Confronting Conscientious Objection

Maggie Little*

What is the role of conscience in medicine? Following the public debate last year over mandating insurance providers to cover contraception, some have argued that it is time to expunge the category of conscientious objection from medicine altogether. After all, it is said, medicine is not just any business. It is a licensed monopoly, and with such licensure comes greater responsibility. Patients in rural areas or in emergency situations often lack the ability to choose who should care for them. And those who do have options often have to find - or suddenly shift to - providers who can meet what the profession itself regards as a legitimate need. Given these issues, patients need to be protected from the harms that refusal can engender by making provision of all basic, core services a condition of professional licensure.

I certainly agree with the importance of preserving patient access to basic medical services. More than that, I am among those who believe that contraception and legal abortion should be understood as belonging to that core. Having the option to control whether to give birth is of central importance to women in maintaining bodily integrity and authorship over their lives. Data shows that access to medically controlling reproduction can have profound effects on women's health, outpacing the importance of even such basics as anti-hypertension medication. The fact that contraception and abortion are not approved of or sought by every woman does not deny their importance to those women who do.

Yet I do not agree with those who would eliminate protection for conscientious refusal. Provision of a need under one guise is commitment of a profound moral wrong under another. By its very nature, medicine intersects with some of the deepest issues in life and some disagreement is inevitable. Medicine itself would be impoverished if dissenting practitioners were not allowed into the guild.

For one, it would radically reduce the number willing to go into specialties that already face critical shortages. Areas such as obstetrics and gynecology can ill afford to lose compassionate, talented and skilled providers - some of whom have profound moral misgivings about services the profession as a whole endorses. Including those views is important to sustaining the field of medicine as a dynamic one, with open dialogue by its practicing members about morally complex issues. Finally, patients who share moral objections to certain interventions may deeply value being cared for by a like-minded practitioner. We risk alienating not just providers, but patients themselves, with policies mandating that medicine be practiced only by those who share a particular perspective.

How, then, do we adjudicate the conflict? For one thing, we should insist on high standards of conscientious objection. Properly understood, genuine conscientious objection reflects a deeply considered position, not a mere aversion, that provision of the service would be a grave wrong or deep threat to integrity. It is premised on a scientifically accurate view of the facts, not unproven assumptions. And it is based on a position that we can understand as deserving our respect. This last is a substantive matter: arbitrating its contours is as difficult as it is inescapable in a pluralist society.

Conscientious objection, then, is not something lightly invoked. Its legitimate exercise brings with it strong obligations. Objecting providers must disclose their limitations early and often to minimize patient burdens. And they must convey those restrictions with compassion and respect. Communication of conscientious objection is, first and foremost, a message about the provider, not the patient and her circumstances - and for good reason. The very premise of protecting conscientious refusal, after all, is that deeply good and reasonable people disagree on the issue.

Finally, there are limits to the right of conscientious objection. To give just one example, specialists who care for high-risk pregnancies - so-called maternal-fetal specialists - will predictably encounter women for whom continued pregnancy is as likely to lead to maternal death as it is not. If someone cannot, in good conscience, personally perform an abortion in such a circumstance, then one needs to partner with willing providers identified ahead of time - or choose a different specialty.

The requirements for and limitations to conscientious objection are surely complex. But medicine does best when it confronts them, because needs in medicine intersect with conflicts over values not just incidentally or occasionally, but deeply and persistently. Those conflicts - as vexing as they are - need to be faced with care and mutual respect.