Health care providers have a duty to provide care. Their values, however, can sometimes conflict with these duties. Is it acceptable to deny a patient care if it goes against the provider’s morals, ethics, or religious beliefs? That is when conscientious objection comes into play. Conscientious objection in medicine is the refusal to provide requested treatment due to the provider’s moral convictions.
“We’re living in a rapidly changing legal and political landscape in terms of health care and health care ethics,” said Ronit Stahl, PhD, of the University of California, Berkeley, a participant on a recent panel of health care and ethics professionals who met to argue for or against conscientious objection in medicine.
The panel, hosted by Yale School of Medicine’s Program for Biomedical Ethics, consisted of moderator Sarah C. Hull, MD, MBE, assistant professor of medicine (cardiology); Stahl, arguing against conscientious objection; and Mark David Siegel, MD, professor of medicine (pulmonary) and director of the Traditional Internal Medicine Residency Program, arguing in favor of conscientious objection. The virtual discussion can be seen here.
Against conscientious objection
“I want to be clear that the argument I’m making is about pluralism and power,” prefaced Stahl, speaking against the right for providers to refuse care based on their individual beliefs.
Conscientious objection, she stated, is tricky because there is no single notion of what constitutes religion or what defines patient-centered care. Regardless of a religious belief, everyone wrestles with ethics based on their values. Furthermore, these values can change over time. Stahl asserted that placing individual beliefs over professional standards is a rejection of the fundamental obligation of health care – the duty to ensure patients’ well being in the way they choose to live.
“As the current system exists, it allows, in my view, the perpetuation of inequities in these domains,” said Stahl, “… especially in a system where people don't always have so many choices, and where they're trying to navigate a lot of complexity without full information.”
“I think this is really important for justice,” said Stahl. “And so the problem of the way conscience has arisen as a system in health care is that this power is lopsided and asymmetrical. The law in this sense allows the imposition of personal beliefs on patients in the form of refusing to provide care.” She said that is especially burdensome at moments when the refusal comes as a surprise to a patient.
“To deny patients care that is a standard part of the profession is in my view, a problem, and indeed, to me, unethical,” said Stahl, who added that conscientious objection in medicine may lead to an erosion in the relationship between provider and patient, as well as trust in health care as a whole.
She also pointed out an imbalance of protection among providers. “It protects those who refuse to treat—who deny care—but not those whose conscience compels them to provide medically accepted but politically-contested care,” most notably in the areas of reproductive services and LGBTQ care.
In favor of conscientious objection
If standard practices change and your moral beliefs don’t, are you obligated to change along with your profession’s expectations?
“Clinicians are also moral beings,” said Siegel, as he argued in favor of conscientious objection. “Morality is intrinsic to our professional identity.”
He noted that the federal government protects conscience rights. In institutions receiving federal funds, health care providers who refuse to participate in services based on moral objections or religious beliefs are protected against discrimination, and have official avenues to complain if they feel that right is violated.
Siegel asserted that if society wants clinicians to take moral and ethical obligations seriously, but if they can’t follow their own beliefs, how can we expect them to adhere to professional responsibilities? He also suggested that talented people who could make great contributions to the profession might choose not to pursue it if they could not object to aspects of it.
“If deeply held moral beliefs are thought to be disposable, that would be problematic,” he said, adding a concern that as they pursue their careers, the world that surrounds practitioners can easily change. “We enter into these professions at an early age, not necessarily knowing what we’re agreeing to, and also not recognizing that there is potentially a changing moral landscape.”
On one important point, Siegel agreed with Stahl. “Any support for conscientious objection has to make sure that vulnerable patients get the care they are entitled to,” he said. “We should acknowledge that clinicians hold power over patients, and we need to recognize patients’ rights.” Siegel added, “There is the potential for abuse, using moral objections as a smokescreen for discrimination. Maybe it’s not really a moral belief, but you just don’t want to take care of a person from a vulnerable group.” He agreed there is a lack of oversight to catch this potential abuse.
For guidance, Siegel referred to the American College of Obstetricians and Gynecologists (ACOG), which has clear recommendations for conscientious refusal—guidelines with parallels in other medical disciplines.
To highlight a few: Patients’ well-being must be paramount; health care providers must impart accurate and unbiased information; clinicians must provide potential patients with accurate and prior notice of their personal moral commitments; clinicians have the duty to refer patients in a timely manner if they cannot provide standard reproductive services that patients request; in an emergency in which referral is not possible or might negatively affect a patient’s mental health, providers have an obligation to provide medically indicated and requested care regardless of the provider’s personal moral objections; and in resource-poor areas, access to safe and legal reproductive services should be maintained.
Being open and honest about beliefs
Hull, the moderator, highlighted that both arguments agree on the importance of providing accurate information and not withholding information, regardless of moral beliefs. Additionally, emergency situations override a right to refuse care based on moral beliefs. “Rather than being an ad hoc individual basis, there should be institutional norms and standards to codify what situations are appropriate for the exercise of conscientious objection,” said Hull. In areas where there isn’t professional consensus on the morality of a certain action, different viewpoints should be allowed while enabling patients to receive care and respecting clinicians as moral agents.
An audience member asked Stahl, ”What place does implicit racial or ethnic bias play in those who choose to object to giving care to a patient?”
“I think what's so challenging about implicit bias is that people are not of course standing up and saying, ‘because I'm racist. I will not care for this person,’ or ‘because I'm homophobic, I'm not going to prescribe PrEP to prevent HIV,’” said Stahl. “... I think we have to be really attentive to the ways in which implicit bias is often undergirding both some of the choices people make and then the outcomes that derive from them. It's why I think we have to be very, very careful about assuming that any claim that someone says is moral is inherently moral, and because I do think it both has been and continues to be used in ways that are discriminatory.”
The definition of care, or “do no harm,” also entered the discussion. For example, clinicians may see physician-assisted suicide or abortion as a harm, a view that is contrary to common professional standards of care. “If inducing death doesn't accord with an orientation to health then it's a misnomer to say that such practitioners refuse care,” stated an audience member. “Rather, such practitioners refuse to participate in a procedure that doesn't lead to health. Again, this is not denying care.”
“For me, that’s a very key distinction to be made,” said Hull, “There may be a lot of room for debate there.”
This 90-minute discussion easily could have gone much longer—a conversation that will certainly continue in numerous health care settings.