Navigating the Grey Zones of Abortion Law in Sri Lanka: Clinical Case Narratives at the Intersection of Law, Ethics, and Reproductive Health

Introduction: In Sri Lanka, abortion is legally permitted only to preserve the life of the woman. In routine obstetric and gynaecological practice, clinicians frequently encounter ethically complex and clinically high-risk situations that fall outside this narrow legal exception. Although unsafe abortion is no longer a leading direct cause of maternal mortality, it continues to contribute substantially to preventable maternal morbidity, psychological harm, and ethical distress within a highly restrictive legal framework. Objectives: To describe recurrent clinical situations not accommodated by Sri Lanka’s abortion law and to explore how clinicians navigate ethical decision-making under legal constraint using experience-based clinical case narratives. Methods: Five anonymised clinical case narratives were purposively selected from long-term government obstetric and gynaecological practice to illustrate commonly encountered but legally unaddressed scenarios. A qualitative descriptive approach using thematic framework analysis was applied. Cases were examined across predefined grey-zone domains, including sexual violence, severe or lethal fetal anomalies, pregnancy in minors, impaired decisional capacity, and significant psychosocial vulnerability. Analysis was situated within statutory law, ethical principles, national clinical guidance, and relevant international human rights standards. Results: Cross-case analysis revealed a consistent pattern of legal-ethical conflict arising from the absence of lawful options beyond the single ground of preserving the woman’s life. Recurrent challenges included the inability to intervene even in the cases with despite lethal fetal prognosis, lack of legal recourse following rape or in minors, uncertainty in best-interest decision-making where decisional capacity was impaired, and constrained or delayed care in situations of profound psychosocial distress. Across all cases, the undefined legal threshold generated clinician uncertainty, moral distress, and a reliance on defensive or temporising management strategies. Conclusion: These narratives illustrate how restrictive abortion law translates into ethical conflict and constrained clinical care in everyday practice. Clarification of legal standards and evidence-informed reform particularly in cases involving rape, severe fetal anomalies, minors, and marked vulnerability would better align law with ethical clinical practice, reduce preventable harm, and support clinicians in providing compassionate, professionally accountable care

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