Setting the Stage: What Are Conscience Objections?

Consider the following cases:

• • A parent objects to vaccinating his or her child
• • A physician refuses to continue as provider if a parent refuses vaccination

• • A provider objects to discussing emergency contraception (EC) with patients since s/he believes that EC results in the killing of early human life
• • A pharmacist refuses to dispense EC due to his religious beliefs
• • A physician objects to withdrawing life-sustaining care for a patient since s/he thinks this is morally equivalent to murder or violates the sanctity of life
• • A physician trained in obstetrics/gynecology avoids performing elective terminations due to fear of harassment by anti-abortion demonstrators, or because such procedures are not as economically lucrative as others
• • Members of the care team refuse to offer post-abortion support care for women
• • A doctor in a fertility clinic objects to helping a same-sex couple conceive via intra-uterine insemination since he is opposed to doing so for same-sex couples/unmarried couples
• • A medical student objects to participating in an anatomy dissection lab experience because she is a Native American whose Navajo belief system forbids her from touching dead bodies
• • The owners of a corporation refuse to provide insurance coverage for certain forms of contraception since they are morally and religiously opposed to these methods

In principle, a conscientious objection is possible in almost any area of medicine, and these ten examples provide a diverse selection. The parental objection to vaccination has already been discussed earlier in this chapter, and several of the other examples will be discussed at some length in this book. At this point, I ask the reader to reflect on these cases and to ponder: “Do all of these cases seem the same? Should they all garner the same amount of moral weight or the same response in terms of deserving a conscientious exemption? Or do some of the examples seem more justified than others?” I will return to discuss this issue of whether some conscientious objections are relatively more justified than others in the next chapter (Chapter 2); at this point it is sufficient to reflect upon one’s pre-theoretical intuitions on the matter.

What makes something a conscience objection? I will understand a conscientious objection as opposition to a patient’s request or participation in a practice based on core (secular or religiously inspired) moral beliefs or reasons. I want to make two key observations about this preliminary account. First, the medical provider’s objection is premised upon an ethical belief, not a clinical belief. Therefore, if a fertility clinic director opposes providing IVF to a woman since she is convinced that the woman cannot become pregnant, then her refusal is based upon medical reasons and as such, it is not a conscience objection. Second, the belief must be a core belief. A core belief is one around which a person centers his or her life. It dictates the practices she opposes and the ones she can accept, and it is a belief that constitutes the firm footing she can use to make sense of many other beliefs she holds with less certainty. In addition, a core moral belief is identity-conferring-, it reflects her authentic self as she conceives it. A conscientious objection is not simply founded upon a disagreement with a patient’s request; it is instead premised upon a medical professional’s condemnation of an action which links importantly to her self-conception. Having to compromise such a belief would result in a significant cost in terms of her moral integrity or would cause some substantial negative change to her as a person.

Drawing a clear distinction between ethical and clinical beliefs can be difficult in practice. My project is not to define the essence of a moral belief. But since conscience objections are founded strictly upon ethical beliefs, I should say a few things about the domain of the ethical. Ethics consists in building a critically reflective morality (Card, 2004). Ethics is critical since it requires openness to examining reasons from all perspectives and sources. Ethics is reflective since a conscientious moral agent is continually attempting to strike a delicate balance that considers the effect of these reasons on his or her deepest values. A morality, or set of mores, is a set of rules or norms that may be adhered to even in a non-reflective manner. Therefore, ethics is a form of morality, yet a morality is not necessarily ethical. To consider ethics to be a critically reflective morality underscores the point that ethics consists of a set of skills and a process of discovery and not strictly speaking a body of knowledge. Given this conception of ethics as a critically reflective morality, individuals should focus on learning what questions are constructive ones to pursue, what tendencies in one’s own thinking need to be kept in check, and how to remain reflective even when one’s deepest values are implicated in a moral controversy. From this point forward, when I use the word “moral” or “morality,” I mean to refer to a critically reflective morality— to the domain of the ethical.

Now, to get a sense of the content of ethical beliefs, imagine a cascade of cases. Suppose a director of a fertility clinic does not wish to give assistance on conscientious grounds to a 55-year-old woman who wants to get pregnant via IVF using donor ova. We could further suppose that the fertility clinic had established a policy that it would not assist women above a certain age in becoming pregnant, say, establishing a cutoff at age 50. Medical workups reveal that the woman is likely to be successful in getting pregnant and carrying the pregnancy to term is unlikely to cause serious harm to her health, since she is in good physical condition. Yet several questions arise with respect to this scruples-based objection. First, are there any significant medical risks to a resulting offspring if donor eggs are used to achieve a pregnancy in a woman of this age? The clinic director has not stated the specific objection and the reason supporting it, but let’s suppose that the objection is simply based on maternal age and he would not object in a similar case if the patient was, say, 25 years old. Perhaps there is some very small incremental increase in medical risks to the offspring if a healthy 55-year-old patient conceives, but that reason is clinical and hence is not clearly the basis of a conscience objection (and is a weak clinical reason at that). One might object based on the woman’s age due to her expected life-span that she may not be able to parent the offspring effectively through adolescence into adulthood. This reason is not strictly clinical and seems to have some social or moral content. Yet such a reason is an arbitrary restriction, unless the clinic is assessing the physical fitness and likely life-span of all other clients and denying participation on this basis. After all, there are some 55-year-olds who are in fantastic health, and some 30-year-olds whose health and future physical outlook are so poor that on this line of reasoning they ought to be rejected. If the clinic is denying patients on this basis, then this seems inconsistent with the notion of promoting reproductive freedom. If (as seems likely) they are not assessing the physical fitness of younger clients and denying treatment on this basis, then their policy is grossly unfair.

Perhaps the refusal based on age is meant to be related to parental unfitness, and this could involve a moral belief and hence constitute a conscientious objection: the clinic director will not assist any woman in getting pregnant who he thinks is unfit to be a parent, since his participation in establishing this pregnancy would harm the resulting child and possibly society at large. Therefore, by his lights, helping the 55-year-old woman get pregnant would be wrong. Again, this seems difficult to support. Health or life expectancy is a very crude measure of parental fitness and linking this lack of fitness strictly to age is arbitrary from a moral point of view. Even if the clinic is consistent and evaluates all clients, strictly using age as a marker for parental fitness or suitability for IVF treatment is very difficult to defend.

One could construct a conscience objection based on social abhorrence to helping women get pregnant that would ordinarily be more suitable as grandparents, not parents. This is a quasi-moral reason, yet it is thin since it is again arbitrary from a moral point of view. Finally, one could construct an argument based on an inequality between men and women that IVF potentially addresses: men have essentially no age limitations on their fertility, so using donor eggs allows women who would not be able to otherwise get pregnant at later ages achieve this end, thereby leveling the playing field (to at least some extent) with the reproductive lives of men. An appeal to equality seems to clearly signal a moral belief, and therefore this objection constitutes a conscience objection. Yet it is unclear exactly how this argument could support denial of reproductive services to the 55-year-old woman. If the reproductive inequality identified is morally inappropriate and we should do whatever we can to reduce this gap (perhaps within the limits of ability to pay), then it seems clinics should help interested women become pregnant even if they are 55 years old if pregnancy appears medically achievable. Perhaps one could add the condition that one must also think the pregnancy will not cause serious harm to the woman, but it seems that this paternalistic condition could be addressed with proper informed consent from the woman (noting that the same harm could occasion a pregnancy by a younger woman, unforeseen or not). Basically, the difference between a clinical reason and a moral reason appears to lie on a spectrum—there can be a thin line between cultural beliefs, beliefs about proper etiquette, and ethical beliefs. Ethical beliefs often engage concepts such as (e.g.) equality, harm, justice, or autonomy and (noting the worry about an element of circularity) engender the familiar attitudes specific to moral thinking. In this book, many of the beliefs motivating conscientious objection will stem from an opposition to taking human life—a paradigm moral belief—as well as others such as opposition to harming another person. Also, a substantial number of the objections lodged by providers seem to be religious in nature, though as I will discuss later, there is very little empirical data on conscientious objection. The analysis presented in this book addresses the central issues but does not philosophically distinguish between conscience objections motivated by religious versus secular reasoning.¹ The key point is that the objection must be based on a sincere, core ethical belief to be a conscience objection. In summary, we recognize the prior-named beliefs (whether motivated by religious or secular considerations) as moral without needing to possess a set of necessary and sufficient conditions for what constitutes a specifically ethical belief, and this allows us to move forward as we philosophically explore the proper boundaries of conscience objections in health care.