Editorials

Conscientious refusal to assist with abortion

BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6955.622 (Published 10 September 1994) Cite this as: BMJ 1994;309:622
  1. D Dooley

    Claims of conscience by doctors and nurses almost always relate to substantial moral issues that touch closely on their identity and integrity.1 Abortion is such an issue. Agreement among reasonable and sincere individuals often seems beyond reach. Ethical reasoning promises no conclusive resolution but might constructively help us to understand the sources of disagreement and search for shared principles in the differences.2

    The issues raised by abortion cannot be restricted to the simple contrast between the rights of a woman to control her reproduction and the rights of the fetus to protection from intentional harm.3,4 The discussion has to take account of fundamental beliefs - religious, cultural, feminist, and political.5 A recognition of the complexity of beliefs about abortion is essential in asking whether health care professionals have rights to refuse to help with abortion on grounds of conscience. Beauchamp and Childress have argued that individuals and society “bear a very heavy burden of proof in arguing that coercion of conscience is necessary.”6

    People commonly decide what is morally right or wrong, good or evil, according to fundamentally different moral perspectives. Consequentialists judge acts right or wrong according to whether they yield the best overall results. This type of reasoning was evident in a commentary arguing that it is morally impermissible for nurses to refuse conscientiously to take part in second trimester abortions.7 Refusals to assist in abortion (in the first or second trimester) are frequently based on beliefs about moral duties, injunctions of natural law, and the almost nonnegotiable rights of people to be protected from intentional harm. People who hold those views recognise and regret the adverse consequences for pregnant women but find no compelling motivation to change their opposition to abortion. Even when people are willing to work at gaining a clearer understanding of their own moral traditions and seeking out shared values within disagreements the prospects remain poor for finding some neutral standpoint for resolution.8

    Critics of conscientious objectors to abortion sometimes claim that they are making an error of fact when they characterise the fetus as “innocent human life.” In reality there is no basis in fact about which anyone can be wrong or comfortably right. A judgment on the moral status of the human fetus is arrived at by a decision to assign moral significance to the agreed facts of human development. The assigning of moral significance is, in turn, dependent on each person's choice of moral perspective and accompanying values about the broader significance of human personal and social life.

    No morally neutral and non-question begging position can be found from which to judge conscientious refusals in abortion. Society can show a respect for autonomy of belief by spelling out a position that allows a presumptive right of conscientious refusal to doctors and nurses. Where abortion legislation is already in place and allows doctors a right to conscientious refusal but refuses it to nurses we need to ask why the nurses have been given second class professional and moral status.9 When a country has not yet drafted legislation a prudent government will consider, in advance, how it will find enough health care professionals who will in good conscience assist in abortions. In too many countries a law permits abortion and requires health care professionals to implement this law but little or no attention has been given to the basic principle of respecting conscientious refusal.

    Some encouragement may be found in the philosophical work being done on the task of articulating and defending an accommodation, discussing the problem of “how people in moral conflict are to live with one another.”2 Once governments take seriously the arguments for a presumptive right to conscientious refusal in abortion then health care systems can define the tasks of redistributing sectors of responsibility among health care workers and introducing necessary changes in recruitment policies for relevant specialisations.

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