BMJ  2006;332:294-297 (4 February), doi:10.1136/bmj.332.7536.294

Analysis and comment

Ethics

Conscientious objection in medicine

¹ Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford OX1 1PT julian.savulescu{at}philosophy.ox.ac.uk

Deeply held religious beliefs may conflict with some aspects of medical practice. But doctors cannot make moral judgments on behalf of patients

Shakespeare wrote that "Conscience is but a word cowards use, devised at first to keep the strong in awe" (Richard III V.iv.1.7). Conscience, indeed, can be an excuse for vice or invoked to avoid doing one's duty. When the duty is a true duty, conscientious objection is wrong and immoral. When there is a grave duty, it should be illegal. A doctors' conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient's good and the patient's informed desires (box). If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.

Problem of conscientious objection

Doctors have always given a special place to their own values in the delivery of health care. They have always had greater knowledge of the effects of medical treatment, and this fostered a belief that they should decide which treatments are appropriate for patients— that is, paternalism. Their values crept into clinical decisions.^{1 2} This has been squarely overturned by greater patient participation in decision making and the importance given to respecting patients' autonomy.³ More recently, doctors' values have reappeared as a right to conscientiously object to offering certain medical services. Examples include, refusal to offer termination of pregnancy, especially late term termination, to women who are legally entitled to it and refusal to provide reproductive advice and help to gay couples, single women, or others deemed socially unacceptable.

Conscience, for Shakespeare's Richard III, was "but a word cowards use" Credit: ©PHILIP MOULD, HISTORICAL PORTRAITS LTD, LONDON, UK;/BRIDGEMAN ART LIBRARY

 

In the United States pressure has been put on Catholic hospitals to allow obstetricians to sterilise women immediately after giving birth.⁴ Alto Charo notes that a recently proposed Wisconsin bill would allow doctors to refrain from a broad range of activities, including counselling patients:

The privilege of abstaining from counseling or referring would extend to such situations as emergency contraception for rape victims, in vitro fertilization for infertile couples, patients' requests that painful and futile treatments be withheld or withdrawn, and therapies developed with the use of fetal tissue or embryonic stem cells. This last provision could mean, for example, that pediatricians... could refuse to tell parents about the availability of varicella vaccine for their children, because it was developed with the use of tissue from aborted fetuses.⁵

Determinants of medical care Law Just distribution of finite resources Patient's informed desires Not doctors' values

Indeed, one Wisconsin pharmacist refused to fill an emergency contraception prescription for a rape victim. She became pregnant and had an abortion.⁵

Arguments against conscientious objection

Inefficiency and inequity
In public medicine, conscientious objection introduces inequity and inefficiency. In a survey I conducted several years ago,⁶ around 80% of clinical geneticists and obstetricians specialising in ultrasonography believed termination of pregnancy should be available for a normal 13 week pregnancy if the woman wants it for career reasons. However, only about 40% were prepared to facilitate it. This implied that less than half of doctors whose primary job is to deal with termination of pregnancy would facilitate a termination at 13 weeks if the woman wanted it for career reasons. The service that patients receive depends on the values of the treating doctor. Not only does this imply that patients must shop among doctors to receive the service to which they are entitled, introducing inefficiency and wasting resources, it also means some patients, less informed of their entitlements, will fail to receive a service they should have received. This inequity is unjustifiable.

Inconsistency
Imagine an intensive care doctor refusing to treat people over the age of 70 because he believes such patients have had a fair innings. This is a plausible moral view,⁷ but it would be inappropriate for him to conscientiously object to delivering such services if society has deemed patients are entitled to treatment.

Or imagine in an epidemic of bird flu or other infectious disease that a specialist decided she valued her own life more than her duty to treat her patients. Such a set of values would be incompatible with being a doctor.

If there is any justification for compromising the care of patients, it must be a grave risk to a doctor's physical welfare. But if self interest and self preservation are not generally deemed sufficient grounds for conscientious objection, how can religious or other values be?

Commitments of a doctor
These examples show that people have to take on certain commitments in order to become a doctor. They are a part of being a doctor. Someone not prepared on religious grounds to do internal examinations of women should not become a gynaecologist. To be a doctor is to be willing and able to offer appropriate medical interventions that are legal, beneficial, desired by the patient, and a part of a just healthcare system.

If we do not allow moral values or self interest to corrupt the delivery of the just and legal delivery of health services, we should not let other values, such as religious values, corrupt them either.

Discrimination
Sometimes religious values are considered special. However, to treat religious values differently from secular moral values is to discriminate unfairly against the secular, a practice not uncommon in medical ethics.⁸ Other values can be as closely held and as central to conceptions of the good life as religious values.

Place for conscientious objection

The argument in favour of allowing conscientious objection is that to fail to do so harms the doctor and constrains liberty. This is true. When a doctor's values can be accommodated without compromising the quality and efficiency of public medicine they should, of course, be accommodated. If many doctors are prepared to perform a procedure and known to be so, there is an argument for allowing a few to object out. A few obstetricians refusing to perform abortions may be tolerable if many others are prepared to perform these, just as a few self-interested infectious disease doctors refusing to treat patients in a flu epidemic, on the grounds of self interest, might be tolerable if there were enough altruistic physicians willing to risk their health. But when conscientious objection compromises the quality, efficiency, or equitable delivery of a service, it should not be tolerated. The primary goal of a health service is to protect the health of its recipients.

Certain constraints are necessary to ensure the legal, equitable, and efficient delivery of health care:

• Medical students and trainees must be aware of the commitments of the profession and be prepared to undertake these or not become doctors
  
• The medical profession has an obligation to ensure that all patients are aware of the full range of services to which they are entitled
  
• Any would-be conscientious objector must ensure that patients know about and receive care that they are entitled to from another professional in a timely manner that does not compromise their access to care
  
• Doctors who compromise the delivery of medical services to patients on conscience grounds must be punished through removal of licence to practise and other legal mechanisms
  
• The place for expression and consideration of different values is at the level of policy relating to public medicine.
  

Legal uncertainty

In some areas of medicine, such as the hastening of death and late termination of pregnancy, doctors may in good faith be uncertain as to whether an intervention is legal. In 1990, the Human Fertilisation and Embryology Act in the United Kingdom reduced the limit for "social termination" to 24 weeks, but placed no upper gestational limit on termination when there is "substantial risk of serious handicap" or if it is necessary to prevent "grave permanent injury to the physical or mental health of the pregnant woman." Concern has been expressed about what constitutes a substantial risk and a serious handicap. Lilford and Thornton claimed that the issue might cause significant public controversy and expressed their "deep personal uncertainty."⁹ In 1993, Green asked 391 obstetric consultants in the United Kingdom how late they would be prepared to offer termination of pregnancy for anencephaly, spina bifida, and Down's syndrome.¹⁰ She found that 89% of consultants would offer termination for anencephaly at 24 weeks, falling to 64% beyond 24 weeks. For Down's syndrome, 60% would offer termination at 24 weeks but only 13% after this time. For open spina bifida, 53% would offer termination at 24 weeks and 21% after 24 weeks.

Summary points A doctor's conscience should not be allowed to interfere with medical care All doctors and medical students should be aware of their responsibility to provide all legal and beneficial care Conscientious objection may be permissible if sufficient doctors are willing to provide the service Conscientious objectors must ensure that their patients are aware of the care they are entitled to and refer them to another professional Conscientious objectors who compromise the care of their patients must be disciplined

In Australia, laws relating to late termination are even more unclear and vary from state to state.^{6 11} My survey of clinical geneticists and obstetricians with specialist training in obstetric ultrasonography showed similar variation in practice to that found by Green.⁶ I asked respondents to imagine that a pregnant woman presents after prenatal testing with one of several diagnoses at 13 and 24 weeks. These included anencephaly, trisomy 18, hypoplastic left heart, spina bifida with hydrocephalus, fragile X syndrome, Down's syndrome, achondroplasia, and cleft palate. I also asked respondents about pregnancies in which the fetus was normal. Some practitioners would not facilitate termination at 24 weeks even for lethal abnormalities. Fewer practitioners supported termination or would facilitate it at 24 weeks than at 13 weeks for all conditions. The difference in opinion between 24 and 13 weeks was greatest for pregnancies in which the fetus was normal or had a relatively mild disorder. There was a lack of consensus about which abnormalities were severe enough to warrant termination and up to what gestation termination is acceptable. For example, around 75% of respondents believed termination should be available for dwarfism at 24 weeks.

Such wide variation in practice around late termination is due both to practitioners' differing values but also to legitimate uncertainty about the legal status of late termination for "milder" conditions. I have argued elsewhere that we urgently need to clarify the law in this area.¹¹ In the absence of such clarification, practitioners have a legitimate right to refuse to provide a service which they believe to be illegal. However, they should make this reason clear to patients and also the fact that the law is unclear. They should also inform patients of the availability of other practitioners who take a different view of the law.

Private elective medicine

Private elective medicine is different from public medicine. Doctors have more liberty to offer the service of their choice, based on their values. Nevertheless, for patients to give valid consent to treatment, they must be informed of relevant alternatives and their risks and benefits (in a reasonable, complete, and unbiased way).

Conclusion

Values are important parts of our lives. But values and conscience have different roles in public and private life. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patient. The door to "value-driven medicine" is a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own.

---

Contributors and sources: JS is a professional medical ethicist with experience in practising general and emergency medicine. This article arose from reflections on the literature and his experience

Competing interests: None declared.

References

1. Hope T, Sprigings D, Crisp R. Not clinically indicated: patients' interests or resource allocation? BMJ 1993;306: 379-81.
2. Savulescu J. Rational non-interventional paternalism: why doctors ought to make judgements of what is best for their patients. J Med Ethics 1995;21: 327-31.[Abstract]
3. Brock DW, Wartman SA. When competent patients make irrational choices. N Engl J Med 1990;322: 1595-9.[ISI][Medline]
4. Collett TS. Protecting the health care provider's right of conscience. Center for Bioethics and Human Dignity, 2004. www.cbhd.org/resources/healthcare/collett_2004-04-27.htm (accessed 23 Jan 2006).
5. Alto Charo R. The celestial fire of conscience—refusing to deliver medical care. N Engl J Med 2005;352: 2471-3.[Free Full Text]
6. Savulescu J. Is current practice around late termination of pregnancy eugenic and discriminatory? Maternal interests and abortion. J Med Ethics 2001;27: 165-71.[Abstract/Free Full Text]
7. Harris J. The value of life. London: Routledge, 1985.
8. Savulescu J. Two worlds apart: religion and ethics. J Med Ethics 1998;24: 382-4.[Abstract]
9. Lilford RJ, Thornton J. Ethics and late TOP. Lancet 1993;342: 499.
10. Green J. Ethics and late TOP. Lancet 1993;342: 1179.[CrossRef]
11. De Crespigny LJ, Savulescu J. Abortion: time to clarify Australia's confusing laws. Med J Aust 2004;181: 201-3.[Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

Conscientious objection in medicine: Author did not meet standards of argument based ethics

Frank A Chervenak and Laurence B McCullough
BMJ 2006 332: 425. [Extract] [Full Text]

Conscientious objection in medicine: Doctors' freedom of conscience

Vaughan P Smith
BMJ 2006 332: 425. [Extract] [Full Text]

Conscientious objection in medicine: The ethics of responding to bird flu

Elizabeth Murray and Paquita de Zulueta
BMJ 2006 332: 425. [Extract] [Full Text]

Learning for life

Fiona Godlee
BMJ 2006 332: 0. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Mirkes, R. (2008). Protecting the Right of Informed Conscience in Reproductive Medicine. J Med Philos 33: 374-393 [Abstract] [Full text]  
• Curlin, F. A., Lawrence, R. E., Chin, M. H., Lantos, J. D. (2007). Religion, Conscience, and Controversial Clinical Practices. NEJM 356: 593-600 [Abstract] [Full text]  
• Evans, E. W. (2007). Conscientious objection: A pharmacist's right or professional negligence?. Am J Health Syst Pharm 64: 139-141 [Full text]  
• Chervenak, F. A, McCullough, L. B (2006). Conscientious objection in medicine: author did not meet standards of argument based ethics.. BMJ 332: 425-425 [Full text]  
• Smith, V. P (2006). Conscientious objection in medicine: doctors' freedom of conscience.. BMJ 332: 425-425 [Full text]  
• Murray, E., de Zulueta, P. (2006). Conscientious objection in medicine: the ethics of responding to bird flu.. BMJ 332: 425-425 [Full text]  

Rapid Responses:

Read all Rapid Responses

benefits

Karen Palmer
bmj.com, 4 Feb 2006 [Full text]

Six objections to Savulescu's salvos

Trevor G Stammers
bmj.com, 4 Feb 2006 [Full text]

Lack of debate

Jose J De Murtinho-Braga
bmj.com, 5 Feb 2006 [Full text]

Objections to conscientious objection

T Everett Julyan
bmj.com, 5 Feb 2006 [Full text]

Should conscientious objection be tolerated?

David R Clegg, et al.
bmj.com, 5 Feb 2006 [Full text]

Savulescu on Conscience

Michael Gillan Peckitt
bmj.com, 5 Feb 2006 [Full text]

A personal moral code

Anthony Papagiannis
bmj.com, 5 Feb 2006 [Full text]

Conscientious objection: Savulescu's illogical arguments

Michael Jarmulowicz
bmj.com, 5 Feb 2006 [Full text]

Execution by lethal injection

rb jones
bmj.com, 5 Feb 2006 [Full text]

Good and evil- its recognition

John. H Scotson
bmj.com, 6 Feb 2006 [Full text]

Doctors have rights too

Charles A. Foster, et al.
bmj.com, 6 Feb 2006 [Full text]

Conscience is our safeguard

Andrew F West
bmj.com, 6 Feb 2006 [Full text]

Please protect me from intolerance

Tom Van der Linden
bmj.com, 6 Feb 2006 [Full text]

Concientious objection is a manifestation of free choice

David Lewis
bmj.com, 6 Feb 2006 [Full text]

Is there a real difference between a 'secular' and 'religious' value?

Stuart J Fergusson
bmj.com, 6 Feb 2006 [Full text]

The path of Savulescu's logic leads to strange places.

James D Stevenson
bmj.com, 6 Feb 2006 [Full text]

Savulescu's interesting take on Law

Peter KK Au-Yeung
bmj.com, 7 Feb 2006 [Full text]

Conscientious objection

Edmund J Dunstan
bmj.com, 7 Feb 2006 [Full text]

So sprach Superego

Adrian Blaj
bmj.com, 7 Feb 2006 [Full text]

Wholesomeness is crucial to ethical care

Paul D Kelly
bmj.com, 7 Feb 2006 [Full text]

A higher duty

Frank H Bloomfield
bmj.com, 7 Feb 2006 [Full text]

Conscientious objection in medicine

John B Zachary
bmj.com, 7 Feb 2006 [Full text]

Autonomy is never absolute

Surendra I Deo
bmj.com, 7 Feb 2006 [Full text]

Objections to objecting to objection

David J Shepherd
bmj.com, 7 Feb 2006 [Full text]

Legal or decriminalised unproven benefit

Anne M Williams
bmj.com, 7 Feb 2006 [Full text]

Please reconsider this unfortunate position

shimon M. Glick
bmj.com, 7 Feb 2006 [Full text]

"Conscientious objection...wrong and immoral"?

Alasdair H B Fyfe
bmj.com, 8 Feb 2006 [Full text]

Analysis and learning for all

Stephen Bamber
bmj.com, 8 Feb 2006 [Full text]

Autonomy and Conscience

Ian McD Jessiman
bmj.com, 8 Feb 2006 [Full text]

Conscientious objection in medicine: the ethics of responding to bird flu.

Elizabeth Murray, et al.
bmj.com, 8 Feb 2006 [Full text]

The value of conscience

Amitava Banerjee
bmj.com, 8 Feb 2006 [Full text]

Failure to Meet Standards of Argument-Based Ethics

Laurence B McCullough, et al.
bmj.com, 9 Feb 2006 [Full text]

Conscience and society

Ronald J Clearkin
bmj.com, 9 Feb 2006 [Full text]

Poor analysis, setting rights against law

Adrian K Midgley
bmj.com, 9 Feb 2006 [Full text]

Doctors' freedom of conscience

Vaughan P Smith
bmj.com, 9 Feb 2006 [Full text]

The Priority of Professional Ethics Over Personal Morality

Rosamond Rhodes
bmj.com, 9 Feb 2006 [Full text]

Discussion warrants more careful precision

Alexander C. Tsai
bmj.com, 9 Feb 2006 [Full text]

Avoid selective use of law

Peter Gooderham
bmj.com, 9 Feb 2006 [Full text]

What are the editors doing?

Steve Kelly
bmj.com, 9 Feb 2006 [Full text]

ethical rules

benjamin dean
bmj.com, 10 Feb 2006 [Full text]

Re: What are the editors doing?

John P Heptonstall
bmj.com, 10 Feb 2006 [Full text]

Is Savulescu displaying double standards?

Christopher J Harrison
bmj.com, 10 Feb 2006 [Full text]

Are Objections to Conscientious Objectors Unconsciously Unconscientious?

Andrew Ashworth
bmj.com, 10 Feb 2006 [Full text]

There will be no loyalty, except loyalty towards the Party

Giles N Cattermole
bmj.com, 11 Feb 2006 [Full text]

Poor example of editing standards at BMJ

Kelly A Markham
bmj.com, 12 Feb 2006 [Full text]

"Beneficial" is a value judgement.

John P. Watson
bmj.com, 13 Feb 2006 [Full text]

Re: Six objections to Savulescu's salvos

Stephen Hayes
bmj.com, 14 Feb 2006 [Full text]

Re: Re: Six objections to Savulescu's salvos

Peter KK Au-Yeung
bmj.com, 21 Feb 2006 [Full text]

Conscientious objection is not cowardice

Eldad J Ben-Eliezer
bmj.com, 15 Feb 2006 [Full text]

Conscientious objection and the difficulty of consensus

Piers M W Benn
bmj.com, 16 Feb 2006 [Full text]

In defence of conscientious objection

Hugo van Woerden
bmj.com, 16 Feb 2006 [Full text]

Re: Conscientious objection and the difficulty of consensus

Tom G Heyes
bmj.com, 17 Feb 2006 [Full text]

Re: The difficulty of consensus in real cases

David Jones
bmj.com, 21 Feb 2006 [Full text]

Conscientious objection in medicine

Tom R C Boyde
bmj.com, 21 Feb 2006 [Full text]

Truth in Unity

Philip G. Ney
bmj.com, 24 Feb 2006 [Full text]

Conscientious objection in medicine

Sylvia M Watkins
bmj.com, 9 Mar 2006 [Full text]

Conscientious objection in medicine: Quoting the Villain in Shakespeare

Brian J Bane
bmj.com, 13 Mar 2006 [Full text]

Without conscience and without wisdom - towards the abolition of man

Marta Munzarova, et al.
bmj.com, 31 Mar 2006 [Full text]