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Forget Evil: Autonomy, the Physician–Patient Relationship, and the Duty to Refer


Aulisio and Arora argue that the moral significance of value imposition explains the moral distinction between traditional conscientious objection and non-traditional conscientious objection. The former objects to directly performing actions, whereas the latter objects to indirectly assisting actions on the grounds that indirectly assisting makes the actor morally complicit. Examples of non-traditional conscientious objection include objections to the duty to refer. Typically, we expect physicians who object to a practice to refer, but the non-traditional conscientious objector physician refuses to refer. Aulisio and Arora argue that physicians have a duty to refer because refusing to do so violates the patient’s values. While we agree with Aulisio and Arora’s conclusions, we argue value imposition cannot adequately explain the moral difference between traditional conscientious objection and non-traditional conscientious objection. Treating autonomy as the freedom to live in accordance with one’s values, as Aulisio and Arora do, is a departure from traditional liberal conceptions of autonomy and consequently fails to explain the moral difference between the two kinds of objection. We outline how a traditional liberal understanding of autonomy would help in this regard, and we make two additional arguments—one that maintains that non-traditional conscientious objection undermines society’s autonomy, and another that maintains that it undermines the physician-patient relationship—to establish why physicians have a duty to refer.

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  1. 1.

    “Personal autonomy is, at a minimum, self-rule that is free from both controlling interference by others and from certain limitations such as an inadequate understanding that prevents meaningful choice” (Beauchamp and Childress 2009, 100–101).

  2. 2.

    Aulisio and Aurora support the practice of informed consent in their paper, but our objection is that they fail to understand the underlying supporting principle of autonomy.

  3. 3.

    For perhaps the most famous proponent of the view that the rule of law requires predictability to ensure liberty, see Hayek (1973).

  4. 4.

    Alta Charo offers a related argument that focuses on the fact that medicine’s professional nature explains why non-traditional conscientious objection is impermissible. Charo argues that because there is a professional affirmative duty to assist in non-traditional cases (for example, a pharmacist’s duty to provide contraception), non-traditional conscientious objection is frequently better characterized as active misfeasance, as opposed to mere nonfeasance. Charo’s argument, however, is distinctly less overtly egalitarian in nature than ours is. Further, our argument can perhaps be seen as explaining why this professional positive duty to assist exists in the first place (Charo 2007).

  5. 5.

    Another objection is that the practical conflict between the physician and patient can be easily avoided if the physician notifies the patient at the beginning of their relationship of her moral beliefs, thus preempting the need to later refuse to refer. However, as Cook and Dickens (2006) have pointed out, this method of conflict avoidance fails when the physician later changes her moral beliefs. We would add that even at the beginning of the relationship, however, the patient still legitimately expects her physician to act in accordance with publicly defensible norms and to uphold the rule of law.

  6. 6.

    A related argument is made by Reva B. Siegel, who claims that contrary to promoting diversity, religious based non-traditional conscientious objection actually serves to “enforce traditional norms against those who do not share their [the objector’s] beliefs” (Siegel 2015, 2591).

  7. 7.

    Our arguments are therefore limited to the context where physician-assisted death is already legalized. They do not provide reasons for legalizing physician-assisted death in the first place.


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Correspondence to Jake Greenblum.

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Greenblum, J., Kasperbauer, T.J. Forget Evil: Autonomy, the Physician–Patient Relationship, and the Duty to Refer. Bioethical Inquiry 15, 313–317 (2018).

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  • Conscientious objection
  • Autonomy
  • Duty to refer
  • Physician–patient relationship
  • Rule of law
  • Rawls