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Law, ethics and medicine

PAPER

When should conscientious objection be accepted?
Morten Magelssen1,2
1

Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway 2 Lovisenberg Diakonale Hospital, Oslo, Norway Correspondence to Morten Magelssen, Senter for Medisinsk Etikk, Universitetet i Oslo, 1130 Blindern, N-0318 Oslo, Norway; magelssen@gmail.com Received 4 March 2011 Revised 3 May 2011 Accepted 24 May 2011 Published Online First 20 June 2011

ABSTRACT This paper makes two main claims: first, that the need to protect health professionals’ moral integrity is what grounds the right to conscientious objection in health care; and second, that for a given claim of conscientious objection to be acceptable to society, a certain set of criteria should be fulfilled. The importance of moral integrity for individuals and society, including its special role in health care, is advocated. Criteria for evaluating the acceptability of claims to conscientious objection are outlined. The precise content of the criteria is dictated by the two main interests that are at stake in the dilemma of conscientious objection: the patient’s interests and the health professional’s moral integrity. Alternative criteria proposed by other authors are challenged. The bold claim is made that conscientious objection should be recognised by society as acceptable whenever the five main criteria of the proposed set are met.
The right to refuse to act against one’s moral or religious convictions is central to a democratic society. The corresponding right for healthcare professionals is the moral right to conscientious objection. The list of morally controversial practices in which some healthcare workers would not want to partake includes abortion, euthanasia, physicianassisted suicide, providing certain kinds of contraception and reproductive technologies. There is a pressing need for debate about the justification and scope of the right to conscientious objection for three reasons. First, moral controversies in health care often concern questions of life and death, and may thus be of great moral significance. Second, advances in medical technology expand medicine’s possibilities. Some new procedures will be morally controversial. Third, many western societies are experiencing increasing cultural, religious and moral pluralism. Conscientious objection in health care may thus become more common.

MORAL INTEGRITY
The fundamental dilemma of conscientious objection is why should society allow healthcare workers to refrain from providing treatment to which the patient has a right? By law, society guarantees the patient’s right to treatment that is held to be beneficial. In exchange for certain privileges, health professionals cater to the medical needs of society. This gives them a prima facie duty to provide all beneficial medical treatment. Why then should society accept their refusal to fulfil their obligations? A substantial reason is needed. Such a reason is found in the need to protect the moral integrity of healthcare workers. The patient’s right to health care and the health professional’s
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moral integrity are both legitimate interests. The combined weight of several factors decides which interest ought to win out in a given case. Some of the other authors on this topic, including Mark Wicclair1 and Dan Brock,2 frame the issue in a similar way. Among authors who argue for a more constricted role for conscientious objection, many either downplay the importance of moral integrity3 4 or employ an impoverished conception of moral integrity.5 This paper offers an account of moral integrity that highlights its great importance to all rational agents and health professionals in particular. Special emphasis will be on what has often not been sufficiently clearly brought out previously: the importance of individuals’ moral integrity to society. The account of moral integrity is more congenial to deontological and virtue ethics than to consequentialism. Only the positive case for the position that conscientious objection is justified by the need to protect moral integrity is supplied. Wicclair1 has argued against alternative justifications for conscientious objection. When a healthcare worker conscientiously objects to a certain procedure, this is because participating in the procedure would go against his deeply held moral or religious judgement. We all have deeply held convictions that we consider important to us, and which constitute central aspects of our identities. Having moral integrity means being faithful towards these deeply held considerations. Moral integrity implies having an internally consistent set of basic moral ideas and principles, and being able to live and act in accordance with these. On this view, perhaps no-one can be said to have complete moral integrity. Nevertheless, moral integrity is commonly considered to be a highly desirable character trait, and something one ought to take pains to preserve. When you act against your deeply held convictions, the link between principles and actions is severed. Your moral integrity is hurt. Refraining from participating in a certain medical procedure can be regarded as an attempt to protect one’s moral integrity. Taking part in the procedure despite one’s belief that it is morally objectionable would be a kind of self-betrayal, and could lead to a loss of self-respect1: ‘I could not live with myself if I did that.’. We choose to act to bring about desirable goods or states of affairs, but our choices also have consequences for our moral character. As Finnis6 explains, when we choose moral or immoral actions, we also choose to become a certain kind of person. If I choose to shoplift, I simultaneously choose to become the kind of person who steals others’ property for my own gain. When you act,
J Med Ethics 2012;38:18e21. doi:10.1136/jme.2011.043646

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Law, ethics and medicine
you necessarily embrace the action’s principles or maxims. By choosing we freely accept these principles, whether, for example, ‘it is right to steal if I stand to gain from it’ or ‘killing is wrong’. We allow our will to be shaped by the principles inherent in the action. In this way choices have a lasting effect on our character. Morally important choices make us the persons we are, for better or for worse. The effects of our actions on our personalities are not something from which we can escape. Acting against your conviction in choice situations of great importance will injure your moral identity, sometimes with psychological and emotional repercussions. Criticising conscientious objection, Rosamond Rhodes5 states, ‘the doctor who chooses to avoid personal psychic distress declares his willingness to impose burdens (.) on his patients so that he might feel pure.’ As we have seen, moral integrity goes far deeper than ‘feeling’. As Pellegrino7 puts it, the right to refrain from performing actions perceived to be immoral is ‘firmly rooted in what it is to be a human person morally, intellectually, and psychologically ’. Empirically, the moral distress that results from acting against one’s conscience has been shown to lead to burnout, fatigue and emotional exhaustion.8 9 Moral integrity is a valuable good for the individual, and is protected by the moral right to conscientious objection. Furthermore, there are three reasons why society should take a special interest in the good of moral integrity. First, moral integrity is a good to all persons, generally benefitting the possessor and the people with whom he interacts. Second, society has a special opportunity for promoting moral integrity. This means shaping society in ways that facilitate citizens’ ability to make morally good choices; including, in the realm of health care, by allowing health professionals to follow their conscience. Third, some professions of central importance to society depend on their practitioners having moral integrity. Arguably, medicine is a moral activity, and so the medical profession needs practitioners with virtuous moral characters.10 Healthcare workers who would consider conscientious objection towards procedures they find immoral take pains to protect their moral integrity. As J.W. Gerrard11 notes, these professionals probably have qualities needed in the medical community: welldeveloped conscience, commitment to the moral ideals of the profession and a reluctance to accept compromises with immorality. Medical history is rife with examples of what atrocities can be committed when these qualities are lacking. In sum, moral integrity is part of the common good.12 Moral integrity is thus an important good for individuals and society. The right to conscientious objection in health care protects this good.

Box 1 Criteria for the acceptance of concientious objection
When the following criteria are met, conscientious objection ought to be accepted: 1. Providing health care would seriously damage the health professional’s moral integrity by a. constituting a serious violation. b. . of a deeply held conviction 2. The objection has a plausible moral or religious rationale 3. The treatment is not considered an essential part of the health professional’s work 4. The burdens to the patient are acceptably small a. The patient’s condition is not life-threatening b. Refusal does not lead to the patient not getting the treatment, or to unacceptable delay or expenses c. Measures have been taken to reduce the burdens to the patient 5. The burdens to colleagues and healthcare institutions are acceptably small In addition, the claim to conscientious objection is strengthened if: 6. The objection is founded in medicine’s own values 7. The medical procedure is new or of uncertain moral status Serious violation of a deeply held conviction
For your objection to the treatment to carry weight, it must be based on a deeply held conviction. An example given by Julian Savulescu3 will illustrate the importance of this point:
‘Imagine an intensive care doctor refusing to treat people over the age of 70 because he believes such patients have had a fair innings. This is a plausible moral view, but it would be inappropriate for him to conscientiously object to delivering such services if society has deemed patients are entitled to treatment.’3

WHEN SHOULD SOCIETY ACCEPT CONSCIENTIOUS OBJECTION?
We will now construct a general framework for the evaluation of claims to conscientious objection. The author argues for the criteria set out in box 1, and shows how they spring from the fundamental dilemma of conscientious objection: the patient’s right to treatment versus the healthcare worker ’s moral integrity. Several criteria get their particular shape from the concept of moral integrity that we have outlined. Previously, other authors have argued for different and less determinate sets of criteria. Wicclair ’s list includes criteria corresponding to 1b, 4a-b, 5 and 6 in the present set.1 Brock mentions 1b and 2e4.2 Meyers and Woods include 1e2.13 The following factors are relevant in deciding whether refusal is warranted. The examples below will refer to medical doctors, but the principles also apply to other health professionals.
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Savulescu3 is correct that conscientious objection would be inappropriate in this case, but he fails to supply the true reason for this. For the objection to the treatment to be acceptable it is not enough that it is based on ‘a plausible moral view ’. Rather, it must violate a deeply held judgement, a principle constitutive of the doctor ’s conception of himself. Savulescu’s doctor ’s judgement about people above the age of 70 is unlikely to be deeply held in this way. In addition, acting against your conscience must constitute a serious violation of your judgement. The reason is that only such actions damage your moral integrity. This point has not always received sufficient emphasis. A ‘serious violation’ always involves participation in the causal chain leading to the disputed treatment. It is often maintained (for instance, by Britain’s General Medical Council) that the conscientious objector has a duty to arrange for referral to another doctor.14 This alleged duty is problematical in that it arguably demands that the doctor play a part in the causal chain ultimately leading to the disputed medical procedure. A point often overlooked is that there is more than one sense of ‘referral’. There is a morally relevant distinction to be made. The paradigmatic referral involves a referral letter in which the physician details the patient’s condition and requests certain health services on the patient’s behalf, and sometimes also involves practical arrangements for the patient’s transfer. This implies, willy-nilly, sharing the patient’s intention to get the requested treatment. On the other hand, a ‘referral’ can also mean simply the physician telling the patient about
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Law, ethics and medicine
practitioners he can to turn to. In this case, that the disputed procedure is to be carried out need not be part of the doctor ’s intention. In the idiom of Wildes15 and Boyle,16 the first doctor ’s cooperation is formal; whereas the second doctor ’s is merely material, meaning that although his action is a necessary part of the causal chain leading to the procedure being carried out, this ultimate result is not part of the doctor ’s intention. The first and second kinds of referral may constitute the upper rungs of a ladder of increasing causal involvement, in which the bottom rung is the act of simply informing the patient about the existence and nature of the disputed procedure. The ‘referral ladder ’ illustrates the importance of the ‘serious violation’ criterion. In the case of a disputed medical procedure, only the full-blown referral would constitute a serious violation of the conscientious objector ’s views and integrity. Objections to referring for morally controversial treatments may thus be warranted. The second and third kinds of involvement, on the other hand, are required of the doctor. The conscientious objector should take pains to protect the patient, in reducing the four sources of harm as much as possible. The doctor should thus communicate his refusal to comply with the patient’s request at the earliest possible stage. If possible, the patient should be notified in advance of the consultation, for instance by a website announcement stating that the doctor will not provide certain specified forms of treatment. As discussed above, in situations in which delay in treatment would be injurious to the patient, the conscientious objector should at least ensure that the patient is informed about the nature of the requested treatment, and knows where to turn to receive it. The patient’s life is usually of overriding importance, and so a healthcare worker ’s conscientious objection to providing potentially life-saving treatment should not be accepted. This is especially so if no colleague is available to take over responsibility for the patient. The more the patient’s health is compromised without the treatment, the less acceptable the refusal to provide treatment is. The patient may very well perceive the doctor ’s refusal to comply with his request as an implicit criticism of his choice or lifestyle, as in the case of in-vitro fertilisation for same-sex couples. The right to conscientious objection is grounded in the need to protect the doctor ’s moral integrity, not in a right to communicate one’s moral views to patients. The doctor objects to the treatment, not to the patient requesting the treatment; nevertheless, the moral criticism of the patient’s intention implicit in conscientious objection may be ineradicable. However, it may certainly be diminished in force by the circumstances of the objection. Moreover, moral disagreement is an inescapable feature of our dealing with other people in society. Therefore, conscientious objection may be acceptable when carried out non-confrontationally and with sensitivity towards the vulnerable patient. For instance, some authors maintain that the objector must explain to the patient the reason for objecting,17 but this may not always be in the patient’s interest. Daniel Sulmasy18 argues that as conscience (or moral integrity) is of such fundamental value to a person, ‘it would seem, in general, that inconvenience, psychological distress, or mild symptoms would not be sufficient grounds to compel conscience.’ Nevertheless, the objector should actively seek to reduce burdens to patients. Importantly, this would signal that his objection is based on a noble moral motivedthe protection of his own integritydand that he has not lost sight of his duty to promote the patient’s interests.

A plausible rationale
You should be able to give well thought-through, detailed and plausible reasons for your conscientious objection. If you were unable to do so, one would suspect that your objection does not spring from a conviction central to your conception of who you are. The role of religious-based reasoning in the public square is a point of contention. On the view of moral integrity espoused, views based in religious morality and secular morality are considered on an equal footing. The reason is that a judgement of religious morality may be as constitutive of a person’s conception of himself as a non-religious view. Acting against one’s religiously based view may then also damage one’s moral integrity. However, in order to merit respect the religiously based conviction must also have certain plausibility, in that it fits into a coherent world view. An objection does not have a plausible rationale if it is based on erroneous factual premises. Brock2 relates the case of the racist Dr A who objects to treating patients with a different skin colour on religious and moral grounds. Brock2 uses this case to justify his criterion that refusal must not ‘violate legal requirements of social justice.’ One might think the real reason why Dr A’s objection is unacceptable is its lack of a plausible rationale; his racist views are incompatible with any plausible world view. If this is the case, the justification for Brock’s additional criterion disappears. An objection to providing regular medical treatment to patients of certain political or religious persuasions, children of single parents or homosexuals, is unacceptable both because refusal lacks a plausible rationale and because providing the treatment does not violate the doctor ’s moral integrity.

Burdens to colleagues and healthcare institutions
If the dilemma of conscientious objection involves the rational assessment of competing legitimate interests, then the interests of the objector ’s coworkers and employer would sometimes also need to be taken into account. Objection may place employers in a quandary, as when all gynaecologists at a hospital object to performing abortions.

The treatment is not considered essential to your work
A claim to conscientious objection is more acceptable when the treatment in question is not an essential part of the health professional’s daily work. For instance, it is unreasonable to accept employment at a fertility clinic and yet refuse to participate in most methods of artificial reproduction.

Medicine’s own values
According to Wicclair,1 ‘an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine’. Correspondingly, objections founded in values that are peripheral to medicine or merely are the health professional’s own, do not carry sufficient moral weight to merit society ’s acceptance. This claim is too strong. An appeal to a deep-seated judgement is more significant if the judgement springs from your conception of yourself as a doctor living up to the profession’s moral
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Burdens to patients
Conscientious objection is more acceptable the better the patient’s interests can be protected in the process. Conscientious objection may conceivably impose at least four kinds of harm on the patient: delay or expense in getting the treatment; restriction of access to the treatment; lack of important information and a sense of moral disapproval of the patient’s choices or lifestyle.
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Law, ethics and medicine
standards. The reason is that the doctor qua doctor has a special obligation towards medicine’s own morality and values. But it does not follow from this that only objections founded in medicine’s own values merit acceptance. Consider Wicclair ’s example of Dr L who is ‘ethically opposed to providing pain medication because he believes that pain is a sign of a moral flaw and is therefore deserved’.1 Presumably, all would agree that there is no acceptable basis for the doctor ’s objection. According to Wicclair,1 this is because the doctor ’s objection is based in values foreign to medicine, but in the author ’s view, his objection just lacks any plausible rationale (criterion 2). It is difficult to conceive of a world view that includes the doctor ’s belief that is coherent and minimally plausible. Wicclair ’s contention is also vulnerable to a counter-example. Consider the case of in-vitro fertilisation for a single woman or a same-sex couple. Some fertility doctors would object to treating such patients because it would violate their judgement that children have a (moral, natural) right to be raised by both their biological parents. This right, although plausible to some, is not a core medical value, and so in Wicclair ’s theory, this reason for refusal is unacceptable. However, although the case is contentious, many would find objection to be well founded in this case. However, the weaker version of Wicclair ’s point is sound: objections founded in medicine’s own values are more acceptable. The proposed framework for the evaluation of conscientious objection is more detailed than any alternative yet. However, the application of the set to any given actual case may still not yield a definite conclusion. This should not be surprising. There is a certain indeterminacy in most of the criteria (‘plausible rationale’, ‘acceptably small burdens’, etc.), which seems to be ineradicable. Applying the criteria does not obviate the need for practical wisdom and the ability to take into account the specifics of each case. To challenge the proposed set of criteria, one would have to argue against either of four things: the crucial importance of protecting the healthcare worker ’s moral integrity; the construal of the issue of conscientious objection as the dilemma of balancing the interests of the patient and the health professional; the cogency or relevance of the specific criteria proposed; or the set’s exclusion of other criteria. Alternatively, one might come up with counter examples of situations in which criteria 1e5 are met, but in which our strong intuition is that conscientious objection is nevertheless unacceptable.

CONCLUSION
The main purpose of this paper has been to present and argue for a set of criteria for the evaluation of claims to conscientious objection. The strong claim has been made that the first five criteria are jointly sufficient for conscientious objection to be morally acceptable from society ’s viewpoint.
Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed.

New or morally uncertain medical procedures
A refusal to provide treatment is strengthened if the treatment was not invented or accepted at the time the health professional selected his profession, specialty or current position. Brock2 argues against this criterion by claiming that it rests on the implausible premise that the profession’s obligations cannot change over time. However, it remains a fact that the health professional did not know about these treatment modalities at the time he entered his position or specialty, and thus his implicit contract with society did not cover these procedures. Therefore, it is reasonable to accord extra weight to conscientious objection in these circumstances. Conscientious objection carries greater weight if the disputed medical procedure is widely regarded to be fraught with moral uncertainty. This may be the case for treatments based on new technologies. For instance, a doctor may object to providing treatment with cells derived from humaneanimal chimeras were this to become available, because of the uncertain moral status of such chimeras. This may also be the case for medical procedures that run counter to traditional moral norms hitherto entrenched in society.

REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Wicclair MR. Conscientious objection in medicine. Bioethics 2000;14:205e27. Brock DW. Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why? Theor Med Bioeth 2008;29:187e200. Savulescu J. Conscientious objection in medicine. BMJ 2006;332:294e7. Swartz MS. Conscience clauses or unconscionable clauses: personal beliefs versus professional responsibilities. Yale J Health Policy Law Ethics 2006;6:269e350. Rhodes R. The ethical standard of care. Am J Bioeth 2006;6:76e8. Finnis J. Fundamentals of Ethics. Washington DC: Georgetown University Press, 1983. Pellegrino ED. The Physician’s Conscience, Conscience Clauses, and Religious Belief: A Catholic Perspective. In: the Philosophy of Medicine Reborn. Notre Dame, Indiana: University of Notre Dame Press, 2008. Bischoff S, DeTienne K, Quick B. Effects of ethics stress on employee burnout and fatigue: an empirical investigation. J Health Hum Serv Adm 1999;21:512. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004;13:202. Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. Oxford: Oxford University Press, 1993. Gerrard JW. Is it ethical for a general practitioner to claim a conscientious objection when asked to refer for abortion? J Med Ethics 2009;35:599e602. George RP. Making Men Moral. Oxford: Clarendon Press, 1993. Meyers C, Woods RD. An obligation to provide abortion services: what happens when physicians refuse? J Med Ethics 1996;22:115e20. General Medical Council. Personal Beliefs and Medical Practice. London: General Medical Council, 2008. Wildes KW. Conscience, referral, and physician assisted suicide. J Med Philos 1993;18:323e8. Boyle J. Radical moral disagreement in contemporary health care: a Roman Catholic perspective. J Med Philos 1994;19:183e200. Davis JK. Conscientious refusal and a doctors’s right to quit. J Med Philos 2004;29:75e91. Sulmasy D. What is conscience and why is respect for it so important? Theor Med Bioeth 2008;29:135e49.

How much guidance does the set of criteria provide?
The proposed set of criteria should be consulted when society has to decide whether a refusal to provide medical treatment should be tolerated. Criteria 1e5 are, in the authors opinion, jointly sufficient for conscientious objection to be acceptable to society. However, they are not necessary: there may be situations in which conscientious objection ought to be accepted, but when, for example, criterion 1a is not met. When burdens to patients and institutions are negligible (criteria 4e5), there is no good reason not to respect the health professional’s refusal.

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When should conscientious objection be accepted?
Morten Magelssen J Med Ethics 2012 38: 18-21 originally published online June 20, 2011

doi: 10.1136/jme.2011.043646

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