This discussion differs from the kind of deliberation associated with ethical decision-making about treatment because it occurs at a level that is usually well “beneath the radar” in professional environments. In some respects, it may even be preliminary to metaethics (Beauchamp and Childress 2013).
The key point is that bioethical discourse about freedom of conscience in health care is controlled by foundational premises, assumptions, and blind spots, so that what is proposed here first intersects with practice at the level of education, policy-making, regulation, and law. Hence, the examples offered to illustrate the implications of what we propose are not ethical controversies at the bedside but at the regulatory level.
Example 1: Tasmania: Access to Terminations Bill 2013
A draft bill in the State of Tasmania requires that a medical practitioner who objects to abortion for reasons of conscience must refer a woman seeking an abortion to a colleague willing to provide the procedure (Tasmania Department of Health and Human Services 2013). Those who fail or refuse to do so will be subject to a fine of up to AU$65,000 (Gora 2013).
The conflict: Some physicians who object to abortion are also unwilling to refer for the procedure on the grounds that referral constitutes morally illicit participation in the act. However, those supporting the mandatory referral requirement deny that referral involves moral complicity and/or claim that medical practitioners are ethically obliged to facilitate access to all legal procedures that are not medically contraindicated.
Example 2: British Columbia: Access to Drugs
A pharmacy regulatory authority issues a directive that pharmacists who have moral objections to dispensing drugs must promptly direct clients to a colleague willing to do so and, in the absence of a willing colleague, dispense the drugs themselves. The regulator’s ethics committee suggests that this expectation would hold even in the case of drugs used for “voluntary or involuntary suicide” and executions by lethal injection (College of Pharmacists of British Columbia 2000).
The conflict: For reasons of conscience, some pharmacists are unwilling to dispense some drugs that are to be used for what they consider to be immoral purposes, even if no willing pharmacists are available to do so. For the same reasons, others are unwilling even to refer patients, since they believe that this makes them morally complicit in a wrongful act. On the other hand, the ethics committee maintains that pharmacists must “respect patient autonomy” by dispensing the drugs or by referral and that this is required by “the ethics of the profession.”
Example 3: Texas: Provision or Withdrawal of Life-Supporting Interventions
The provision or withdrawal of life-supporting interventions, especially near the end of life, can be a contentious issue. In some cases, patients and families wish interventions to continue, while physicians believe they should be withdrawn. In others, patients and families seek withdrawal of life-supporting interventions, while physicians believe they should continue.
The conflict: Some physicians want to ensure that they are not compelled to provide or continue interventions they believe are wrongful; others want to ensure that they are not forced to wrongfully withdraw interventions. Both groups insist that they should not be compelled to act against their conscientious convictions, either by providing interventions or by withholding/withdrawing. On the other hand, some patient and family advocates demand that physicians should be required to comply with their wishes and should not “impose their morality” by refusing to do so.