countries that have abortion laws that disproportionately affect women of distinct racial or ethnic status could well be challenged on grounds of sex and race discrimination. Nondiscrimination serves the ethic of justice, half of which requires that we treat the same interests equally, without discrimination – for example, in access of people of both sexes to education. The other half requires that we treat different interests in ways that adequately respect those differences, particularly in women’s distinct interests in safety in abortion services. Rights to equitable protection of different interests are violated when governments fail to address the fundamental biological difference between men and women through which, year after year worldwide, many hundreds of thousands of women die unnecessarily. Men and women are equal, codependent partners in human societies, and the biological difference between them should not be invoked as immutably destining women for pregnancy-related or abortion-related death or disability. The CEDAW General Recommendation 24 on Women and Health requires that states should eliminate all forms of discrimination against women in the context of Book ch.02.qxd 11.2.2005 10:36 Page 26 health and health care, and should ensure that women can exercise and enjoy human rights and fundamental freedoms on the basis of equality with men. The Recommendation makes clear that discrimination occurs against women when health systems refuse or neglect to provide health services that only women need, such as safe abortion services. The Recommendation further argues that states are obligated to remedy this situation. Human rights needs assessment A necessary step towards applying human rights to advance women’s health in the context of abortion is an assessment of the scope, causes and consequences of unsafe abortion in a particular community and culture, based on available data sources, or on the collection of relevant new data. Local assessment should identify laws, including the language of enacted laws and the decisions of courts, and the policies of governments, health care facilities and other influential agencies, which facilitate or obstruct availability of and access to abortion services. The extent to which laws that would facilitate access are actually implemented or how they might be, if they are not adequately implemented, should be determined. Laws and policies that obstruct women’s autonomy and choice in decisions regarding their health generally and abortion specifically, and the availability of and access to services, should also be identified, along with laws that facilitate women’s empowerment, and laws that obstruct such empowerment. Assessment is needed of what must be done to foster compliance with human rights at different levels including clinical care, health systems, and underlying social, economic and legal conditions. These levels are not necessarily distinct and often overlap. Failure to respect women’s human rights at one level can exacerbate problems at another level. Examples of the ways a human rights needs assessment might be applied in the contexts of clinical care, health systems, and social, economic, and legal conditions are explored below. This is not the only approach to human rights needs assessment in a public health context. Work has been done on developing a human rights impact assessment in the context of HIV/AIDS (18). Indeed, careful thought, perhaps through the use of operations research, is needed to determine how best to apply it in the context of abortion services. Clinical care An assessment of the degree to which women’s human rights are respected in the context of clinical care might find that providers show a lack of respect for women’s 27 ABORTION, HUMAN RIGHTS AND THE ICPD Book ch.02.qxd 11.2.2005 10:36 Page 27 28 REBECCA J. COOK dignity and may be judgemental toward abortion clients. However, even in countries where abortion is legal on extended grounds, women’s rights to privacy in abortion care are often ignored. Health care providers should be trained in the importance of maintaining confidentiality of women seeking services. Breaches of confidentiality are not only violations of the service providers’ professional ethical duties, but also of the laws on patient confidentiality (19). One approach to ensuring respect for women’s human rights in the context of clinical care might be to examine treatment protocols for women seeking safe abortion services, or seeking treatment for incomplete or spontaneous abortion. Where such treatment protocols do not exist, steps might be taken to develop and apply them, first on a pilot basis and then, after appropriate evaluation and amendments, on a wider scale. There is need to examine the ways clinical care for abortion incorporates attention to diseases or conditions specific to or more prevalent among certain subgroups of pregnant women, such as malaria, sickle-cell trait, hepatitis and HIV/AIDS. Steps need to be taken to ensure that abortion services are provided to such women, but also to ensure that these underlying conditions are treated and that affected women are referred for appropriate treatment. A challenge is to address such health problems among women in a nondiscriminatory, constructive way. There is also a need to examine conditions with clinical