Conscientious objection – to be or not to be

In this issue we publish two manuscripts dealing with the problem of conscientious objection by health care professionals with regard to medical interventions they consider incompatible with their personal ethical values. The focus of both papers is on the right of women to have rapid and easy access to safe and effective abortion. The question both papers deal with is whether allowing conscientious objection to health care professionals working in the field of sexual and reproductive health undermines this right and harms women’s reproductive health, and as such should not be allowed.

Lerxtundi et al. define the framework and obligations of a health care system to ensure effective abortion care in a country where individual conscientious objection is allowed. The authors focus on the necessary regulations for institutions and individuals to assure best abortion care.

Fiala et al. argue, that the health care professional is in a powerful position and abuses this power by putting his or her values above the right of a patient to receive the care she feels that she needs or to which she is entitled to by the national law in her country. In this perspective, conscientious objection is by definition unethical and as such should be banned. The authors cite the examples of Sweden, Finland and Iceland, where conscientious objection is not allowed and where, according to the authors, sexual and reproductive health care and abortion care reaches the highest standards. To become a health care professional in obstetrics/gynaecology or reproductive health in Sweden, Finland and Iceland individuals have to perform abortions as part of their professional duties. If for personal moral reasons these individuals do not want to be trained in and to perform abortion they are advised to train and specialise in another field of medicine.

Both papers argue that conscientious objection in reproductive medicine is a way of indirectly undermining women’s sexual rights and autonomy.

The European Society of Contraception and Reproductive Health (ESC) is not only a scientific society but also one committed to defending women’s sexual and reproductive rights. Should the ESC therefore regard conscientious objection as professional disobedience and argue that objectors should either be excluded from the profession or compelled to do what they do not want to do?

This is a complicated issue that raises many questions. Why is it that in some countries conscientious objection for doctors is enshrined in law? Is it simply due to the influence and power of the (Catholic) Church, or is there an ethical dimension? Does the fact that this concept is abused by anti-choice movements make the whole notion invalid, even destructive?

What happens if we define, even insist, that a doctor is a service provider whose personal values must not have any impact on his or her behaviour, and that he or she must accede either to the law or to the wishes of the patient (unconditional obedience to the law or to the autonomy of the patient)?

Some would argue that in times when the law prohibited abortion there were some brave doctors who were unlawful and followed their conscience in performing abortion. And do we not need doctors who are human beings with values who reflect on what they are doing according to a transparent, ethical framework?

Let me first make a personal remark: I have carried out and continue to carry out abortions according to the well-known bioethical principles described by Beauchamp and Childress:[1]

• respect for the autonomy of the woman with regard to her reproductive choice;

• non-maleficence (by not leaving her alone in a situation with which she cannot cope);

• beneficence (by helping her to achieve her goals and maintain her physical and psychosocial health);

• justice (by providing medical intervention to every woman in need, independently of sociocultural differences).

The conscientious objector within me would tell me that I am destroying life and therefore acting against a fundamental moral and ethical value. This is true: there is indeed a conflict between my professional and ethical duties towards the woman and my general professional and ethical duties towards emerging life (embryo, fetus). In this conflict, however, my duties towards the woman override all others, because without her body there would be no new life and without her support there would be no good life.

We must be transparent and make it clear that performing an abortion is an act based on professional ethics, i.e., on a conscious decision to resolve an ethical conflict. In my experience as an academic teacher and trainer, almost all trainees and colleagues are able to follow this argument.

What should we do, however, with those who refuse to follow this argument and who put their personal conscience above their professional duties? According to the ethical guidelines of the American College of Physicians (ACP) in the chapter ‘Decisions about reproduction’:[2] ‘The ethical duty to disclose relevant information about human reproduction to the patient may conflict with the physician’s personal moral standards on abortion, sterilisation, contraception, or other reproductive services. A physician who objects to these services is not obligated to recommend, perform, or prescribe them’. This sounds simple: the physician’s personal moral standards are a criterion for conscience-based refusal to provide professional help. In the military, however, this would not be sufficient grounds for acceptance of conscientious objection.

What constitutes a ‘real’ conscientious objector as opposed to someone who just does not want to do his or her job? In his book Conscientious objection in health care: an ethical analysis,[3] Mark Wicclair provides an important definition:

An agent’s refusal to provide a good or service is a conscience-based refusal if, and only if:

• the agent has a core set of moral (i.e., ethical or religious) beliefs;

• providing the good or service is incompatible with the agent’s core beliefs; and

• the agent’s refusal is based on his or her core moral beliefs.

This is about the credibility of the conscientious objector. Are the moral values on which refusal to provide a service is based visible and general in the objector’s life; for example, is the objector active in helping abandoned children, engaged in child protection programmes, does he or she help support single mothers? Provided that these conditions are fulfilled, individual conscience would then override specific professional duties. But, again this is not so simple because, according to McCullough:[4] ‘Conscientious objection is made against clinically justified (because it protects and promotes the health-related interests of patients according to professional standards of clinical judgment and practice), ethically justified (because there is valid consent), and legally justified (because permitted or sanctioned by law) forms of clinical management’. Therefore, conscientious objection creates by definition a conflict with regard to the limitations and duties of the conscientious objector. According to Wicclair:[3]

There are three core professional obligations – i.e., obligations to patients central to its [each profession’s] self-definition or identify and provide a basis for more specific obligations. These are an obligation:

• to respect patient dignity and refrain from discrimination;

• to promote patient health and well-being; and

• to respect patient autonomy.

These core professional obligations generate ethically justified constraints on conscience in relation to: (1) discrimination; (2) patient harms and burdens; (3) disclosing options; (4) referral and/or facilitating a transfer; and (5) advance notification.

Based on this concept of professional ethics, specific duties of conscientious objectors have been defined in the ACP guidelines mentioned above:[2] ‘As in any other medical situation, however, the physician has a duty to inform the patient about care options and alternatives, or refer the patient for such information, so that the patient’s rights are not constrained. Physicians unable to provide such information should transfer care as long as the health of the patient is not compromised’.

A more detailed description is provided by the UK’s General Medical Council:[5]

• You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients. This means you must not refuse to treat a particular patient or group of patients because of your personal beliefs or views about them. And you must not refuse to treat the health consequences of lifestyle choices to which you object because of your beliefs.

• Employing and contracting bodies are entitled to require doctors to fulfil contractual requirements that may restrict doctors’ freedom to work in accordance with their conscience. This is a matter between doctors and their employing or contracting bodies.

• If, having taken account of your legal and ethical obligations, you wish to exercise a conscientious objection to particular services or procedures, you must do your best to make sure that patients who may consult you about it are aware of your objection in advance. You can do this by making sure that any printed material about your practice and the services you provide explains if there are any services you will not normally provide because of a conscientious objection.

• You should also be open with employers, partners or colleagues about your conscientious objection. You should explore with them how you can practise in accordance with your beliefs without compromising patient care and without overburdening colleagues.

• Patients have a right to information about their condition and the options open to them. If you have a conscientious objection to a treatment or procedure that may be clinically appropriate for the patient, you must do the following:

  1. Tell the patient that you do not provide the particular treatment or procedure, being careful not to cause distress. You may wish to mention the reason for your objection, but you must be careful not to imply any judgement of the patient.

  2. Tell the patient that they have a right to discuss their condition and the options for treatment (including the option that you object to) with another practitioner who does not hold the same objection as you and can advise them about the treatment or procedure you object to.

  3. Make sure that the patient has enough information to arrange to see another doctor who does not hold the same objection as you.

• If it’s not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made – without delay – for another suitably qualified colleague to advise, treat or refer the patient. You must bear in mind the patient’s vulnerability and act promptly to make sure they are not denied appropriate treatment or services. If the patient has a disability, you should make reasonable adjustments to your practice to allow them to receive care to meet their needs. In emergencies, you must not refuse to provide treatment necessary to save the life of, or prevent serious deterioration in the health of, a person because the treatment conflicts with your personal beliefs.

• You will not necessarily need to end a consultation with your patient because you have an objection to a treatment or procedure that may be appropriate for them. However, if you feel (or the patient feels) that your conscientious objection prevents you from making an objective assessment, you should suggest again that the patient seeks advice and treatment elsewhere.

• You must not obstruct patients from accessing services or leave them with nowhere to turn.

• Whatever your personal beliefs about the procedure in question, you must be respectful of the patient’s dignity and views.

So we are left with two options:

1. Allow conscientious objection as an ethical value, but define it clearly and indicate its limitations with regard to the professional duties of health care professionals and the right of women to receive patient-centred, effective and safe abortion care.

2. Disallow conscientious objection in the field of women’s reproductive health specifically with respect to abortion and female reproductive health.

Your comments and contributions are welcome.

Johannes Bitzer

Editor-in-Chief, The European Journal of Contraception and Reproductive Health Care

[email protected]