Here we include excerpts from our first major article on the topic: “Dishonourable disobedience” — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014)

Position

The refusal to provide necessary care due to “conscience” creates a fundamental contradiction and injustice. It is not about protecting the right to conscience because it has nothing in common with military conscientious objection, where objectors must justify their stance, are often required to undergo a rigorous review process, and face consequences. In contrast, healthcare professionals usually face no obligation to justify their refusals, rarely face any disciplinary measures, retain their positions and salaries, and even have their objection protected by law and policy.

Physicians have a monopoly on the practice of medicine and they voluntarily entered a profession that fulfills a public trust. They know they have obligations to provide care to patients without discrimination, and that patients are completely reliant on them for essential health care and can’t go elsewhere. These factors make belief-based care denials a violation of medical ethics and an abuse of doctors’ position of trust and authority. It is discrimination because it mostly affects women, as well as increasingly the LGBTQ community, and the aged/disabled who need medical assistance in dying.

A just society and an evidence-based medical system should deem belief-based care denial as an ethical breach that should be handled in the same way as any other professional negligence or malpractice. Unless workers are able to adopt an attitude of professional distance that would allow them to deliver necessary healthcare with which they personally disagree, they should quit the field of reproductive healthcare, or not get involved in it at all. In fact, those two options represent the only honest exercise of conscientious objection in medicine.

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Origin and Meaning of ‘‘conscientious objection’’

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Impacts of Belief-based Denial

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Eliminating CO in reproductive healthcare

The unregulated practice of CO in reproductive healthcare has become entrenched in many countries and health systems, resulting in widespread negative consequences for the women concerned and violations of their rights (Council of Europe Parliamentary Assembly, 2010). Even where a law or policy allows limited CO, abuse of that right is common. This implies that objecting personnel cannot be trusted to exercise the right responsibly, and that those who abuse CO are not qualified to be healthcare workers. Even doctors who exercise CO within the law are arguably unsuited for their position because they are demonstrating an inability to perform their job — that is, they are allowing religious beliefs or some other personal issue to interfere with their job performance to the extent of negating their professional duty to patients.

Abortion is the most frequently performed surgical intervention in the obstetrics/gynecology specialty (although it is also performed by many general practitioners). Becoming an Ob/Gyn engenders a special responsibility towards female patients, since a significant number of them will experience an unwanted pregnancy leading them to request abortions. Ob/Gyns have serious ethical obligations to those patients.

We argue that healthcare personnel should respect the accepted ethical standard of a non-judgmental approach towards their patients for all essential healthcare, with no exceptions. Consequently, we propose that healthcare providers be prohibited from a blanket right to refuse to perform or refer for abortion or dispense contraception for personal or religious reasons. Our recommended prohibition is specific to abortion and contraception because these two medical services are both essential and common, but are overwhelmingly the ones that objectors refuse to deliver.

Further, we propose the following specific remedies to reduce and eventually eliminate CO in reproductive healthcare. Everyone aspiring to enter health professions that involve reproductive healthcare should be required to declare that they will not allow their personal beliefs to interfere with their management of patients to the point of discrimination.  Medical students entering the Ob/Gynspecialty should be informed about the full scope of the specialty, including treating women with unwanted pregnancies. Students should be rejected if they do not wish to learn and prescribe contraception or perform abortions for CO reasons. All Ob/Gyns should be required to dispense birth control and perform abortions as part of their practice (unless there is a legitimate medical or professional reason not to). General practitioners should be expected to dispense contraception if requested, and perform abortions if they have the skills and capacity, or else refer appropriately. Pharmacists should be compelled to dispense all lawfully prescribed drugs without exceptions. Institutional CO should be completely prohibited for health systems and businesses that serve the general public.

Monitoring and enforcement measures should be put into place to ensure that prohibitions on CO are followed. After all, CO is a form of resistance to rules or laws, so those who exercise CO must be prepared to accept punishment for their disobedience,  just as in any other profession. Doctors should be sanctioned when they violate laws or codes of ethics that prohibit CO. Disciplinary measures could include a review process, an official reprimand and order to correct, and could escalate to loss of medical license, dismissal, or even criminal charges. In addition, any costs involved in the exercise of CO should be borne by the health professional or institution, who must be held liable for any health risks and negative consequences of their refusal. Patients should be legally entitled to sue and to claim compensation for any physical or mental harm, and for additional costs resulting from the refusal to treat.

Over time, such measures should result in a reduction in the number of anti-choice healthcare workers in the field of reproductive healthcare who refuse to deliver patient-centered care. Those who decide to remain and provide abortions and contraception could adopt an attitude of ‘‘professional distance’’ in order to separate their personal beliefs from their work duties. They could derive satisfaction from obeying laws and codes of ethics, respecting patient needs and autonomy, keeping their jobs or licenses, and furthering workplace harmony (McLeod, 2008) Outside their work lives, they are free to express their beliefs in many other ways.

Implementing such measures may seem like a daunting task given the ongoing stigma against abortion and the strength of the anti-choice movement. But with political will, much could be done at local, national, and international levels to ensure that contraception and abortion services are widely available and accessible to all who need them. For example, governments could regulate public health systems to guarantee abortion provision, and provide financial aid to hospitals to recruit abortion providers. Other needed measures include compulsory training in contraception provision and abortion techniques at medical schools, security measures to protect doctors and patients such as clinic buffer zones, full funding of contraception and abortion through government health insurance,  public education to reduce abortion stigma, and other initiatives. The Council of Europe has already recommended that States should ‘‘guarantee women’s effective exercise of their right of access to a safe and legal abortion;. . .lift restrictions which hinder. . .access to safe abortion, and. . .offer suitable financial cover.’’ (Council of Europe Parliamentary Assembly, 2008b)

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014), http://dx.doi.org/10.1016/j.woman.2014.03.001