Controversies over the conscience rights of health care workers are not limited to state and federal governments. Professional medical associations have recently constructed codes of ethical conduct concerning the right of health care workers to refuse to participate in certain medical procedures. One of the most influential is “The Limits of Conscientious Refusal in Reproductive Medicine,” a statement by the Ethics Committee of the American College of Obstetricians and Gynecologists. While it claims to respect the value of conscientious objection, the statement places such severe limits on the exercise of this objection that little of conscience finally survives.
The A.C.O.G. declaration begins with praise of personal conscience as having “a critical and useful place in the practice of medicine. In many cases, it can foster thoughtful, effective, and human care.” However, as the declaration attempts to “balance” the claims of conscience against other considerations, the scope for the exercise of conscience is progressively reduced.
One limitation on the right of conscience is the danger of imposition. The A.C.O.G. statement underlines the value of patient autonomy. “To respect a patient’s autonomy is to respect her capacities and perspectives, including her right to hold certain views, make certain choices, and take certain actions based on personal values and beliefs.” The committee fears that conscientious medical objection can constitute an “imposition of religious or moral beliefs on a patient who may not share these beliefs,” thus assaulting patient autonomy. The refusal to prescribe contraceptives is cited as an example of such an assault. In this exaltation of patient autonomy, the health care professional becomes a simple servant of patient desire, as long as the desired treatment is legal. The traditional duty of the doctor to promote the actual good rather than the subjective wishes of the patient crumbles in such a consumerist indenture to the other’s will.
A second limitation stresses the health of the patient, an indisputable medical good. But the A.C.O.G. code places health into a consequentialist framework. The refusal, based on religious convictions, to perform a sterilization could impinge on the patient’s own conception of maximal health. “Religiously based refusals to perform tubal sterilization at the time of caesarean delivery can place a woman in harm’s way.” There is no consideration of the grave assault on physical integrity represented by such an act of mutilation, regardless of hypothetical future health benefits.
Despite the statement’s insistence that health care professionals consider the broader social context of their actions, it nowhere recognizes the grim history of coercion accompanying such post-delivery tubal ligations, especially when performed upon poor women dependent on state welfare.
Another limitation arises from the question of social discrimination represented by acts of conscientious objection. “The impact of conscientious refusals on the oppression of certain groups of people should guide limits for claims of conscience.” Two examples cited by the committee are the refusal to provide fertility treatments to same-sex couples and the refusal to provide certain “reproductive services to women.” The declaration condemns such refusals on the ground that they constitute discrimination against homosexuals and women as a class.
But the A.C.O.G.’s censure rests on a dangerous confusion between the refusal to perform a certain act and the refusal to serve a certain group. The refusal of a doctor to provide the surgery and hormonal treatments to change the gender appearance of a patient is not the same as refusing to provide cancer treatment to a transgender patient. Many institutions refusing to perform abortions, notably Catholic hospitals, have a distinguished record of serving a disproportionately female group of clients.
If the A.C.O.G. code reduces conscience to a minor concern, other contemporary voices would simply abolish conscience altogether. The Oxford philosopher Julian Savulescu argues that “a doctor’s conscience has little place in the delivery of modern medical care.... If people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.” Benighted health care workers still clinging to the Hippocratic Oath’s prohibition of abortion and euthanasia need not apply.