1. ‘Dishonourable Disobedience’: Why Refusal to Treat in Reproductive Healthcare Is Not Conscientious Objection.

Christian Fiala and Joyce H. Arthur. Woman – Psychosomatic Gynaecology and Obstetrics. December 2014 (first published online March 2014).  www.sciencedirect.com

Synopsis: A comprehensive paper that uniquely delves into the underlying premises of CO to show that it is fundamentally contradictory and unworkable, and has nothing in common with the military CO from which it is supposedly derived. Current laws and practices in various countries around CO in reproductive healthcare show that it is frequently abused, with harmful impacts on women’s healthcare and rights. CO in reproductive health is not actually Conscientious Objection, but Dishonourable Disobedience (DD) to laws and ethical codes. It should be dealt with like any other failure to perform one’s professional duty, through enforcement and disciplinary measures.

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2. Conscientious objection and induced abortion in Europe

Heino A, Gissler M, Apter D, Fiala C. Eur J Contracept Reprod Healthcare. 2013 Aug;18(4):231-3. doi: 10.3109/13625187.2013.819848. www.ncbi.nlm.nih.gov

Abstract: The issue of conscientious objection (CO) arises in healthcare when doctors and nurses refuse to have any involvement in the provision of treatment of certain patients due to their religious or moral beliefs. Most commonly CO is invoked when it comes to induced abortion. Of the EU member states where induced abortion is legal, invoking CO is granted by law in 21 countries. The same applies to the non-EU countries Norway and Switzerland. CO is not legally granted in the EU member states Sweden, Finland, Bulgaria and the Czech Republic.* The Icelandic legislation provides no right to CO either. European examples prove that the recommendation that CO should not prevent women from accessing services fails in a number of cases. CO puts women in an unequal position depending on their place of residence, socio-economic status and income. CO should not be presented as a question that relates only to health professionals and their rights. CO mainly concerns women as it has very real consequences for their reproductive health and rights. European countries should assess the laws governing CO and its effects on women’s rights. CO should not be used as a subtle method for limiting the legal right to healthcare.
*In fact, both Bulgaria and the Czech Republic allow CO.

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3. Why We Need to Ban ‘Conscientious Objection’ in Reproductive Healthcare

Joyce Arthur and Christian Fiala. Rewire. May 14, 2014. Rewire.news

Synopsis: A criticism of the global consensus by secular medical and health organizations and human rights bodies that “conscientious objection” is a legitimate right of physicians. All such groups that accept CO simply assume without question that healthcare providers have a right to CO, while they contradictorily often devote considerable discussion and resources to documenting and trying to limit the systemic harms caused by the exercise of CO. Not a single statement, article, report, or study by any group that supports CO can cite any benefits of CO in healthcare, other than supposedly respecting clinicians’ “right” of conscience. But all groups fail to see that the term “conscientious objection” as applied to refusals of reproductive healthcare is fraudulent, and not true CO.

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6. Christian doctors angry they can no longer abandon their patients

Joyce Arthur. Rabble.ca. April 3, 2015. www.rabble.ca

Synopsis:  A critique of anti-choice views on “conscientious objection”, including in particular the views of the Christian Medical and Dental Society of Canada, which is suing the College of Physicians and Surgeons of Ontario for enacting a policy requiring objecting doctors to refer patients to someone who can provide the services.

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7. “Conscientious Objection” in Reproductive Healthcare is Immoral and Should Be Abolished

Joyce Arthur. October 2015. (blog) www.choice-joyce.blogspot.ca

Synopsis: In this piece, I discuss or expand upon a few aspects that have come up in informal discussions with researchers and academics, mostly around philosophical and epistemological issues. 
– A summary of my position on CO
– Is CO ever justifiable in healthcare?
– Is CO in reproductive healthcare really discrimination?
– Should patients’ rights be “balanced” with providers’ rights?
– Can we really prohibit CO?  (and how, exactly?)

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8. Yes We Can!  Successful Examples of Disallowing ‘Conscientious Objection’ in Reproductive Healthcare

Christian Fiala, Kristina Gemzell Danielsson, Oskari Heikinheimo, Jens A. Guðmundsson, and Joyce Arthur. IN PRESS, European Journal of Contraception and Reproductive Healthcare. 2016. tandfonline.com

Abstract: Three countries – Sweden, Finland, and Iceland – do not generally permit HCPs in the public healthcare system to refuse to perform a legal medical service for reasons of ‘CO’ when the service is part of their professional duties. We investigate the laws and experiences of these countries to show that disallowing ‘CO’ is workable and beneficial. It facilitates good access to reproductive health services because it reduces barriers and delays. Other benefits include the prioritization of evidence-based medicine, rational arguments, and democratic laws over faith-based refusals. Most notably, disallowing ‘CO’ protects women’s basic human rights, avoiding both discrimination and harms to health. Finally, holding HCPs accountable for their professional obligations to patients does not result in negative impacts. Almost all HCPs and medical students in Sweden, Finland, and Iceland who object to abortion or contraception are able to find work in another field of medicine. The key to successfully disallowing ‘CO’ is a country’s strong prior acceptance of women’s civil rights, including their right to healthcare.

Full Article (PDF)

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9. The dishonourable disobedience of not providing abortion

Letter to the Editor
European Journal of Contraception and Reproductive Health Care
Joyce Arthur, Christian Fiala, Kristina Gemzell Danielsson, Published online: 04 Nov 2016

Synopsis: While stigma negatively impacts almost every aspect of abortion care to some degree, ‘dishonourable disobedience’ is a form of full-blown, officially-approved stigma, which makes it particularly unsupportable, especially when abortion access is already curtailed by stigma in so many other ways.

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10. “Conscientious objection” kills women

The following letter was submitted to the Irish Times on June 9, 2017, but not printed.

“Conscientious objection” kills women

We object to the ill-informed letter (June 5, Italy and Abortion) by Dr Angelo Bottone of the Iona Institute – a conservative Catholic organization. He claims that a pregnant woman in Italy did not die because she was refused an abortion. We (a gynecologist and an advocate) have followed the case of Valentina Milluzzo, the 19-weeks pregnant woman who died of sepsis on October 16, 2016 in Catania Italy, and we are in contact with her family. In reality, Valentina’s death is scarily similar to that of Savita Halappanavar, the pregnant dentist who was left to die in an Irish hospital 5 years ago.

In Valentina’s case, the timeline of events, medical facts, and witnesses all contradict the conclusion of the “investigations” by authorities. In fact, Valentina’s doctors claimed “conscientious objection” and refused to perform a medically-required termination of pregnancy. She died because the necessary standard of care in her case was delayed until it was far too late to save her. Valentina had been in hospital for two weeks already, suffering from a threatened miscarriage of twins. But doctors refused to act even after the first twin died, and even after she predictably developed sepsis 12 hours before she died. A doctor objected that “The child’s heart is still beating,” even though the pregnancy was doomed in any case.

Sepsis is a very rapid and life-threatening infection that must be prevented, not managed as if the life of a fetus outranks a woman’s life. If sepsis occurs, doctors have only minutes to act – not hours to wait. For doctors to allow Valentina’s health to deteriorate until her life was in “imminent danger” is unconscionable. She also spent many hours in agony while sepsis destroyed her organs – but without pain relief or medical attention because doctors dismissed her pain as “renal colic” or “the pains of childbirth”.

The very fact that Valentina died is undeniable proof that the abortion was done way too late. It also shows that the provision to allow abortion when a woman’s life is in danger does not work, because doctors can’t be absolutely certain about the risk of death until the patient is dead. “Conscientious objectors” disobey the law by gambling with women’s lives, like they also did with Savita. It was the “conscience” of doctors that killed Valentina.

Christian Fiala MD, PhD, Gynmed Clinic, Vienna, Austria
Joyce Arthur, Executive Director, Abortion Rights Coalition of Canada, Vancouver BC

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11. There Is No Defense for ‘Conscientious Objection’ in Reproductive Health Care

European Journal of Obstetrics & Gynecology and Reproductive Biology

By Christian Fiala and Joyce H. Arthur
Published online 23 July 2017

Abstract: A widespread assumption has taken hold in the field of medicine that we must allow health care professionals the right to refuse treatment under the guise of ‘conscientious objection’ (CO), in particular for women seeking abortions. At the same time, it is widely recognized that the refusal to treat creates harm and barriers for patients receiving reproductive health care. In response, many recommendations have been put forward as solutions to limit those harms. Further, some researchers make a distinction between true CO and ‘obstructionist CO’, based on the motivations or actions of various objectors.

This paper argues that ‘CO’ in reproductive health care should not be considered a right, but an unethical refusal to treat. Supporters of CO have no real defence of their stance, other than the mistaken assumption that CO in reproductive health care is the same as CO in the military, when the two have nothing in common (for example, objecting doctors are rarely disciplined, while the patient pays the price). Refusals to treat are based on non-verifiable personal beliefs, usually religious beliefs, but introducing religion into medicine undermines best practices that depend on scientific evidence and medical ethics. CO therefore represents an abandonment of professional obligations to patients. Countries should strive to reduce the number of objectors in reproductive health care as much as possible until CO can feasibly be prohibited. Several Scandinavian countries already have a successful ban on CO.


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12. Letter to the Editor: Refusal to Treat Patients Does Not Work in Any Country—Even If Misleadingly Labelled “Conscientious Objection”

Health and Human Rights Journal

By Christian Fiala and Joyce H. Arthur
Published online 6 September 2017

We would like to point out some serious problems and contradictions in the study “Regulation of Conscientious Objection to Abortion: An International Comparative Multiple-Case Study,” by Wendy Chavkin, Laurel Swerdlow, and Jocelyn Fifield (Health and Human Rights Journal, vol. 19, no. 1, 2017).

The study purports to show that it is possible to accommodate health care providers’ “conscientious objection” (CO) to legal abortion while assuring that women with an unwanted pregnancy have access to health care services. The researchers examined four countries—England, Italy, Portugal, and Norway—all Western democracies with laws that allow CO for abortion. They conclude that England, Norway, and Portugal are able to permit CO by law and still provide and fund abortion care. Italy is the major exception, where access to legal abortion is seriously compromised due to a very high number of objectors.

Continued: Health and Human Rights Journal

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13. Letter to the Editor: The FSRH guideline on conscientious objection disrespects patient rights and endangers their health

BMJ Sexual and Reproductive Health (Volume 44, Issue 2)

By Christian Fiala and Joyce H. Arthur
Published online 12 April 2018

We write to offer feedback on the new Faculty of Sexual & Reproductive Healthcare (FSRH) guideline on conscientious objection (CO) that was the subject of an editorial in the January 2018 issue of this journal. Our position, for which we have a clear evidence base, is set out below.

Essential parts of the new FSRH guideline, as well as the reasoning behind it, contradict the available evidence around the practice of CO, so we predict that the guideline will largely fail in practice.

We have written extensively on the problem of so-called CO in reproductive healthcare. The available evidence clearly shows that CO is a violation of medical ethics and patients’ rights, has no place in reproductive healthcare, and has misleadingly been co-opted from military CO. CO in healthcare is about imposing one’s religious or personal beliefs, including any negative consequences, on vulnerable others. This is the opposite of military CO. Refusing medical care based on personal beliefs is a negation of evidence-based medical practice and a repudiation of the overriding goal of medicine – to care for patients.

Continued: BMJ Sexual and Reproductive Health

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