The Case for Medical Conscientious Objection

COMMENTARY: If there is an area of the public square in which freedom of conscience should be robustly granted and reluctantly curtailed, health care is it.

Freedom of conscience is key to the vocation of health care.
Freedom of conscience is key to the vocation of health care. (photo: Shutterstock / Shutterstock)

Freedom of conscience, when it makes the headlines, often does so because of conscientious refusals by health-care workers to participate in certain procedures or prescribe certain drugs. The prevalence of conscience in health care is understandable, given that the substance of this field — life, death, and the human body — inevitably and regularly raises moral and ethical issues.

Although freedom of conscience is not absolute, health care is a context in which ample room should be made for moral and ethical freedom. If there is an area of the public square in which freedom of conscience should be robustly granted and reluctantly curtailed, health care is it. The idea of physicians, nurses or pharmacists assuming the posture of uncritical bureaucrats rather than morally sensitive health-care providers is unsettling, given the nature of their work.

Conscientious objection implicates procedures and drugs such as abortion, contraception, euthanasia, assisted reproduction and sex reassignment. The number of procedures and drugs that attract conscientious objection is extremely small when one considers the vast range of services that fall under the category of lawful health care in most countries.

Even so, some of the common arguments against conscientious objection in health care include claims that lawful health-care services should not be obstructed and that patients have a right to receive these services. These arguments and others fail to account properly for the human right of freedom of conscience, the circumstances of health-care workers and the nature of health care. Viewed from another perspective, they also ignore the prospect that many patients prefer to be treated by providers who share their convictions about what constitutes good medicine.

The basic motivation for conscientious objection is that the health-care service at issue does not help but harms: It injures health and is not care. Physicians who conscientiously refuse to intentionally terminate a patient’s life do so because health care, in their moral judgment, excludes killing. Health care, in their view, seeks to alleviate suffering while preserving life. Accordingly, removing moral reflection from health care may adversely affect patient care. If health care is laden with moral issues, it is dangerous to restrict the moral agency of health-care workers.

Procedures and drugs that often attract conscientious objection often involve difficult and painful decisions. In the case of abortion, a woman’s body, psychological integrity, life and the future are at stake. However, physicians who conscientiously refuse to perform abortions do so because the body, life and the future of the fetus are also at stake — not to mention their own moral and psychological integrity. The focus of health care is undoubtedly the well-being of the patient, but health-care workers are not — and given what is at stake in health care, should never be — robotic functionaries. They are human beings with human rights and must not be instrumentalized.

Accommodating conscientious objection in health care supports pluralism and sustains diversity. If the state bars conscientious objection to abortion, for example, not only will persons who conscientiously oppose abortion find themselves excluded from the medical profession, but patients who oppose abortion will lack access to like-minded physicians and other health-care workers to whom they may want to entrust their care. 

Detractors of conscientious objection in health care at times argue that this practice creates disparities in health-care delivery and disadvantages vulnerable communities, but this critique is premised on a particular vision of what counts as health care and lacks nuance. As a matter of sound public policy, a morally diverse health-care workforce is sensible for a morally diverse society.

In most jurisdictions, health-care workers may conscientiously refuse to perform certain procedures or prescribe certain drugs — though legal protections on this front are diminishing. The main point of contention, however, is referrals. Referrals are problematic for some health-care workers because, in their view, they amount to material cooperation with immoral activity. 

When it comes to abortion and euthanasia, a referral is similar to driving the robber to the bank — a degree of complicity that makes the driver no less a bank robber than the person who forces the teller to empty the safe at gunpoint. Alternatives to mandatory referrals for procedures that commonly attract conscientious objection — such as centralized coordination services for these procedures — can reconcile patient access to the full range of lawful services with the moral freedom of health-care workers to avoid becoming complicit in delivering them.

If moral freedom is what freedom of conscience protects, why we protect this freedom boils down to the fact that conscience touches on core convictions that sustain our identity and integrity — who I am and what I stand for, in the deepest sense. In this respect, matters of conscience are not matters of discretion. They are matters of duty. Professionals in a crisis of conscience have two choices: Resign or violate these convictions. If they resign, they give up their professional calling. If they violate their conscience, they engage in self-betrayal, which our modern world in nearly any other circumstance would assuredly recognize as a deep harm.  

Many health-care workers view their work as more than just a job or a career. The practice of medicine has existed since antiquity. The Hippocratic Oath, the classic statement of ethics for physicians, dates to the fourth or fifth century B.C. For many, joining this profession was a response to a calling. To them, it is a vocation. It is fair to say, especially in the era of COVID-19, that most of us think of health-care workers in this way. 

Today, many people believe that a physician mired in a crisis of conscience should resign. Some might even say that she should not have been allowed to attend medical school. These opinions are side effects of our failure to understand freedom of conscience and the principles it safeguards — identity and integrity, both of which intersect with human dignity. This failure increases the chance that this basic human right, which serves to orient the moral compass of a society, will be curtailed more than is necessary. 

We should not place fellow citizens in a crisis of conscience unless there is a compelling justification for doing so. This principle ought to apply throughout the public square, but we violate it with particular risk in the realm of health care.

Brian Bird is an assistant professor at the Peter A. Allard School of Law at the University of British Columbia and a research fellow at the Religious Freedom Institute.