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Medical students’ attitudes towards conscientious objection: a survey
  1. Sven Jakob Nordstrand,
  2. Magnus Andreas Nordstrand,
  3. Per Nortvedt,
  4. Morten Magelssen
  1. Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
  1. Correspondence to Sven Jakob Nordstrand, Centre for Medical Ethics, Institute of Health and Society, University of Oslo, 1130 Blindern, Oslo N-0318, Norway; sven_nordstrand{at}hotmail.com

Abstract

Objective To examine medical students’ views on conscientious objection and controversial medical procedures.

Methods Questionnaire study among Norwegian 5th and 6th year medical students.

Results Five hundred and thirty-one of 893 students (59%) responded. Respondents object to a range of procedures not limited to abortion (up to 19%)—notably euthanasia (62%), ritual circumcision for boys (52%), assisted reproduction for same-sex couples (9.7%) and ultrasound in the setting of prenatal diagnosis (5.0%). A small minority (4.9%) would object to referrals for abortion. In the case of abortion, up to 55% would tolerate conscientious refusals, whereas 42% would not. Higher proportions would tolerate refusals for euthanasia (89%) or ritual circumcision for boys (72%).

Discussion A majority of Norwegian medical students would object to participation in euthanasia or ritual circumcision for boys. However, in most settings, many medical students think doctors should not be able to refuse participation on grounds of conscience. A minority would accept conscientious refusals for procedures they themselves do not object to personally. Most students would not accept conscientious refusals for referrals.

Conclusions Conscientious objection remains a live issue in the context of several medical procedures not limited to abortion. Although most would want a right to object to participation in euthanasia, tolerance towards conscientious objectors in general was moderate or low.

  • Conscientious Objection
  • Abortion
  • Ethics

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Introduction

A 2011 study by Strickland surveyed the attitudes of British medical students and found that as many as 45% thought that doctors should be allowed to refuse any procedure to which they object on cultural, moral or religious grounds.1 This proportion was even higher in students with a Muslim background.

Strickland's study raised two questions that the present study attempts to shed light on with data from a Norwegian context. First, Strickland's study focused mainly on abortion, but several other areas, such as euthanasia, prenatal diagnosis and ritual circumcision are also fraught with ethical disagreement. To what extent will there be claims to conscientious objection in such situations? Second, to what extent is conscientious objection tolerated by those who do not object?

In Norway, abortion is available on demand until week 12. Norwegian health law gives health professionals the right to conscientious refusals in the case of abortion (performing and assisting) only. However, in most parts of Norway, abortions require a referral from a general practitioner (GP), and several GPs have refused to refer for abortions, citing moral and religious reasons. These refusals were tolerated until October 2011, when a new regulation explicitly outlawed a GP's refusal to refer. This has spurred debate. A previous study found that as many as 27% of medical students would consider making use of a right to conscientious refusals in the context of abortion.2

Recently, controversy has erupted on two other areas in particular. First, regarding the practice of ritual circumcision for infant boys, some argue that this should be kept out of public hospitals or outlawed altogether.3 Second, the proposed provision of prenatal ultrasound screening for chromosomal abnormalities as part of routine pregnancy care is controversial. Opponents argue against this proposal on ethical and medical grounds.4

There is an extensive literature on the normative aspects of conscientious objection.5–10 Empirical studies such as the present can provide a factual basis for normative analysis, for instance, by identifying distinctions—such as performing versus referring for controversial procedures—that appear morally relevant to healthcare professionals.

Methods

Questionnaire and study population

An anonymous questionnaire was distributed between lectures to 5th and 6th year medical students from all four medical faculties in Norway in the first half of 2012. Participants were informed in writing about participation being voluntary and the responses anonymous. As the study did not involve patients, then according to Norwegian law, it did not require ethics committee approval. Questions were revised following a pilot study involving 14 medical students. Respondents were asked to provide demographic data (table 1), and to take a stand on statements about controversial procedures (table 2). Strickland's question about refusals for any procedure, ‘Do you think that doctors should be entitled to object to any procedure for which they have a moral, cultural or religious disagreement?’ was translated and included in the questionnaire.1

Table 1

Respondents and characteristics

Table 2

Views on controversial procedures and the coverage of conscientious objection in the curriculum

The other main question was: ‘For each procedure below, indicate whether you think it should be possible for doctors to refuse to participate in the procedure, and whether you as a doctor would want to refuse to participate in the procedure' (cf. tables 3 and 4). Respondents who reported their religion to be very or quite important to them were grouped together for subsequent analysis (as ‘students for whom religion is important’; tables 3 and 4).

Table 3

Students stating that it should be possible for doctors to object (%)

Table 4

Students who themselves would refuse to participate in the procedure (%)

Statistics

Completed questionnaires were entered into Statistical Package for the Social Sciences (SPSS). Frequency analyses and cross-tabulations were used for descriptive data. Statistical significance was assessed by χ2 and Fisher's exact test.

Results

Demographics

Five hundred and thirty-one students participated. The eligible classes consisted of 893 students, yielding a response rate of 59%. Characteristics of the respondents are listed in table 1.

Objections to specific procedures

Table 2 shows the attitudes towards certain controversial medical procedures. Table 3 shows the respondents’ views on whether it should be possible to object to different procedures, whereas table 4 shows the proportion who themselves would refuse to perform a specific procedure.

Of all respondents, 53%–55% supported a right to conscientious objection against abortion in different contexts (table 3), whereas 36%–42% did not (data not shown). Fifteen to nineteen per cent would themselves object to participation in abortion (table 4). Thirty-eight per cent would not object to performing abortion themselves, but would support a right to conscientious refusal. Ten per cent supported the right to refuse to refer for abortions (table 3), whereas 4.9% would themselves refuse to refer (table 4). Eighty-nine per cent agreed that it should be possible to object to euthanasia if this were to be legalised (table 3), whereas only 3% disagreed (6% of men, 2% of women (p=0.03); data not shown). Sixty-two per cent would themselves object to performing euthanasia (table 4), whereas 12% would not (data not shown).

Conscientious objection in general and referrals

To the question of whether doctors should be entitled to object to any procedure for which they have a moral or religious disagreement, 7% of our respondents strongly agreed, 14% agreed and 28% disagreed, whereas 46% strongly disagreed. Of students for whom religion was important, 47.2% agreed (p<0.001, table 3). Men (22%, p=0.04) agreed significantly more often than women.

To the statement ‘if the doctor objects to participation in a treatment or procedure the doctor should have a duty to refer the patient to a colleague who does not object’, 86% strongly agreed, 10% agreed and 2% disagreed, whereas only 1% strongly agreed. Of students for whom religion was important, 6.5% disagreed (moderately or strongly; table 3). Women agreed with the statement significantly more often than men (98% vs 93%, p=0.01).

The impact of religion

Tables 3 and 4 show the considerable impact of importance of religion on the students’ views. In general, students for whom religion was important were more likely to support conscientious objection. Of respondents who would object to referrals for abortion or prescribing contraceptives with postfertilisation effects, all indicated high importance of religion (data not shown). As there were only 15 Muslim respondents, differences between Christians and Muslims must be interpreted with caution. Generally, Muslim responses were in line with the responses of the Christians who indicated high importance of their religion.

Moral and religious reasons

Students who would themselves object to participation in a procedure were asked to specify if their reasons for objecting were of a moral or religious nature or both (data not shown). In general, the majority of objections were for moral reasons (59%). Only 5% of objections were exclusively for religious reasons. The remainder (37%) were for both moral and religious reasons.

Discussion

Tolerance and rejection of conscientious objection

In general, a substantial minority (eg, regarding abortion, 38%) support a right to conscientious objection even though they themselves do not object to the procedure in question. This attitude of tolerance is exhibited by a considerable minority in most cases, whereas in some cases (eg, objecting to the treatment of self-inflicted conditions) the tolerant attitude has almost no support.

However, the finding that as many as 42% of respondents do not support the only legally established right to conscientious objection, the right to refuse participation in abortion, was surprising, as this right is supported by all major political parties (no surveys of popular attitudes exist). At the same time, a large majority (89%) accept conscientious objection if euthanasia were to be legalised. The latter finding suggests that most students do not reject conscientious objection wholesale, but consider it to be justified in some contexts.

These findings also highlight the relationship between the degree of moral controversy and tolerance of conscientious objection in our survey. For particularly controversial procedures (eg, euthanasia, ritual circumcision), a higher proportion of students tolerate conscientious refusals, whereas for procedures that are less controversial and perhaps have become partially ‘normalised’ (eg, abortion) a lower proportion tolerate refusals.

Objections to a wide range of procedures

Whereas Strickland's study focused on abortion, we find that medical students would consider objecting to a range of procedures. In addition to abortion, substantial minorities would object to performing ultrasound for the purpose of prenatal diagnosis or performing assisted reproduction for lesbian couples (the latter being legal in Norway since 2009).

These latter objections were mainly, but not exclusively, made by students citing high importance of religion. Some—all indicating high importance of religion—would also object to the prescription of contraception with postfertilisation effects.

Ritual circumcision for infant boys is a controversial procedure in Norway. Fifty-five per cent of respondents would disallow ritual circumcision in public hospitals, whereas 72% support a right to refuse to participate in the procedure. Fifty-two per cent would themselves refuse to participate, most citing moral not religious reasons. This observation highlights that there can be a demand for policies protecting conscientious objection also outside the context of the ‘traditional’ controversies regarding life and death. We were surprised by the greater support for conscientious objection in this instance than in the ‘classical’ case of abortion. In addition, together with the high number of non-religiously motivated objections to euthanasia, the finding accentuates that conscientious objection is not solely linked to religious belief. As Savulescu put it, “Other values can be as closely held and as central to conceptions of the good life as religious values”.8

Conscientious objection to referrals

In the Norwegian healthcare system the GP has a crucial role as a ‘gatekeeper’ for the specialist services. Referrals to specialists are a considerable part of the GP's tasks. Each citizen is assigned a particular GP, leading some to fear that the patient's access to treatment could be compromised if the GP objects to certain referrals, for example, abortion. This worry was a main motivation for outlawing the GP's conscientious refusal in 2011, a decision which has been controversial. Our study sheds some light on this particular topic. Only 10% of students think that it should be possible for a GP to refuse to refer for abortion. The number rises to 32% among students for whom religion is important, implying that, surprisingly, a majority of religious students do not think it should be possible for a GP to refuse to refer for abortion. Merely 4.9% would themselves refuse to refer for abortion. However, most likely many of these will go into general practice, and so conscientious objection to referrals will remain a live issue.

In a US study, 57% of physicians from all specialities agreed that conscientious objectors must refer patients regardless of whether the doctor believes the referral itself is immoral.11 Another US study from 2011 found that 90% of physicians in family medicine residency training thought that a physician has an obligation to refer patients to procedures to which he or she has a moral objection.12 Physicians who were themselves religious or personally objected to a procedure were less inclined to accept an obligation to refer.13

In the Norwegian debate, among those who argue for a GP's right to object to referrals, almost all recognise a duty to pass the patient on to a colleague, who then refers for the procedure.14 ,15 In our study, a mere 2.7% of respondents do not accept such a duty.

Teaching and the support for conscientious objection in general

Strickland found that as many as 45% accepted conscientious objection for any procedure the doctor would object to, whereas in a US study, 42% of primary care physicians thought that physicians are never obligated to do what they believe is wrong.1 ,16 Using the same question as Strickland, we found a corresponding figure of 21%. However, when respondents were asked about objections to specific procedures, almost all of those who accepted objection in general did not support objection in certain instances (eg, treatment for self-inflicted diseases, where objection was supported by a mere 0.9%). As Strickland plausibly suggests, it may be the case that the respondents who gave their assent to objection in general had more controversial procedures in mind when answering this particular question.

However, we would suggest that this particular point be put to use didactically. Medical ethics, though a vast field, is a minor subject in medical schools, necessitating careful prioritisation of topics. In Norwegian medical schools the topic of conscientious objection is usually not taught. We suggest, though, that the topic is eminently suited for facilitating reflection on aspects of professionalism and the relationship between the doctor's own moral values, the profession and society. As Strickland's study and the present study indicate, many students harbour the idea that society ought not restrict the doctor's exercise of conscientious objection. However, being exposed to possible counterexamples, for example, objections to treatment for self-inflicted diseases, could bring about a didactically powerful realisation that there must be limits to the exercise of the doctor's conscience—there must be criteria for when conscientious objection is morally justified.6 Correspondingly, a large majority approved of conscientious objection in the case of euthanasia. This means that most students accept that conscientious objection is at least sometimes justified and a good. Additionally, the finding that two-thirds of respondents found the coverage of the topic in the teaching inadequate supports our suggestion of assigning conscientious objection a place in the curriculum.

Limitations

The response rate was modest, thus possibly introducing a selection bias. The study's aim was to examine the attitudes of future doctors in Norway. However, many doctors practising in Norway are educated abroad. Their attitudes have not been surveyed here. These doctors will have been influenced by other cultural and professional mores, and might conceivably exhibit other attitudes towards conscientious objection. In addition, the students’ views can change during their subsequent training and work experience. The survey studies the students’ personal beliefs and stated attitudes, which is not the same as actual behaviour. For instance, some students who stated objections to a procedure may not refuse when confronted with the procedure as doctors. It remains an interesting question for normative analysis whether, in which situations, and on what conditions conscientious objection may be morally justified.

Conclusion

This study shows that there will be requests that doctors be excused from providing interventions for which they have conscientious objections to several other procedures than abortion. Some of these, for example, ritual circumcision and assisted reproduction for same-sex couples, differ in several respects from the more classical case of objections in ‘life and death’ issues (eg, abortion, euthanasia).

Future studies could examine the attitudes and actual practices of doctors. Conceivably, there might be differences between doctors and students that are due to generation effects or to the socialisation of the medical profession.

References

Footnotes

  • Contributors SJN, MAN and MM designed the study, with contributions by PN. SJN and MAN gathered the data and performed the statistical analyses. SJN and MM wrote the first draft. All authors critically revised the paper and approved the final version.

  • Competing interests None.

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

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