Upon successful completion of this course, you will be able to:

• Identify and discuss the major issues associated with the debate about whether health professionals may refuse to provide treatments to which they object on moral grounds
• Describe and evaluate the survey presented in this course of physician's attitudes on this issue
• Discuss the roles of religion and the law in formulating a health-care professional's attitudes regarding these issues
• Explain the importance of patients being aware of their physician's views on controversial medical procedures and practices
• Identify and discuss some of the more controversial issues raised in the "cases" section of this course

Background There is a heated debate about whether health professionals may refuse to provide treatments to which they object on moral grounds. It is important to understand how physicians think about their ethical rights and obligations when such conflicts emerge in clinical practice.

Methods We conducted a cross-sectional survey of a stratified, random sample of 2000 practicing U.S. physicians from all specialties by mail. The primary criterion variables were physicians' judgments about their ethical rights and obligations when patients request a legal medical procedure to which the physician objects for religious or moral reasons. These procedures included administering terminal sedation in dying patients, providing abortion for failed contraception, and prescribing birth control to adolescents without parental approval.  (Farr A. Curlin, M.D., Ryan E. Lawrence, M.Div., Marshall H. Chin, M.D., M.P.H., and John D. Lantos, M.D.)

Results A total of 1144 of 1820 physicians (63%) responded to our survey. On the basis of our results, we estimate that most physicians believe that it is ethically permissible for doctors to explain their moral objections to patients (63%). Most also believe that physicians are obligated to present all options (86%) and to refer the patient to another clinician who does not object to the requested procedure (71%). Physicians who were male, those who were religious, and those who had personal objections to morally controversial clinical practices were less likely to report that doctors must disclose information about or refer patients for medical procedures to which the physician objected on moral grounds (multivariate odds ratios, 0.3 to 0.5).

Conclusions Many physicians do not consider themselves obligated to disclose information about or refer patients for legal but morally controversial medical procedures. Patients who want information about and access to such procedures may need to inquire proactively to determine whether their physicians would accommodate such requests.

Recent controversies regarding physicians and pharmacists who refuse to prescribe or dispense emergency and other contraceptives have sparked a debate about conscientious objection in health care.1,2,3,4,5 On the one hand, most people believe that health professionals should not have to engage in medical practices about which they have moral qualms. On the other hand, most people also believe that patients should have access to legal treatments, even in situations in which their physicians are troubled about the moral implications of those treatments.6 Such situations raise a number of questions about the balance of rights and obligations within the doctor-patient relationship. Is it ethical for physicians to describe their objections to patients? Should physicians have the right to refuse to discuss, provide, or refer patients for medical interventions to which they have moral objections?

The medical profession appears to be divided on this issue. Historically, doctors and nurses have not been required to participate in abortions or assist patients in suicide, even where those interventions are legally sanctioned. In recent years, several states have passed laws that shield physicians and other health care providers from adverse consequences for refusing to participate in medical services that would violate their consciences.7 For example, the Illinois Health Care Right of Conscience Act protects a health care provider from all liability or discrimination that might result as a consequence of "his or her refusal to perform, assist, counsel, suggest, recommend, refer or participate in any way in any particular form of health care service which is contrary to the conscience of such physician or health care personnel."8 In the wake of recent controversies over emergency contraception, editorials in leading clinical journals have criticized these "conscience clauses" and challenged the idea that physicians may deny legally and medically permitted medical interventions, particularly if their objections are personal and religious. Charo, for example, suggests that the conflict about conscience clauses "represents the latest struggle with regard to religion in America," and she criticizes those medical professionals who would claim "an unfettered right to personal autonomy while holding monopolistic control over a public good."2 Savulescu takes a stronger stance, arguing that "a doctor's conscience has little place in the delivery of modern medical care" and that "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."9

In spite of such debates, there have been few empirical studies of how physicians think about their responsibilities when their own moral convictions conflict with their patients' requests for legal medical procedures. We examined data from a national survey of U.S. physicians to determine what practicing physicians think their obligations are when a patient requests a legal medical procedure to which the physician has a religious or other moral objection. We quantify the percentage of physicians who might refrain from presenting all treatment options to patients or refuse to refer them to an accommodating provider, and we examine whether particular subgroups of physicians are more likely to do so. We then discuss the implications for ongoing debates concerning the ethics of the doctor-patient relationship.

This study's methods have been described in detail elsewhere.10,11 In 2003, we mailed a confidential, self-administered, 12-page questionnaire (see the Supplementary Appendix, available with the full text of this article at www.nejm.org) to a random sample of 2000 practicing U.S. physicians 65 years of age or younger. The sample was stratified according to specialty. These physicians were chosen from the American Medical Association Physician Masterfile — a database intended to include all physicians in the United States. We included modest oversamples of psychiatrists and physicians who work in several other subspecialties that deal particularly with death and severe suffering, in order to enhance the power of analyses that are not central to this article. Physicians received up to three separate mailings of the questionnaire, and the third mailing offered $20 for participation. The study was approved by the institutional review board of the University of Chicago.

The primary criterion variables were physicians' responses to the following three questions: "If a patient requests a legal medical procedure, but the patient's physician objects to the procedure for religious or moral reasons, would it be ethical for the physician to plainly describe to the patient why he or she objects to the requested procedure? Does the physician have an obligation to present all possible options to the patient, including information about obtaining the requested procedure? Does the physician have an obligation to refer the patient to someone who does not object to the requested procedure?" Response categories were yes, no, and undecided.

We also assessed physicians' intrinsic religiosity and religious affiliations. Intrinsic religiosity - the extent to which a person embraces his or her religion as the "master motive" that guides and gives meaning to his or her life12 - was measured on the basis of agreement or disagreement with two statements: "I try hard to carry my religious beliefs over into all my other dealings in life" and "My whole approach to life is based on my religion." Both statements are derived from Hoge's Intrinsic Religious Motivation Scale13 and have been validated extensively in previous research.13,14,15 Intrinsic religiosity was categorized as being low if physicians disagreed with both statements, moderate if they agreed with one but not the other, and high if they agreed with both.

The religious affiliations of the physicians in the survey were categorized as none (a category that included atheist, agnostic, and none), Protestant, Catholic, Jewish, or other (a category that included Buddhist, Hindu, Mormon, Muslim, Eastern Orthodox, and other). Organizational16 or participatory17 religiosity was measured according to the frequency of attendance at religious services (never, once a month or less, or twice a month or more).

Weights18 were assigned and included in the analyses to account for the sampling strategy and the modest differences in response rates according to the respondents' sex and whether they had graduated from a U.S. or foreign medical school. We first generated overall population estimates for agreement with each of the criterion measures. We then used a Mantel-Haenszel test for trend with one degree of freedom (for ordinal predictors) and the chi-square test (for nonordinal predictors) to examine the associations between each predictor and each criterion measure. Finally, we used multivariate logistic regression to examine whether associations persisted after controlling for other covariates. All reported P values are two-sided and have not been adjusted for multiple statistical testing. All analyses were conducted with Stata SE statistical software (version 9.0).

Of the 2000 potential respondents, an estimated 9% could not be contacted because their addresses were incorrect or they had died (see the Supplementary Appendix). Among physicians who could be contacted, the response rate was 63% (1144 of 1820). Graduates of foreign medical schools were less likely to respond than graduates of U.S. medical schools (54% vs. 65%, P<0.001), and men were less likely to respond than women (61% vs. 67%, P=0.03). These differences were accounted for by assigning case weights. The response rates did not differ significantly according to age, region, or board certification. The characteristics of the respondents are listed in Table 1.

Table 1. Characteristics of the 1144 Survey Respondents and Objections to Controversial Clinical Practices.

On the basis of these results, we estimated that when a patient requests a legal medical procedure to which the doctor objects for religious or moral reasons, most physicians believe it is ethically permissible for the doctor to describe that objection to the patient (63%) and that the doctor is obligated to present all options (86%) and to refer the patient to someone who does not object to the requested procedure (71%) (Table 2).

Table 2. Opinions about the Ethical Obligations of a Physician Who Objects to a Legal Medical Procedure Requested by a Patient.

Physicians who were more religious (as measured by either their attendance at religious services or their intrinsic religiosity) were more likely to report that doctors may describe their objections to patients, and they were less likely to report that physicians must present all options and refer patients to someone who does not object to the requested procedure (Table 3). As compared with those with no religious affiliation, Catholics and Protestants were more likely to report that physicians may describe their religious or moral objections and less likely to report that physicians are obligated to refer patients to someone who does not object to the requested procedure.

Table 3. Opinions about Physicians' Ethical Obligations According to the Religious Characteristics of the Respondents.

Physicians who objected to abortion for failed contraception and prescription of birth control for adolescents without parental consent were more likely than those who did not oppose these practices to report that doctors may describe their objections to patients (P<0.001 for both comparisons); the association for the objection to terminal sedation was not significant (P=0.11) (Table 4). Physicians who objected to the three controversial medical practices were less likely to report that doctors must present all options and refer patients to other providers (P<0.001 for all comparisons). The associations for religious characteristics and objections to controversial clinical practices persisted after controlling for age, sex, ethnic group, region, and specialty.

After adjustment for religious characteristics and other covariates, region, race or ethnic group, practice in an academic medical center, and practice in a religiously oriented health center were not significantly associated with any of the criterion variables. However, with increasing age, physicians were more likely to report that doctors may describe their objections to patients (odds ratio for each additional year of age, 1.02; 95% confidence interval [CI], 1.00 to 1.04). Men were more likely than women to report that physicians may describe their objections (odds ratio, 1.8; 95% CI, 1.3 to 2.5) and less likely to report that physicians are obligated to present all options (odds ratio, 0.5; 95% CI, 0.3 to 0.9) and refer patients to an accommodating provider (odds ratio, 0.5; 95% CI, 0.3 to 0.7).

Most of the physicians in our survey reported that when a patient requests a legal medical intervention to which the physician objects for religious or moral reasons, it is ethically permissible for the physician to describe the reason for the objection but that the physician must also disclose information about the intervention and refer the patient to someone who will provide it. However, the number of physicians who disagreed with or were undecided about these majority opinions was not trivial. If physicians' ideas translate into their practices, then 14% of patients - more than 40 million Americans - may be cared for by physicians who do not believe they are obligated to disclose information about medically available treatments they consider objectionable. In addition, 29% of patients - or nearly 100 million Americans - may be cared for by physicians who do not believe they have an obligation to refer the patient to another provider for such treatments. The proportion of physicians who object to certain treatments is substantial. For example, 52% of the physicians in this study reported objections to abortion for failed contraception, and 42% reported objections to contraception for adolescents without parental consent.

The findings of this study may be important primarily for patients. They should know that many physicians do not believe they are obligated to disclose information about or provide referrals for legal yet controversial treatments. Patients who want full disclosure from their own physicians might inform themselves of possible medical interventions - a task that is not always easy — and might proactively question their physicians about these matters. Patients may not have ready access to information about physicians' religious characteristics and moral convictions. Thus, if patients are concerned about certain interventions for sexual and reproductive health and end-of-life care, they should ask their doctors ahead of time whether they will discuss such options. If a patient wants a treatment that the physician will not provide, the patient may choose to consult a different physician.

These conflicts might be understood in the context of perennial debates about medical paternalism and patient autonomy. Strong forms of paternalism are based on the assumption that physicians know what is best for their patients and may therefore make decisions without informing their patients of all the facts, alternatives, or risks. Paternalism is widely criticized for violating the right of adults to self-determination. The inverse of strong paternalism is a strict emphasis on patient autonomy, which suggests that physicians must simply disclose all options and allow patients to choose among them. Models that emphasize patient autonomy to such an extent have been criticized for diminishing the moral agency and responsibility of physicians by making them mere technicians or vendors of health care goods and services.2,19,20,21,22,23

This study suggests that the balance that most physicians strike between paternalism and autonomy involves both full disclosure and an open dialogue about the options at hand. This balance resembles the interactive models proposed by Emanuel and Emanuel,19 Quill and Brody,20 Siegler,23 and Thomasma.21 These ethicists have all recommended models for the doctor–patient relationship that retain the moral agency of both the physician and the patient by encouraging them to engage in a dialogue and negotiate mutually acceptable accommodations that do not require either of the parties to violate their own convictions. In Emanuel and Emanuel's terms, these interactive models retain a role for the influence of "the physician's values, the physician's understanding of the patient's values, [and] his or her judgment of the worth of the patient's values."19 Although these models require physicians to disclose all information relevant to patients' decisions, they do not require physicians to be value-neutral. Rather, they allow physicians to explain the reasons for their objections to the requested procedures.

The lack of consensus among physicians about whether referrals to other providers who will offer a controversial treatment should be required mirrors the ambivalence about this point within the field of bioethics. Childress and Siegler22 say that physicians "may" have a duty to inform patients about other physicians who would provide what the patient requests, and Quill and Brody20 comment that physicians are "perhaps" obligated to facilitate the transfer of care. This ambivalence stems from a long-standing concern that physicians not be asked to act in ways that "would violate [their] personal sense of responsible conduct."23 Unfortunately, at times the only accommodation that is acceptable to both the patient and the physician may be termination of the clinical relationship.19,20,22,23

Our study has several important limitations. Although we did not find substantial evidence of a response bias,10,11 unmeasured characteristics may have systematically affected physicians' willingness to respond in ways that bias our results. In addition, physicians in different specialties face different arrays of morally controversial practices. Because this study included physicians from all specialties, many participants were asked to report moral judgments about medical practices with which they may have had little or no clinical experience. Moreover, physicians' judgments about their general obligations do not necessarily correspond with their judgments about any particular clinical scenario, and we do not know how their judgments about their obligations translate into their actual practices. Finally, we had three criterion measures and several predictors. Therefore, although hypotheses were theoretically specified and the expected associations were consistently observed, there was the risk of an inflated type 1 error due to multiple comparisons. For all of these reasons, our findings should be considered preliminary, and future studies should use vignettes, patients' reports, or direct observation to measure more directly the ways in which physicians respond to moral conflict in the clinical encounter.

Notwithstanding these limitations, the results of our study suggest that when patients request morally controversial clinical interventions, male physicians and those who are religious will be most likely to express personal objections and least likely to disclose information about the interventions or to refer patients to more accommodating providers. Ongoing debates about conscientious objections in medicine should take account of the complex relationships among sex, religious commitments, and physicians' approaches to morally controversial clinical practices. In the meantime, physicians and patients might engage in a respectful dialogue to anticipate areas of moral disagreement and to negotiate acceptable accommodations before crises develop.

Supported by grants from the Greenwall Foundation and the Robert Wood Johnson Clinical Scholars Program (to Drs. Curlin, Chin, and Lantos) and the National Center for Complementary and Alternative Medicine (1 K23 AT002749, to Dr. Curlin).

R. Alta Charo, J.D. Apparently heeding George Washington's call to "labor to keep alive in your breast that little spark of celestial fire called conscience," physicians, nurses, and pharmacists are increasingly claiming a right to the autonomy not only to refuse to provide services they find objectionable, but even to refuse to refer patients to another provider and, more recently, to inform them of the existence of legal options for care.

Largely as artifacts of the abortion wars, at least 45 states have "conscience clauses" on their books - laws that balance a physician's conscientious objection to performing an abortion with the profession's obligation to afford all patients nondiscriminatory access to services. In most cases, the provision of a referral satisfies one's professional obligations. But in recent years, with the abortion debate increasingly at the center of wider discussions about euthanasia, assisted suicide, reproductive technology, and embryonic stem-cell research, nurses and pharmacists have begun demanding not only the same right of refusal, but also — because even a referral, in their view, makes one complicit in the objectionable act — a much broader freedom to avoid facilitating a patient's choices.

State Requirements Governing the Refusal by Pharmacists to Fill Certain Prescriptions.

Illinois has a regulation that requires pharmacies to fill valid contraception prescriptions in a timely manner, but a resolution has been introduced to permit refusals. Massachusetts has a pharmacy-board policy that requires pharmacists to fill valid prescriptions in a timely manner. North Carolina has a pharmacy-board policy that requires pharmacists to ensure that valid prescriptions are filled in a timely manner. Wyoming has a bill that would permit providers to refuse to abide by advance directives that might, in some scenarios, apply to pharmacists who refuse to fill certain prescriptions. Adapted from a map compiled by the National Women's Law Center.

A bill recently introduced in the Wisconsin legislature, for example, would permit health care professionals to abstain from "participating" in any number of activities, with "participating" defined broadly enough to include counseling patients about their choices. The privilege of abstaining from counseling or referring would extend to such situations as emergency contraception for rape victims, in vitro fertilization for infertile couples, patients' requests that painful and futile treatments be withheld or withdrawn, and therapies developed with the use of fetal tissue or embryonic stem cells. This last provision could mean, for example, that pediatricians — without professional penalty or threat of malpractice claims — could refuse to tell parents about the availability of varicella vaccine for their children, because it was developed with the use of tissue from aborted fetuses.

This expanded notion of complicity comports well with other public policy precedents, such as bans on federal funding for embryo research or abortion services, in which taxpayers claim a right to avoid supporting objectionable practices. In the debate on conscience clauses, some professionals are now arguing that the right to practice their religion requires that they not be made complicit in any practice to which they object on religious grounds.

Although it may be that, as Mahatma Gandhi said, "in matters of conscience, the law of majority has no place," acts of conscience are usually accompanied by a willingness to pay some price. Martin Luther King, Jr., argued, "An individual who breaks a law that conscience tells him is unjust, and who willingly accepts the penalty of imprisonment in order to arouse the conscience of the community over its injustice, is in reality expressing the highest respect for law."

What differentiates the latest round of battles about conscience clauses from those fought by Gandhi and King is the claim of entitlement to what newspaper columnist Ellen Goodman has called "conscience without consequence."

And of course, the professionals involved seek to protect only themselves from the consequences of their actions — not their patients. In Wisconsin, a pharmacist refused to fill an emergency-contraception prescription for a rape victim; as a result, she became pregnant and subsequently had to seek an abortion. In another Wisconsin case, a pharmacist who views hormonal contraception as a form of abortion refused not only to fill a prescription for birth-control pills but also to return the prescription or transfer it to another pharmacy. The patient, unable to take her pills on time, spent the next month dependent on less effective contraception. Under Wisconsin's proposed law, such behavior by a pharmacist would be entirely legal and acceptable. And this trend is not limited to pharmacists and physicians; in Illinois, an emergency medical technician refused to take a woman to an abortion clinic, claiming that her own Christian beliefs prevented her from transporting the patient for an elective abortion.

At the heart of this growing trend are several intersecting forces. One is the emerging norm of patient autonomy, which has contributed to the erosion of the professional stature of medicine. Insofar as they are reduced to mere purveyors of medical technology, doctors no longer have extraordinary privileges, and so their notions of extraordinary duty - house calls, midnight duties, and charity care - deteriorate as well. In addition, an emphasis on mutual responsibilities has been gradually supplanted by an emphasis on individual rights. With autonomy and rights as the preeminent social values comes a devaluing of relationships and a diminution of the difference between our personal lives and our professional duties.

Finally, there is the awesome scale and scope of the abortion wars. In the absence of legislative options for outright prohibition, abortion opponents search for proxy wars, using debates on research involving human embryos, the donation of organs from anencephalic neonates, and the right of persons in a persistent vegetative state to die as opportunities to rehearse arguments on the value of biologic but nonsentient human existence. Conscience clauses represent but another battle in these so-called culture wars.

Most profoundly, however, the surge in legislative activity surrounding conscience clauses represents the latest struggle with regard to religion in America. Should the public square be a place for the unfettered expression of religious beliefs, even when such expression creates an oppressive atmosphere for minority groups? Or should it be a place for religious expression only if and when that does not in any way impinge on minority beliefs and practices? This debate has been played out with respect to blue laws, school prayer, Christmas crèche scenes, and workplace dress codes.

Until recently, it was accepted that the public square in this country would be dominated by Christianity. This long-standing religious presence has made atheists, agnostics, and members of minority religions view themselves as oppressed, but recent efforts to purge the public square of religion have left conservative Christians also feeling subjugated and suppressed. In this culture war, both sides claim the mantle of victimhood — which is why health care professionals can claim the right of conscience as necessary to the nondiscriminatory practice of their religion, even as frustrated patients view conscience clauses as legalizing discrimination against them when they practice their own religion.

For health care professionals, the question becomes: What does it mean to be a professional in the United States? Does professionalism include the rather old-fashioned notion of putting others before oneself? Should professionals avoid exploiting their positions to pursue an agenda separate from that of their profession? And perhaps most crucial, to what extent do professionals have a collective duty to ensure that their profession provides nondiscriminatory access to all professional services?

Some health care providers would counter that they distinguish between medical care and nonmedical care that uses medical services. In this way, they justify their willingness to bind the wounds of the criminal before sending him back to the street or to set the bones of a battering husband that were broken when he struck his wife. Birth control, abortion, and in vitro fertilization, they say, are lifestyle choices, not treatments for diseases.

And it is here that licensing systems complicate the equation: such a claim would be easier to make if the states did not give these professionals the exclusive right to offer such services. By granting a monopoly, they turn the profession into a kind of public utility, obligated to provide service to all who seek it. Claiming an unfettered right to personal autonomy while holding monopolistic control over a public good constitutes an abuse of the public trust — all the worse if it is not in fact a personal act of conscience but, rather, an attempt at cultural conquest.

Accepting a collective obligation does not mean that all members of the profession are forced to violate their own consciences. It does, however, necessitate ensuring that a genuine system for counseling and referring patients is in place, so that every patient can act according to his or her own conscience just as readily as the professional can. This goal is not simple to achieve, but it does represent the best effort to accommodate everyone and is the approach taken by virtually all the major medical, nursing, and pharmacy societies. It is also the approach taken by the governor of Illinois, who is imposing an obligation on pharmacies, rather than on individual pharmacists, to ensure access to services for all patients.

Conscience is a tricky business. Some interpret its personal beacon as the guide to universal truth. But the assumption that one's own conscience is the conscience of the world is fraught with dangers. As C.S. Lewis wrote, "Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron's cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience."

http://www.bmj.com/cgi/content/full/332/7536/294

Shakespeare wrote that "Conscience is but a word cowards use, devised at first to keep the strong in awe" (Richard III V.iv.1.7). Conscience, indeed, can be an excuse for vice or invoked to avoid doing one's duty. When the duty is a true duty, conscientious objection is wrong and immoral. When there is a grave duty, it should be illegal. A doctors' conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient's good and the patient's informed desires (box). 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. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.

Problem of conscientious objection

Doctors have always given a special place to their own values in the delivery of health care. They have always had greater knowledge of the effects of medical treatment, and this fostered a belief that they should decide which treatments are appropriate for patients— that is, paternalism. Their values crept into clinical decisions.1 2 This has been squarely overturned by greater patient participation in decision-making and the importance given to respecting patients' autonomy.3 More recently, doctors' values have reappeared as a right to conscientiously object to offering certain medical services. Examples include, refusal to offer termination of pregnancy, especially late term termination, to women who are legally entitled to it and refusal to provide reproductive advice and help to gay couples, single women, or others deemed socially unacceptable.

In the United States pressure has been put on Catholic hospitals to allow obstetricians to sterilize women immediately after giving birth.4 Alto Charo notes that a recently proposed Wisconsin bill would allow doctors to refrain from a broad range of activities, including counseling patients:

The privilege of abstaining from counseling or referring would extend to such situations as emergency contraception for rape victims, in vitro fertilization for infertile couples, patients' requests that painful and futile treatments be withheld or withdrawn, and therapies developed with the use of fetal tissue or embryonic stem cells. This last provision could mean, for example, that pediatricians... could refuse to tell parents about the availability of varicella vaccine for their children, because it was developed with the use of tissue from aborted fetuses.5   

Indeed, one Wisconsin pharmacist refused to fill an emergency contraception prescription for a rape victim. She became pregnant and had an abortion.5 

Arguments against conscientious objection

Inefficiency and Inequity

In public medicine, conscientious objection introduces inequity and inefficiency. In a survey I conducted several years ago,6 around 80% of clinical geneticists and obstetricians specializing in ultrasonography believed termination of pregnancy should be available for a normal 13 week pregnancy if the woman wants it for career reasons. However, only about 40% were prepared to facilitate it. This implied that less than half of doctors whose primary job is to deal with termination of pregnancy would facilitate a termination at 13 weeks if the woman wanted it for career reasons. The service that patients receive depends on the values of the treating doctor. Not only does this imply that patients must shop among doctors to receive the service to which they are entitled, introducing inefficiency and wasting resources, it also means some patients, less informed of their entitlements, will fail to receive a service they should have received. This inequity is unjustifiable.

Inconsistency

Imagine an intensive care doctor refusing to treat people over the age of 70 because he believes such patients have had a fair innings. This is a plausible moral view,7 but it would be inappropriate for him to conscientiously object to delivering such services if society has deemed patients are entitled to treatment.

Or imagine in an epidemic of bird flu or other infectious disease that a specialist decided she valued her own life more than her duty to treat her patients. Such a set of values would be incompatible with being a doctor.

If there is any justification for compromising the care of patients, it must be a grave risk to a doctor's physical welfare. But if self-interest and self-preservation are not generally deemed sufficient grounds for conscientious objection, how can religious or other values be?

These examples show that people have to take on certain commitments in order to become a doctor. They are a part of being a doctor. Someone not prepared on religious grounds to do internal examinations of women should not become a gynecologist. To be a doctor is to be willing and able to offer appropriate medical interventions that are legal, beneficial, desired by the patient, and a part of a just healthcare system.

If we do not allow moral values or self-interest to corrupt the delivery of the just and legal delivery of health services, we should not let other values, such as religious values, corrupt them either.

Discrimination

Sometimes religious values are considered special. However, to treat religious values differently from secular moral values is to discriminate unfairly against the secular, a practice not uncommon in medical ethics.8 Other values can be as closely held and as central to conceptions of the good life as religious values.

Place for conscientious objection

The argument in favor of allowing conscientious objection is that to fail to do so harms the doctor and constrains liberty. This is true. When a doctor's values can be accommodated without compromising the quality and efficiency of public medicine they should, of course, be accommodated. If many doctors are prepared to perform a procedure and known to be so, there is an argument for allowing a few to object out. A few obstetricians refusing to perform abortions may be tolerable if many others are prepared to perform these, just as a few self-interested infectious disease doctors refusing to treat patients in a flu epidemic, on the grounds of self interest, might be tolerable if there were enough altruistic physicians willing to risk their health. But when conscientious objection compromises the quality, efficiency, or equitable delivery of a service, it should not be tolerated. The primary goal of a health service is to protect the health of its recipients

Certain constraints are necessary to ensure the legal, equitable, and efficient delivery of health care:

• Medical students and trainees must be aware of the commitments of the profession and be prepared to undertake these or not become doctors
• The medical profession has an obligation to ensure that all patients are aware of the full range of services to which they are entitled
• Any would-be conscientious objector must ensure that patients know about and receive care that they are entitled to from another professional in a timely manner that does not compromise their access to care
• Doctors who compromise the delivery of medical services to patients on conscience grounds must be punished through removal of license
• The place for expression and consideration of different values is at the level of policy relating to public medicine

Legal Uncertainty

In some areas of medicine, such as the hastening of death and late termination of pregnancy, doctors may in good faith be uncertain as to whether an intervention is legal. In 1990, the Human Fertilization and Embryology Act in the United Kingdom reduced the limit for "social termination" to 24 weeks, but placed no upper gestational limit on termination when there is "substantial risk of serious handicap" or if it is necessary to prevent "grave permanent injury to the physical or mental health of the pregnant woman." Concern has been expressed about what constitutes a substantial risk and a serious handicap. Milford and Thornton claimed that the issue might cause significant public controversy and expressed their "deep personal uncertainty."9 In 1993, Green asked 391 obstetric consultants in the United Kingdom how late they would be prepared to offer termination of pregnancy for anencephaly, spina bifida, and Down's syndrome.10 She found that 89% of consultants would offer termination for anencephaly at 24 weeks, falling to 64% beyond 24 weeks. For Down's syndrome, 60% would offer termination at 24 weeks but only 13% after this time. For open spina bifida, 53% would offer termination at 24 weeks and 21% after 24 weeks.

Summary points

A doctor's conscience should not be allowed to interfere with medical care

All doctors and medical students should be aware of their responsibility to provide all legal and beneficial care

Conscientious objection may be permissible if sufficient doctors are willing to provide the service

Conscientious objectors who compromise the care of their patients must be disciplined

Australia, laws relating to late termination are even more unclear and vary from state to state.6 11 My survey of clinical geneticists and obstetricians with specialist training in obstetric ultrasonography showed similar variation in practice to that found by Green.6 I asked respondents to imagine that a pregnant woman presents after prenatal testing with one of several diagnoses at 13 and 24 weeks. These included anencephaly, trisomy 18, hypoplastic left heart, spina bifida with hydrocephalus, fragile X syndrome, Down's syndrome, achondroplasia, and cleft palate. I also asked respondents about pregnancies in which the fetus was normal.

Some practitioners would not facilitate termination at 24 weeks even for lethal abnormalities. Fewer practitioners supported termination or would facilitate it at 24 weeks than at 13 weeks for all conditions. The difference in opinion between 24 and 13 weeks was greatest for pregnancies in which the fetus was normal or had a relatively mild disorder. There was a lack of consensus about which abnormalities were severe enough to warrant termination and up to what gestation termination is acceptable. For example, around 75% of respondents believed termination should be available for dwarfism at 24 weeks.

Such wide variation in practice around late termination is due both to practitioners' differing values but also to legitimate uncertainty about the legal status of late termination for "milder" conditions. I have argued elsewhere that we urgently need to clarify the law in this area.11 In the absence of such clarification, practitioners have a legitimate right to refuse to provide a service which they believe to be illegal. However, they should make this reason clear to patients and also the fact that the law is unclear. They should also inform patients of the availability of other practitioners who take a different view of the law.

Private elective medicine

Private elective medicine is different from public medicine. Doctors have more liberty to offer the service of their choice, based on their values. Nevertheless, for patients to give valid consent to treatment, they must be informed of relevant alternatives and their risks and benefits (in a reasonable, complete, and unbiased way).

Conclusion

Values are important parts of our lives. But values and conscience have different roles in public and private life. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patient. The door to "value-driven medicine" is a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own.

References

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• Brock DW, Wartman SA. When competent patients make irrational choices. N Engl J Med 1990;322: 1595-9.[ISI][Medli