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Commentary
Conscientious objection and its social context
  1. Ryan E Lawrence
  1. Correspondence to Dr Ryan E Lawrence, Department of Psychiatry, Columbia University Medical Center, New York-Presbyterian Hospital, and the New York State Psychiatric Institute, Box 90, 1051 Riverside Drive, New York, NY 10032, USA;rlawrence{at}uchicago.edu

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Conscientious objection among physicians is a perennial hot topic on both sides of the Atlantic. Sven Nordstrand's survey of Norwegian medical students adds fresh data to this ongoing debate.1

Their starting point, whether doctors should be allowed to refuse any procedure to which they object on cultural, moral or religious grounds, is truly at the heart of the debate. Their finding that only 20.8% of students endorse this position is striking as it is less than half the number reported by Sophie Strickland (45.2%) in her survey of medical students in the UK.2 It also suggests much less support for conscientious objection than was found among USA primary care physicians, where 78% agreed that “A physician should never do what he or she believes is morally wrong, no matter what experts say.”3

These data invite speculation about why there is such dramatic variation between countries. Much can be made of Nordstrand's comments that in Norway “each citizen is assigned a particular general practitioner” and “In the Norwegian healthcare system the general practitioner has a crucial role as a ‘gatekeeper’ for the specialist services.”1 Allowing physicians to exercise conscientious objection has vastly different implications if there is a single payer healthcare system where patients are assigned a general practitioner (Norway), versus a multiple payer system where patients can often choose their payer and their primary care provider (USA). In the USA, there are even some healthcare payment arrangements that allow patients to make their own appointments with specialists without requiring a referral from a primary care physician or general practitioner. Thus, a Norwegian physician who exercises conscientious objection and refuses to refer a patient for a procedure could readily be viewed as blocking that patient's access to the procedure. However, a physician in the USA might refuse to refer and not feel that he or she has significantly hindered the patient's access to that procedure. In each of these settings, conscientious objection is likely to be viewed differently.

A related possibility is that different countries have different degrees of consensus on what the physician's role entails. A number of ethicists have argued that physicians have a socially defined role, which individuals must be willing to assume if they are to become physicians. Julian Savulescu wrote, People have to take on certain commitments in order to become a doctor. They are part of being a doctor… To be a doctor is to be willing and able to offer appropriate medical interventions that are legal, beneficial, desired by the patient, and part of a just healthcare system.4

This idea has been echoed by Dan Brock,5 Eva and Hugh Lafollette.6 Importantly though, this position assumes consensus on what is expected of physicians. Where consensus is strong, where the medical profession has clearly outlined what it will provide to society and where persons entering the profession more strongly view themselves as acting on behalf of the profession (or perhaps even on behalf of the state), one might anticipate weaker support for physician conscientious objection. Conversely, where the medical profession is less unified and where physicians perceive themselves as acting more independently (perhaps as independent practitioners), one might anticipate stronger support for physician conscientious objection. Different views of physician conscientious objection regarding Norway and the USA might stem from different perceptions of the profession: one emphasising collective unity and the other emphasising individual choice.

Religious differences between the countries suggest additional reasons for the different views on conscientious objection. Among Norwegian students who said religion is important (almost all of whom were Christian), nearly half (47.2%) said it should be possible for doctors to object to any procedure to which the doctor has a moral or religious objection. Strickland found similar rates among students in the UK who were Protestant (51.2%), Roman Catholic (46.3%), Jewish (54.5%) and Buddhist (41.7%); Muslims (76.2%) and Hindus (34.2%) were outliers.2 Among USA physicians who attend religious services twice a month or more, 58% believed physicians are never obligated as professionals to do what they personally believe is wrong. Thus the perspective of religious physicians is fairly consistent between countries, suggesting the difference in overall support is affected by the balance of religious and nonreligious respondents: 46.6% of Norwegian respondents had a religious affiliation, 58.6% of respondents in the UK had an affiliation (including a significant number of Muslims who strongly supported conscientious objection) and 88.8% of USA physicians had an affiliation.

The particular religious traditions present in each country might also play a role. Roman Catholic teaching, for instance, is explicit that an individual should always follow his or her conscience (Catechism, #1790).7 In Norway, just 1.67% of the general population identifies as Catholic, yet the numbers are higher in the UK (9.30%) and the USA (22.76%).8 While it cannot be assumed that every Catholic endorses this view, or that only Catholics hold this view, it is probably safe to assume this teaching carries more weight in regions where there are more Catholics.

These data raise additional questions. Do students’ views change as they advance in their training? Who decides when conscientious objection should be permitted? What happens to conscientious objection when new procedures transition from controversial, to commonplace, to compulsory? These data serve as a helpful reminder of the work that remains in understanding physician conscientious objection.

References

Footnotes

  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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