Healthcare relationships: Should providers have the right of conscientious objection?

Should you be able to count on your doctor to provide you with medical care that meets professional standards? In this Wi-Phi video, we’ll consider whether healthcare providers should be allowed to deny care that conflicts with their conscience. June is worried about her sudden fatigue and headaches, so she makes an appointment with her provider, Dr. Joseph. When Dr. Joseph’s examination reveals that June is five weeks pregnant, she immediately knows she wants an abortion. She’s never wanted children, and as a 44-year-old woman with high blood pressure, her pregnancy comes with a high risk that she and the fetus will develop health complications – or worse. Asking Dr. Joseph about options for terminating her pregnancy, June is taken aback June is taken aback when he simply replies that he can’t help her with that. When June asks about the abortion pill, he refuses to write a prescription. He also refuses to refer her to another provider or even explain the pill’s safety and effectiveness. “Sorry, but I believe abortion is murder,” he says, and he cannot in good conscience be involved. Conscientious objection is when a person refuses to participate in an activity expected by their position, basing their objection on an irreconcilable conflict between doing their job and adhering to their personal morals. You might have heard about pacifists refusing to report for mandatory military duty. But conscientious objection is also relevant in healthcare, where decisions often touch on deeply personal issues, like how to deal with suffering and what makes life worth living. Many oppose conscientious objection in healthcare, emphasizing our vulnerability as patients. We trust clinicians with our bodies, expecting them to prioritize our health and well-being, not their own agenda or moral purity. From this perspective, a provider like Dr. Joseph is violating his duty to help his patients. After all, the abortion pill meets standards of care for unwanted early-stage pregnancies, especially in high-risk cases. Dr. Joseph’s refusal doesn’t help June; it only complicates her effort to care for her health and well-being, especially since he refuses to give her a referral or even do the bare minimum of providing her with basic information. And while June might have the knowledge, resources, and self-confidence to ultimately find another provider, many in similar situations don’t have these advantages – especially where medical services are scarce. Some have little choice but to turn to illicit and dangerous alternatives. Such people – those already facing social and material disadvantages – are particularly vulnerable to the dangers of allowing conscientious objection in healthcare, thus exacerbating societal injustices. Conscientious objection also undermines a patient’s autonomy – that is, their ability to live their life as they see fit. If June had to bring the pregnancy to term, her life would take a very different direction than she’d intended – likely more stressful and less satisfying. On the other hand, those who want to protect conscientious objection claim that the biggest threat to autonomy in such cases is that faced by the clinicians themselves. After all, it’s not simply that Dr. Joseph finds abortion distasteful – we all have to tolerate some unpleasant parts of our job. Dr. Joseph’s objection to prescribing the abortion pill despite accepted standards, is that it conflicts with his moral beliefs about which beings are worthy of care and, thus, which acts of killing qualify as murder. Like other conscientious objectors, Dr. Joseph is standing up for convictions core to his identity. Requiring him to participate in June’s abortion would mean requiring him to compromise his moral integrity. Nor would it be just this once. Without the right of conscientious objection, Dr. Joseph will be forced to violate his core convictions every time a patient wants an abortion. How can he assist them time after time and continue to see himself as a moral person, standing against abortion as a form of murder? Nor would a blanket prohibition on conscientious objection only create problems for providers on Dr. Joseph’s side of the abortion debate. Consider Dr. Emily, a fierce advocate for reproductive choice, whose local government’s healthcare standards require her to show patients an ultrasound image of their fetus, and fully describe it, before fulfiling their abortion request. Dr. Emily objects to this mandatory process, convinced it doesn’t help inform patients, but rather aims to emotionally manipulate them not to abort even when they’re otherwise sure they should. Prohibiting conscientious objection in healthcare would threaten not just Dr. Joseph’s moral integrity, but Dr. Emily’s as well. As proponents see it, living in a pluralist society – a society that recognizes and welcomes people with a wide range of identity commitments – requires making as much room as possible for everyone to live autonomous lives. And this includes protecting conscientious objection. Critics, though, deny that prohibitions on conscientious objection undermine provider autonomy. Sure, clinicians will sometimes have to do things they have a hard time living with. But these are among the personal risks and sacrifices they knowingly and voluntarily take on in choosing to enter their profession. Unlike a pacifist drafted for mandatory military service, no one forced Dr. Joseph to become a primary care doctor, serving people who might get pregnant and want an abortion. He could easily have chosen geriatric or orthopedic medicine – or something outside of healthcare, entirely. Still, we might not want to be too quick about telling anyone who objects to meeting some current standard of care that they should just pursue some other career instead. While the development of standards has been importan in increasing the safety, reliability and integrity of clinical care, the experts developing these standards tend to come from a narrow segment of the population and have their own biases. Intentionally or not, then, these standards might be infused with ethical, cultural, and other norms and assumptions that fail to reflect the perspectives of all groups, especially groups most likely to be excluded from the process of developing these standards. Telling people, especially those already marginalized, that they must either abide by accepted standards or pursue other – perhaps less interesting or lucrative – career options seems unfair to these individuals, and a recipe for perpetuating injustice in these higher-status careers. It also means that patients from these underrepresented and more vulnerable groups might have a harder time finding clinicians they identify with and trust when they need care or need to make tough medical decisions. More generally, making people who otherwise have all the hallmarks of being good clinicians feel unwelcome in the field or in certain specializations could lead to problematic shortages in quality providers. Finally, strong demands of conformity tend to undermine the kind of critical, innovative thinking that’s essential for challenging professional biases and blindspots and exploring unproven ideas in a field that already depends heavily on trial and error to further understanding and develop better solutions. On the one hand, then, we need standards of care to ensure that patients at their most vulnerable are being cared for by a system that has their best interests in mind, not left to the mercy of their provider’s idiosyncratic beliefs. On the other hand, it’s important that these standards reflect a wide range of perspectives and be open to critical reassessment to mitigate their own errors, biases, and injustices. So, when, if ever, should conscientious objection in healthcare be protected? What do you think?