Christian doctors angry they can no longer abandon their patients,  April 3, 2015

Photo: TimmyGUNZ/flickr

Photo: TimmyGUNZ/ flickr

By Joyce Arthur

The Christian Medical and Dental Society of Canada is throwing a tantrum over a new requirement that Ontario physicians must refer patients appropriately when they refuse to provide a health-care service they personally disagree with. On March 20, the group launched a lawsuit against the College of Physicians and Surgeons of Ontario. The College’s new policy on “Professional Obligations and Human Rights” is really a no-brainer, as well as long overdue. The part that is peeving the Christian doctors stipulates that if doctors are “unwilling to provide certain elements of care for reasons of conscience or religion” they must make an “effective referral” — which means a timely referral made in good faith to a “non-objecting, available, and accessible physician, other health-care professional, or agency.” Further, physicians must provide “urgent care” to prevent imminent harm, even when doing so conflicts with their conscience or religious beliefs. Those violating the new policy may face discipline. The Christian doctors are dead set against all of this.

If you’re new to this issue, you might feel bewildered and alarmed at the prospect of doctors actually suing for their “right” to basically abandon patients and even put their health and lives at risk. Did these doctors miss the memo about modern medical ethics in which the patient comes first? Did they not swear an oath to that effect? Are they aware that 92 per cent of the public are in favour of requiring doctors to refer patients to another doctor who can provide the refused treatment?

Apparently, none of that matters. When you read some of the blustery fulminations on the topic from objecting doctors, it’s all about ME, and MY RIGHTS, and HOW DARE YOU take away my privilege and power over subservient patients. Ok, that’s my own interpretation, so to be fair, I’ll let one of the doctors speak for herself:

“My conscience and religious beliefs do not allow me to engage in procedures to which I have a moral, ethical or religious objection. I, and all physicians in Ontario, have the right to practice medicine according to my conscience and free from state compulsion.”

Michelle Korvemaker, emergency room physician

Actually, you do NOT have that right, Dr. Korvemaker, for several reasons. Canada’s public medicare system means that Canadians are entitled to funded medical care on an equitable and comprehensive basis. Doctors are paid with taxpayers’ money, making them much closer to public servants than private entrepreneurs. Doctors owe a fiduciary duty of care to patients, which must supersede their own personal beliefs. People who serve the public in their jobs cannot cite their personal beliefs to justify refusing services to a particular group of people — that is discrimination and a violation of human rights.
Finally, Dr. Korvemaker and her fellow doctors are forgetting that physicians’ autonomy and right to self-regulation is a privilege given to them by Canadians on the basis of trust. If we cannot trust certain physicians to fulfill their professional obligations by providing the most appropriate care that is available and legal, then those doctors do not deserve an unencumbered right to self-regulation. If doctors are allowed to continue refusing services, they should at least be subject to close monitoring by the College, and be disciplined if they flout the policy.

What are the services that Christian doctors don’t want to provide? The vast lion’s share of refusals relate to contraception and abortion, both of which are common and medically required. Further, these services are largely delivered to women, with abortion care provided only to women and some trans people. This makes these refusals discrimination, contrary to the claims of the Christian doctors.

Of course, anyone is entitled to believe that abortion and contraception are “immoral,” but such a stance has no place in science-based medicine. Doctors’ religious objections to providing this care are based on a denial of the overwhelming evidence that abortion and contraception save women’s lives and health, allow them to participate fully in society, and give them a shot at equality. The provision of contraception and safe, legal abortion is therefore a vital public interest that negates any grounds for religiously based objections.

But never mind such trifling matters. The Christian doctors have placed their “BIG CONCERN” front and centre: doctor-assisted suicide. In the wake of the Supreme Court’s February ruling that Canadians with severe and irremediable suffering have the right to end their life with a doctor’s help, the Christian doctors fear they will be forced to participate in the “culture of death” by killing people.

Sorry, but I smell something fishy here. So did blogger Fern Hill, who observed: “[They] know exactly how ridiculous their stand on birth control and abortion is and are trying to divert the reasonable new requirements into a SHRIEEEEK-FEST over euthanasia.” Likewise, Hill quoted Julie Lalonde of the pro-choice group Radical Handmaids, who said: “I think the assisted suicide issue is a red herring that is meant to dredge up support for their cause because they know that their views on birth control and abortion are in the minority. But since assisted suicide is a relatively new public discussion in Canada, they’re trying to piggy-back on top of it to get people on their side.”

It’s far too early to know how doctor-assisted suicide will be handled in Canada. Considerable consultation and proper regulation will be required, and it’s extremely improbable that doctors would be compelled to participate. Also, the College’s new policy has nothing to do with euthanasia, so the Christian doctors are being disingenuous. The whole debate was sparked by three Ottawa doctors in January 2014, because they refused to prescribe birth control to their patients.

Right-wing lawyer John Carpay supports the Christian doctors, and claims that they have a Charter right to freedom of conscience, while patients have no Charter right to health care. Further, he says that while the Ontario College has a duty to uphold the Charter, individual doctors have no such obligation. This misstates the issue. Physicians work in a publicly funded and regulated profession, so they are accountable to the public through the College, as well as to the provincial and federal courts. Of course, doctors have the same Charter rights as anyone, but no right is absolute. When they conflict, they must be balanced, and it’s the court’s job to determine the right balance.

It sounds shocking and even offensive to say that Canadians have no right to health care. This argument certainly won’t win the Christian doctors any fans. While there may not be a specific right to health care in the Charter, health-care delivery is governed by the federal Canada Health Act, which requires provinces to provide equitable access to funded health care to all Canadians. Regardless, it’s not just about a patient’s right to health care — that’s another smokescreen by the Christian doctors. Although you’ll be hard-pressed to find any admission by them that patients have any rights at all, of course they do — including Charter rights to life, conscience, liberty, equal protection, privacy, and dignity. Some or all of these may be compromised or denied when a doctor refuses treatment. This surely outweighs a doctor’s right to freedom of conscience, even if we discount their professional duty to patients.

Actually, refusing care to patients is not even true freedom of conscience. It’s an imposition of the doctor’s personal beliefs onto the patient and an abuse of authority. This makes it “dishonourable disobedience.” In the health-care field, true freedom of conscience can only be exercised when the objecting worker either quits their job or doesn’t take the job in the first place. Anyone entering family practice or gynecology should be fully aware they will be expected to provide reproductive health care, so there is no excuse for going into those fields if you object to some of that care.

The Christian doctors claim there’s no need to refer patients for abortion, because such referrals are not required. This is very misleading if not outright false. Many hospitals in Ontario that perform abortions DO require a referral. While patients can make their own appointments at abortion clinics, most people are likely unaware of that fact. Besides, if a doctor can’t provide a particular service for whatever reason, what patient doesn’t expect some immediate useful advice on where to go instead? The Christian doctors are trying to sow confusion by conflating this basic expected guidance to patients with a formal referral to a specialist. (The College’s policy requires the former, not the latter.)

Finally, our medical system is not a capitalist supermarket where patients can easily pick and choose which doctors to go to. Many people don’t even have a family doctor because it’s so hard to find one. Doctors act as gatekeepers. They have a monopoly over medical care and patients are completely dependent on them. Refusals to refer can therefore represent a significant barrier to services.


I really hope that the College of Physicians and Surgeons of Ontario withstands this bully lawsuit by the Christian doctors, and that the courts uphold the new policy. The College’s future challenge will lie in enforcement, because I predict that most anti-choice doctors will flout the policy and continue refusing to refer or provide care with which they disagree. They won’t refer because they feel that makes them “complicit.”

In my February submission to the College on behalf of the Abortion Rights Coalition of Canada, I recommended that they implement new safeguards to ensure that objectors are identified, monitored and disciplined appropriately as required. For example, they should be required to justify each refusal, as well as accept liability and discipline for each refusal, including the risk of being transferred, demoted or terminated. Objectors should be prohibited from working alone, especially in small communities where they are the only physician. Employers should be allowed to prioritize hiring of non-objecting physicians, and pay objecting physicians less. Over time, such measures should reduce or eliminate the presence of doctors who refuse to deliver health care for which they would normally be responsible.

Author’s note: I would like to thank Dr. Christian Fiala for his original ideas and collaboration with me on the issue of “conscientious objection” in reproductive health care. He has contributed significantly to my views as expressed in this article.

Joyce Arthur is the founder and Executive Director of Canada’s national pro-choice group, the Abortion Rights Coalition of Canada (ARCC), which protects the legal right to abortion on request and works to improve access to quality abortion services.



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New Zealand list of providers who have refused to provide a reproductive health-care related service.

How This Site Works

Below you will find links to pages where you can find out about providers already reported, or add a provider (and providers can add themselves).

There are two main parts to the site: the stories people tell us, which appear on our home page and which don’t include identifying information; and the list of providers reported to us who have refused to provide or resisted providing a reproductive health-care related service. This data is set out in a table, organised by region, town, type (doctor, pharmacist, counsellor etc.) and name.

We will never identify people who tell their stories and report providers to us.

Look Up Providers:

• Find out which providers have refused or disapproved of services HERE.
• Find out which providers have told us about services they prefer not to provide HERE.
Report Providers

• As a patient, tell us about when a health care provider denied or discouraged you from a service you needed HERE.
• As a provider, tell us about what services you do and do not offer HERE.


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Why We Need to Ban ‘Conscientious Objection’ in Reproductive Health Care

Reproductive Health Care, 2014,  by

Joyce Arthur Joyce Arthur
Christian Fiala Christian Fiala


Do health-care professionals have the right to refuse to provide abortions or contraception based on their “conscientious objection” to these services? Many pro-choice activists would retort, “No way! If you can’t do your job, quit and find another career!” We agree with them, and have detailed why in our new paper, “‘Dishonourable Disobedience’: Why Refusal to Treat In Reproductive Healthcare Is Not Conscientious Objection

Reproductive health care is the only field in medicine where freedom of conscience is accepted as an argument to limit a patient‘s right to a legal medical treatment. It is the only example where the otherwise accepted standard of evidence-based medicine is overruled by faith-based actions. We argue in our paper that the exercise of conscientious objection (CO) is a violation of medical ethics because it allows health-care professionals to abuse their position of trust and authority by imposing their personal beliefs on patients. Physicians have a monopoly on the practice of medicine, with patients completely reliant on them for essential health care. Moreover, doctors have chosen a profession that fulfills a public trust, making them duty-bound to provide care without discrimination. This makes CO an arrogant paternalism, with doctors exerting power over their dependent patients—a throwback to the obsolete era of “doctor knows best.”

Denial of care inevitably creates at least some degree of harm to patients, ranging from inconvenience, humiliation, and psychological stress to delays in care, unwanted pregnancy, increased medical risks, and death. Since reproductive health care is largely delivered to women, CO rises to the level of discrimination, undermining women’s self-determination and liberty. CO against providing abortions, in particular, is based on a denial of the overwhelming evidence and historical experience that have proven the harms of legal and other restrictions, a rejection of the human rights ethic that justifies the provision of safe and legal abortion to women, and a refusal to respect democratically decided laws. Allowing CO for abortion also ignores the global realities of poor access to services, pervasive stigma, and restrictive laws. It just restricts access even further, adding to the already serious abrogation of patients’ rights.

Slide20CO in reproductive health care should be dealt with like any other negligent failure to perform one’s professional duty: through enforcement and disciplinary measures, including possible dismissal or loss of license, as well as liability for costs and any negative consequences to victims. Because abortion and contraception are integral elements of women’s reproductive health care, those who would refuse to provide those services because of a personal or religious objection should not be allowed to enter disciplines that deliver that care, including family medicine and the obstetrics-gynecology specialty.

Unfortunately, a global consensus seems to have emerged among (pro-choice) medical professionals that clinicians do indeed have a right to deny reproductive health care that they personally disagree with. A recent example of this consensus was a special supplement called “Conscientious Objection to the Provision of Reproductive Healthcare,” published by the International Journal of Gynecology and Obstetrics (IJGO) in December. The supplement contains five pieces on the topic: an editorial, three short articles, and a long white paper by three physicians from Global Doctors for Choice. The latter paper does a very good job of presenting all the various laws, regulations, and policies on CO around the world, revealing a huge variation in requirements and standards and almost no enforcement against the abuse of CO.

However, all the articles (posted in full here) suffer from a glaring contradiction. Each simply assumes without question that health-care providers have the right to CO, yet each devotes considerable space to documenting the systemic harms caused by the exercise of CO. None of the articles can cite a single benefit of CO in health care, other than respecting clinicians’ “right” of conscience. One paper does give an example of legitimate CO: refusing to participate “in the process of interrogation of suspects, which may include procedures reaching the limits of torture.” But refusing to subject people to torture is completely different than refusing to deliver legal, essential, common medical care that all women expect and are entitled to.

Slide25Likewise, CO in reproductive health care has nothing in common with CO in the military. The basic premise of conscientious objection is to refrain from doing harm or violence against others, but this is turned upside down in reproductive health care. Abortion and contraception preserve the health and lives of women, while doctors practicing CO put women’s health and lives at risk. CO in reproductive health care is actually a reflection of stigma against abortion and women’s autonomy, not CO in the true sense of that term. It is an attempt to claw back the legality of abortion and return women to their traditional roles of wife and mother, producing soldiers and citizens for the state. We also see it as a form of revenge by organized religion for its loss of power in a world dominated by democracy, self-determination, and evidence-based science and medicine.

To be fair, the journal authors’ unquestioned acceptance of CO appears to be based on the position of higher authorities, specifically the United Nations and the World Health Organization, as well as FIGO, the International Federation of Gynecology and Obstetrics (which publishes the journal that produced the supplement on CO). Generally speaking, the current consensus of World Health Organization, FIGO, and other health bodies grants the refusal to treat under the excuse of CO for health-care professionals, but only if the objector refers the patient appropriately to a clinician who can provide the service. Further, objectors must dispense accurate information on all available treatment options, and provide emergency care regardless of their personal beliefs.

As our article documents, the obligation to refer is systematically ignored or abused. Many, if not most, anti-choice doctors cannot be trusted to refer because they feel this still makes them “complicit.” Also, their idea of “accurate” information on abortion or contraception may bear little relation to the actual evidence and too often strays into ideology and moral judgment. In terms of emergency care, some anti-choice doctors will let women die rather than do an abortion, regardless of the law or any CO requirements, as has occurred in Poland, Ireland, and elsewhere. Since doctors will express different opinions about a particular woman’s risk of death anyway, it’s easy for doctors to refuse treatment and deny culpability if something goes wrong.

Expecting doctors to make the required compromises in their exercise of CO rests on the misconception that they will be rational. But we can’t trust people to set aside deeply held beliefs that have already been deemed strong enough to invoke CO. As soon as we allow any degree of CO, we’ve made medical care contingent on the provider’s personal or religious beliefs, instead of the patient’s right to health care. Further expansions of CO cannot even be opposed with evidence-based arguments since we’ve already ceded the ground to religious doctrine.

To a large extent, the journal articles represent an attempt to define criteria to regulate the exercise of CO, in accordance with WHO and UN guidelines. The UN Special Rapporteur on the Right to Health has recommended that states should “ensure that conscientious objection exemptions are well-defined in scope and well-regulated in use and that referrals and alternative services are available in cases where the objection is raised.” The white paper by Global Doctors for Choice contains several policy recommendations toward that end, such as standardizing a definition of CO, developing eligibility criteria for objectors, registering objectors, and defining objector obligations to refer, give accurate information, and provide emergency treatment.

But why should health bodies like FIGO or WHO waste their time and resources helping health-care providers shirk their duties and deny legitimate care to patients? Why should entire health systems be burdened by having to recruit additional non-objecting providers, ensure alternate providers are always available, develop eligibility criteria for CO, register objectors, and train them on CO limits and obligations?

The fundamental contradiction of CO is revealed in the attempts to limit it. FIGO’s directive is a typical example: “Assure that a physician’s right to preserve his/her own moral or religious values does not result in the imposition of those personal values on women.” But when physicians are permitted the “right” to preserve their own values, they automatically impose those values onto women and deny them necessary care.

Likewise, the tolerance of CO by Global Doctors for Choice contradicts their own policy statement, which says:

Doctors offer scientific authority. They’re devoted to their patients’ best interests and they have a first-hand familiarity with the devastating consequences that can result from lack of care. … Global Doctors for Choice believes that physicians’ commitment to the scientific process and to the best interests of their patients compels them to advocate on behalf of universal access to comprehensive, evidence-based reproductive health care.

But if you allow CO, health care is no longer comprehensive, it’s no longer based on science and evidence, it’s no longer in the patient’s best interests, and doctors are no longer committed to any of the above. The lack of care can harm or even kill women, which should qualify as “devastating consequences.” So why is Global Doctors for Choice helping to regulate a practice that fundamentally violates everything they supposedly stand for?

We recognize that the attempt to “balance” a physician’s right to CO with a patient’s right to treatment is well-intentioned, and is a response to the global reality of widespread CO. But let’s not be fooled by the fraudulent promotion of the term “conscientious objection” by religious and anti-choice groups to deny women’s right to health and life. CO in reproductive health care is not true CO at all, but dishonorable disobedience. It should be dealt with accordingly.

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The CO debate: ‘Conscientious Objection’ is still dishonourable disobedience

bpas reproductive review,  14 July 2014

An article by Joyce Arthur and Christian Fiala arguing ‘Why We Need to Ban “Conscientious Objection” in Reproductive Health Care’ provoked much discussion. Here, Arthur and Fiala respond to their critics.

So-called ‘conscientious objection’ (CO) to contraception and abortion is a misnomer because it is actually an abuse of authority on the part of healthcare professionals who refuse to provide this care. We argue it is more correct to call CO ‘dishonourable disobedience’ to professional duties, ethical codes, and democratically decided laws.

In March 2014, the journal Woman – Psychosomatic Gynaecology and Obstetrics published our comprehensive article explaining why CO in reproductive healthcare is dishonourable disobedience. Our criticism of CO uniquely delved into the underlying premises of CO to show that it is fundamentally contradictory and unworkable. Our shorter follow-up article then criticised the acceptance of CO by secular medical and health organisations.

We received several critiques, one published in bpas Reproductive Review, another in RH Reality Check by Global Doctors for Choice, and a few informal criticisms relayed on listservs or online comments, and at a recent conference in Lisbon, Portugal, where we presented our ideas. We paraphrase these criticisms below – most of which we feel ignored or misunderstood our position – and follow with our response.

1. The individual’s right to hold and manifest religious or other personal beliefs is an essential human right. The ability to exercise conscience is fundamental to individual integrity.

We fully agree. But defending the right to freedom of conscience totally misses our key point – that CO in reproductive healthcare is not genuine CO. Refusal by a health care provider to treat a dependent patient is not an exercise of conscience, it is an imposition of one’s personal beliefs on a vulnerable person. It is a veto of a patient’s right to healthcare. It is an unjustified refusal to do the job one was hired and paid to do. It is an act of discrimination because reproductive healthcare is largely delivered to women.

CO in reproductive healthcare has nothing in common with the military CO from which it is derived – or more accurately, falsely appropriated from. Those who object to military service are ordinary citizens drafted into compulsory service, while healthcare professionals are in a privileged position of trust and authority – a position they chose and willingly trained for, with the full understanding that it entails duties to patients and an obligation to provide safe and necessary medical care. The specialty of Obstetrics/Gynecology in particular carries with it the obligation to help women with unplanned pregnancies.

Licensed medical professionals also enjoy a monopoly on healthcare, and people have no choice but to go to them for care. Despite this, healthcare professionals usually face no obligation to justify their refusals, rarely face any disciplinary measure, retain their positions and salaries, and often have their objection protected by law. They may also benefit in other ways, such as freeing up their time by offloading work burdens onto colleagues (while still being paid for ‘treating’ patients they refused), protecting their reputation by avoiding abortion stigma, and boosting their careers by performing more lucrative or prestigious activities instead. In contrast, military objectors must justify their stance to higher authorities, are often required to undergo a rigorous review process, and are always punished.

The alleged parallel in terms of refraining from killing is also turned upside down for CO in reproductive healthcare. Abortion and contraception preserve the health and lives of women, while those practicing CO in medicine put women’s health and lives at risk. There is no comparison between killing a living person in war and ending the development of a gestational sac, especially since prohibiting the latter directly endangers women’s lives.

2. Doctors should not be forced to do what they don’t want to do, and certainly no doctor should be forced to do an abortion if they are opposed. It is hard to see how laws designed to compel professionals to act against their conscience can be of benefit to anybody.

This is a specious argument, one that also reinforces abortion stigma by treating it differently from other forms of healthcare. We should not lend support to the anti-choice view that it’s a natural and expected thing to not want to do abortions.

When a person is paid to do a job, we don’t consider them ‘forced’ into doing it, even if they don’t like the job. Being forced implies having no choice or recompense, but workers apply and compete for jobs in order to earn money, with an understanding of the duties involved.

When you rush to the hospital for an emergency appendectomy, you don’t worry whether the surgeon is being ‘forced’ to do it. Even if the surgeon hates doing appendectomies, or dislikes you personally, you still fully expect the surgeon to perform your surgery in a professional manner. Likewise, you don’t worry if your plumber is being ‘forced’ to fix your pipes when you call, or if the cashier is being ‘forced’ to ring up your purchases when you go shopping.
It’s their job!

If a worker doesn’t believe in their job or objects to certain required tasks, they always have options, as do healthcare professionals:

1. In the first place, they should refrain from training for or accepting a job they will be unable to carry out for personal reasons. For example, a person should not train to be a pilot if they are afraid of flying and will refuse to take off.
2. They can quit and find another job, request a transfer to an area where the objected-to task is not required, or obtain training for something different that they won’t object to.
3. They can keep their job by making the considered decision to fully adhere to the job requirements despite their distaste or reluctance. (No job is ‘perfect,’ after all.)
4. They can refuse to do their job and submit to discipline by their employer, including the risk of demotion or termination.

Only Options 1 and 2 represent true conscientious objection, by the way.

3. We need to find a balance between the rights of women and the rights of health care professionals. It’s an issue of competing rights.

This argument has a false premise – that a patient’s need for basic medical care is morally equivalent to protecting a healthcare provider’s personal beliefs. The belief that women’s right to life and health ‘competes with’ or should be ‘balanced’ with doctors’ supposed right to refuse them care trivialises the health and lives of women. It assumes that women’s human rights are negotiable and dispensable as soon as someone disagrees with them. But why should the refusal to treat a woman who needs reproductive care be accepted, when the refusal to treat someone who is gay, black, or Muslim would be considered discrimination? Indeed, various attempts by governments and businesses in the U.S. to refuse services to gay people have failed for good reason, such as bakeries refusing to bake cakes for gay weddings. Like many other enterprises, medicine serves the public, which means healthcare workers have no right to refuse certain services to women.

In addition to the right to life and health, patients also have a right to conscience, as well as liberty, equal protection, privacy, dignity, and other basic rights. These may all be denied in addition when a doctor vetoes their healthcare. Even if the exercise of CO was true CO (which it isn’t), the sole right of freedom to conscience cannot possibly outweigh or be balanced against this long list of fundamental human rights. Ironically, Global Doctors for Choice and others recognize that human rights are ‘subject only to limitations necessary to protect the fundamental rights of others,’ but they fail to see that a full range of human rights need protection from the tyranny of CO.

There is no ‘balance’ when an authority figure is allowed to impose their beliefs on a powerless person who needs the services that only the person in power can provide. It’s the patient who pays the price and bears the burden of CO in reproductive healthcare, not the healthcare provider. Any denial of care is unacceptable because it inevitably creates at least some degree of harm to patients, ranging from inconvenience, humiliation, and psychological stress, to additional costs, delays in care, unwanted pregnancy, increased medical risks, and even death. The resulting real harms inflicted onto patients mean that CO in reproductive healthcare cannot be justified.

4. Conscientious objection too often is ill defined, unregulated, and inconsistently practiced. The harms and excesses of CO can be mitigated by regulating CO, educating healthcare professionals on their duties, and requiring healthcare systems to ensure that patients have access to legal services.

Many people support what we call ‘limited CO,’ which generally allows physicians to refuse to provide a particular medical service, but requires them to disclose their objection to patients, refer them to another provider who can deliver the service, impart accurate information on all options, and provide care in cases of emergency. Further, healthcare institutions are encouraged to have a system to ensure oversight of objectors and availability of non-objecting staff, so that all patients have access to services.

Our critics are simply repeating what they wish for, while failing to provide a single example where the practice of limited CO works consistently in real life. We describe in our journal paper why limited CO is a fundamental contradiction and consequently cannot work. Attempts to regulate CO are ignored and abused worldwide because the objectives of the requirements imposed on refusers are completely at odds with the refusers’ own objectives. The only reason healthcare workers invoke CO is to hinder their patients from a certain action, such as using contraception or having an abortion. But requirements such as the obligation to refer aim to negate the refuser’s actions so the patient can still obtain the needed treatment. That’s a contradiction – it’s giving with one hand while taking away with the other. Since the refuser’s personal beliefs have already been allowed to override patient care, how can we expect them to suddenly backtrack and compromise their beliefs?

Real life experience confirms that objecting healthcare workers often believe that giving a referral makes them ‘complicit,’ so they may refuse to do so. Some will also provide misinformation or treat the patient disrespectfully, or even let a woman die rather than give her a legal abortion, as happened in Ireland in 2012.

We don’t deny that some portion of objectors are probably more uninformed than ‘conscientious’ – or perhaps just ambivalent – and we agree that some could be persuaded to stop exercising CO for contraception and abortion. That would require education on the need for those services and why women request them, exposure to patients requesting the services, knowledge of the negative effects of CO on patients, and a clear understanding of the fiduciary duty to patients.

Nevertheless, it must be recognised that a significant proportion of objectors, perhaps even a majority, will never agree to abide by restrictions on CO – particularly those who believe that abortion is murder. Limited CO is therefore seriously inadequate to mitigate the harms of CO. Moreover, it places extra burdens on healthcare systems and non-objecting colleagues, burdens they should not have to shoulder. It is inappropriate for healthcare systems to spend resources to help employees shirk their duties, deny legitimate care to patients, and transfer their workload to colleagues.

5. CO is supported by professional medical groups and international human rights and health organisations.

It’s true that many medical organizations have policies or codes that attempt to limit or regulate CO in the ways we mentioned above, such as FIGO, the WHO, the ACOG, the AAFP, and others. The United Nations asks states to ‘ensure that conscientious objection exemptions are well-defined in scope and well-regulated in use and that referrals and alternative services are available in cases where the objection is raised.’ Global Doctors for Choice (page S53) has made policy recommendations to accommodate objectors, such as standardizing a definition of CO, developing eligibility criteria for objectors, registering objectors, and defining objector obligations to refer, give accurate information, and provide emergency treatment.

In other words, these organisations recognise the inherent challenges in administering CO and its harms to patients, yet permit them to occur in the mistaken belief that they can be mitigated to an acceptable extent. Part of the problem is that these groups have accepted the dishonest use of the term ‘conscientious objection’ by religious and anti-choice groups who wish to deny women’s right to health and life. Secular and pro-choice medical organizations should have no part in this. In fact, tolerance of CO by these groups often directly contradicts other key parts of their policies and ethical codes, such as clauses instructing doctors to do no harm, provide care in their patients’ best interests, and practice evidence-based medicine.

Medical and human rights organisations should instead be at the forefront of exposing the harms of CO and working to reduce and prohibit it. This should involve implementing mechanisms to prevent CO by screening out objectors from entry into training programs or disciplines that involve reproductive health, including family medicine and the obstetrics-gynecology specialty. Enforcement also needs to include punishment for objectors.

6. ‘Health-care institutions have an obligation to provide all components of care and to define the limits of refusal… but we disagree about whether that obligation rests primarily at the practitioner or the institutional level.’

This criticism is a direct quote from Global Doctors for Choice in response to our follow-up article. Note the two contradictory statements that sit side-by-side in the first part of the sentence. An obligation to provide ‘all components of care’ must obviously preclude the refusal of care.

We’re not sure why Global Doctors for Choice thinks we disagree that the obligation to provide all components of care rests primarily with healthcare institutions (and the state and civil society). We only disagree on what those specific obligations should be. Our journal paper has various suggestions on what these institutions should do to ensure comprehensive reproductive care without barriers or stigma – such as regulating public health systems to guarantee abortion provision, providing financial aid to hospitals to recruit abortion providers, providing compulsory training in contraception provision and abortion techniques at medical schools, public education to reduce abortion stigma, and other initiatives.

Obviously, some responsibility always rests with individual healthcare workers, who need to fulfill their duty to patients, follow medical protocols, adhere to codes of ethics, and so on. But monitoring and enforcement needs to be done at the institutional level – by hospitals, government health authorities or departments, and medical organizations. For example, if objectors are allowed to continue objecting, they should be required to justify each refusal to a Board or committee, as well as accept financial liability and discipline for each refusal, including the risk of being transferred, demoted, or terminated.

7. Reproductive healthcare is not the only area of medicine affected by CO. End-of-life care and treatments involving stem-cell therapies are also areas where CO has been invoked.

Our paper focused on abortion and contraception because these two services are both essential and common, unlike the first two examples given in the criticism. Together, contraception and abortion comprise the vast majority of healthcare services objected to.

There are some valid cases where a healthcare professional may conscientiously refuse a requested legal treatment, but this should be done in the context of honoring their professional obligations and medical ethics. Doctors can refuse treatment on the principle of ‘beneficence’ or ‘non-maleficence’ to ensure the patient is helped or at least not harmed. This only applies in limited circumstances, such as a patient who requests a risky experimental treatment, or a mentally disturbed patient who wants an unnecessary procedure such as an amputation.

We also support refusal by healthcare professionals if they are asked to perform illegal or quasi-legal activities that injure people and violate their rights, such as torture or genital mutilation of children. However, these are not legitimate medical treatments and are not requested by the patient; therefore, they cannot be called CO.

8. Banning CO could have the inadvertent consequence of worsening access by hardening the opposition of those who might be incrementally persuaded to provide these services.

This is pure speculation with no evidence or examples to support it. But there is evidence to the contrary: Allowing CO significantly worsens access to legal medical services for women. Decades of this ‘social experiment’ have shown it to be a clear-cut failure. Wouldn’t it be worth trying another approach?

The real challenge in banning ‘dishonourable disobedience’ will not be from those who might be persuaded to provide reproductive health services, but from those who will never be persuaded. The anti-choice movement fights ferociously against any restriction on their claimed right to deny rights to others. But the fear of intimidation and ugly politics is not a good basis for continuing to allow patients’ rights to be violated. We need to stand up to the bullying from anti-choice activists, who aren’t as strong as they think they are. We can defeat them. Most of their claims are demonstrably false as well as oppressive. Their views are increasingly at odds with the world’s ever-stronger focus on securing equality and human rights for all, especially women. Our modern society owes no respect to views that deny basic life-saving healthcare to women.

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CO as dishonourable disobedience

As shown above, CO in reproductive healthcare is largely unworkable and inappropriate, and arguably unethical and unprofessional as well. As a ‘‘refusal to treat,’’ CO should more aptly be called dishonourable disobedience, because it violates women’s fundamental right to lawful healthcare and places the entire burden of consequences, including risks to health and life, on the shoulders of women.

The accommodation of CO in reproductive healthcare is actually surprising. Why should a doctor’s private beliefs trump the medical needs of an individual? No other sector of medicine or other kind of service delivery would allow a service refusal with so little resistance. Perhaps it arises from society’s reluctance to allow women the freedom to make their own reproductive decisions, and the perception that women need guidance or even some moral persuasion to carry an unwanted pregnancy to term.

However, most women have already decided to have an abortion before they speak to any healthcare professional. They go to a doctor only because abortion is a medical service they need but cannot perform themselves in a safe way. The reliance on a doctor to protect one’s life and health makes any right to CO in medicine unethical — and down-right dangerous in light of the fact that women often resort to unsafe do-it-yourself abortions when they are unable to access medical care. If peoples’ right to life means anything, they must be able to access necessary healthcare, which should supersede the conscience rights of others.

CO gives a person a pretext not to do their job, even though they were specifically hired to do that job and are being paid for it. Indeed, if you can opt out of part of your work without being punished, why wouldn’t you? CO is a shield to protect employees from liability for their own negligence, while placing unfair burdens on colleagues and employers. They are like employees who arrive late for work every day, forcing more dependable employees to cover for them. The unfair effects of allowing CO can be seen at the University of Medicine and Dentistry of New Jersey, which had to hire additional staff to make up for the refusal by 12 nurses to have any contact whatsoever with patients having an abortion — even routine tasks like taking a temperature, filling out paperwork, or walking a patient to the door after recovery. These nurses, who had essentially abandoned their professional duties and discriminated against patients, even filed a lawsuit against the hospital for ‘‘forcing’’ them to assist in abortion care against their religious objections (Giambusso, 2011).

The principle of public accommodation requires the discounting of individual conscience within a profession. Everyone’s conscience is different and cannot be coerced, which is why a free democratic society places a high value on tolerance and equal respect for all citizens. However, if individuals are permitted to exercise their conscience when serving the public, it gives social sanction to the practice of intolerance. CO invites discrimination against people needing the services being refused, and infringes their freedom of conscience. This is why the American Civil Rights Act prohibited discrimination by facilities that serve the general public — a racist waiter working in a restaurant cannot refuse service to a black person.  As one writer stated about an Iowabill that would have allowed any business or organization to refuse to recognize gay marriage: ‘‘It uses a word we associate with compassion — conscience — for the sole purpose of discriminating.’’ (Basu, 2011) Similarly, CO in medicine contravenes the ethical obligation to serve the public, which is why it is dishonourable disobedience.

A healthcare provider’s personal right of conscience can and should be limited to protect the rights of others, including their safety and health. As stated in the United Nations’ International Covenant on Civil and Political Rights, Article18(3)  (Office of the United Nations High Commissioner for Human Rights, 1976):

Freedom to manifest one’s religion or beliefs may be subject only to such limitations as are prescribed by law and are necessary to protect public safety order, health or morals, or the fundamental rights and freedoms of others.

CO violates medical ethics because doctors agree to assume professional obligations to patients when they join the profession. Patients cannot obtain services elsewhere because doctors enjoy a legal monopoly on provision of medical services, with their profession and medical knowledge fulfilling a public trust. Doctors are bound by laws on negligence and by ‘‘fiduciary duty’’ — a legal or ethical relationship of confidence or trust between two or more parties (Based on British common law, 2014). When doctors cite CO as a reason to refuse healthcare to a patient, they renege on their professional and public duties and their legal responsibilities. As such, CO should require a greater sacrifice on the part of the refuser, including a willingness to resign their position or even to go to prison (Cannold, 2010)

CO also clashes with the recent revolution in healthcare in western countries, where a new paradigm of patient-centred care, together with evidence-based medicine and a commitment to prevention, has been accepted (Weitz and Berke and Berke Fogel, 2010). One such example is in the UK, with its new Patient Choice framework adopted by the National Health Service (Department of Health, 2013). When patients take a more proactive role in managing their own health and treatments, it leads to significantly better health outcomes. But CO reinforces the stereotype of the ‘‘all-knowing’’ doctor who dictates what is best for patients, with little regard for their individual needs or even the evidence. The exercise of CO becomes an excuse for the doctor to exert personal power over the patient by imposing their own views. In practical terms, time pressures and the unequal power dynamic between a patient and a doctor mean there may be no time or opportunity to negotiate, anyway. As Dr. Julie Cantor states: ‘‘There is little recourse when care is obstructed— patients have no notice, no process, and no advocate to whom they can turn.’’ (Cantor, 2009)

Most countries still enforce abortion laws that originated in the 18th and 19th centuries, reflecting the knowledge and social mores of those times. The spirit of those laws is still alive in countries where abortion is legal but access is restricted by political measures that have nothing to do with protecting women’s health, such as obligatory counseling, waiting periods, and doctors’ signatures to confirm the woman’s mental distress. Laws that accommodate CO are even more inappropriate for less developed countries. Anthropologist and bioethicist Debora Diniz points out that developing countries tend to have greater anti-choice sentiment, a less secular culture, more dominance by the Catholic Church, and less access to abortion because of fewer facilities and providers and poor healthcare infrastructure. Such factors led Diniz to conclude that ‘‘conscientious objection in developing countries should not be seen only as an issue of accommodation, but as a constitutional offense against the stability of the secular state.’’ (Diniz, 2010)

Source: Fiala C, Arthur JH. ‘‘Dishonourable disobedience’’ — Why refusal to treat in reproductive healthcare is not conscientious objection. Woman – Psychosom Gynaecol Obstet (2014),

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