Competing Rights: Exploring the Boundaries of ‘Conscientious Objection’

Earlier this month, Joyce Arthur and Christian Fiala argued in a piece for RH Reality Check that clinicians should not be permitted to claim “conscientious objection” as grounds for refusing to provide abortion or contraception. They take issue with any tolerance of conscientious objection as expressed by Global Doctors for Choice in a white paper, and by the other authors of a set of articles published in the December special issue of the International Journal of Gynecology and Obstetrics. Global Doctors for Choice thinks differently on both philosophic and strategic grounds.

We are all concerned that conscience-based refusal to provide contested components of reproductive health care exacerbates limited access to such care and thus threatens women’s health and rights. Where we differ with Arthur and Fiala is in our analysis of the issues at stake. We believe that there are competing rights here, and that resolution of such tension is primarily a societal, not individual, responsibility. We also differ in our pragmatic assessment of how best to proceed.

From the human rights perspective, we see the ability to exercise conscience as fundamental to individual integrity. In fact, allegiance to this principle undergirds our collective defense of the individual woman’s right to autonomy in reproductive decision-making. The international and human rights covenants cited all concur that the individual’s right to hold and manifest beliefs and religion are essential, and subject only to limitations necessary to protect the fundamental rights of others. International and national professional associations have similarly defended the individual clinician’s right of conscience while also asserting that it should be circumscribed by the primary duty to the patient, including requirements to disclose, refer, and impart accurate information, and provide care in cases of emergency.

The obvious tension here is when the rights of individuals collide: the objecting clinician’s right to refuse, another clinician’s conscience-based commitment to providing that care, the woman’s right to follow through on her conscientiously chosen course of action. In a secular society, we consider it the state’s responsibility to negotiate the boundaries of these competing rights. This means that the health-care system is obligated to assure that all patients have access to legal services and thus to implement systems for oversight, staff, and resource allocation in order to make that a reality.

We do have areas of agreement: that conscience-based refusal to provide specific elements of reproductive health care is a topic of concern, because in some contexts it aggravates limited access to needed health services and thus most threatens the health and rights of those with least access to care. As described in thwhite paper, conscientious objection too often is ill defined, unregulated, and inconsistently practiced. The white paper examines conscientious objection to prenatal diagnosis, assisted reproductive technologies, care of ill pregnant women, care in cases of inevitable spontaneous abortion, as well as to induced abortion and contraception. However, reproductive health care is not the only area of medicine affected, as end-of-life palliative care and hematologic/oncologic and other treatments involving stem-cell therapies are other areas of medicine where conscientious objection has been invoked. Nor are physicians the only group claiming this right, as nurses, midwives, and pharmacists have invoked it as well.

We also concur that we should collectively think through whether health care has unique features that distinguish it from other domains where conscientious objection is invoked. Some argue that state licensure gives clinicians a monopoly over essential universally needed services and thus confers a special level of obligation. The white paper outlines a range of regulatory efforts by health systems and professional organizations such as requiring registration, specifying performance of abortion as a job criterion, or conditioning specialty certification on proficiency in all components of care. Again, we agree that health-care institutions have an obligation to provide all components of care and to define the limits of refusal as outlined above, but we disagree about whether that obligation rests primarily at the practitioner or the institutional level.

This brings us to the strategic and pragmatic. Definition, oversight, and enforcement of regulations on conscientious objection in health care are rarities, limited mostly to a few European countries. The white paper reviews the evidence about the patchy nature of monitoring and regulation in most of the world and highlights the practical difficulties in advancing such systemic supervision and responsibility.

Moreover, health systems officials and studies report that many clinicians do not fully understand the concept of conscientious objection and might provide at least some of the components of sexual and reproductive health care if other systemic supports were in place. They argue that provider attitudes are often fluid and that it would be most useful to concentrate on educating them about the law, patients’ rights, providers’ obligations, and teaching technical skills. Global Doctors for Choice considers this type of engagement with clinicians and health systems a key strategic approach; we appeal to clinicians’ primary fiduciary duty to patients and their aspirations to provide care in keeping with the highest professional ethical and evidence-based standards.

Given the messiness, limited infrastructure, and lack of consensus characterizing the real world, how would the ban proposed by Arthur and Fiala be implemented? Would such a ban advance our shared overarching goal of providing good access to high-quality sexual and reproductive health care for all? Might it have the inadvertent consequence of worsening access by hardening the opposition of those who might be incrementally persuaded to provide these services?

We consider these to be thorny issues as conscience, integrity, and autonomy are critically important to all the players involved—to those refusing, to those providing, and to those seeking reproductive health care. We think it useful to broaden the frame beyond the individual and charge pluralistic diverse societies with the task of honoring dissent while limiting its negative impact on others.

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  • cjvg

    So why are the conscientious objectors deliberately choosing a field where their “conscience ” pits them in direct conflict with a woman’s conscience and beliefs and rights? Especially since they are assured that their conscience has the power position in that dynamic and is much more likely to prevail.?

    There are numerous medical specialties from which these conscientious objectors can choose without ever being placed in this position. The woman patient has no such deliberate and freely made choice, no one choices to have medical complications or the need for a medical procedure and/or medications. It seems to me that these so called medical “professionals” are deliberately and willingly seeking this conflict of their own making.

    Not buying the arguments made in this article and think it is a dishonest position to take

    • Arekushieru

      CJVG, WELL put, as usual. (This is also a shout-out to Lady_Black, as well, btw.) THIS is my main contention with Archbishops like Thomas Collins who protest that their freedom of conscience is limited when Justin Trudeau argued that he will only accept candidates for the Liberal party who will support Pro-Choice legislation. I had to ask, why does ANYONE’s but the pregnant woman’s conscience matter? Ugh.

      • BJ Survivor


  • lady_black

    Look Wendy, it’s just TOO EASY to be a “conscientious objector” when someone else pays the price. I have nothing against conscientious objection and might do it myself in certain circumstances. For example, I would sooner sit in jail than be forced to participate in any way, in war where the USA is the aggressor. I am willing to pay that price. If a doctor, nurse, or other practitioner wishes not to participate in abortion, choose to work in a different specialty. Be an ophthalmologist or radiologist instead of an OB/GYN. Pharmacists are a different story. If you have serious issues with dispensing any drug that’s ordered, don’t enter that field or be willing to hire someone else to dispense the medication. COs are those who are willing to break laws, engage in civil disobedience, risk jail, etc. for their beliefs. It’s a hard road, and under NO CIRCUMSTANCES is it OK to lay the consequences of your beliefs on the shoulders of anyone but yourself. When I was a nursing student, this was drummed into us from day one. We are there to advocate for the patient, not ourselves.

    • Shan

      I can’t vote this up enough times.

      I’d also add this: I think that employers should take this into account and be able to accommodate CO employees but only if they can make arrangements that don’t dis-accommodate the patient/customer in any way. Otherwise, the CO employee should just look elsewhere.

    • BJ Survivor

      Exactly! No need to add to this. No more needs to be said.

      What busts my craw is that this medical “conscientious objection” only ever applies to medical issues specific to women. But, somehow, this is considered to be okay, even with self-professed allies. There is simply no defense of this, as it is clearly discrimination against women. Would we even consider allowing conscientious objection against providing blood transfusion? No, we absolutely would not, because men need blood transfusions, too.

      Wendy, you really need to address this glaring hole in your argument for allowing such egregious religious discrimination against women.

  • purrtriarchy

    What cjvg and lady black said.

  • fiona64

    It is awfully easy to raise a “conscientious objection” to something that doesn’t affect you: writing a script for hormonal contraception, for example, doesn’t mean that the clinician is being forced to use it. Ditto filling said script.

    Maybe those people with”conscientious objections” to such things should find a different line of work.

  • colleen2

    The notion I find galling is the idea that these people are motivated by their conscience. In this case you are insisting that we accept a situation in which the patients are doing the sacrificing (and paying for it!) . How much integrity is contained in THAT stance? I think that Global Doctors for Choice needs to solve their staffing issues another way.
    The problem with the ‘consciences’ of the religious right is that women don’t WANT to have 15 kids and we don’t WANT to pay for proselytizing when we go in for reproductive healthcare. Women should not have to negotiate the religious beliefs of healthcare providers in order to receive the care they need.

  • colleen2

    Here is an example of actual ‘Conscientious Objection’:

    Notice how the person with a conscience is quitting her job? Rather than trying to force her religious beliefs down the throats of women who are paying for reproductive healthcare? I am hoping that Global Doctors for Choice will understand the difference.

  • Suba gunawardana

    A doctor is duty bound to protect his/her patient. They should not put the interests of any other individual (including invaders/parasites in the patient’s body) before those of their patient, for conscience or any other reason.

    A doctor who puts their patients’ safety & well being second to ANYTHING (including his/her own belief system) is not fit to be a doctor and should find a different job.