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

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 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.

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.

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.

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.

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 motive—the protection of his own integrity—and that he has not lost sight of his duty to promote the patient's interests.

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.

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 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.

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 human–animal 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.

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 1–5 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 4–5), there is no good reason not to respect the health professional's refusal.

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 1–5 are met, but in which our strong intuition is that conscientious objection is nevertheless unacceptable.