Conscientious objection in medicine

This survey revealed that nearly half of the students in this survey believed in the right of doctors to conscientiously object to any procedure. Once qualified as doctors, if all these respondents acted on their conscience and refused to perform certain procedures, it may become impossible for conscientious objectors to be accommodated in medicine.

However, there are subtle variations in the answers given in the questionnaire. Although 45.2% of respondents agreed that doctors can object to any procedure, this did not appear to be supported by the results in table 2. It could be that, when asked if they thought that doctors should be able to object to any procedure, the students thought of more controversial procedures. On the other hand, the difference between the results could be because, although nearly half of the students believe in the general right for doctors to claim conscientious objection in medicine, they personally would not uphold this right in the procedures listed in table 2.

Some conscientious objectors are accepted in the medical profession in the UK, and the GMC has issued clear guidelines about what doctors should do when they object to a procedure, stating that, if a medical practice conflicts with a doctor's religious or moral beliefs, then the doctor must explain this to the patient and refer the patient on.8

Conscientious objection and religion

This survey found that a greater percentage of the objections in the survey were for non-religious reasons than religious ones. The factors behind the non-religious objections were not specifically explored. It is sometimes easier to understand an objection based on religious teachings, rather than on an individual's personal moral framework, but non-religious beliefs can be just as firmly held and as central to a person's life. It is perhaps too easy to equate conscientious objection with religious belief.

Conscientious objection and abortion

Abortion is probably the most highly debated issue in conscientious objection. The survey revealed that almost a third of students would not perform an abortion for a congenitally malformed fetus after 24 weeks, a quarter would not perform abortion for failed contraception before 24 weeks, and a fifth would not perform abortion on a minor who was the victim of rape. Interestingly, not all students in the survey who objected to the idea of performing an abortion would necessarily conscientiously object to performing it in practice (see table 2). However, if these students are prepared to perform a procedure despite their objection to it, it could be argued that they are compromising their own moral integrity and that they may experience some moral distress. It would be valuable to find out why they would still perform a procedure in the belief that it is morally wrong. Do they feel coerced into the perceived wrongdoing?

In light of increasing demand for abortions, these results may have implications for women's access to abortion services in the future. The Department of Health has issued statistics showing that, although there are an increasing number of abortions taking place in the UK, fewer doctors are willing to perform them.9 The Royal College of Obstetricians and Gynaecologists has issued a statement recognising the growing problem of its doctors refusing to train in abortion. It stated that it is ‘aware of the slow but growing problem of trainees opting out of training in the termination of pregnancy and is therefore concerned about the abortion service of the future… The RCOG recognises that it is an important right for any doctor to object to performing abortion. The future of the sexual healthcare services requires careful workforce planning in order for abortion services to be available to the women who need it most.’10

Furthermore, there are fewer students opting for a career in obstetrics and gynaecology, which could further complicate the problem.11 In 1995, it was the main career choice of 26 out of 545 UK graduates, in 1998 this was 16 out of 509, and by 2002 only six out of 487. The RCOG has recognised the downturn in recruitment to the specialty in recent years and has stated that ‘unless recruitment improves there will be insufficient obstetricians to deliver the NHS service’.12

Conscientious objection at medical school

While it is considered acceptable for doctors to object to medical procedures on moral or religious grounds, medical students are prohibited from doing the same. The GMC acknowledges that every medical student has ‘a right to freedom of expression’, but it also states that this ‘cannot compromise the fundamental purpose of the medical course: to train doctors who have the core knowledge, skills, attitudes and behaviour that are necessary at graduation’.2

There have been reports that Muslim medical students are refusing to attend lectures on alcohol-related diseases, answer exam questions on alcohol-related issues, and treat patients of the opposite sex.6 The Sunday Times stated that a male Muslim medical student failed his final exams after refusing to carry out a basic examination of a female patient.6 No Muslim student in this study noted a conscientious objection to learning about the clinical aspects of alcohol. However, we found that 76.2% of the Muslim students in the study stated that doctors should be able to object to any procedure. This represented the largest proportion of any single religious group within the survey claiming the need for indiscriminate objection. Furthermore, a greater proportion of Muslim students reported an objection to procedures across all questions in table 2 when compared with all students in the study. The views of large numbers of Muslim students are contrary to GMC guidelines, and thus the medical profession needs to think about how it will deal with the conflict.

The 2-year Foundation Programme in the UK involves an array of clinical experiences in which all graduates must be able to treat a range of unselected and acutely ill patients. The GMC believes that, in such an environment, it would simply not be possible to accommodate personal and religious preferences.2 It specifically states that a foundation level doctor cannot practise while refusing to examine patients on grounds of gender or those patients whose illness can be attributed to their lifestyle.2 The foundation level doctor is often the first doctor seeing acute patients and any delay in assessment or treatment may lead to unnecessary harm to the patient. The current job allocation system, which equates to a lottery, may not give conscientiously objecting doctors the ability to avoid jobs in which they might encounter roles that they object to.