{"id":4795,"date":"2026-07-13T05:36:00","date_gmt":"2026-07-13T04:36:00","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=4795"},"modified":"2026-07-13T05:36:00","modified_gmt":"2026-07-13T04:36:00","slug":"whose-permission-counts-rethinking-abortion-access-through-the-lens-of-authorization","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2026\/07\/13\/whose-permission-counts-rethinking-abortion-access-through-the-lens-of-authorization\/","title":{"rendered":"Whose permission counts? Rethinking abortion access through the lens of authorization"},"content":{"rendered":"<p>By Shizuko Takahashi<\/p>\n<p>A law permits abortion. A court has ruled, or a legislature has voted. Legality appears settled. But for the pregnant person in front of a clinician, legality is often not enough. Someone still has to authorize the abortion in practice.<\/p>\n<p>This is the starting point of the second instalment of the <a href=\"https:\/\/doi.org\/10.1136\/jmepb-2026-000290\">Global Bioethics Bulletin, a dispatch series<\/a> I worked on with contributors covering Africa, Asia-Pacific, Latin America and the Caribbean, North America, Europe, and Western, Central and Southwest Asia. We asked who actually authorizes abortion once the law has already permitted it, and what happens when that authorization is withheld, delayed, or given to someone other than the pregnant person.<\/p>\n<p><a href=\"https:\/\/doi.org\/10.1136\/jmepb-2026-000290\">The pattern appears across every region.<\/a> In Japan and Indonesia, spousal consent is a legal requirement. In Israel, a termination committee approves most requests, but applicants must still frame their circumstances to fit accepted categories. In El Salvador, the line between a medical emergency and a criminal act can depend on how a clinician\u2019s judgment is scrutinized later by a prosecutor. Even where the legal threshold is low, counselling requirements, provider shortages, and clinician discretion determine whether a legal right becomes actual care.<\/p>\n<p>I came to this work through my own experience of these decisions, first as a resident in OB-GYN, and later as a physician performing abortions in Japan. As a resident in a rural hospital in Japan, I worked part-time at a Catholic hospital that did not perform abortions at all. Pregnant people with unwanted pregnancy were instead housed there until birth. Delivery was centered on the well-being of the pregnant person, not the infant. C-sections were not performed, in situations that would normally have been indicated for a wanted pregnancy. In this sense, I was told that it was an ideal place for a fresh OB-GYN to learn how to deliver babies because I would never be held responsible for the consequences to the child from the pregnant person. After delivery, the mother was discharged. The infant stayed at the hospital, with all the other babies, wanted and unwanted, in a single room.<\/p>\n<p>What stayed with me was not the ward as it usually looks, with infants under a week old. Here, there were babies a month old or more, sometimes a dozen at once, waiting to be adopted. Each was in a plastic crib already too small for some of them, with a bottle propped in their mouth and stabilized with a towel because there was no one available to hold them while they fed. Some of these infants had disabilities, including disabilities associated with difficult or complicated labours. What troubled me was not their disability, but the conditions into which they had been born: a system that claimed to protect life, while offering too little care, support, or social commitment to the children whose lives followed from that claim. I fed them and held them when they cried whenever I could, and wrote letters to adoption agencies overseas, since finding adoptive families for children with disabilities in Japan was extraordinarily difficult.<\/p>\n<p>Holding these little people taught me, physically and not only intellectually, that \u201csaving\u201d a life cannot mean only preventing its end. It must also mean asking what care, recognition, and support that life will receive afterwards.<\/p>\n<p>Since then, I have practiced as a physician performing abortions in Japan, where spousal consent is required and where the only grounds on which I may act\u2014maternal health or economic hardship, and rape or sexual assault\u2014are the law\u2019s permitted categories. These are not choices I made.<\/p>\n<p>I have also worked at a hospital that authorized abortion only for fetal indications, under an explicit mission to \u201cprotect life\u201d rather than to provide abortion on request. This left me with a question I still have not resolved: how can a fetal indication justify authorization within a framework built around protecting life, while no other reason a pregnant person might have is accepted?<\/p>\n<p>I suspect few OB-GYNs enter this specialty aspiring to perform abortions. It is not work most of us raise our hands for. That reluctance, together with how common conscientious objection is among colleagues, places real weight on those of us who do provide this care. It forces an ongoing reckoning with what we owe to a patient\u2019s own authority over their decision, against the institutional, legal, and personal constraints within which we practice.<\/p>\n<p>This dispatch grew out of that reckoning. We do not try to resolve the underlying philosophical debates about the moral status of the fetus or the permissibility of abortion. Instead, we argue that bioethics needs to pay more attention to what happens after a society has already decided that abortion should be available under certain conditions.<\/p>\n<p>Someone still has to decide, in a specific clinical moment, whether those conditions are met, who bears the risk if they are wrong, and whose judgment counts. From the practical standpoint of a physician, this deserves at least as much attention as the conceptual debates that have long dominated the field.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Paper title:<\/strong> <a href=\"https:\/\/jmepb.bmj.com\/content\/2\/3\/e000290\">Global Bioethics Bulletin: Dispatches on access to abortion<\/a><\/p>\n<p><strong>Authors:<\/strong> Shizuko Takahashi<sup>1*<\/sup>, Gabriela Arguedas Ram\u00edrez<sup>2<\/sup>, Hossein Dabbagh<sup>3,4<\/sup>, Brian D. Earp<sup>1<\/sup>, Ehsan Shamsi Gooshki<sup>5<\/sup>, Yonghui Ma<sup>6<\/sup>, Ignacio Mastroleo<sup>7,8<\/sup>, Joona R\u00e4s\u00e4nen<sup>9<\/sup>, Keisha Ray<sup>10<\/sup>, Sabine Salloch<sup>11<\/sup>, Natalie Tegama<sup>12,13<\/sup><\/p>\n<p><strong>Affiliations:<\/strong> 1 Centre for Biomedical Ethics, National University of Singapore, Singapore<\/p>\n<p>2 School of Philosophy, University of Costa Rica, San Jos\u00e9, Costa Rica<\/p>\n<p>3 Oxford Department for Continuing Education, University of Oxford, Oxford, UK<\/p>\n<p>4 Department of Philosophy, Northeastern University, London, UK<\/p>\n<p>5 Monash Bioethics Centre, Monash University, Melbourne, Australia<\/p>\n<p>6 Centre for Bioethics, School of Medicine, Xiamen University, Xiamen, China<\/p>\n<p>7 National Council of Science and Technology (CONICET), Buenos Aires, Argentina<\/p>\n<p>8 Bioethics Program, FLACSO Argentina, Buenos Aires, Argentina<\/p>\n<p>9 Turku Institute for Advanced Studies &amp; Department of Philosophy, Contemporary History and Political Science, University of Turku, Turku, Finland<\/p>\n<p>10 McGovern Center for Humanities and Ethics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, USA<\/p>\n<p>11 Institute for Ethics, History and Philosophy of Medicine, Hannover Medical School, Hannover, Germany<\/p>\n<p>12 University of Zimbabwe, Harare, Zimbabwe<\/p>\n<p>13 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK<\/p>\n<p><strong>Competing interests:<\/strong> None<\/p>\n<p><strong>Social media accounts of post author(s):<\/strong> <a href=\"https:\/\/www.linkedin.com\/in\/shizuko-takahashi-636788144\/\">Shizuko Takahashi on LinkedIn<\/a><!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>By Shizuko Takahashi A law permits abortion. A court has ruled, or a legislature has voted. Legality appears settled. But for the pregnant person in front of a clinician, legality is often not enough. Someone still has to authorize the abortion in practice. This is the starting point of the second instalment of the Global [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2026\/07\/13\/whose-permission-counts-rethinking-abortion-access-through-the-lens-of-authorization\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":503,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8059,2148,2022],"tags":[],"class_list":["post-4795","post","type-post","status-publish","format-standard","hentry","category-abortion","category-law","category-reproduction"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Whose permission counts? Rethinking abortion access through the lens of authorization - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2026\/07\/13\/whose-permission-counts-rethinking-abortion-access-through-the-lens-of-authorization\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Whose permission counts? Rethinking abortion access through the lens of authorization - Journal of Medical Ethics blog\" \/>\n<meta property=\"og:description\" content=\"By Shizuko Takahashi A law permits abortion. A court has ruled, or a legislature has voted. Legality appears settled. But for the pregnant person in front of a clinician, legality is often not enough. Someone still has to authorize the abortion in practice. 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