Commentary Health Systems

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

Joyce Arthur

The exercise of conscientious objection 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.

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.

CO 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.

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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.

Likewise, 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.

News Abortion

Study: United States a ‘Stark Outlier’ in Countries With Legal Abortion, Thanks to Hyde Amendment

Nicole Knight Shine

The study's lead author said the United States' public-funding restriction makes it a "stark outlier among countries where abortion is legal—especially among high-income nations."

The vast majority of countries pay for abortion care, making the United States a global outlier and putting it on par with the former Soviet republic of Kyrgyzstan and a handful of Balkan States, a new study in the journal Contraception finds.

A team of researchers conducted two rounds of surveys between 2011 and 2014 in 80 countries where abortion care is legal. They found that 59 countries, or 74 percent of those surveyed, either fully or partially cover terminations using public funding. The United States was one of only ten countries that limits federal funding for abortion care to exceptional cases, such as rape, incest, or life endangerment.

Among the 40 “high-income” countries included in the survey, 31 provided full or partial funding for abortion care—something the United States does not do.

Dr. Daniel Grossman, lead author and director of Advancing New Standards in Reproductive Health (ANSIRH) at the University of California (UC) San Francisco, said in a statement announcing the findings that this country’s public-funding restriction makes it a “stark outlier among countries where abortion is legal—especially among high-income nations.”

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The researchers call on policymakers to make affordable health care a priority.

The federal Hyde Amendment (first passed in 1976 and reauthorized every year thereafter) bans the use of federal dollars for abortion care, except for cases of rape, incest, or life endangerment. Seventeen states, as the researchers note, bridge this gap by spending state money on terminations for low-income residents. Of the 14.1 million women enrolled in Medicaid, fewer than half, or 6.7 million, live in states that cover abortion services with state funds.

This funding gap delays abortion care for some people with limited means, who need time to raise money for the procedure, researchers note.

As Jamila Taylor and Yamani Hernandez wrote last year for Rewire, “We have heard first-person accounts of low-income women selling their belongings, going hungry for weeks as they save up their grocery money, or risking eviction by using their rent money to pay for an abortion, because of the Hyde Amendment.”

Public insurance coverage of abortion remains controversial in the United States despite “evidence that cost may create a barrier to access,” the authors observe.

“Women in the US, including those with low incomes, should have access to the highest quality of care, including the full range of reproductive health services,” Grossman said in the statement. “This research indicates there is a global consensus that abortion care should be covered like other health care.”

Earlier research indicated that U.S. women attempting to self-induce abortion cited high cost as a reason.

The team of ANSIRH researchers and Ibis Reproductive Health uncovered a bit of good news, finding that some countries are loosening abortion laws and paying for the procedures.

“Uruguay, as well as Mexico City,” as co-author Kate Grindlay from Ibis Reproductive Health noted in a press release, “legalized abortion in the first trimester in the past decade, and in both cases the service is available free of charge in public hospitals or covered by national insurance.”

Roundups Politics

Campaign Week in Review: Trump Selects Indiana Gov. Mike Pence to Join His Ticket

Ally Boguhn

And in other news, Donald Trump suggested that he can relate to Black people who are discriminated against because the system has been rigged against him, too. But he stopped short of saying he understood the experiences of Black Americans.

Donald Trump announced this week that he had selected Indiana Gov. Mike Pence (R) to join him as his vice presidential candidate on the Republican ticket, and earlier in the week, the presumptive presidential nominee suggested to Fox News that he could relate to Black Americans because the “system is rigged” against him too.

Pence Selected to Join the GOP Ticket 

After weeks of speculation over who the presumptive nominee would chose as his vice presidential candidate, Trump announced Friday that he had chosen Pence.

“I am pleased to announce that I have chosen Governor Mike Pence as my Vice Presidential running mate,” Trump tweeted Friday morning, adding that he will make the official announcement on Saturday during a news conference.

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The presumptive Republican nominee was originally slated to host the news conference Friday, but postponed in response to Thursday’s terrorist attack in Nice, France. As late as Thursday evening, Trump told Fox News that he had not made a final decision on who would join his ticket—even as news reports came in that he had already selected Pence for the position.

As Rewire Editor in Chief Jodi Jacobson explained in a Thursday commentary, Pence “has problems with the truth, isn’t inclined to rely on facts, has little to no concern for the health and welfare of the poorest, doesn’t understand health care, and bases his decisions on discriminatory beliefs.” Jacobson further explained: 

He has, for example, eagerly signed laws aimed at criminalizing abortion, forcing women to undergo unnecessary ultrasounds, banning coverage for abortion care in private insurance plans, and forcing doctors performing abortions to seek admitting privileges at hospitals (a requirement the Supreme Court recently struck down as medically unnecessary in the Whole Woman’s Health v. Hellerstedt case). He signed a ‘religious freedom’ law that would have legalized discrimination against LGBTQ persons and only ‘amended’ it after a national outcry. Because Pence has guided public health policy based on his ‘conservative values,’ rather than on evidence and best practices in public health, he presided over one of the fastest growing outbreaks of HIV infection in rural areas in the United States.

Trump Suggests He Can Relate to Black Americans Because “Even Against Me the System Is Rigged”

Trump suggested to Fox News’ Bill O’Reilly that he could relate to the discrimination Black Americans face since “the system [was] rigged” against him when he began his run for president.

When asked during a Tuesday appearance on The O’Reilly Factor what he would say to those “who believe that the system is biased against them” because they are Black, Trump leaped to highlight what he deemed to be discrimination he had faced. “I have been saying even against me the system is rigged. When I ran … for president, I mean, I could see what was going on with the system, and the system is rigged,” Trump responded.

“What I’m saying [is] they are not necessarily wrong,” Trump went on. “I mean, there are certain people where unfortunately that comes into play,” he said, concluding that he could “relate it, really, very much to myself.”

When O’Reilly asked Trump to specify whether he truly understood the “experience” of Black Americans, Trump said that he couldn’t, necessarily. 

“I would like to say yes, but you really can’t unless you are African American,” said Trump. “I would like to say yes, however.”

Trump has consistently struggled to connect with Black voters during his 2016 presidential run. Despite claiming to have “a great relationship with the blacks,” the presumptive Republican nominee has come under intense scrutiny for using inflammatory rhetoric and initially failing to condemn white supremacists who offered him their support.

According to a recent NBC News/Wall Street Journal/Marist poll released Tuesday, Trump is polling at 0 percent among Black voters in the key swing states of Ohio and Pennsylvania.

What Else We’re Reading

Newt Gingrich, who was one of Trump’s finalists for the vice presidential spot, reacted to the terrorist attack in Nice, France, by calling for all those in the United States with a “Muslim background” to face a test to determine if they “believe in sharia” and should be deported.

Presumptive Democratic nominee Hillary Clinton threw her support behind a public option for health insurance.

Bloomberg Politics’ Greg Stohr reports that election-related cases—including those involving voter-identification requirements and Ohio’s early-voting period—are moving toward the Supreme Court, where they are “risking deadlocks.”

According to a Reuters review of GOP-backed changes to North Carolina’s voting rules, “as many as 29,000 votes might not be counted in this year’s Nov. 8 presidential election if a federal appeals court upholds” a 2013 law that bans voters from casting ballots outside of their assigned precincts.

The Wall Street Journal reported on the election goals and strategies of anti-choice organization Susan B. Anthony List, explaining that the organization plans to work to ensure that policy goals such as a 20-week abortion ban and defunding Planned Parenthood “are the key issues that it will use to rally support for its congressional and White House candidates this fall, following recent setbacks in the courts.”

Multiple “dark money” nonprofits once connected to the Koch brothers’ network were fined by the Federal Election Commission (FEC) this week after hiding funding sources for 2010 political ads. They will now be required to “amend past FEC filings to disclose who provided their funding,” according to the Center for Responsive Politics. 

Politico’s Matthew Nussbaum and Ben Weyl explain how Trump’s budget would end up “making the deficit great again.”

“The 2016 Democratic platform has the strongest language on voting rights in the party’s history,” according to the Nation’s Ari Berman.