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Is it ethical for a general practitioner to claim a conscientious objection when asked to refer for abortion?
  1. J W Gerrard
  1. Correspondence to Dr J W Gerrard, Windmill Health Centre, Mill Green View, Leeds LS14 5JS, UK; james.gerrard{at}nhs.net

Abstract

Abortion is one of the most divisive topics in healthcare. Proponents and opponents hold strong views. Some health workers who oppose abortion assert a right of conscientious objection to it, a position itself that others find unethical. Even if allowance for objection should be made, it is not clear how far it should extend. Can conscientious objection be given as a reason not to refer when a woman requests her doctor to do so? This paper explores the idea of the general practitioner (GP) who declines to make a direct referral for abortion, asking the woman to see another GP instead. The purpose is to defend the claim that an appeal to conscientious objection in this way can be reasonable and ethical.

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Many people consider it draconian to force people to act against their consciences. Jennifer Jackson1 comments:

“It is widely assumed to be a hallmark of civilized society that we exercise tolerance towards people with whom we disagree deeply on moral or religious matters. And it might seem to be a minimal and entirely reasonable exercise of this tolerance that we find ways to avoid forcing people to disobey the dictates of their consciences.”

One problem is deciding what limits we set for this tolerance. Perhaps the assumption that doctors can refrain from aspects of their job while workers in other fields cannot is incorrect. Many doctors, though, have a sense that there are limits to the tasks they should take part in. A former acting medical director of the abortion provider the British Pregnancy Advisory Service has said:2

“Early in my career, I came to the view that I would not carry out surgical abortions at 16 weeks for ‘lifestyle’ reasons, when a pregnancy would not put the health of mother or child at risk… once I had seen what was involved, and the flimsy grounds on which some women sought them, I could not stomach the idea of providing such a ‘service’.”

If this stance is taken by someone fully involved in abortion provision, it is not surprising that other doctors’ ethical barometers are set tighter still. Piers Benn3 recognises this when he says:

“Whatever our views about abortion, women’s rights and the metaphysical status of the embryo or foetus, we can see that the anti-abortion position does connect intelligibly with the core values of medicine”.

Even so, an attitude of partial assent coupled with the erection of personal barriers is not acceptable to everybody. Ian Kennedy4 writes:

“[I]t is no part of a doctor’s role qua doctor to legislate morality for others and impose his views on others…. To the doctor who complains that he wants to practise medicine without abortions, the answer must be that he can choose to engage in private practice…. If he joins the NHS, he should remember the last word of the three, ‘service’, and serve.”

Kennedy has hit upon something here. Of course it is no part of the medical role to legislate morality, and it is well to remember it. In addition to its relevance to abortion, this gets us to the reason it is wrong for doctors to refuse to treat smokers, alcoholics, or any others they might loftily feel have contributed to their own situation. Nor is it the place of a doctor to refuse those seeking care for injuries sustained in the course of crime, or terrorism, or beating up a spouse. All of these individuals are far less attractive than a distressed woman with a crisis pregnancy. The misinterpretation of this point causes some of the strongest revulsion against conscientious objection by its opponents. Objection pertains to the act requested, not to the individual requesting it, and is acceptable on such grounds only. That this is misunderstood, even by some conscientious objectors, causes much confusion and ill feeling. So, an objection to abortion would apply equally (no more, no less) if the request came from a prostitute seeking her tenth, or Mother Teresa of Calcutta for her first. Any feelings towards them of carelessness or hypocrisy are immaterial. An objection could not extend to medical care after the operation was performed. Each of them is deserving, and should expect, equal and best medical attention following it (including what looks like the requirement of both women for sound contraceptive advice).

This also shows why refusing to attend lectures on subjects that may help patients is wrong, including those conflicting with religiously held views on alcohol, homosexuality, or anything else. It would also cover attending a lecture on abortion. Among many imperative reasons to go, knowledge of the procedure may, for example, help someone with postoperative complications.

However, Kennedy is wrong in conflating this with the morality of what is being asked to be done. It is reasonable for doctors to claim an interest here, in their role as doctors and as citizens. There is another aspect to Kennedy’s mistake, in his comment regarding the provision of a state-run health service. He interprets the idea of “service” strictly, in the manner of a Victorian paterfamilias expecting the housemaid to do whatever he requests, merely because she is in his pay. He appears to think the situation does not transfer to private practice. In Kennedy’s world, it is all right for a doctor to express a conscientious objection there. It is not clear from Kennedy what the justification for this difference is. Most people believe that doctors’ ethical duties apply to the NHS and private practice equally. A doctor wanting to practise without respecting confidentiality cannot just choose private practice. Likewise with conscientious objection: acceptable or unacceptable, it is equally so for NHS and private work, but Kennedy seems to think that ethics can be left with the porter at the door of a Harley Street consulting room and picked up again on leaving.

Contrary to Kennedy,4 I believe that it is reasonable for doctors to claim an extended interest in the tasks they are asked to perform, suggesting something specific about medicine that separates it from other endeavours. Mark Wicclair5 addresses this when he wonders why employees of accounting firms and advertising agencies are not allowed, nor expected, to withdraw from representing, for example, a weapons manufacturer. He suggests this is not just because they are employees rather than self-employed professionals but also that medicine is what he terms a “moral enterprise”. It seems we might expect doctors to abide by a code of ethics and a personal moral framework less flexible than advertising agencies allow. After all, this expectation goes back at least to the days of the Hippocratic oath.

If medicine is a moral enterprise, interpretation of the ethics involved is going to vary. Doctors, in common with other sections of the community, will hold views on abortion across a spectrum. For some, what draws them to practise medicine will be the same thing that informs their conscientious objection. I think very strong reasons would need to be brought forward before disallowing these doctors’ practice. Wicclair5 outlines suggestions as guidelines for assessing whether particular interpretations of ethics should be allowed to objectors. He suggests an objection becomes more important when it is an expression of core ethical values central to the physician’s sense of self, such that undermining it would damage personal moral integrity. Applying this to our debate, we can see that it is a reasonable position to hold that killing is prima facie wrong, and will be a value we want all doctors to be aware of. Given the range of rational views possible on abortion, it may be expected that some doctors are going to extend this core value to interpret fetal life as coming under this purview.

Wicclair also suggests that an objection should be considered of more value when rooted in recognised professional norms and when important to the conception of the individual as an ethical physician. This is in contrast to an objection that lies outside the boundaries of medical norms, or is grounded in the belief of the individual as a member of a particular cultural group. As an example of the latter let us now consider an extreme example:

Imagine two brothers—doctors who have been brought up in a religious sect that views the appendix as the repository of the soul. The sect believes that in a case of appendicitis, surgery is forbidden. Many people will survive the illness with antibiotics and prayer. Those that die remain in unity with their souls and live on in heaven. The first brother, although never able to consider having an appendicectomy himself, understands this is not the usual view. Working as a general practitioner (GP), when he sees patients with appendicitis he refers them on for the operation. His brother is less accommodating. When someone comes to see him with appendicitis he explains he has a conscientious objection, and directs the patient to another doctor in the practice. This fictitious conscientious objection fails on two counts. Such an idiosyncratic view of the appendix has nothing to do with the usual professional or scientific norms of medicine. Also, the second brother’s objection is rooted in his view of himself as a faithful member of his religion; it seems an implausible claim it could be anything to do with his view of himself as a physician.

We can contrast this with a parallel scenario regarding abortion. Here, the view that the fetus is alive and worth saving is rooted within usual professional norms. That this is the case is witnessed, for example, by in-vitro fertilisation programmes, as well as early assessment units for recurrent miscarriage. At the other end of the UK abortion time limit, it is common practice for very preterm infants to be resuscitated and nursed in the intensive care unit, even when there may be a slim chance of survival. It is thus a tenable idea that to go against a conscientious objection to abortion would undermine a doctor’s view of himself as an ethical physician. It is quite possible there is a simultaneous sense of self as a member of a particular religious group operating. That sense of religious identity would be of no value in assessing the strength of a conscientious objection, but conversely should not detract from it.

Returning to Wicclair’s guidelines, he recommends that when a doctor holds an objection, patients’ rights and interests should not be compromised. He suggests this should be done by referral on to a non-objecting physician, or ideally by informing a patient in advance of any objections the doctor may hold. Finally, he thinks it is worth weighing in the balance the competing interests of physician and patient. Some patient requests, and some objections, may be more trivial, some more weighty, than others.5

Although interesting, it is difficult to know whether Wicclair’s guidelines are of practical help. They are not without problems of interpretation themselves. Assessing when an objection can be viewed as coming under professional norms might be straightforward, but whether an action may be damaging to individual integrity is largely subjective. He does not address the difficult point that some objecting physicians will also find onward referral damaging to their integrity. Informing patients of an objection in advance leaves unasked how far in advance the matter should be aired. Nor does Wicclair make clear that an objector has a personal duty to his own integrity. Part of this would appertain to job applications and interviews. It would be strange for a physician with a conscientious objection to apply for a job at an abortion clinic, and careless of an objecting GP to take up a position as a single-hander serving a population with a high level of abortion requests. It would also undermine integrity, as well as being unfair to colleagues, not to mention the matter during an interview but bring the subject up when the first problem arose.

This begins to show one of the curious features of conscientious objection, hinting at areas of conflict. Although conscience concerns personal conduct, it has implications for the conduct of others who accommodate it. Actions done to assist an objection will by necessity be those objected to. Added to this, onward referral itself might cast doubt on the objector’s sincerity, as Benn3 observes:

“[A] doctor who says, in effect, ‘I don’t refer for abortions because they are murderous, but it so happens that Dr X does, so go to him’ is surely to some extent complicit in any abortion that subsequently takes place. If you genuinely think that abortion is murder, just as wicked as the murder of an adult, then you should hardly feel comfortable about facilitating the process whereby someone else commits the murder.”

From this, it is easy to imagine that conscientious objectors could be viewed as judgemental hypocrites. Even so, Benn’s statement warrants closer scrutiny. First, an objection does not necessitate a belief that abortion is commensurate with adult murder. There are many serious wrongs that are not so commensurate. Although the objector may indeed feel complicit referring the patient, he might take the pragmatic position that there is only so much one individual can do. An objector unable to hold this stance is unlikely to stay long in the job, or like an objector seeing an advertisement for a post at an abortion clinic, should not apply.

In discussing personal integrity further, like Jackson, Benn3 agrees most of us realise we should avoid making people do what they think is wrong, saying:

“[T]o do so is a fundamental attack on their integrity…. We hear talk of people’s ‘core values’, which define their ‘innermost being’ and are central to their self-image and self-understanding. We hear how making people act against these values assaults their ‘identity’… to pressurise or force someone to involve herself in what she deems morally terrible, is a special kind of attack on her.”

Although the personal integrity of physicians is important, it seems inadequate to argue this as the sole defence of conscientious objection. Jackson1 believes that, as well as the principled reason of it being unjust to force someone to do what they believe to be wrong (even when their view of what is wrong may be mistaken) there is also a pragmatic reason:

“The pragmatic reason is that the professions may have problems recruiting and retaining talented members in certain specialties if they do not find a way to accommodate those with divergent views.”

In fact, this point goes deeper still. It is not just that conscientious objectors should be tolerated, but that they may have qualities of benefit to the practice of medicine. Nor is this merely allowing healthy pluralism, important though that is. As discussed before, the idea of feticide being contrary to principles of respect for human life is a reasonable position to hold. Having doctors who are prepared to object when this position is undermined is something that should be at least accepted. Beliefs of this sort, like many aspects of human behaviour, probably lie along a normal distribution curve. Exclude individuals at the conscientious objection end of the spectrum and the graph is likely to shift towards recruitment at the other end. Allowing only those who have no objection to abortion to practise medicine, using this as a discriminator in student selection, is intriguing territory. Most, as now, will lie under the main body of the curve and be caring and thoughtful practitioners. However, Julian Savulescu6 believes that

“A doctor’s conscience has little place in the delivery of modern medical care…. Doctors who compromise the delivery of medical services to patients on conscience grounds must be punished…”.

If the barring of objectors is pursued with this degree of enthusiasm, it is possible that attitudes at the far end of the spectrum will shift to encompass more of those who accept termination at late gestation without fetal abnormality, or even infanticide. This position would be in keeping with the ideas of Peter Singer,7 Michael Tooley,8 and others who argue in favour of the permissibility of infanticide in the first weeks of life on the basis of the lack of the attainment of personhood by the neonate and the lack of morally significant differences between a fetus and the newborn. It would be controversial (at least) to consider a move in this direction a welcome development. Therefore, as well as being important for the moral integrity of objectors, acceptance of their position also allows a healthier moral climate than would their punishment.

There is another consideration too, which concerns the welfare of the person central to this debate, the woman requesting an abortion. Initially, suggesting doctors with a conscientious objection to abortion are an asset to these women sounds bizarre, a claim thar popular commentators would be quick to dismiss. Germaine Greer9 said this:

“[I]n any other case the muddle and delay which results in second-trimester terminations would be considered highly unethical… any practitioner who refuses a minor operation in the full knowledge that a few weeks later a major operation with general anaesthesia will be necessary if the minor operation was not performed, is not acting in the best interests of his patient. Nor is he behaving responsibly to the foetus, whose capacity for suffering increases as its capacity for independent life develops.”

This is a powerful statement. Instinctively, conscientious objectors might be thought responsible for delays, adding to ill-feeling. Yet, research from the University of Southampton suggests that among factors involved in delay, those prior to the request and in awaiting surgery after referral are the most significant. Many were “not related to service provision but were linked to the woman’s continuing indecision about the procedure.”10

This is relevant in the following way. Delay before seeking abortion is often due to women being unsure of their decision. There can be many conflicting issues to resolve. Much is made in abortion discussions of choice and the importance of medical staff being neutral when giving advice. Neutrality is hard to quantify, and it is not at all clear what we should understand by the term. A half-open railway carriage window is not neutral, if one passenger wants it shut and the other open. There may be more than one way of being “neutral” leading to profound implications for decision making. Barry Schwartz,11 Professor of Psychology and author of “The paradox of choice: why more is less” (2005) discussed this in an article in relation to organ donation:

“[M]ore than 90 percent of Europeans are organ donors, while only about 25 percent of Americans are—even though most Americans approve of organ donation. In the United States, to be an organ donor you have to sign a form. The reverse is true in Europe, where you are an organ donor unless you expressly indicate you don’t want to be…. It’s close to impossible to be neutral when setting options in front of people; the format almost always nudges people in one direction or the other.”

If neutrality means being able to discuss available options under the law of the land, whether or not one is prepared to refer, there seems little evidence to suggest that conscientious objectors are any less neutral than other doctors. If, however, it means being prepared to refer under those laws, then neutrality means something else, subject to change and varying by country. Under these circumstances neutrality seems an inconsistent quality, and dependent on jurisdiction and era, not necessarily a desirable one. For women who are sure of their abortion decision, meeting a GP with a conscientious objection will be an added stress and inconvenience to all and an annoyance for some. But these women are generally well served by access to abortion, evidenced by the increasing numbers performed in total and at lower gestation. It is women who have conflicts, for many reasons, who are more vulnerable. It might be argued that such women are more prone to pressure from unscrupulous pro-life organisations following their own agenda. I think there is more subtle influence at work. The language of abortion can be emotional and subjective. This is not necessarily a bad thing. The issue is after all both of these things. Yet the idea of an abortion decision being presented as a choice, even the term pro-choice itself, may have implications for decision-making if it increases the apparent attractiveness of one option over another. Bryant et al12 have discussed the psychology of choice in relation to healthcare decision-making. They argue that humans have developed a “heuristic” or cognitive shortcut, a rule of thumb, that “choice is better than no choice”. They use the term “lure of choice” to describe a situation in which the presence of choice can bias a decision.

“In some cases, people may select an option that appears to offer choice, even when doing so results in a worse outcome than the one that would have resulted from selecting the ‘no choice’ option… framing a decision as a choice can enhance the perceived value of a particular option.”

While they are not addressing abortion, the principle is likely to hold for this too; and this becomes more important if government policies equate faster abortion acquisition with choice. In fact, the likelihood is that the opposite may be the case.

“Because the use of an heuristic reduces cognitive and emotional involvement with the decision-making process, use of the ‘choice heuristic’ may not always be advantageous in important healthcare situations where a more reasoned approach is generally preferable.”12

They argue that it is important to

“[s]low down the decision-making process. Heuristics are more likely to come into play in situations where the time for making a decision is constrained, or the person perceives a pressure to make a quick decision.”12

It is one of the unfortunate aspects of abortion that time, so important a commodity for the decision, advances pregnancy; making that decision and any consequences more difficult. That this is so is no reason to dodge the issue. If as a society we are serious about offering real choice for women in abortion we are not there yet. Faster is not the same thing as choice. It may act against it. The presence of conscientious objectors within the system of medicine, including at the level of GP referral, acts as a balance against the scales tipping in favour of too fast abortion provision, a situation detrimental to real choice.

In summary, I propose that a conscientious objection to direct referral for abortion by a GP is reasonable in ways relevant to the doctor as an individual, society more generally, and to women seeking abortion in particular. For those reasons, I believe that it is ethical for a GP to decline to refer directly for abortion on the grounds of conscientious objection. It would be detrimental to our society were this position to be prevented.

Acknowledgments

The author is grateful to Georgia Testa and Rob Lawlor for helpful advice and encouragement in preparing this paper.

REFERENCES

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Footnotes

  • Competing interests None.

  • Provenance and Peer review Not commissioned; externally peer reviewed.

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