the whole spectrum of bioethical issues, and has given special attention to reproductive health. It has trained members of hospital ethics committees on bioethics, making sure that reproductive health is always included. It has also promoted a permanent discussion seminar on legal, medical and ethical issues related to abortion and assisted reproduction. However, in reality, leadership in working with service providers has been more vigorous in the NGO sector. This role has been assumed by a few organizations. While not directly focused on ethics, Ipas, which trains doctors to provide legal abortion services, includes values clarification workshops. In these workshops, people are invited to examine their own basic values, moral reasoning and reactions towards abortion and reproduction health services. Since the idea behind these workshops is usually that people change their minds towards a more liberal way of conceiving abortion, values clarification techniques more generally have long been criticized as a form of indoctrination19 and of limited value for those whose values are against those of the trainers. These courses should be replaced with bioethics training courses aimed at developing the moral capacities of people, using the concepts and frameworks of bioethical theories. These moral capacities include the ability to deliberate morally, considering opposing points of view, and taking into account the different reasons involved in moral situations. 6 Electronic copy available at: https://ssrn.com/abstract=3721686 A more extensive program of reproductive health ethics with a strong focus on abortion for service providers has been developed by the US-based organization, the Center for Health, Ethics and Social Policy (disclosure: Kissling is the president of the Center) and fulfilled in Mexico by the Center and CDD. Among the extensive tools developed by CDD/CHESP, is the Spanish language edition of the International Federation of Gynecology and Obstetrics (FIGO) ethics manual developed by the FIGO Committee for the Study of Ethical Aspects of Human Reproduction and Women’s Health. It is available on the CDD website.20 Beginning in 2016 in Mexico City, the leadership team for abortion services in public hospitals meets periodically with an ethicist to discuss difficult cases and add to their knowledge. At the same time Kissling, who teaches reproductive health ethics in the MBE program at the University of Pennsylvania and also at UNAM, began training five members of the CDD staff and colleagues to conduct workshops for health professionals in various Mexican states. The group included three educators, a psychologist and an Ob-Gyn who performs abortions. Ten days of training were provided and the group then apprenticed with Kissling in conducting three-day workshops in three states. The CHESP program was originally developed for Population Services International, an international health service organization, for use in its platforms that were beginning to distribute misoprostol for post-abortion care. It was designed for a mixed group of health providers, about a third in favor of legal abortion, a third against and a third in the middle. Before offering the program in Mexico, it had been conducted in eight African countries, Central America, and several Asian countries. It has now been offered to over 250 doctors and psychologists in states where abortion is available in limited circumstances. Each program has the approval of the state’s health department and is attended by health department leadership. From the attendees at these workshops, 15 health professionals were selected for advanced training in conducting the workshop. Five of those professionals have been able to offer short, several hour-long modules in their hospitals reaching an additional 125 professionals. No attempt is made to change anyone’s mind about abortion. The goal is to provide basic education in the four core principles of health care ethics and to teach basic critical thinking skills so that participants can more rationally decide what they believe about abortion. The use of the four principles situates abortion in a larger context, less charged with unexamined beliefs. The first two principles, Do No Harm and Do Good, when applied to abortion, highlight the risk of mortality and morbidity if abortion is denied and the need for attention to the woman’s broader health needs. They also stress a health provider’s duty of care. Respect for patient autonomy, the third principle, is a difficult concept for some health care providers who are still accustomed to deciding for the patient. Do Justice, the fourth principle, is more dominant in the time of Covid-19 where issues such as who gets scarce drugs and services, as well as highlighting the fact that women are least likely to receive safe abortion care when they are at the margins of society. The principles are examined first in the abstract from abortion and efforts are made to demonstrate that decisionmaking is not simple. Both thought experiments and case studies are used extensively. Particularly useful is the classic Philippa Foot Trolley Problem, involving directing a trolley that is hurtling towards five persons who cannot escape but which can be 7 Electronic copy available at: https://ssrn.com/abstract=3721686 diverted to a different track on which only one person is trapped. This requires people to decide whether to take an action that will save the lives of 5 people, but result in the death of one other person.21 The exercise, which requires split second action, pits people’s principles up against their beliefs. Case studies are a key component of the course. One, on female genital mutilation (FGM), provides a direct parallel to abortion. Participants are asked to decide whether hospitals should be allowed an exemption to the law against FGM and provide safe cuttings so as to prevent harm to young children from imposition of unskilled procedures and risk of infections and even death. Participants are encourage to address the dilemma of competing values by determining what is more important: , the do no harm principle by sparing the child of a likely harmful mutilation or refusing to violate the autonomy of a child by an unwanted cutting. Being able to examine the four core bioethics principles in the context of real cases as the one above develops critical thinking and offers a way to deal with complexity. The second day includes an extensive session on progressive Catholic thought about abortion and several case studies on various abortion-related challenges. The final day is developed from the first two days with sessions focused on those areas attendees would like to explore more deeply. Participant evaluations are very positive, often remarking that greater tolerance and acceptance of different points of view was a major learning experience. The case study model is particularly valued. Conducting such workshops requires considerable skill and knowledge. Most especially, facilitators need to put aside any desire to fall back on standard pro-choice ways of discussing abortion; to be open to every participant, indeed to encourage those who are anti-abortion to express their views. In part, the reason for this is that in many health care institutions there is no space for people to discuss the abortion issue rationally, so we are teaching ethics, critical thinking and how to disagree civilly. In addition to working with health professionals, the project has worked with staff of various reproductive health organizations in Mexico City. They have completed six sessions in reproductive health ethics conducted by the CHESP, ethicists from UNAM and a progressive Catholic priest. Shifting from a woman’s rights frame to a bioethics frame has been difficult, as advocates tend to have a fixed set of values. In the case of abortion, it seems necessary to use a women’s rights and human rights frame along with non-interference by the state and the exclusion of religious ideas as the key messages. Even when advocates understand that these approaches and ideas limit how far progress can advance, it is hard not to reflexively return to them in messaging. Service providers are somewhat more open; in many cases they are looking for a frame closer to their work to justify providing services and to answer questions they may get from the public and patients. 5. WHAT’S NEXT? The development of bioethics education for abortion and other reproductive health services is more advanced in Mexico than in most countries where abortion access is 8 Electronic copy available at: https://ssrn.com/abstract=3721686 legally limited. Even though, in the short term, it seems hard to change abortion laws in Mexico in a way that fully acknowledges women’s rights (the decriminalization of abortion in the state of Oaxaca in 2019 was exceptional22), reproductive rights organizations can advance their cause by training all the different actors in bioethical discussions. In this context, what needs to happen for the bioethical framework to have a wider impact? We identify several tasks that have to be undertaken:  FEMECOG should establish committees similar to the FIGO Ethics Committee to explore ways of developing capacities in bioethical thinking. This could include organizing sessions at, for example, its annual meetings to discuss how bioethics can be applied to clarify problems facing the profession, such as the FIGO Ethics Committee does.23 FEMECOG’s code of medical ethics should also be discussed, particularly the implications of its requirement to respect the human rights and wellbeing of the patient.  Formal bioethics training at the university. Many people who teach ethics courses in colleges do not practice bioethics in health care settings nor have a formal education in the field. The field has to go through a process of professionalization. Students at schools of medicine—which is studied at the college level—need to have formal ethics training in the field.  More direct work with ethics committees at the hospital level. Even though the law requires that individuals who compose these committees have formal training in bioethics, very often this is not the case.  More direct work with states’ bioethics commissions, which are in charge of supervising hospital ethics committees. Many of the people who compose these commissions do not have any formal training in bioethics or in topics related to reproduction. 6. CONCLUSIONS Since the 1990s, Mexico has witnessed a battle over abortion, assisted reproduction and related issues. The success of modern secular bioethics from the 1970s caused the Catholic Church’s initiatives of the 1990s: the establishment of the first graduate programs in bioethics in the country and initiation of educating bioethicists and health-care personnel in the principles of personalism. However, around the same time, feminist and other liberal organizations started supporting a nonreligious and science-based perspective on bioethics and, along with a few public universities, created competing secular graduate programs in bioethics. These initiatives restored the purpose of bioethics: to promote debate free from having to justify conclusions that conform to religious orthodoxy. Even though no major reforms on the restrictive abortion laws that prevail in most of the country are foreseeable, there have been changes on issues such as assisted reproduction, surrogacy, and others, which remain mostly unregulated. Politicians of different ideological orientations have presented several bills on these issues, both at the state and the federal level, but most of them with little legal, medical and bioethical background. In this scenario, training health-care personnel, members of hospitals’ ethics committees, members of states’ bioethics commissions, 9 Electronic copy available at: https://ssrn.com/abstract=3721686 lawyers, activists, and political assistants in the bioethical aspects of reproductive health at different levels has been of utmost importance. More direct work has to be done in training all these different actors in the principles of a science-based, nonreligious bioethics framework. AUTHOR CONTRIBUTIONS Gustavo Ortiz-Millán wrote the first draft. Frances Kissling reviewed, made significant changes and wrote the section on the activities of the civil society movements to develop ethical knowledge among health professionals and the movement for abortion rights. Ortiz-Millán produced another draft that the authors discussed and he wrote the final draft. ACKNOWLEDGMENTS The authors are indebted to Isabel Fulda, Rebeca Ramos and Raffaela Schiavon for many comments and criticisms. CONFLICTS OF INTEREST The authors have no conflicts of interest. References 1. Ruiz de Chávez MH. Veinte años de bioética en México: desarrollo y perspectivas de la Comisión Nacional de Bioética. Cirugía y Cirujanos. 2014;82:699–708. 2. GIRE. La pieza faltante. Justicia reproductiva. Mexico: Grupo de Información sobre Reproducción Elegida; 2018. https://justiciareproductiva.gire.org.mx/assets/pdf/JusticiaReproductiva.pdf. Accessed on July 14, 2020. 3. GIRE. Motherhood or Punishment. Criminalizing Abortion in Mexico. Mexico: Grupo de Información sobre Reproducción Elegida; 2019. http://criminalizacionporaborto.gire.org.mx/assets/pdf/GIRE_Motherhood_or _Punishment.pdf. Accessed on July 23, 2020. 4. Reich WT. The “wider view”: Andre Helleger’s passionate, integrating intellect and the creation of bioethics. Kennedy Institute of Ethics Journal. 1999;9:25–51. 5. Evans J. The History and Future of Bioethics. New York: Oxford University Press: 2012. 6. Williams TD, Bengtsson, JO. Personalism. The Stanford Encyclopedia of Philosophy (Winter 2018 Edition), Ed. EN Zalta, https://plato.stanford.edu/archives/win2018/entries/personalism/. Accessed on July 3, 2020. 7. Mercier H, Sperber D. The Enigma of Reason. Cambridge, Mass.: Harvard University Press; 2017. 8. Lamas M. La interrupción legal del embarazo. El caso de la Ciudad de México. Mexico: FCE; 2017. 9. Romero C. ed. La vida ante la corte: inconstitucionalidad del aborto. Mexico: Enlace; 2008. 10 Electronic copy available at: https://ssrn.com/abstract=3721686 10. Enríquez L, De Anda C. eds. Despenalización del aborto en el D.F. Argumentos para la reflexión. Mexico: UNAM-IPAS-GIRE; 2009. 11. GIRE. Constitutionality of the Abortion Law in Mexico City. Mexico: Grupo de Información sobre Reproducción Elegida; 2010. 12. Madrazo A. The evolution of Mexico City’s abortion laws: From public morality to women’s autonomy. Int J Gynecol Obstet. 2009;106:266–269. 13. Madrazo A. Narratives of prenatal personhood in abortion law. Abortion Law in Transnational Perspective. Cases and Controversies. Ed. Cook RJ, Erdman JN, Dickens, BM. Philadelphia: University of Pennsylvania Press; 2014, pp. 327– 346. 14. Mendoza H. El inicio de la vida: discurso bioético-jurídico en la legislación mexicana, Revista de Bioética y Derecho. 2015;33:28–43. 15. GIRE. Surrogacy in Mexico. The Consequences of Poor Regulation. Mexico: Grupo de Información sobre Reproducción Elegida; 2017. https://gestacionsubrogada.gire.org.mx/en/#/. Accessed on July 3, 2020. 16. Ortiz-Millán G. Abortion and conscientious objection. Rethinking conflicting rights in the Mexican context. Global Bioethics. 2018;29:1–15. http://dx.doi.org/10.1080/11287462.2017.1411224. 17. Soberón R. Comités de bioética impiden acceso al aborto a niñas que fueron violadas en México, Animal Político, August 27, 2019. https://www.animalpolitico.com/2019/08/comites-bioetica-niegan-abortoviolacion/. Accessed July 3, 2020. 18. GIRE. NOM 046: ¿Qué pasó en la Suprema Corte? Animal politico, August 12 2019. https://www.animalpolitico.com/punto-gire/nom-046-que-paso-en-lasuprema-corte/. Accessed on July 3, 2020. 19. Baer RA. Values Clarification as Indoctrination. The Educational Forum 41(2), 1977. 20. Introducción de FIGO a los principios y a la práctica de la bioética: casos de estudio relacionados con la salud de las mujeres. http://catolicasmexico.org/i/wpcontent/uploads/2020/02/4-Introduccion-de-Figo-a-los-principios.pdf. Accessed on July 14, 2020. 21. Foot P. The problem of abortion and the doctrine of the double effect. Virtues and Vices. Berkeley and Los Angeles: University of California Press; 1978, pp. 19– 32. 22. ‘We have made history’: Mexico’s Oaxaca state decriminalises abortion. The Guardian. September 26, 2019. https://www.theguardian.com/world/2019/sep/26/we-have-made-historymexicos-oaxaca-state-decriminalises-abortion. Accessed on July 6, 2020. 23. FIGO Committee for the Study Ethical Aspects of Human Reproduction and Women’s Health. Ethical Issues in Obstetrics and Gynecology. October 2015. https://www.figo.org/sites/default/files/202007/English%20Ethical%20Issues%20in%20Obstetrics%20and%20Gynecolog y.pdf. Also available in Spanish at https://www.figo.org/sites/default/files/202007/Spanish%20Ethical%20Issues%20in%20Obstetrics%20and%20Gynecolog y.pdf. Accessed on July 23, 2020. 11 Electronic copy available at: https://ssrn.com/abstract=3721686