The Reproductive Health of Refugees
THE REPRODUCTIVE HEALTH OF REFUGEES
Pontifical Councils for Pastoral Assistance to Health Care Workers, for the Pastoral Care of Migrants and Itinerant People, and for the Family
A NOTE FOR THE BISHOPS' CONFERENCES
In 1999, the United Nations High Commissioner for Refugees (UNHCR), in collaboration with the World Health Organisation (WHO), the United Nations Fund for Population Activities (UNFPA), and some NGOs, published the Inter-agency Field Manual on Reproductive Health in Refugee Situations; this is a Manual that deals with methods of assistance to refugees in the area termed "Reproductive Health ".
The Field Manual forms the object of serious concern for the Church; that is the reason for this Note, which has been expressly prepared by three Departments of the Holy See: The Pontifical Councils for Health Pastoral Care, for the Pastoral Care of Migrants and Itinerant People, and for the Family, with the goal of emphasizing the reservations of the Holy See on some problematic issues of the Manual.
This Interdicasterial Note takes the Field Manual as a pastoral challenge for the Church and calls both Pastors and other pastoral workers involved in the area of health, family, migrants and Itinerant people to be vigilant, so that the love, respect and protection of refugees and their rights, among which the inalienable right to life, may be the underlying reason and incentive for their action for the improvement of the conditions of life of millions of displaced persons and refugees, to insure they benefit from the protection of their life and health.
The Field Manual contains negative values that offend the dignity of the poorest and most vulnerable populations, with proposals to restrict the birth rate, an irresponsible concept of sexual relations, and even abortion. It presents us with a current of thought that may be defined as both utilitarian and neo-Malthusian.
The Note, divided into five parts, offers a horizon of hope different from that expressed in the Field Manual and makes a pastoral proposal ad hoc, which is based on love for refugees in full respect of moral truth and the dignity of personal opinion.
Finally, the Note encourages the various authorities responsible for public life, and all men and women of good will to pursue efforts that will insure the refugees, a future capable of restoring to each and every one features resembling the image and likeness of God.
May this Note help our communities, following the example of Jesus who was himself a refugee, to understand the problems and difficulties of the refugees better, to offer them particular attention and care, to help them in body and spirit, to protect their rights and, especially, the right to life and health.
The tragedy of refugees is a "wound which typifies and reveals the imbalances and conflicts of the modem world", (John Paul II, Encyclical Letter Sollicitudo rei socialis, 30December 1987, n. 24). The pastoral solicitude of the present Note regards refugees, asylum-seekers, exiles, displaced persons, and every person who experiences forced migration. In dealing with the concept of "refugee" as used by the Holy See, it is to be hoped that the same protection and the same rights prescribed by international law in the defence of refugees will also be accorded to those who live the experience of forced migration within their own countries. (See Pontifical Council for the Pastoral care of Migrants and Itinerant People, IRifugiati: Una Sfida alla Solidarietà [Libreria Editrice Vaticana, 1992], nn. 3-4.) in which the Church is present with her love and care. For believers in Christ, what matters first and foremost, in the service to their neighbour, is the inalienable dignity of the human person created in the image of God (Gn 1,27). In the spirit of the Great Jubilee, the Church rejoices at the co-operation between "peoples of every language, race, nationality and religion" in facing up to the great challenges of the new millennium, and hopes and wishes that it will lead to the creation of "a new culture of solidarity and co-operation" (John Paul II, Incarnationis Mysterium, Bullof Indiction of the Great Jubilee of the Year 2000, n. 12; cf. John Paul II, Message for the Celebration of the World Day of Peace, 1January 2001, n. 17).
I. The Holy See, the United Nations Organisation, and reproductive health
Among the organisations with which the Holy See co-operates at various levels, the United Nations occupies a special place of importance. Within its structures the United Nations High Commissioner for Refugees (UNHCR) has been concerned for 50 years with protecting the dignity and rights of refugees. There are many examples of fruitful co-operation between the UNHCR and the Catholic Church at both an international level and in the various countries experiencing the forced movement of people.
The Holy See, while appreciating the principles which guide the action of the UNHCR, cannot refrain from expressing its own reservations when the ways in which help is given, or even the means employed, could cause grave damage to the dignity of the person and his/her life, from the first stages of conception until natural death, as is recognised by human reason and expressed by Catholic morality. It is within this context that the meaning of this Note on the Interagency Field Manual on Reproductive Health in Refugee Situations, published in 1999 by the UNHCR, must be understood. (This manual is the outcome of the co-operation of various agencies of the United Nations Organisation, principally the WHO, the UNPFA and the UNHCR, and certain NGOs. A draft of this manual was published in 1996. The publication of 1999 goes back to the text of 1996 with some changes). Although there are positive aspects to the manual, it is incumbent upon us to point out others which run counter to morality. The Catholic organisations that are involved with the UNHCR in the protection and provision of assistance to refugees, are in a privileged position to promote the true dignity of refugees as regards sexuality, the family, adolescents, and children. This Note offers Bishops and Catholic pastoral and humanitarian workers a short analysis of the Field Manual as well as certain indications for the protection and the promotion of the dignity and the integral health of refugees.
Our reservations with regard to the Field Manual form part of the concern of the Church about the moral and intellectual confusion that in recent years has taken root in public opinion, among various political leaders, in international institutions, and in the practice of medicine itself. More precisely, one is dealing with the way of answering the question: what is man? (cf.Second Vatican Ecumenical Council, Pastoral Constitution Gaudium et spes, n. 12). The implicit and at times explicit answer given in the Field Manual reflects a philosophical approach that, in its attempt to promote individual freedom, neglects corresponding individual and social duties. It runs the risk of offending the very dignity of the poorest and most vulnerable populations with proposals that imply the reduction of their birth rate, an irresponsible concept of sexual relations that includes abortion. No attention is paid to the culture and the religion of the refugees. The Manual isguided by what we can define as a utilitarian or neo-Malthusian approach.
The Field Manual reflects the discussions on "reproductive health" that were held during the "Conference on Population and Development" which took place in Cairo in 1994. This kind of "reproductive health" is promoted today by certain organisations of the United Nations such as the World Health Organisation (WHO), and the United Nations Fund for Population Activities (UNPFA). At the concluding session of the Cairo Conference, the Holy See issued a declaration in which the Church expressed her reservations regarding the ideology of "reproductive health" (Archbishop R. Martino on Holy See's "Partial Consensus to Final Document of Cairo Conference", 13 September 1994, L'Osservatore Romano, English edition, n. 38, p. 7, 1994). The same reservations can apply to the Field Manual.
II. The Church's love for refugees
Within the context of her universal missionary mandate, the Church, paying special attention to the signs of the times, perceives with increasing awareness the existence of the phenomenon of millions of displaced persons and refugees. She intends to cooperate so that these people can improve their conditions of life and health and benefit from necessary protection.
In a Message on the subject of emigrants—a message especially relevant for refugees— Pope Paul VI said: "We are looking closely at what emigrants suffer in such movements: they suffer a spiritual and moral trauma which disturbs every inner judgement, and while their minds are subtly exposed to aspirations of every kind, some of which are good and worthy, such as a better condition of life, confused ideas are easily produced which shake the principles on which the honesty, the normality, and the humanity of their psychology are based. How many emigrants thus lose their religious customs ... and how many have their own family affections upset by the sad conditions in which they find themselves and by the rise of disordered passions? Emigration provokes such serious and widespread moral and religious crises and takes place with such suffering and such painful consequences that the pastoral ministry of the Church cannot be unconcerned about it; and during these years the worse the phenomenon of emigration becomes, the more the concern and care of the diocesan clergy, of religious, and of the Catholic laity must intervene and demonstrate a quick, versatile capacity to bring comfort and help to emigrants in proportion to their need, which today has grown and is urgent" (Paul VI, Messaggio per la Giornata dell'Emigrazione, 24 novembre 1963, in Insegnamenti di Paolo V1, vol. 1, 1963, p. 347). The original context was that of emigration in general, of which the experience of refugees is a particularly dramatic example).
The Church, called upon by these inhuman situations, intervenes out of her apostolic concern, convinced that "the proclamation of Christ and the kingdom of God must become the means for restoring the human dignity of these peoples" (John Paul II, Encyclical Letter Redemptoris Missio, 7December 1990, n. 37).
III. Worrying points in the "Field Manual"
Before engaging in a specific analysis of the most worrying points of the Field Manual , itshould be remembered that we are dealing here with a basic difference between the utilitarian conception of human sexuality, connected with the concept of reproductive health, and the perspective offered by the Church in her respect for the dignity of man and his sexuality (cf. Pontifical Council for the Family, Sessualità umana: verità e significato. Orientamenti educativi in famiglia [8December 1995],nn. 8-15).The sexual anthropology based upon divine revelation asserts that "man and woman have been created, which is to say, willed by God: on the one hand, in perfect equality as human persons; on the other, in their respective beings as man and woman" (Catechism of the Catholic Church, 369;see Jn 2,7-22).God "created them to be a communion of persons, in which each can be "helpmate" to the other, for they are equal as persons ('bone of my bones ... ') and complementary as masculine and feminine" (ibid., 372).Their conjugal life is destined to be fertile and to fulfill itself in the common work of watching over the creation, (cf. ibid., 1604)in conformity with the generosity appropriate to responsible fatherhood-motherhood according to the objective criteria of morality (cf. ibid., 2368).One should, therefore, respect the dual meaning of the mutual giving of the man and the woman, open to life, in marriage, which the contraception promoted by so-called "reproductive health" contradicts.
Today's forms of scientific knowledge allow us to affirm that human life begins at the moment of fertilisation. Reason is thus called upon to accept, in philosophical and ethical terms, the pre-eminent human value of individual life from that moment, and its defence and protection is a requirement of natural law. The Church also affirms, on the basis of reason as well as of Revelation, the obligation to respect and to protect the right to life of every human embryo and rejects as immoral every action which brings about its abortion or manipulation (cf. John Paul II, Encyclical Letter Evangelium Vitae, 25 March 1995,n. 60).
The Field Manual (in particular in chapter IV) proposes, without reservations, after forced sexual relations, the use of so-called "emergency contraception", previously called the "moming-after-pill", and presents it as a "contraceptive". The reality is that it is not just a contraceptive but an abortifacient, because in the case of effective fertilisation a chemical abortion would be carried out during the first days of pregnancy. The World Health Organisation relativises the biological status of the embryo during the first days by terming it a "pre-embryo", that is, a group of cells. Here we encounter a sophism because such a label does not correspond to the precise biological reality. Natural morality cannot accept the use of this "emergency contraception" (Pontifical Academy for Life's Statement on abortifacient pill made available in Italian pharmacies, 31 Oct. 2000, L'Osservatore Romano, English edition, n. 46, 15November 2000, p. 9).
In the same way, the means of birth control promoted by the Field Manual are unacceptable, (cf. Paul VI, Encylical Letter Humanae Vitae, 25 July 1968, n. 14)because of their wellknown abortifacient effect (chapter VI). Here what are offered are contraceptive pills based on progestagens (the 'mini-pill"), injectable contraceptives (Depoprovera) or implants placed under the skin (Norplant), and the coil (IUD).
It should be observed that the Field Manual presents sterilisation. as simple "contraception". It is instead a radical suppression of the procreative function, which is often carried out in poor countries without the subject of this procedure always being correctly informed.
In addition, the distinction between sexuality and procreation promoted by the Field Manual through the promotion of a "non-judgemental approach" towards extra-marital relations as well as homosexual relations cannot be accepted. For this reason, Pastors must be very careful about the information programmes on reproductive health proposed by the Field Manual for adolescent refugees (chapter VIII). Rather than being educated for real love, within the prospect of marriage and a future family, these boys and girls are introduced into the world of individualistic and irresponsible sexual pleasure, which increases the risk of spreading the HIV/AIDS epidemic. The Field Manual,rather than promoting the education of young people for responsible procreation, as a true prevention for this disease, limits itself to offering the condom, as has already happened in the past in schools and trouble spots with the distribution of contraceptive material and printed matter. The Field Manual envisages the ubiquity of the condom in massive quantities, although the significant percentage rate of failure of this "protection" is more than demonstrated today. The Field Manual isnot the most suitable instrument for education in mature sexual responsibility.
Natural methods are morally legitimate when there are good reasons for employing them, and they are therefore suitable to responsible procreation, in refugee camps as well, because they do not cost anything, respect the body and the relationship of the couple, and foster dialogue and a responsible approach by the spouses. (On the anti-values implicit in the contraceptive mentality [very different from the responsible practice of fatherhood and motherhood which takes place in the full truth of the conjugal act], see John Paul II, Encyclical Letter Evangelium Vitae,n. 13).
There is a last rather worrisome point presented by the Field Manual:the presence of equipment in the camps in which refugees have to live, allows the carrying out of abortions (suction with MVAs or "manual vacuum aspirators") in the form of post-abortion medical care. This is equipment that will be put into the hands of health care workers with different levels of qualifications although it should only be used by medical doctors. It will be very difficult, in such conditions, to control the present-day use of this equipment and to verify whether the declaration inserted at the express request of the Holy See in chapter VI of the Field Manual ("in no cases should abortion be promoted as a method of family planning"), is effectively respected.
IV. The pastoral approach
The distribution of the Field Manual among refugee populations or to other displaced people must not be taken lightly by the Pastors of souls who care for them both in camps and elsewhere. The circulation of the Field Manual is another reason why the Church should insure a more incisive pastoral presence, and not only a presence restricted to the provision of aid, in these situations. Thus the Christian community, with Gospel-based morality, will make its specific contribution, working with all refugees and the organisations dedicated to serving them.
Refugees and displaced peopleoften have nothing at all and require, according to their practical needs, greater love, care, concern, and active solidarity from the Christians and Pastors who live side by side with them. Organising the pastoral care of these people, ensuring their spiritual well-being, their access to the Word of God, to sacramental forgiveness, to the Eucharist and to the other sacraments, forms a part of the response that Christians must give to the commandment of Christ to love our brethren.
Naturally, the local Church as well as the Universal Church is committed to material, psychological and medical help for refugees. Catholic agencies that are involved in providing refugees with help and relief are generally under the guidance of a Bishops' Conference. The Bishops' Conferences themselves, in countries where there are refugees, are in contact with them through these agencies and also through their own instruments of humanitarian aid. In the co-operation of these institutions of the Church in providing assistance, under the guidance of the Bishops' Conferences, these institutions, in their loyalty to Christ, should have special respect for the person of the refugee and for his/her rights, whatever their state or their religion may be. The Pastors of souls who visit the refugees to help them at a spiritual level also assume the duty to promote amongst them a feeling of dignity, self-respect, and by their example to arouse mutual respect, and consideration amongst those who help refugees and the bodies responsible for providing such help.
V. Specific pastoral problems
The distribution of the Field Manual on Reproductive Health,it should also be observed, raises specific problems at a pastoral and moral level. The pastoral care of the faithful requires from every Bishops' Conference that their physical health also be taken into account. Among the faithful there are those who make up the refugee population. They are generally under-fed, weak, and often in precarious conditions of health. The Field Manual promotes so-called "reproductive health" from a more than narrow perspective. Given that the Church, with her charitable bodies, with the help of her consecrated members, and with her Catholic health care workers and medical doctors, is usually present at an executive level in such situations involving refugees, Pastors must be vigilant to insure that the practices proposed in the Field Manual and considered to be immoral do not dominate.
First of all, pastors have the duty to insure respect for refugees as persons and for their rights. This involves knowing the refugees and the health care workers who are looking after them, winning their trust, listening to their complaints, and paying attention to everything said in confidence.
Education is a duty of pastoral workers and the Christian laity who are involved in the service of refugees. This is not a matter of merely providing health care information but also of making an appeal to ethics based upon the Word of the Gospel, with all its force and with its on-going call to holiness, in whatever conditions a Christian may live. By such an initiative, the Christian vision of life and human sexuality and its requirements will be presented, as well as the teaching of the Magisterium regarding the immorality of co-operating in abortion, sterilisation and contraception. Above all else, efforts will be made to give time and attention to refugee children and adolescents, organising, where possible, meetings with them to prepare them for real love and for the prospect of their future engagement and marriage. AIDS, too, should be spoken about, as well as its prevention through respect for the dignity of one's own body.
Lastly, pastors of souls will try to offer specific spiritual help to the health care personnel caring for refugees as much as possible. Health care workers and medical doctors who work in this area are often devoted, warm-hearted foreign volunteers who frequently find they are expected to work in difficult circumstances with, at times, few resources at their disposal to perform their task. All of this can lead them to neglect the requirements of moral truth. As a result, they may be led to apply to refugees the means which appear to them to be the simplest and the speediest, with little information being offered to the patient treated, especially when communication is difficult. It is therefore important to establish good human relationships with the health care workers, medical doctors, and helpers, encouraging them, appreciating their service, and reminding them of the Word of God. Those of them who are Catholic should receive special catechetical and spiritual assistance, and clear information about the teaching of the Church in moral matters regarding the family and sexuality.
The Catholic Church cannot but listen to the cry of the poorest, of the weakest, of those who cannot intervene in the decisions that are taken on their behalf. The Church welcomes and supports them, and takes up their defence against every harmful authoritative or manipulative measure. Her relationship with the UNHCR takes place in this perspective: with her knowledge of human nature and her ethical vision, the Church can effectively encourage the UNHCR in its mission to protect the human dignity of refugees, as well as suitably lead it back, when the need arises, to a more integral respect for moral truth and the dignity of personal consciences. In this sense, the relationship between the Catholic Church and the UNHCR, in assisting refugees, can be increasingly closer and more fruitful. In this spirit of co-operation we present these indications regarding the Field Manual on Reproductive Health in Refugee Situations.
Vatican City, 14 September 2001, Feast of the Exaltation of the Holy Cross.
Pontifical Council for Health Pastoral Care
Javier Lozano Barragán,
José Luis Redrado Marchite, O.H.,
Pontifical Council for the Pastoral Care of Migrants
and Itinerant People
Stephen Fumio Hamao,
Rev. Fr. Michael A. Blume, S.V.D.,
Pontifical Council for the Family
Cardinal Alfonso López Trujillo,
Francisco Gil Hellín,
Weekly Edition in English
16 January 2002, page 7
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