Conscientious Objection, Not Refusal: The Power of a Word

Abstract

Conscientious objection (CO) in medicine grew out of the need to protect healthcare providers who objected to performing abortions after the Roe v. Wade decision in the 1970s which has since over time expanded to include sterilization, contraception, in vitro fertilization, stem cell research, and end-of-life issues. Since 2006, there has been a growing amount of published literature arguing for the denial of CO. Over the last three years, there has also been an increase in calling this conscientious refusal. This article will argue that the term conscientious objection is more accurate than conscientious refusal because those who object are not refusing to provide care. CO also emphasizes that there are reasoned arguments behind one’s decision not to perform certain actions because of one’s own principles and values.

Summary

How something is presented matters. Objection emphasizes the thought behind the action while refusal gives the impression that medical care is not given.

There has been a shift from the use of the term conscientious objection (CO) to conscientious refusal (CR) over the past fifteen years. This shift signals a change in the perspective of the physician–patient relationship and lends itself to an increasing hostility to accommodating people of faith in the delivery of medical care. Although on the surface this appears to be a minor change in terminology, its potential ramifications are considerable.

CO in medicine grew out of the need to protect healthcare professionals who did not wish to be involved in performing abortions after the Roe v Wade decision in 1973. For decades, this precept was allowed to stand with minimal comment and little opposition, until, in 2006, Savulescu (2006, 294–98) argued that CO had no place in medicine. His reasoning was that physicians who make medical decisions based on their values are morally judging their patients, and such judgment is wrong because, based on respect for autonomy, patients should be able to avail themselves of all legal services.

The next year, 2007, the American College of Obstetricians and Gynecologists (ACOG) (2016) published committee opinion #387 “The Limits of Conscientious Refusal in Reproductive Medicine,” which stated that, in the provision of reproductive services, the patient’s well-being is paramount. CRs must limit harm, in particular “significant bodily harm,” including pain, disability, death, or “a patient’s conception of well-being.” In an emergency, the “medically indicated and requested care” (emphasis mine) should be provided. Those who do conscientiously object should practice in close proximity to those willing to provide those services or “ensure that referral processes are in place,” especially in resource-poor areas so that access to “safe and legal reproductive services be maintained.” Legal policies should ensure “timely, effective, evidence-based, and safe access.”

By 2014, Fiala and Arthur (2014, 1) stated that CO should be renamed as “dishonorable disobedience,” calling it “systemic abuse” (p. 3). In their view, CO is unworkable, inappropriate, unethical, and unprofessional, thereby giving social sanction to intolerance and discrimination (p. 7). It denies respect to an “accepted ethical standard of a non-judgmental approach” (p. 9). Physicians who refuse based on their values are unsuited to the practice of medicine because they are allowing their religious beliefs or personal issues to interfere with their medical decisions (p. 8). As mere providers, they must subordinate their interests and beliefs to serve others, making the sacrifice to leave the profession or face prison time (p. 8).

The most recent major attack came from an article by Stahl and Emmanuel (2017) who stated that physicians who cannot provide “accepted medical interventions” (p. 1383) based on professional standards made by professional associations should leave the profession. They further held that not to do so is discriminatory. In their view, abortion and contraception are “medically not controversial” (p. 1382) and are the standard of care. Under such a view, CO means substituting cultural and political judgment for “professional medical judgement” (p. 1384), and they hold that objectors should be penalized for prioritizing their “personal commitment” (p. 1384) over patient interests. They should either find a specialty that does not involve that to which they object to or leave the profession altogether. If they don’t, the medical profession should punish them if the legal system will not (p. 1384). It is of interest that the authors state this even though the American Medical Association (AMA) allows for CO (AMA Code of Ethics 1.1.7, 2020), and 44 percent of members do not support abortion (Lawrence and Curlin 2009, 1279).

Fiala and Arthur (2017, 255) state that it is well-known that CO causes harm but present no evidence-based data to back themselves up, only anecdotes. While admitting that the profession has harmed patients in the past, Stahl and Emmanuel (2017, 1382) claim that medicine is able to correct itself. However, this desired self-correction would be made much harder by the profession’s cleansing itself of any dissenters to the status quo or at the very least silencing them with threats of professional sanctions if they adhere strictly to guidelines determined by professional societies to which they may not even belong.

The term “conscientious refusal” (CR) was first used by Childress in his paper in 1985 (p. 63) according to a PubMed search. The term was used five times between 1993 and 1994, then not at all until 2003 where it was used once a year until 2007 and one to two times per year during 2008–2012. It came into more common use after the ACOG (2016) publication in 2007, especially after the policy was reaffirmed in 2016 (p. 1). A PubMed search on February 20, 2021, shows that, while the vast majority of published papers continue to use CO, the use of CR has increased especially since 2017. This is especially among those who would eliminate CO in health care. Of thirty papers using CR instead of CO over the last ten years, eighteen were published between 2017 and 2019. Of those eighteen, eleven were against. Of those who stated support for CR, one supported it for physicians who want to violate an institution’s ban of abortions, and another stated that the healthcare professional could refuse to perform the requested treatment, but then must refer to someone who will, which is considered by some to be complicit in the act itself and does not solve the moral problem. Even the Catholic Health Association has referred to CO as CR (Eberl and Ostertag 2020).

Why use the term conscientious refusal, especially given ACOG’s insistence on using it since 2007? No discussion can be found regarding the reasons behind that decision, but ACOG (2017) does state that when “providers anticipate that providing indicated, even standard, care would present for them a personal moral problem—a conflict of conscience…(S)ome providers claim a right to refuse.”

Does this make a difference? If CO becomes CR, what are the implications, especially because CR is used in a practice guideline from ACOG? What is in the power of a word? First, we must look at the history of CO.

History of CO

CO was first applied to men who objected to military service and has been recognized since colonial times, though with penalties associated with it varying from fines to alternative service. Originally, the concept covered only those whose objections were religious (Matheson 2009) following the Christian tradition of pacifism, the belief that any taking of human life is evil (http://www.conscientious-objection.info/origin-meaning-of-conscientious-objection), primarily Quakers, Mennonites, and Jehovah’s Witnesses. By the Vietnam War, it was expanded to those with “moral, ethical, or religious beliefs about what is right and wrong…held with the strength of traditional religious convictions” and not “politics, expediency, or self-interest” (Matheson 2009).

After Roe v. Wade and Doe v. Bolton in 1973, CO was applied to medicine. During the time of the Vietnam War (which had the highest number of conscientious objectors to military service; Negley 2017), CO developed a more positive connotation as opposition to the war increased. Initially, CO, as applied to medicine, only covered abortion but over time expanded to include sterilization to avoid reproduction, contraception, in vitro fertilization, stem cell research, and end-of-life issues (Sawicki 2018, 15). In 1996, with the passage of the Public Health Service Act, institutions were covered as well. CO has been codified into law starting with the Church Amendments and ending with the Affordable Care Act (Conscience Protections, 2018). Protection for healthcare professionals and institutions regarding the treatment of transgender individuals has been open to litigation, with courts both allowing CO (Samuels 2021) and opposing (Avery 2019).

One principle differentiating CO in medicine from the standard of CO as applied to the military is that those in the medical profession willingly enter it and are not punished for refusing (Fiala and Arthur 2014, 2; Stahl and Emmanuel 2017, 1381, 1382). Nor are medical objectors subjected to a tribunal to assess their sincerity (Stahl and Emmanuel 2017, 1382), though Fiala and Arthur (2017, 256) state that it would be useless because sincerity is impossible to verify. Fiala and Arthur (2014, 6) note that objecting physicians benefit compared to their nonobjecting colleagues without showing proof. These arguments neglect a critical point: a soldier is not just simply one who follows orders. A good soldier’s commitment to being a good soldier means that carrying out orders according to one’s best judgment; it does not mean that one is “checking one’s moral judgement at the door” (Blythe and Curlin 2018, 432). A good soldier disobeys immoral orders. Moreover, the military accepts CO even in today’s all-volunteer army, in which no one is forced to serve (Army Public Affairs 2020).

Opponents of CO may have thought that over time, the United States would become an “enlightened, progressive, secular” nation (Savulescu and Schuklenk 2017, 162), following the way of Europe in terms of support for abortion, contraception, and so on. That has not been the case. In the United States, around 50 percent of women oppose abortion (Gallup 2020), whereas in Scandinavian countries, support is 70–90 percent (Salazar and Starr 2018). Even within the AMA itself, objectors to abortion number 44 percent (Lawrence and Curlin 2009, 1279).

The Power of a Word

In all cultures and for all people, words have power. For the Navajo, words have such power that they believe even the mere mention of a possible complication during the informed consent process will lead to its occurring (Carrese and Rhodes 1995, 829). It is not unusual for parents to name a child for a special reason or after a particular person. In surveys, asking a question in a different way can lead to different responses. This particular effect is demonstrated in surveys regarding whether or not terminally ill patients can take medication to end their lives. When asked whether it is permissible for a physician to “end the patient’s life by some painless means,” 71 percent approve. However, when asked whether a physician can “assist a patient to commit suicide,” support drops to 51 percent (Saad 2013).

Critics of CO state that CO should not be used because it is not used completely in the same manner as CO in the military (Fiala and Arthur 2014, 1–2; Stahl and Emmanuel 2017, 1382). By contrast, their silence on the matter of changing the definition of marriage supported by AMA policy is striking. By emphasizing the differences between CO in the military versus medicine, they downplay the similarities. That is simply this: when it comes to abortion, CO in medicine as in CO in the military, the objection is to the intentional killing of another human being.

How the topic is framed is also important. First impressions, termed in psychology the primacy effect, matter and are hard to change (Pam 2015). Moreover, how words that are used shape the way we reason even when presented with a list of options to compare and select, and we are rarely aware that it is occurring (Thibodeau and Boroditsky 2013). The order of presentation of characteristics leads to differing assumptions about the character of a person (Asch 1946, 271–72). Thus, if something is presented first in a more negative manner, one is more likely to think of it in negative terms thereafter. It becomes harder to change the point of view and think of it as positive because of the primacy effect. These realities come into play when we consider the implications of the switch from “objection” to “refusal.”

According to Merriam-Webster, to refuse is “to express oneself as unwilling to accept,” “unwillingness to do, or comply,” and “to withhold acceptance, compliance, or permission.” It is also “to not allow someone to have or do (something).” It comes from the Old French word “refuser” which means “to reject, disregard or avoid” (Online Etymology Dictionary 2021). Refusal is the act of putting this perspective into action, both in common usage (Merriam-Webster 2020) and legally (Legal Dictionary 2020).

To object is to “put forth in opposition, oppose firmly, usually with words or argument” or “reason or argument in opposition,” a “feeling or expression of disapproval,” though it can also include “to feel distaste” (Merriam-Webster 2020). It comes from the word “objection,” to “bring forward as a ground of opposition, doubt, or criticism; raise an argument against…” from Old French objector and the Latin obiectus “to cite as grounds for disapproval, set against, oppose.” Literally, it is “to put or throw before or against” (Online Etymology Dictionary 2021). An objection is its act (Merriam-Webster 2020). In legal parlance, it is a “formal attestation or declaration of disapproval” (Legal Dictionary 2020).

CO, therefore, both in the military and in the medical sense, is a formal declaration of disapproval formed by one’s conscience. It arises from one’s conscience, which can be considered an act of the will, an assent to truth to act morally, and a fundamental commitment to act that way (Sulmasy 2008, 140). The conscience puts forth the reasons and arguments for a certain line of action. If the conscience determines a proposed action to be wrong, it objects. This can result in the refusal to perform a certain action, but it is fundamentally a refusal based on reason, that is, an objection. That objection, however, is based on a positive precept in the mind of the objector, a precept by which, in the objector’s view, medical care and personal practice must adhere. It is a positive obligation of duty. By contrast, CR emphasizes not doing something seen as desirable. It assumes that the healthcare professional wants to deny treatment, in a sense, refuse to fulfill a duty owed to the patient.

Conclusion

Words matter and they shape our conceptions and responses. Because words have such power, then the use of them also has meaning and positive or negative connotations. Opponents of CO such as Savulescu (2006)^, Savulescu and Schuklenk (2017)^, Fiala and Arthur (2014^{, 2017}), and Stahl and Emmanuel (2017) do not see it as reasonable and do not want others to think that there are just reasons for objecting. They see only the negatives. They naturally wish to emphasize it as a denial of care rather than a compliance with the obligations of moral living. The use of the word “refusal” by ACOG and in the literature perpetuates that myth and implies a lack of access to care as a result. But in most circumstances, physicians and other medical professionals who have COs against certain interventions do not prevent patients from accessing that care as patients generally have other options in the community. If they do not, as is sometimes the case, then the lack of alternative care becomes the problem rather than the objection of the physician.

It is important to recognize that those who have a CO to a particular intervention are not refusing to treat the patient. Because of their particular set of values, they are just refusing to treat a patient in the way other medical professionals might and in a way which the law allows. Conscientious objectors are willing to treat the patient (they are not refusing) but not in a way that violates their conscience.

Conflicts due to different ideas of care and different values are inevitable in this multicultural society. CO is a critical legal and moral right that allows persons to act according to conscience when they sincerely opposed to what is an unjust war or an unjust ruling. Reducing the concept to mere refusal denies the importance of the underlying moral commitment and weakens the principle to one of simple willingness to engage in a particular practice without attention to how that affects the physician who objects to a course of care.

CO better explains the relationship between physician and patient and to the proposed care by emphasizing the underlying cause for the declining to perform certain interventions. As Catholic healthcare professionals, we respect the dignity of the human person because we object to seeing the value of human life based merely on its function and not just because that life reflects the image of God. Like a lawyer in the courtroom of public morality, we rise to say, “I object!”

Biographical Note

Cynthia Jones-Nosacek, MA, MD, is a retired family physician after practicing for more than thirty-five years the full range of medicine from obstetrics to hospice as well as inpatient, outpatient, and nursing home care. She received her medical degree from Loyola University Chicago—Stritch School of Medicine and did her residency at Resurrection Hospital in Chicago. She is also a bioethicist, having received her Master of Arts degree from Ohio State University. She splits her time between the United States and mission work in Uganda.