Protecting reasonable conscientious refusals in health care
Abstract
Recently, debate over whether health care providers should have a protected right to conscientiously refuse to offer legal health care services—such as abortion, elective sterilization, aid in dying, or treatments for transgender patients—has grown exponentially. I advance a modified compromise view that bases respect for claims of conscientious refusal to provide specific health care services on a publicly defensible rationale. This view requires health care providers who refuse such services to disclose their availability by other providers, as well as to arrange for referrals or facilitate transfers of care. This requirement raises the question of whether providers are being forced to be complicit in the provision of services they deem to be morally objectionable. I conclude by showing how this modified compromise view answers the most significant objections mounted by critics of the right to conscientious refusal and safeguards providers from having to offer services that most directly threaten their moral integrity.
Keywords
Conscientious objection Conscience Conscientious refusal Abortion Aid in dying Thomas Aquinas CatholicismNotes
Acknowledgements
I am most grateful to Abram Brummett, Christopher Ostertag, Udo Schuklenk, an anonymous reviewer, and participants at the 2018 meeting of the American Society for Bioethics and Humanities for helpful comments on earlier drafts of this paper.
References
- 1.Roe v. Wade, 410 U.S. 113 (1973).Google Scholar
- 2.Doe v. Bolton, 410 U.S. 179 (1973).Google Scholar
- 3.Health Programs Extension Act of 1973 (Church Amendment), Pub. L. No. 93-45, § 401, 87 Stat. 91, 95–96 (codified as amended at 42 U.S.C. § 300a-7 (2018)).Google Scholar
- 4.Card, Robert F. 2007. Conscientious objection and emergency contraception. Target article, American Journal of Bioethics 7(6): 8–14.Google Scholar
- 5.Lawrence, Ryan E., and Farr A. Curlin. 2007. Clash of definitions: Controversies about conscience in medicine. Target article, American Journal of Bioethics 7(12): 10–14.Google Scholar
- 6.Nelson, Lawrence. 2018. Provider conscientious refusal of abortion, obstetrical emergencies, and criminal homicide law. Target article, American Journal of Bioethics 18(7): 43–50.Google Scholar
- 7.Curlin, Farr A. (ed.). 2008. Conscience and clinical practice: Medical ethics in the face of moral controversy. Special issue, Theoretical Medicine and Bioethics 29(3): 129–212.Google Scholar
- 8.McLeod, Carolyn, and Jocelyn Downie (eds.). 2014. Let conscience be their guide? Conscientious refusals in health care. Special issue, Bioethics 28(1): 1–48.Google Scholar
- 9.Howe, Edmund G. (ed.). 2016. Physicians’ exercise of conscience: Commentaries on the AMA’s Code of Medical Ethics. Special section, Journal of Clinical Ethics 27(3): 219–253.Google Scholar
- 10.Giubilini, Alberto, and Julian Savulescu (eds.). 2017. Conscientious objection in healthcare: Problems and perspectives. Special section, Cambridge Quarterly of Healthcare Ethics 26(1): 3–158.Google Scholar
- 11.Clarke, Steve (ed.). 2017. Conscientious objection in healthcare: New directions. Special issue, Journal of Medical Ethics 43(4): 191–278.Google Scholar
- 12.Miles, Steven H., and Arthur Caplan. 2018. Confusion and conscientious objection in Arizona. Bioethics.net (blog). July 1, 2018. http://www.bioethics.net/2018/07/confusion-and-conscientious-objection-in-arizona.
- 13.Redinger, Michael. 2018. Catholic pharmacist didn’t get Catholic medical ethics right. Detroit Free Press, October 19. https://www.freep.com/story/opinion/contributors/2018/10/19/catholic-pharmacist-medical-ethics/1697138002.
- 14.Brummett, Abram. 2018. Conscience claims, metaphysics, and avoiding an LGBT eugenic. Bioethics 32: 272–280.Google Scholar
- 15.Stahl, Ronit Y., and Ezekiel J. Emanuel. 2017. Physicians, not conscripts—conscientious objection in health care. New England Journal of Medicine 376: 1380–1385.Google Scholar
- 16.Bedford, Elliott L. 2016. The reality of institutional conscience. National Catholic Bioethics Quarterly 16: 255–272.Google Scholar
- 17.Savulescu, Julian, and Udo Schuklenk. 2017. Doctors have no right to refuse medical assistance in dying, abortion or contraception. Bioethics 31: 162–170.Google Scholar
- 18.Savulescu, Julian. 2006. Conscientious objection in medicine. BMJ 332: 294–297.Google Scholar
- 19.Hardt, John J. 2008. The conscience debate: Resources for rapprochement from the problem’s perceived source. Theoretical Medicine and Bioethics 29: 151–160.Google Scholar
- 20.MacIntyre, Alasdair. 2016. Ethics in the conflicts of modernity: An essay on desire, practical reasoning, and narrative. New York: Cambridge University Press.Google Scholar
- 21.Aquinas, Thomas. 1947. Summa theologica. Trans. Fathers of the English Dominican Province. New York: Benziger.Google Scholar
- 22.Aquinas, Thomas. 1953. Quaestiones disputatae de veritate, vol. 2. Trans. James V. McGlynn. Chicago: Henry Regnery.Google Scholar
- 23.Eberl, Jason T., and Christopher Ostertag. Forthcoming. Conscience, compromise, and complicity. In Proceedings of the American Catholic Philosophical Association 92.Google Scholar
- 24.Pellegrino, Edmund D. 1987. Toward an expanded medical ethics: The Hippocratic ethic revisited. In In search of the modern Hippocrates, ed. Roger J. Bulger, 45–64. Iowa City: University of Iowa Press.Google Scholar
- 25.Pellegrino, Edmund D., and David C. Thomasma. 1993. The virtues in medical practice. New York: Oxford University Press.Google Scholar
- 26.Lombardo, Paul A. 2008. Three generations, no imbeciles: Eugenics, the Supreme Court, and Buck v. Bell. Baltimore: Johns Hopkins University Press.Google Scholar
- 27.Wicclair, Mark R. 2011. Conscientious objection in health care: An ethical analysis. New York: Cambridge University Press.Google Scholar
- 28.Lantos, John D., and Farr A. Curlin. 2008. Religion, conscience and clinical decisions. Acta Paediatrica 97: 265–266.Google Scholar
- 29.Beauchamp, Tom L., and James F. Childress. 2013. Principles of biomedical ethics, 7th ed. New York: Oxford University Press.Google Scholar
- 30.Wicclair, Mark R. 2008. Is conscientious objection incompatible with a physician’s professional obligations? Theoretical Medicine and Bioethics 29: 171–185.Google Scholar
- 31.Robertson, John A. 1994. Children of choice: Freedom and the new reproductive technologies. Princeton: Princeton University Press.Google Scholar
- 32.Crigger, B.J., Patrick W. McCormick, Stephen L. Brotherton, and Valarie Blake. 2016. Report by the American Medical Association’s Council on Ethical and Judicial Affairs on physicians’ exercise of conscience. Journal of Clinical Ethics 27: 219–226.Google Scholar
- 33.American College of Obstetrics and Gynecologists. 2007. ACOG Committee Opinion No. 385 November 2007: The limits of conscientious refusal in reproductive medicine. Obstetrics and Gynecology 110: 1203–1208.Google Scholar
- 34.Ballantyne, Angela, Robert Card, Steve Clarke, Katrien Devolder, Thomas Douglas, Alberto Giubilini, Jeanette Kennett, et al. 2016. Consensus statement on conscientious objection in healthcare. Practical Ethics (blog). August 29, 2016. http://blog.practicalethics.ox.ac.uk/2016/08/consensus-statement-on-conscientious-objection-in-healthcare.
- 35.Savulescu, Julian, and Udo Schuklenk. 2018. Conscientious objection and compromising the patient: Response to Hughes. Bioethics 32: 473–476.Google Scholar
- 36.Schuklenk, Udo. 2015. Conscientious objection in medicine: Private ideological convictions must not supercede public service obligations. Bioethics 29(5): ii–iii.Google Scholar
- 37.Schuklenk, Udo, and Ricardo Smalling. 2017. Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. Journal of Medical Ethics 43: 234–240.Google Scholar
- 38.Nussbaum, Martha. 2008. Liberty of conscience: In defense of America’s tradition of religious equality. New York: Basic Books.Google Scholar
- 39.Rawls, John. 2005. Political liberalism, exp. ed. New York: Columbia University Press.Google Scholar
- 40.John Paul II. 1995. Encyclical letter Evangelium vitae on the value and inviolability of human life (March 25, 1995). Acta Apostolicae Sedis 87: 401–522. http://w2.vatican.va/content/john-paul-ii/en/encyclicals/documents/hf_jp-ii_enc_25031995_evangelium-vitae.html.
- 41.George, Robert P., and Christopher Tollefsen. 2008. Embryo: A defense of human life. New York: Doubleday.Google Scholar
- 42.Lee, Patrick. 2010. Abortion and unborn human life, 2nd ed. Washington, DC: Catholic University of America Press.Google Scholar
- 43.Finnis, John. 2015. Abortion and health care ethics. In Bioethics: An anthology, 3rd ed, ed. Helga Kuhse, Udo Schuklenk, and Peter Singer, 15–22. Oxford: Blackwell.Google Scholar
- 44.Kaczor, Christopher. 2015. The ethics of abortion: Women’s rights, human life, and the question of justice, 2nd ed. New York: Routledge.Google Scholar
- 45.Condic, Samuel B., and Maureen L. Condic. 2018. Human embryos, human beings: A scientific and philosophical approach. Washington, DC: Catholic University of America Press.Google Scholar
- 46.Kant, Immanuel. 1963. Duties towards the body in regard to life. In Lectures on ethics, trans. Louis Infield, 147–148. New York: Harper and Row.Google Scholar
- 47.Aristotle. 1999. Nicomachean ethics, 2nd ed. Trans. Terence Irwin. Indianapolis: Hackett.Google Scholar
- 48.Eberl, Jason T. 2003. Aquinas on euthanasia, suffering, and palliative care. National Catholic Bioethics Quarterly 3: 331–354.Google Scholar
- 49.Callahan, Daniel. 1992. When self-determination runs amok. Hastings Center Report 22(2): 52–55.Google Scholar
- 50.Sulmasy, Daniel P., John M. Travaline, Louise A. Mitchell, and E. Wesley Ely. 2016. Non-faith-based arguments against physician-assisted suicide and euthanasia. Linacre Quarterly 83: 246–257.Google Scholar
- 51.Anscombe, G.E.M. 1958. Modern moral philosophy. Philosophy 33: 1–19.Google Scholar
- 52.Smart, J.J.C., and Bernard Williams. 1973. Utilitarianism: For and against. Cambridge: Cambridge University Press.Google Scholar
- 53.Longmore, Paul K. 2005. Policy, prejudice, and reality: Two case studies of physician-assisted suicide. Journal of Disability Policy Studies 16: 38–45.Google Scholar
- 54.Francis. 2015. Encyclical letter Laudato Si’ on care for our common home (May 24, 2015). Acta Apostolicae Sedis 107: 847–945. http://w2.vatican.va/content/francesco/en/encyclicals/documents/papa-francesco_20150524_enciclica-laudato-si.html.
- 55.Francis. 2018. Apostolic exhortation Gaudete et exsultate on the call to holiness in today’s world (March 9, 2018). http://w2.vatican.va/content/francesco/en/apost_exhortations/documents/papa-francesco_esortazione-ap_20180319_gaudete-et-exsultate.html.
- 56.Paul VI. 1968. Encyclical letter Humanae vitae on the regulation of birth (July 25, 1968). Acta Apostolicae Sedis 60: 481–503. http://w2.vatican.va/content/paul-vi/en/encyclicals/documents/hf_p-vi_enc_25071968_humanae-vitae.html.
- 57.United States Conference of Catholic Bishops. 2018. Ethical and religious directives for Catholic health care services, 6th ed. Washington, DC: United States Conference of Catholic Bishops. http://www.usccb.org/about/doctrine/ethical-and-religious-directives.
- 58.Cavanaugh, Thomas A. 2006. Double-effect reasoning: Doing good and avoiding evil. New York: Oxford University Press.Google Scholar
- 59.Woodward, Paul A. (ed.). 2001. The doctrine of double effect: Philosophers debate a controversial moral principle. Notre Dame: University of Notre Dame Press.Google Scholar
- 60.Cataldo, Peter J. 2017. Moral certitude in the use of levonorgestrel for the treatment of sexual assault survivors. In Contemporary controversies in Catholic bioethics, ed. Jason T. Eberl, 197–222. Dordrecht: Springer.Google Scholar
- 61.Davis, Thomas J., Jr. 2017. Evaluation of the mechanism of action of anti-fertility treatment in cases of sexual assault: Moral certitude and human acts. In Contemporary controversies in Catholic bioethics, ed. Jason T. Eberl, 223–254. Dordrecht: Springer.Google Scholar
- 62.Kaczor, Christopher. 2017. Is it ethically permissible to separate conjoined twins? Murder, mutilation, and consent. In Contemporary controversies in Catholic bioethics, ed. Jason T. Eberl, 123–133. Dordrecht: Springer.Google Scholar
- 63.Watt, Helen. 2017. Vital conflicts, bodily respect, and conjoined twins: Are we asking the right questions? In Contemporary controversies in Catholic bioethics, ed. Jason T. Eberl, 135–145. Dordrecht: Springer.Google Scholar
- 64.Ozoliņš, Jānis T. 2017. On the provision of medical nutrition and hydration. In Contemporary controversies in Catholic bioethics, ed. Jason T. Eberl, 405–424. Dordrecht: Springer.Google Scholar
- 65.Boyle, Joseph. 2017. A Catholic approach to withholding medically provided food and water. In Contemporary controversies in Catholic bioethics, ed. Jason T. Eberl, 425–441. Dordrecht: Springer.Google Scholar
- 66.Eberl, Jason T. (ed.). 2017. Contemporary controversies in Catholic bioethics. Dordrecht: Springer.Google Scholar
- 67.Christopher, Meyers, and Robert D. Woods. 2007. Conscientious objection? Yes, but make sure it is genuine. American Journal of Bioethics 7(6): 19–20.Google Scholar
- 68.Clarke, Steve. 2017. Conscientious objection in healthcare, referral and the military analogy. Journal of Medical Ethics 43: 218–221.Google Scholar
- 69.Card, Robert F. 2016. In defence of medical tribunals and the reasonability standard for conscientious objection in medicine. Journal of Medical Ethics 42: 73–75.Google Scholar
- 70.Hughes, Jonathan A. 2017. Conscientious objection in healthcare: Why tribunals might be the answer. Journal of Medical Ethics 43: 213–217.Google Scholar
- 71.Cowley, Christopher. 2016. Conscientious objection and healthcare in the UK: Why tribunals are not the answer. Journal of Medical Ethics 42: 69–72.Google Scholar
- 72.Myskja, Bjørn K., and Morten Magelssen. 2018. Conscientious objection to intentional killing: An argument for toleration. BMC Medical Ethics 19: 82. https://doi.org/10.1186/s12910-018-0323-0.CrossRefGoogle Scholar
- 73.Mayer, Lawrence S., and Paul R. McHugh. 2016. Sexuality and gender: Findings from the biological, psychological, and social sciences. New Atlantis 50: 4–143.Google Scholar
- 74.Dhejne, Cecilia, Paul Lichtenstein, Marcus Boman, Anna L.V. Johansson, Niklas Långström, and Mikael Landén. 2011. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: Cohort study in Sweden. PLOS ONE 6(2): e16885. https://doi.org/10.1371/journal.pone.0016885.CrossRefGoogle Scholar
- 75.NeJaime, Douglas, and Reva B. Siegel. 2015. Conscience wars: Complicity-based conscience claims in religion and politics. Yale Law Journal 124: 2516–2591.Google Scholar
- 76.Liguori, Alphonsus. 1905–1912. Theologia moralis, 4 vols. Ed. Leonardi Gaudé. Rome: Typographia Vaticana.Google Scholar
- 77.Flannery, Kevin L. 2019. Cooperation with evil: Thomistic tools of analysis. Washington, DC: Catholic University of America Press.Google Scholar
- 78.Kaczor, Christopher. 2013. A defense of dignity: Creating life, destroying life, and protecting rights of conscience. Notre Dame: University of Notre Dame Press.Google Scholar
- 79.Medical Assistance in Dying Statute Law Amendment Act, S.O. 2017, c. 7, Bill 84. https://www.ontario.ca/laws/statute/s17007.
- 80.McGowan, Carter Anne. 2018. Conscience rights and “effective referral” in Ontario. National Catholic Bioethics Quarterly 18: 255–268.Google Scholar
- 81.Cabal, Luisa, Monica Arango Olaya, and Valentino Montoya Robledo. 2014. Striking a balance: Conscientious objection and reproductive health care from the Colombian perspective. Health and Human Rights 16(2): 73–83.Google Scholar
- 82.Dickens, B.M., and R.J. Cook. 2000. The scope and limits of conscientious objection. International Journal of Gynecology and Obstetrics 71: 71–77.Google Scholar
- 83.Buetow, Stephen, and Natalie Gauld. 2018. Conscientious objection and person-centered care. Theoretical Medicine and Bioethics 39: 143–155.Google Scholar
- 84.Camosy, Charles C. 2018. Defending against formally innocent material mortal threats: A response to Joshua Evans. National Catholic Bioethics Quarterly 18: 217–225.Google Scholar
- 85.Camosy, Charles C. 2015. Beyond the abortion wars: A way forward for a new generation. Grand Rapids: Eerdmans.Google Scholar
- 86.Mumford, James. 2013. Ethics at the beginning of life: A phenomenological critique. New York: Oxford University Press.Google Scholar
- 87.Rhonheimer, Martin. 2009. Vital conflicts in medical ethics: A virtue approach to craniotomy and tubal pregnancies. Washington, DC: Catholic University of America Press.Google Scholar