Erasing Conscience

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.

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Abigail Woods-Ferreira
4 years 4 months ago
The key to protecting the conscience of both patients and doctors is choice and transparency. All medical care, especially care surrounding fertility and childbirth and parenting, is going to involve complex negotiations between the religious beliefs, personal preferences, and judgement of both the woman and her doctor. Women should have real, accessible choices about their OB-GYN given to them by their insurance network, and doctors should be very transparent about their philosophy and approach about everything from birth control to prenatal testing, induction, c-sections, natural birth, and other interventions to breastfeeding or formula feeding, to what to do in a tragic or emergency situation. Different faiths bring very different answers to some of the serious ethical issues posed by obstetrics and gynecology. And individual women have very different expectations of childbirth - some prefer many tests and interventions, some are deeply opposed to what they see as the "medicalization" of childbirth and want as natural an experience as is safe and possible. A Jewish family might have the ethical expectation that a woman's life takes priority over a fetus, a Catholic woman, such as myself, might prefer that her doctor prioritize the life of the child over hers should such a situation arise. In situations surrounding fertility and childbirth, most women very much consider their "subjective wishes" to be a vital aspect of their care. When there is transparency between patients, hospitals, and doctors, clashes over conscience can be significantly reduced. But ultimately it is the woman's body, fertility, motherhood, and the life of her child that are at stake, making her "subjective" wishes of very serious consideration, which makes having choice about doctors and hospitals vital. I have an excellent OB-GYN with whom I've had two babies and dealt with many other issues; I've found the practice to be very collaborative in their approach to my care, always maintaining dialogue about balancing my wishes, style of mothering, and ethical values with the doctors' clinical judgements. I would wish such a doctor - patient relationship for all women. Perhaps the ACOG could work to foster the kind of transparency that empowers women to choose doctors that will serve their subjective and objective needs, while also providing a structure for doctors to act according to their conscience in a way that fully informs their potential patients of their personal ethical limitations and provides those patients with other options. I could not imagine anything more violating than being denied or forced into care based on a doctor's personal ideological beliefs and having no choice for another doctor. At the same time, professionals should have their conscience rights protected.
Marie Rehbein
4 years 4 months ago
This article is odd. It presumes that an opinion about what other people should or should not do is the same as conscience. The author describes surgical sterilization as "an act of mutilation", as if this was widely understood to be such. It is not. He then continues with a paragraph that equates the procedure when requested by a patient and the procedure when it is imposed upon someone, because (as we all presumably understand) it is an act of mutilation. He completely dismisses the medical benefit of the procedure. Using his logic, a woman having a mastectomy because she carries the breast cancer gene would also be guilty of "an act of mutilation". What the author seems to not recognize is that when women were sterilized against their will, the doctor was acting in accordance with his conscience as defined by the author. The doctor was sure that what he was deciding for these women was for the best. Therefore, for consistency's sake, following the logic that the author is attempting to follow in order to find fault with the A.C.O.G. guidelines, one would have to side with the doctor who performed the sterilizations and not the women who were sterilized without their permission. While it might be tempting to try to make it impossible for people to find a way to have procedures done that the Catholic Church teaches are immoral by convincing people involved in the practice of medicine that they have a right to choose on behalf of their patients, it is probably not a wise. Sorry, but this approach to "ending" abortion is doomed to fail.
Eugene Fitzpatrick
4 years 4 months ago
Conley finding the procedure of tubal ligation a "grave assault on physical integrity " and "an act of mutilation" clearly infers that it reeks of immorality. In his last "Philosopher's Notebook" piece in "America", labeled "For Israel", Conley pitches his tent fully in the Zionist' camp synchronously with Israel's 24/7 GRAVE ASSAULTS on the people of Gaza for many weeks in July/August. While it's apparent that Conley's code of ethics is withered it's not apparent why he's enabled by the Jesuit leadership to transmit it to students at Loyola and to readers of "America".


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