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Law, ethics and medicine


When should conscientious objection be accepted?

Morten Magelssen 1,2

1 Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway 2 Lovisenberg Diakonale Hospital, Oslo, Norway


This paper makes two main claims: first, that the need to protect health professionals’ moral integrity is what grounds the right to conscientious objection in health

  • care; and second, that for a given claim of conscientious objection to be acceptable to society, a certain set of criteria should be fulfilled. The importance of moral integrity for individuals and society, including its special role in health care, is advocated. Criteria for evaluating the acceptability of claims to conscientious objection are

Correspondence to

Morten Magelssen, Senter for Medisinsk Etikk, Universitetet i

Oslo, 1130 Blindern, N-0318 Oslo, Norway;

Received 4 March 2011 Revised 3 May 2011 Accepted 24 May 2011 Published Online First 20 June 2011

outlined. The precise content of the criteria is dictated by the two main interests that are at stake in the dilemma of conscientious objection: the patient’s interests and the health professional’s moral integrity. Alternative criteria proposed by other authors are challenged. The bold claim is made that conscientious objection should be recognised by society as acceptable whenever the five main criteria of the proposed set are met.

The right to refuse to act against ones moral or religious convictions is central to a democratic society. The corresponding right for healthcare professionals is the moral right to conscientious objection. The list of morally controversial practices in which some healthcare workers would not want to partake includes abortion, euthanasia, physician- assisted suicide, providing certain kinds of contra- ception and reproductive technologies. There is a pressing need for debate about the justication and scope of the right to conscientious objection for three reasons. First, moral controversies in health care often concern questions of life and death, and may thus be of great moral signicance. Second, advances in medical technology expand medicines possibilities. Some new procedures will be morally controversial. Third, many western societies are experiencing increasing cultural, religious and moral pluralism. Conscientious objection in health care may thus become more common.


The fundamental dilemma of conscientious objec- tion is why should society allow healthcare workers to refrain from providing treatment to which the patient has a right? By law, society guarantees the patients right to treatment that is held to be benecial. In exchange for certain privi- leges, health professionals cater to the medical needs of society. This gives them a prima facie duty to provide all benecial medical treatment. Why then should society accept their refusal to full their obligations? A substantial reason is needed. Such a reason is found in the need to protect the moral integrity of healthcare workers. The patients right to health care and the health professionals

moral integrity are both legitimate interests. The combined weight of several factors decides which interest ought to win out in a given case. Some of the other authors on this topic, including Mark Wicclair 1 and Dan Brock, 2 frame the issue in a similar way. Among authors who argue for a more constricted role for conscientious objection, many either down- play the importance of moral integrity 3 4 or employ an impoverished conception of moral integrity. 5 This paper offers an account of moral integrity that highlights its great importance to all rational agents and health professionals in particular. Special emphasis will be on what has often not been suf- ciently clearly brought out previously: the impor- tance of individualsmoral integrity to society. The account of moral integrity is more congenial to deontological and virtue ethics than to conse- quentialism. Only the positive case for the position

that conscientious objection is justied by the need to protect moral integrity is supplied. Wicclair 1 has argued against alternative justications for consci- entious objection. When a healthcare worker conscientiously objects to a certain procedure, this is because participating in the procedure would go against his deeply held moral or religious judgement. We all have deeply held convictions that we consider important to us, and which constitute central aspects of our identities. Having moral integrity means being faithful towards these deeply held considerations. Moral integrity implies having an internally consistent set of basic moral ideas and principles, and being able to live and act in accor- dance with these. On this view, perhaps no-one can be said to have complete moral integrity. Never- theless, moral integrity is commonly considered to be a highly desirable character trait, and something one ought to take pains to preserve. When you act against your deeply held convic- tions, the link between principles and actions is severed. Your moral integrity is hurt. Refraining from participating in a certain medical procedure can be regarded as an attempt to protect ones moral integrity. Taking part in the procedure despite ones belief that it is morally objectionable would be a kind of self-betrayal, and could lead to a loss of self-respect 1 : I could not live with myself if I did that.. We choose to act to bring about desirable goods or states of affairs, but our choices also have consequences for our moral character. As Finnis 6 explains, when we choose moral or immoral actions, we also choose to become a certain kind of person. If I choose to shoplift, I simultaneously choose to become the kind of person who steals othersproperty for my own gain. When you act,


J Med Ethics 2012;38:18e21. doi:10.1136/jme.2011.043646

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Law, ethics and medicine

you necessarily embrace the actions principles or maxims. By choosing we freely accept these principles, whether, for example, it is right to steal if I stand to gain from itor killing is wrong. We allow our will to be shaped by the principles inherent in the action. In this way choices have a lasting effect on our character. Morally important choices make us the persons we are, for better or for worse. The effects of our actions on our personal- ities are not something from which we can escape. Acting against your conviction in choice situations of great importance will injure your moral identity, sometimes with psychological and emotional repercussions. Criticising consci- entious objection, Rosamond Rhodes 5 states, the doctor who chooses to avoid personal psychic distress declares his willing- ness to impose burdens (.) on his patients so that he might feel pure.As we have seen, moral integrity goes far deeper than feeling. As Pellegrino 7 puts it, the right to refrain from performing actions perceived to be immoral is rmly rooted in what it is to be a human person morally, intellectually, and psychologically . Empirically, the moral distress that results from acting against ones conscience has been shown to lead to burnout, fatigue and emotional exhaustion. 8 9 Moral integrity is a valuable good for the individual, and is protected by the moral right to conscientious objection. Furthermore, there are three reasons why society should take a special interest in the good of moral integrity. First, moral integrity is a good to all persons, generally benetting the possessor and the people with whom he interacts. Second, society has a special opportunity for promoting moral integrity. This means shaping society in ways that facilitate citizensability to make morally good choices; including, in the realm of health care, by allowing health professionals to follow their conscience. Third, some professions of central importance to society depend on their practitioners having moral integrity. Arguably, medicine is a moral activity, and so the medical profession needs practitioners with virtuous moral characters. 10 Healthcare workers who would consider conscientious objection towards procedures they nd immoral take pains to protect their moral integrity. As J.W. Gerrard 11 notes, these professionals probably have qualities needed in the medical community: well- developed conscience, commitment to the moral ideals of the profession and a reluctance to accept compromises with immorality. Medical history is rife with examples of what atrocities can be committed when these qualities are lacking. In sum, moral integrity is part of the common good. 12 Moral integrity is thus an important good for individuals and society. The right to conscientious objection in health care protects this good.


We will now construct a general framework for the evaluation of claims to conscientious objection. The author argues for the criteria set out in box 1, and shows how they spring from the fundamental dilemma of conscientious objection: the patients right to treatment versus the healthcare worker s moral integ- rity. Several criteria get their particular shape from the concept of moral integrity that we have outlined. Previously, other authors have argued for different and less determinate sets of criteria. Wicclair s list includes criteria corresponding to 1b, 4a-b, 5 and 6 in the present set. 1 Brock mentions 1b and 2e4. 2 Meyers and Woods include 1e2. 13 The following factors are relevant in deciding whether refusal is warranted. The examples below will refer to medical doctors, but the principles also apply to other health professionals.

J Med Ethics 2012;38:18e21. doi:10.1136/jme.2011.043646

Box 1 Criteria for the acceptance of concientious objection

When the following criteria are met, conscientious objection ought to be accepted:

  • 1. Providing health care would seriously damage the health professional’s moral integrity by

  • a. constituting a serious violation.

  • b. . of a deeply held conviction

  • 2. The objection has a plausible moral or religious rationale

  • 3. The treatment is not considered an essential part of the health professional’s work

  • 4. The burdens to the patient are acceptably small

  • a. The patient’s condition is not life-threatening

  • b. Refusal does not lead to the patient not getting the treatment, or to unacceptable delay or expenses

  • c. Measures have been taken to reduce the burdens to the patient

  • 5. The burdens to colleagues and healthcare institutions are acceptably small

In addition, the claim to conscientious objection is strengthened if:

  • 6. The objection is founded in medicine’s own values

  • 7. The medical procedure is new or of uncertain moral status

Serious violation of a deeply held conviction

For your objection to the treatment to carry weight, it must be based on a deeply held conviction. An example given by Julian Savulescu 3 will illustrate the importance of this point:

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, but it would be inappropriate for him to conscientiously object to delivering such services if society has deemed patients are entitled to treatment.3

Savulescu 3 is correct that conscientious objection would be inappropriate in this case, but he fails to supply the true reason for this. For the objection to the treatment to be acceptable it is not enough that it is based on a plausible moral view . Rather, it must violate a deeply held judgement, a principle constitutive of the doctor s conception of himself. Savulescus doctor s judge- ment about people above the age of 70 is unlikely to be deeply held in this way. In addition, acting against your conscience must constitute a serious violation of your judgement. The reason is that only such actions damage your moral integrity. This point has not always received sufcient emphasis. A serious violationalways involves participation in the causal chain leading to the disputed treatment. It is often maintained (for instance, by Britains General Medical Council) that the conscientious objector has a duty to arrange for referral to another doctor. 14 This alleged duty is problematical in that it arguably demands that the doctor play a part in the causal chain ultimately leading to the disputed medical procedure. A point often overlooked is that there is more than one sense of referral. There is a morally relevant distinction to be made. The paradigmatic referral involves a referral letter in which the physician details the patients condition and requests certain health services on the patients behalf, and sometimes also involves practical arrangements for the patients transfer. This implies, willy-nilly, sharing the patients intention to get the requested treatment. On the other hand, a referralcan also mean simply the physician telling the patient about


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practitioners he can to turn to. In this case, that the disputed procedure is to be carried out need not be part of the doctor s intention. In the idiom of Wildes 15 and Boyle, 16 the rst doctor s cooperation is formal; whereas the second doctor s is merely material, meaning that although his action is a necessary part of the causal chain leading to the procedure being carried out, this ultimate result is not part of the doctor s intention. The rst and second kinds of referral may constitute the upper rungs of a ladder of increasing causal involvement, in which the bottom rung is the act of simply informing the patient about the exis- tence and nature of the disputed procedure. The referral ladder illustrates the importance of the serious violationcriterion. In the case of a disputed medical procedure, only the full-blown referral would constitute a serious violation of the conscientious objector s views and integrity. Objections to referring for morally controversial treatments may thus be warranted. The second and third kinds of involvement, on the other hand, are required of the doctor.

A plausible rationale

You should be able to give well thought-through, detailed and plausible reasons for your conscientious objection. If you were unable to do so, one would suspect that your objection does not spring from a conviction central to your conception of who you are. The role of religious-based reasoning in the public square is a point of contention. On the view of moral integrity espoused, views based in religious morality and secular morality are considered on an equal footing. The reason is that a judgement of religious morality may be as constitutive of a persons conception of himself as a non-religious view. Acting against ones religiously based view may then also damage ones moral integrity. However, in order to merit respect the religiously based conviction must also have certain plausibility, in that it ts into a coherent world view. An objection does not have a plausible rationale if it is based on erroneous factual premises. Brock 2 relates the case of the racist Dr A who objects to treating patients with a different skin colour on religious and moral grounds. Brock 2 uses this case to justify his criterion that refusal must not violate legal requirements of social justice.One might think the real reason why Dr As objection is unac- ceptable is its lack of a plausible rationale; his racist views are incompatible with any plausible world view. If this is the case, the justication for Brocks additional criterion disappears. An objection to providing regular medical treatment to patients of certain political or religious persuasions, children of single parents or homosexuals, is unacceptable both because refusal lacks a plausible rationale and because providing the treatment does not violate the doctor s moral integrity.

The treatment is not considered essential to your work

A claim to conscientious objection is more acceptable when the treatment in question is not an essential part of the health professionals daily work. For instance, it is unreasonable to accept employment at a fertility clinic and yet refuse to participate in most methods of articial reproduction.

Burdens to patients

Conscientious objection is more acceptable the better the patients interests can be protected in the process. Conscientious objection may conceivably impose at least four kinds of harm on the patient: delay or expense in getting the treatment; restric- tion of access to the treatment; lack of important information and a sense of moral disapproval of the patients choices or lifestyle.


The conscientious objector should take pains to protect the patient, in reducing the four sources of harm as much as possible. The doctor should thus communicate his refusal to comply with the patients request at the earliest possible stage. If possible, the patient should be notied in advance of the consultation, for instance by a website announcement stating that the doctor will not provide certain specied forms of treatment. As discussed above, in situations in which delay in treatment would be injurious to the patient, the conscientious objector should at least ensure that the patient is informed about the nature of the requested treatment, and knows where to turn to receive it. The patients life is usually of overriding importance, and so a healthcare worker s conscientious objection to providing potentially life-saving treatment should not be accepted. This is especially so if no colleague is available to take over responsi- bility for the patient. The more the patients health is compromised without the treatment, the less acceptable the refusal to provide treatment is. The patient may very well perceive the doctor s refusal to comply with his request as an implicit criticism of his choice or lifestyle, as in the case of in-vitro fertilisation for same-sex couples. The right to conscientious objection is grounded in the need to protect the doctor s moral integrity, not in a right to communicate ones moral views to patients. The doctor objects to the treatment, not to the patient requesting the treatment; nevertheless, the moral criticism of the patients intention implicit in conscientious objection may be ineradicable. However, it may certainly be diminished in force by the circumstances of the objection. Moreover, moral disagreement is an inescapable feature of our dealing with other people in society. Therefore, conscientious objection may be acceptable when carried out non-confrontationally and with sensitivity towards the vulnerable patient. For instance, some authors maintain that the objector must explain to the patient the reason for objecting, 17 but this may not always be in the patients interest. Daniel Sulmasy 18 argues that as conscience (or moral integ- rity) is of such fundamental value to a person, it would seem, in general, that inconvenience, psychological distress, or mild symptoms would not be sufcient grounds to compel conscience.Nevertheless, the objector should actively seek to reduce burdens to patients. Importantly, this would signal that his objection is based on a noble moral motivedthe protection of his own integritydand that he has not lost sight of his duty to promote the patients interests.

Burdens to colleagues and healthcare institutions

If the dilemma of conscientious objection involves the rational assessment of competing legitimate interests, then the interests of the objector s coworkers and employer would sometimes also need to be taken into account. Objection may place employers in a quandary, as when all gynaecologists at a hospital object to performing abortions.

Medicine’s own values

According to Wicclair, 1 an appeal to conscience has signicant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Corre- spondingly, objections founded in values that are peripheral to medicine or merely are the health professionals own, do not carry sufcient moral weight to merit society s acceptance. This claim is too strong. An appeal to a deep-seated judgement is more signicant if the judgement springs from your conception of yourself as a doctor living up to the professions moral

J Med Ethics 2012;38:18e21. doi:10.1136/jme.2011.043646

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Law, ethics and medicine

standards. The reason is that the doctor qua doctor has a special obligation towards medicines own morality and values. But it does not follow from this that only objections founded in medicines own values merit acceptance. Consider Wicclair s example of Dr L who is ethically opposed to providing pain medication because he believes that pain is a sign of a moral aw and is therefore deserved. 1 Presumably, all would agree that there is no acceptable basis for the doctor s objection. According to Wicclair, 1 this is because the doctor s objection is based in values foreign to medicine, but in the author s view, his objection just lacks any plausible rationale (criterion 2). It is difcult to conceive of a world view that includes the doctor s belief that is coherent and minimally plausible. Wicclair s contention is also vulnerable to a counter-example. Consider the case of in-vitro fertilisation for a single woman or a same-sex couple. Some fertility doctors would object to treating such patients because it would violate their judgement that children have a (moral, natural) right to be raised by both their biological parents. This right, although plausible to some, is not a core medical value, and so in Wicclair s theory, this reason for refusal is unacceptable. However, although the case is conten- tious, many would nd objection to be well founded in this case. However, the weaker version of Wicclair s point is sound:

objections founded in medicines own values are more acceptable.

New or morally uncertain medical procedures

A refusal to provide treatment is strengthened if the treatment was not invented or accepted at the time the health professional selected his profession, specialty or current position. Brock 2 argues against this criterion by claiming that it rests on the implausible premise that the professions obligations cannot change over time. However, it remains a fact that the health professional did not know about these treatment modalities at the time he entered his position or specialty, and thus his implicit contract with society did not cover these procedures. Therefore, it is reasonable to accord extra weight to conscien- tious objection in these circumstances. Conscientious objection carries greater weight if the disputed medical procedure is widely regarded to be fraught with moral uncertainty. This may be the case for treatments based on new technologies. For instance, a doctor may object to providing treatment with cells derived from humaneanimal chimeras were this to become available, because of the uncertain moral status of such chimeras. This may also be the case for medical procedures that run counter to traditional moral norms hitherto entrenched in society.

How much guidance does the set of criteria provide?

The proposed set of criteria should be consulted when society has to decide whether a refusal to provide medical treatment should be tolerated. Criteria 1e5 are, in the authors opinion, jointly sufcient for conscientious objection to be acceptable to society. However, they are not necessary: there may be situa- tions in which conscientious objection ought to be accepted, but when, for example, criterion 1a is not met. When burdens to patients and institutions are negligible (criteria 4e5), there is no good reason not to respect the health professionals refusal.

The proposed framework for the evaluation of conscientious objection is more detailed than any alternative yet. However, the application of the set to any given actual case may still not yield a denite conclusion. This should not be surprising. There is a certain indeterminacy in most of the criteria (plausible rationale, acceptably small burdens, etc.), which seems to be ineradicable. Applying the criteria does not obviate the need for practical wisdom and the ability to take into account the specics of each case. To challenge the proposed set of criteria, one would have to argue against either of four things: the crucial importance of protecting the healthcare worker s moral integrity; the construal of the issue of conscientious objection as the dilemma of balancing the interests of the patient and the health professional; the cogency or relevance of the speci c criteria proposed; or the set s exclusion of other criteria. Alternatively, one might come up with counter examples of situations in which criteria 1 e5 are met, but in which our strong intuition is that conscientious objection is nevertheless unacceptable.


The main purpose of this paper has been to present and argue for a set of criteria for the evaluation of claims to conscientious objection. The strong claim has been made that the rst ve criteria are jointly sufcient for conscientious objection to be morally acceptable from society s viewpoint.

Competing interests None declared. Provenance and peer review Not commissioned; externally peer reviewed.


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When should conscientious objection be accepted?

Morten Magelssen

J Med Ethics 2012 38: 18-21 originally published online June 20, 2011

doi: 10.1136/jme.2011.043646

Updated information and services can be found at:





These include:

This article cites 13 articles, 7 of which can be accessed free at:

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