Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons

Valerie Fleming Lucy Frith, Ans Luyben, Beate Ramsayer

BMC Medical Ethics

Abstract | Background: Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion.

Method: We conducted a systematic review of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection.

Results: Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one (81) narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons (n =  58). The reasons and their associated mentions in this category outnumber those in the sum of the other three categories.

Conclusions: We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals.


Fleming V, Frith L, Luyben A, Ramsayer B. Conscientious objection to participation in abortion by midwives and nurses: a systematic review of reasons. BMC Medical Ethics. 2018;19:31. doi:10.1186/s12910-018-0268-3.

Testing conscientious objection by the norm of medicine

Toni C. Saad, Gregory Jackson

Abstract

Clinical Ethics

Debate persists over the place of conscience in medicine. Some argue for the complete exclusion of conscientious objection, while others claim an absolute right of refusal. This paper proposes that claims of conscientious objection can and should be permitted if they concern kinds of actions which fall outside of the normative standard of medicine, which is the pursuit of health. Medical practice which meets this criterion we call medicine qua medicine. If conscientious refusal concerns something consonant with the health-restoring aims of medicine, it entails a desertion of professional duty. If, however, it relates to something other than medicine qua medicine, it can rightly be refused. It thus becomes possible to test instances of conscientious objection to determine their validity, and thereby conserve both the principle of conscientious objection and define its scope. This test of conscience prevents arbitrary discrimination, and preserves doctors’ agency. It is a theoretical razor rooted in the practical reasoning of medicine whose operation will prompt, if nothing else, reflection on the goals of medicine.


Saad TC, Jackson G. Testing conscientious objection by the norm of medicine. Clinical Ethics 2018 Mar; 13(1); 9-16.

There is no defence for ‘Conscientious objection’ in reproductive health care

Christian Fiala, Joyce H. Arthur

There is no defence for 'Conscientious objection' in reproductive health care

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.


Fiala C, Arthur JH. Eur J Obstet Gynecol Reprod Biol. 2017 Jul 23. pii: S0301-2115(17)30357-3. doi: 10.1016/j.ejogrb.2017.07.023. [Epub ahead of print]

Abortion decriminalisation and statutory rights of conscience

Mary Neal

Abortion decriminalisation and statutory rights of conscience

On 13 March 2017, the House of Commons voted by 172 to 142 in favour of a second reading for the Reproductive Health (Access to Terminations) Bill. The bill, introduced by Diana Johnson MP, would decriminalise abortion until the end of the 24th week of pregnancy, meaning that abortion could be performed until the end of the 24th week of pregnancy without the need to satisfy any statutory grounds, or to obtain two doctors’ authorisation. Many campaigners see this bill as a first step toward the longer-term goal of fully decriminalising abortion. [1]

The prospect of decriminalisation raises a number of interesting and important issues, including an issue which has been neglected in the debates over decriminalisation so far, namely what any change in the law might mean for the right of health professionals to withdraw from participation in abortion on grounds of conscience, under section 4 of the Abortion Act 1967. . . .


Neal M. Abortion decriminalisation and statutory rights of conscience. the bmjopinion [Internet]. 2017 Mar 24.

“She’s on her own”: a thematic analysis of clinicians’ comments on abortion referral

Nazeneen Homaifar, Lori Freedman,Valerie French

“She's on her own”: a thematic analysis of clinicians' comments on abortion referral

Abstract

Objective

The objective was to understand the motivations around and practices of abortion referral among women’s health providers.

Methods

We analyzed the written comments from a survey of Nebraska physicians and advanced-practice clinicians in family medicine and obstetrics-gynecology about their referral practices and opinions for a woman seeking an abortion. We analyzed clinician’s responses to open-ended questions on abortion referral thematically.

Results

Of the 496 completed surveys, 431 had comments available for analysis. We found four approaches to abortion referral: (a) facilitating a transfer of care, (b) providing the abortion clinic name or phone number, (c) no referral and (4) misleading referrals to clinicians or facilities that do not provide abortion care. Clinicians described many motivations for their manner of referral, including a fiduciary obligation to refer, empathy for the patient, respect for patient autonomy and the lack of need for referral. We found that abortion stigma impacts referral as clinicians explained that patients often desire additional privacy and clinicians themselves seek to avoid tension among their staff. Other clinicians would not provide an abortion referral, citing moral or religious objections or stating they did not know where to refer women seeking abortion. Some respondents would refer women to other providers for additional evaluation or counseling before an abortion, while others sought to dissuade the woman from obtaining an abortion.

Conclusions

While practices and motivations varied, few clinicians facilitated referral for abortion beyond verbally naming a clinic if an abortion referral was made at all.

Implications

Interprofessional leadership, enhanced clinician training and public policy that addresses conscientious refusal of abortion referral are needed to reduce abortion stigma and ensure that women can access safe care.


Homaifar N, Freedman L,French V. “She’s on her own”: a thematic analysis of clinicians’ comments on abortion referral. Contraception. 2017 May;95(5):470-476. doi: 10.1016/j.contraception.2017.01.007. Epub 2017 Jan 25.

Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception

Julian Savulescu, Udo Schuklenk

Bioethics

Abstract:  In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors’ personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: (1) removing a right to conscientious objection; (2) selecting candidates into relevant medical specialities or general practice who do not have objections; (3) demonopolizing the provision of these services away from the medical profession.

Savulescu J, Schuklenk U.  (2016) Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics. doi:10.1111/bioe.12288

Referrals for Services Prohibited In Catholic Health Care Facilities

Debra B. Stulberg, Rebecca A. Jackson, Lori R. Freedman

Perspectives on Sexual and Reproductive Health

Abstract | Context: Catholic hospitals control a growing share of health care in the United States and prohibit many common reproductive services, including ones related to sterilization, contraception, abortion and fertility. Professional ethics guidelines recommend that clinicians who deny patients reproductive services for moral or religious reasons provide a timely referral to prevent patient harm. Referral practices in Catholic hospitals, however, have not been explored.

Methods: Twenty-seven obstetrician-gynecologists who were currently working or had worked in Catholic facilities participated in semistructured interviews in 2011–2012. Interviews explored their experiences with and perspectives on referral practices at Catholic hospitals. The sample was religiously and geographically diverse. Referral-related themes were identified in interview transcripts using qualitative analysis.

 Results: Obstetrician-gynecologists reported a range of practices and attitudes in regard to referrals for prohibited services. In some Catholic hospitals, physicians reported that administrators and ethicists encouraged or tolerated the provision of referrals. In others, hospital authorities actively discouraged referrals, or physicians kept referrals hidden. Patients in need of referrals for abortion were given less support than those seeking referrals for other prohibited services. Physicians received mixed messages when hospital leaders wished to retain services for financial reasons, rather than have staff refer patients elsewhere. Respondents felt referrals were not always sufficient to meet the needs of low-income patients or those with urgent medical conditions.

 Conclusions: Some Catholic hospitals make it difficult for obstetrician-gynecologists to provide referrals for comprehensive reproductive services.

Stulberg DB, Jackson  RA, Freedman LR.  Referrals for Services Prohibited In Catholic Health Care Facilities. Perspect Sex Repro H, 48:111–117. doi:10.1363/48e10216

When Policy Produces Moral Distress: Reclaiming Conscience

Nancy Berlinger

The Hastings Center Report

Abstract

For too long, bioethics has followed law in reducing “conscience” to “conscientious objection,” in other words, to laws and policies permitting and protecting refusal. In “Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide,” Mara Buchbinder and colleagues draw our attention to one dimension of the problem of reducing conscience to refusal to provide certain forms of medical care: what about the conscience problems experienced by the professionals who are attempting to provide safe, effective health care that includes services that others associate with conscientious objection? In seeking to disrupt a specific medical practice – one that is legal, desired by the patient, and conducted in accordance with medical standards – North Carolina House Bill 854, The Women’s Right to Know Act, and laws like it, appear to be designed to produce moral distress in physicians and other professionals involved in the provision of abortions. For abortion providers in North Carolina and other states, conscientious objection to the mandates of laws like HB 854 isn’t a realistic option. So what can bioethics offer to professionals bound by such laws? We can start by reclaiming the idea of “conscience” as something that can say “yes” to providing health care.

Berlinger, N. (2016), When Policy Produces Moral Distress: Reclaiming Conscience. Hastings Center Report, 46: 32–34. doi: 10.1002/hast.547

Conscience, Courage, and “Consent”

Mark A. Hall, Nancy M. P. King

The Hastings Center Report

Abstract

How should we think about physicians who object to what law in North Carolina and many other states requires them to tell patients seeking legal abortions? A federal appellate court helped to place this situation in perspective when it struck down the part of the Woman’s Right to Know Act, North Carolina’s mandatory informed consent statute for abortions, that required physicians to show such patients real-time ultrasound images of their fetuses and describe the stage of fetal development. In this court’s view, the state’s WRTK Act forces physicians to express a viewpoint that may be contrary to their medical judgment. Moreover, the ultrasound-viewing provision “simultaneously threaten[s] harm to the patient’s psychological health, interfer[es] with the physician’s professional judgment, and compromis[es] the doctor-patient relationship.” The court continued, “Transforming the physician into the mouthpiece of the state undermines the trust that is necessary for facilitating healthy doctor-patient relationships, and through them, successful treatment outcomes.” Based on this reasoning, the court invalidated the ultrasound-viewing portion of the statute, but the other provisions remain in effect, mandating a long list of disclosures; similar laws exist in many other states.

In this essay, we want to consider what the abortion legislation says about the state’s regard for professional judgment. At the same time that these laws threaten patient trust in physicians – a point Mara Buchbinder and colleagues explore in “Reframing Conscience: Providing Abortion Care When Law and Conscience Collide” (in this same issue of the Report) – the laws display a deep-seated distrust by government in the integrity of medical professionals. The WRTK statute bristles with measures that control physicians’ interactions with patients. In addition to the most egregious example of coerced display and discussion of live ultrasound images, which has now been invalidated, this statute and others like it script in great detail what treating physicians must say to patients in specified settings at prescribed times.

Hall, M. A. and King, N. M. P. (2016), Conscience, Courage, and “Consent”. Hastings Center Report, 46: 30–32. doi: 10.1002/hast.546

Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide

Mara Buchbinder, Dragana Lassiter, Rebecca Mercier, Amy Bryant, Anne Drapkin Lyerly

The Hastings Center Report

Abstract

“It’s almost like putting salt in a wound, for this person who’s already made a very difficult decision,” suggested Meghan Patterson (an alias), a licensed obstetrician-gynecologist whom we interviewed in our qualitative study of the experiences of North Carolina abortion providers practicing under the state’s Woman’s Right to Know Act (House Bill 854; 2011). The act requires that women receive counseling with state-mandated information at least twenty-four hours prior to obtaining an abortion. After the law was passed, Patterson worked with clinic administrators, in consultation with a lawyer, to write a script to be used in the state-mandated counseling procedure. She and her colleagues took particular steps to mitigate the effects of what she described as HB 854’s “forced language” – such as referring to the “father of the child.” While HB 854 stipulated that patients must be informed of the medical risks associated with the particular abortion procedure as well as those of carrying the child to term, Patterson’s script made explicit the magnitude of comparative risks, emphasizing that the risks of carrying a pregnancy to term are substantially greater than the risks of an early-term abortion. She felt that these contextualization strategies helped to facilitate trust and rapport in a clinical care situation that proved relationally and morally challenging.

In this article, we take up and expand on this point by elucidating an empirically grounded approach to ethically justified care when health care providers face legal or institutional policy mandates that raise possible moral conflicts. Our approach builds on recent bioethics discourse addressing conscience in the practice of medicine. While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious objection or refusal. Here, we suggest a broader frame for thinking about claims of conscience in health care. Our approach draws on the feminist bioethics and the ethics of care literatures to highlight how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. What emerges are two possibilities: not only conscientious refusal to comply with a policy mandate but also conscientious compliance – working conscientiously within a mandate’s confines.

Buchbinder, M., Lassiter, D., Mercier, R., Bryant, A. and Lyerly, A. D. (2016), Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide. Hastings Center Report, 46: 22–30. doi: 10.1002/hast.545