Behind the Scrubs: Should Doctors Be Allowed to Conscientiously Object to Participating in Abortions?

Will Davison, Fourth Year Medicine

Abortion still sparks controversy, even among doctors. While it is a generally accepted practice in western medicine, some doctors feel it is unethical and wish to conscientiously object. This may be because of religious or secular ethical beliefs. Yet whether doctors should be allowed to refuse to participate in abortions, which are largely seen as beneficial, should be questioned. Importantly, objecting appears to clash with a doctor’s duty to their patients to provide treatment. However, it equally feels wrong to obligate someone to perform a procedure that they believe is morally impermissible. 

Here, I will make the case that it is morally justified for doctors to conscientiously object to performing abortions, provided the objection is based on a conflict with core medical values. Firstly, I will explore the commonly provided moral integrity argument and explain why it falls short as a justification. Instead, I will outline how abortion can be seen as conflicting with certain core medical values for some doctors and argue that conscientious objection based on this discord is permissible. 

One of the main, and perhaps most intuitive, arguments for supporting conscientious objection is by appealing to moral integrity (Wicclair, 2000). The argument goes as follows: an individual has deeply held ethical values that are integral to their self-identity. These may come in various forms, such as personal values, maxims, or religious principles. If a procedure goes against an individual’s personal ethical values, performing it would be a form of self-betrayal, and someone should not be forced into doing this. Regarding abortion, if you believe it is wrong, carrying it out would therefore damage integrity and likely cause great distress. On the face of it, this seems a good reason to allow doctors to object to abortion. 

Yet personal distress is not necessarily enough to release a doctor from their professional obligation to provide beneficial treatment, which an abortion can be. Doctors do many things that are distressing, such as breaking bad news and dealing with children suffering from abuse. But distress does not release a doctor from carrying out these duties. So why should abortion be a special case? Perhaps it is specifically the distress of doing an action oneself that directly conflicts with one’s deeply held values that is problematic. The philosopher Piers Benn attempts to summarise the problem: (1) it is wrong to act in ways that one believes are wrong, and (2) it is wrong to ask someone to do something that is wrong. From these, he concludes that it is wrong to ask someone to do something they consider wrong (Benn, 2005p. 175).

However, premise (1) doesn’t necessarily hold. People can believe actions are wrong and feel guilty about being involved with them, even if the guilt is a result of morally questionable loyalties. A racist might think it is wrong to treat an ethnic minority and that doing so would conflict with their core values. If we think it is wrong to require someone to do something they consider wrong, then it would follow that the racist could correctly refuse to give treatment. But we should not let these views affect professional conduct, and especially not of a medical professional. 

Benn, however, would not acknowledge this as a problem. He argues some core values are simply not compatible with morality and therefore do not deserve respect. He takes the Nazis as an example, arguing their values have no connection with a moral code. Their code is evil, containing nothing we can properly value, and thus we do not need to respect it (Benn, 2005p. 175). By the same logic, we could argue that nothing grounds racism and it is therefore an invalid objection. Benn’s argument seems to be that one can conscientiously object based on moral integrity, provided your beliefs have some reasonable grounding in morality. 

However, in a medical profession consisting of people from many backgrounds and beliefs, with a plurality of values, judging an objection’s validity by determining whether it is based on what is deemed a reasonable form of morality is simply too broad. This view lacks any obvious underpinning principles or moral code, instead appealing to an undefined notion of ‘morality’. This may not be a problem in cases that clearly align with universally condemned actions like those of the Nazis. However, most objections are not so despicable. Moral integrity would fail to dismiss some cases which are clearly wrong for a doctor, as they can appeal to some vague concept of being grounded in moral values.

Consider the example of the doctor who refuses to give pain medication, except when it reaches an extreme level. This seems an invalid objection for a doctor. Yet dismissing it based on moral integrity is challenging. While it is impermissible for a doctor, it is no extreme moral evil. There may be some strange values, such as prioritising the natural sensation to experience as something sacred, that could feasibly relate to a moral code, and which Benn would therefore have to accept. Moral integrity falls short of distinguishing between which objections are arbitrary and impermissible for a medical professional and what is a genuine objection, other than being based on an intuitive view of what is reasonable. A different grounding is needed that considers factors beyond moral integrity and general reasonableness and that could be applied to abortion

I have argued above that grounding conscientious objections on personal ethical values does not effectively distinguish between what is a valid objection and what is an arbitrary one.  An important context to remember when examining conscientious objection is that doctors are professionals with professional obligations and values. A general appeal to moral integrity is too thin as it stands to relieve a doctor of these obligations. Nevertheless, being held to standardised professional values can still be compatible with conscientious objection. Whether or not an objection is valid should be evaluated in line with professional medical values, such as beneficence, non-maleficence, autonomy, and justice (Varkey, 2021), among others. Abortion seems to involve the competing professional values of helping the mother versus not doing harm to a foetus. Saving foetuses is a professional norm in itself, as can be seen in in-vitro fertilisation programs and early assessment units for recurrent miscarriage (Gerrard, 2009, p.600). If saving a foetus is part of the job and values of a doctor in some situations, it may be difficult in others to accept its termination. 

Nevertheless, justifying objection to abortion based on conflicting professional medical values relies on accepting that abortion is an area of genuine contention. The Oxford bioethicist Alberto Giubilini disputes this. He acknowledges that one can conscientiously object if it is based on the values of the medical profession, using the example of capital punishment as this can conflict with values such as justice and non-maleficence (2017, p.408). However, he responds that refusing to perform an abortion is actually against professional values because the procedure is widely accepted in western medicine, autonomously requested, beneficial and safe (Giubilini, 2017, p.404). He suggests that there is no real difference between a doctor objecting to abortion and one objecting to giving antibiotics based on a view that bacterial life is sacred. Both doctors are failing to provide medical care that will improve patient health so one cannot object based on conflicting medical values. 

However, Giubilini dismisses abortion too readily. The autonomy of the mother is in competition with the professional norm of helping foetuses survive. One could respond that it is a matter of prioritising which value is more important, not an uncommon challenge in medicine. But although for a proponent of abortion this may seem obvious, someone may have entered the profession of medicine with the aim of saving life, so that killing a foetus goes against their most strongly held view of medicine. It is not a matter of respecting integrity, but of respecting how they fundamentally conceive medicine (Cowley, 2016, p.362). Giubilini also conflates all abortions as morally equivalent. While in some cases an individual may accept abortion when it is an obvious benefit to the mother, in other situations they may feel the value they place on saving life is stronger and feel a need to object. Furthermore, abortion carries some risk to the mother. A consideration for this harm against the autonomy of the woman could pose another conflict. 

Overall, I have argued that the general appeal to moral integrity alone cannot be used to justify conscientious objection to abortion because it fails to differentiate which reasons are valid for a doctor to object with and which are not. However, by acknowledging that doctors are held to professional values, abortion can be seen as a genuine area of contention of these values. If this is true, we should not compel a doctor to do something that goes against their very view of medicine and conscientious objection to abortion should therefore be accommodated. 

Bibliography 

Benn, P. 2005. the role of conscience in medical ethics Philosophical reflections on medical ethics.   Palgrave Macmillan, pp.160-180.

Cowley, C. 2016. A Defence of Conscientious Objection in Medicine: A Reply to Schuklenk and Savulescu. Bioethics. 30(5), pp.358-364.

Gerrard, J.W. 2009. Is it ethical for a general practitioner to claim a conscientious objection when asked to refer for abortion? Journal of Medical Ethics. 35(10), pp.599-602.

Giubilini, A. 2017. Objection to Conscience: An Argument Against Conscience Exemptions in Healthcare. Bioethics. 31(5), pp.400-408.

Varkey, B. 2021. Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract. 30(1), pp.17-28.

Wicclair, M.R. 2000. Conscientious objection in medicine. Bioethics. 14(3), pp.205–227.