The Value of Conscience

Chapter 1 looks at why it is important to value conscience in health care, or what health care professionals might lose if their conscientious conduct was not protected. This chapter establishes that conscience has value, generally speaking, in health care, although not because it leads health care professionals on the path to moral righteousness or truth, as some would have it. Rather, it can allow health care professionals to have integrity, which itself has both personal and social value. The claim that conscience promotes integrity is common in bioethics, although the author interprets “integrity” differently than most bioethicists do.

Why Not Compromise?

Chapters 1 to 3 show that important interests are at stake in regulating conscientious refusals in reproductive health care, and that this is true for both conscientious objectors and patients. One might think, therefore, that devising a compromise between the parties would be the best way to deal with these conflicts. Chapter 4 rejects this approach, however, on the grounds that developing a good or even a true (i.e. genuine) compromise is unlikely to happen for typical refusals in reproductive health care. The chapter delves deeply into the nature of compromises and also uses what has been called the “conventional compromise” (conscientious objectors can refuse to provide the offending service but must offer a proper referral for it) to illustrate why the compromise approach fails.

Fidelity to Patients

The central claims of Chapter 5 are that health care professionals who serve a gatekeeping role are fiduciaries for their patients (normatively speaking), they therefore have a fiduciary duty of loyalty to them, and this duty prohibits them from making typical conscientious refusals because doing so jeopardizes health interests of their patients. This chapter explains why this argument works even though typical objectors tend to view the fetus or embryo whose life is at risk as their second patient. At the same time, the author agrees that making a referral to a colleague who is willing and able to provide the offending service, rather than providing it oneself, can be a morally appropriate option for a conscientious objector. The chapter as a whole defends the approach to typical refusals of prioritizing patient interests, specifically for cases where the objector and patient have an existing fiduciary relationship. The author also extends her analysis to atypical refusals in reproductive health care.

Harm or Mere Inconvenience?

Commentators often point out—in discussions about conscientious objection in reproductive health care in particular—that patients are merely inconvenienced rather than harmed by conscientious refusals. Chapter 2 opposes this view. Since good empirical evidence is lacking about the effects of conscientious refusals on patients, the author has to speculate about their impact, which she does based on various factors, including the power dynamic between health care professionals and patients, and the well-documented stigma that patients experience when they request services such as abortions or emergency contraception. The author argues that in light of these factors, typical refusals in reproductive health care (those that aim to protect the life of the “unborn”) very likely cause harm. They do so by threatening the moral identity of patients (as good or fine people), their sense of security (in being able to control what happens to their body), or their reproductive autonomy.

Introduction

Conscientious objections by health care professionals to abortion are a pressing global health issue (IWHC 2017; Chavkin et al. 2013). Many countries have in place laws or policies permitting abortion that include clauses providing some protection for conscientious objectors. Although it is difficult to know how often health care professionals exercise the freedom that “conscience clauses” offer them, there is evidence that they are using these policies more and more frequently to avoid having to provide abortions and similar services, such as contraception. For example, a recent report of the International Women’s Health Coalition (IWHC)—entitled ...

Fidelity to Purposes

Chapter 6 centers on a duty—endorsed by licensing bodies and health professional organizations—that health care professionals have to the public to promote public health, and more narrowly, to foster equitable access to medical care. The author argues that this duty is a type of fiduciary duty, although a different type than the one health care professionals have in their relationships with current patients. The duty to the public demands the professional’s fidelity not to individual people but to abstract purposes. Health care professionals are morally required to be loyal to the purposes of furthering public health and equitable access, which they can achieve only by prioritizing the interests of prospective patients in gaining access to care over their own interests. Such prioritizing limits, in turn, the extent to which they can legitimately refuse to take on new patients because of their conscientious objections.

Conclusion

The interests of patients in receiving standard services should therefore be prioritized over the conscience of health care professionals. This book has defended this prioritizing approach over the compromise approach, which is dominant in bioethics. It has also focused on what I’ve called “typical refusals” in reproductive health care—especially, refusals to offer abortions or so-called “abortifacients”—because of a global trend of health care professionals engaging in such conduct (...

Damage to Trust

Chapter 3 focuses on the harm that conscientious refusals cause when they diminish the trust that patients have in health care professionals and professions. The author argues that damage to trust from typical refusals is very likely to occur, because of the nature of these refusals as well as the nature of trust. She also critiques a response to this concern about trust by Holly Fernandez Lynch. In her Conflicts of Conscience in Health Care (2008), Lynch develops what she calls an “institutional compromise” to the problem of how to regulate conscientious refusals. She contends that one benefit of her solution is that it would prevent damage to trust from conscientious refusals. Chapter 3 of this book endeavors to show, on the contrary, that insofar as our concern is with patient trust, we should reject Lynch’s proposal.