How should a liberal democracy react to conscientious objection claims?

Panel 2: Conscience in Legal Perspective: Challenges and Controversies 

Royal Irish Academy


Professor David Smith, RCSI University of Medicine and Health Sciences


  • Advocate General Gerard Hogan, Court of Justice of the European Union
  • Professor Ronan McCrea, University College London
  • Dr. Regina McQuillan, St Francis Hospice

Conscientious objections in healthcare, services, resistance to authoritarian regimes: effects on third parties: meaning of ‘complicity’ .

Royal Irish Academy: How should a liberal democracy react to conscientious objection claims?

How should a liberal democracy react to conscientious objection claims?

Panel 1: Concepts of Conscience

Royal Irish Academy Symposium

Chair: Professor Bert Gordijn, Dublin City University


  • Professor Kimberley Brownlee, The University of British Columbia
  • Dr Katherine Furman, University of Liverpool

Discussion of concepts of conscience, freedom of conscience, conscientious objection, civil disobedience, individual and corporate conscience

When Physicians Engage in Practices That Threaten the Nation’s Health

Philip A. Pizzo,David Spiegel, Michelle M. Mello

Journal of the American Medical Association
Journal of the American Medical Association

In December 2020, less than a year after severe acute respiratory syndrome coronavirus 2 was identified as the cause of the coronavirus pandemic, an extraordinary collaboration between scientists, the pharmaceutical industry, and government led to 2 highly efficacious, safe vaccines being approved by the US Food and Drug Administration . . .

. . . However . . . A number of leaders in federal, state, and local government, guided by political exigency and recommendations from a small number of physicians and scientists who ignored or dismissed science, refused to promote sensible, effective policies such as mask wearing and social distancing. This contributed to the US having more infections and deaths than other developed nations in proportion to population size . . .

Among the ways in which science-based public health evidence has been dismissed in the US is the replacement of highly experienced experts . . . with persons who appear to have been chosen because of their willingness to support government officials’ desire to discount the significance of the pandemic. . .

. . . History is a potent reminder of tragic circumstances when physicians damaged the public health, from promoting eugenics to participating in the human experiments that took place in Tuskegee to asserting erroneously that vaccines cause autism. It can be difficult to hold physicians accountable, especially when they are acting in policy roles in which malpractice lawsuits will not succeed. Professional self-regulation serves as the primary vehicle for accountability and is critical if trust in science and medicine is to be maintained.

To that end, action from within the medical profession is an important but underused strategy. . .

Pizzo PA, Spiegel D, Mello MM. When Physicians Engage in Practices That Threaten the Nation’s Health. JAMA; 2021 Feb 04. Published online February 04, 2021. doi:10.1001/jama.2021.0122

Why human germline genome editing is incompatible with equality in an inclusive society

Calum MacKellar

The New Bioethics
The New Bioethics

Human germline genome editing is increasingly being seen as acceptable provided certain conditions are satisfied. Accordingly, genetic modifications would take place on eggs or sperm (or their precursor cells) as well as very early embryos for the purpose of bringing children into existence with or without particular genetic traits. In this context, a number of already discussed and separate arguments, such as the (1) synecdoche, (2) non-identity (3) inherent equality and (4) expressivist arguments, can be brought together in the new context of examining, from an ethical perspective, some of the possible consequences of such germline genome editing. In so doing, it becomes clear that these novel procedures are incompatible with the concept of equality in value and in worth of all human beings in a genuinely inclusive society. Such equality is expressed in Article 1 of the United Nations’ Universal Declaration of Human Rights which states that: ‘All human beings are born … equal in dignity and rights.’

MacKellar C. Why human germline genome editing is incompatible with equality in an inclusive society. New Bioeth. 2021 Mar;27(1):19-29. doi: 10.1080/20502877.2020.1869467. Epub 2021 Jan 17. PMID: 33459206.

Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation

A. Stef Groenewoud, Femke Atsma, Mina Arvin, Gert P. Westert, Theo A. Boer

BMJ Supportive & Palliative Care
BMJ Supportive & Palliative Care

The annual incidence of euthanasia in the Netherlands as a percentage of all deaths rose from 1.9% in 1990 to 4.4% in 2017. Scarce literature on regional patterns calls for more detailed insight into the geographical variation in euthanasia and its possible explanations.

Objectives This paper (1) shows the geographical variation in the incidence of euthanasia over time (2013–2017); (2) identifies the associations with demographic, socioeconomic, preferential and health-related factors; and (3) shows the remaining variation after adjustment and discusses its meaning.

Design, setting and methods This cross-sectional study used national claims data, covering all healthcare claims during 12 months preceding the death of Dutch insured inhabitants who died between 2013 and 2017. From these claims all euthanasia procedures by general practitioners were selected (85% of all euthanasia cases). Rates were calculated and compared at three levels: 90 regions, 388 municipalities and 196 districts in the three largest Dutch cities. Data on possibly associated variables were retrieved from national data sets. Negative binomial regression analysis was performed to identify factors associated with geographical variation in euthanasia.

Results There is considerable variation in euthanasia ratio. Throughout the years (2013–2017) the ratio in the three municipalities with the highest incidence was 25 times higher than in the three municipalities with the lowest incidence. Associated factors are age, church attendance, political orientation, income, self-experienced health and availability of voluntary workers. After adjustment for these characteristics a considerable amount of geographical variation remains (factor score of 7), which calls for further exploration.

Conclusion The Netherlands, with 28 years of legal euthanasia, experiences large-scale unexplained geographical variation in the incidence of euthanasia. Other countries that have legalised physician-assisted dying or are in the process of doing so may encounter similar patterns. The unexplained part of the variation may include the possibility that part of the euthanasia practice may have to be understood in terms of underuse, overuse or misuse.

Groenewoud AS, Atsma F, Arvin M, Westert GP, Boer TA. Euthanasia in the Netherlands: a claims data cross-sectional study of geographical variation BMJ Support Palliat Care. 2021 Jan 14:bmjspcare-2020-002573. doi: 10.1136/bmjspcare-2020-002573. Epub ahead of print. PMID: 33446488.

Developing Public Policy for Sectarian Providers: Accommodating Religious Beliefs and Obtaining Access to Care

Kathleen M Boozang

The Journal of Law, Medicine & Ethics
The Journal of Law, Medicine & Ethics

Author Extract
The market changes sweeping the U.S. health care industry have a distinctive impact on communities that rely on religiously affiliated health care providers. When a sectarian sponsor subsumes multiple providers, its assertion of religious beliefs can preclude the provision of certain health care services to the entire community. In addition, the sectarian provider’s refusal to offer certain services may violate state certificates of need, licensing, Medicaid managed care, or even professional liability law. This situation challenges both the provider and the state: the provider seeks adherence to religious law, and the state seeks compliance with its law and citizens access to health care.

I propose that the state attempt to ameliorate tensions between civil and religious laws through negotiated accommodation. This concept encourages the sectarian institution to reassess its mission in the current market and to identify alternative avenues of health care delivery that will preserve patients’ access to care without excessively diluting religious identity or beliefs.

Boozang KM. Developing Public Policy for Sectarian Providers: Accommodating Religious Beliefs and Obtaining Access to Care. J Law Med Ethics. 1996;24(2):90-98.

Twin pregnancy, fetal reduction and the ‘all or nothing problem’

Joona Räsänen

Journal of Medical Ethics
Journal of Medical Ethics

Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton’s all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue that in the case of a twin pregnancy, there are two intuitively plausible claims: (1) abortion is morally permissible, and (2) it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution.

Räsänen J. Twin pregnancy, fetal reduction and the ‘all or nothing problem’. J Med Ethics. 2020 Dec 21:medethics-2020-106938. doi: 10.1136/medethics-2020-106938. Epub ahead of print. PMID: 33443129.

The Declaration of Geneva: Conscience, Dignity and Good Medical Practice

Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding, Rene Leiva

World Medical Journal
World Medical Journal

Since 1948 the Declaration of Geneva (the Declaration) has insisted that physicians must practise medicine “with conscience and dignity.” In 2017 this provision was modified by adding, “and in accordance with good medical practice” [1].

Good medical practice in Canada is said to include providing euthanasia and assisted suicide or arranging for someone else to do so. From this perspective, physicians who cannot in conscience kill their patients or collaborate in killing are not acting “in accordance with good medical practice,” and – some might say – the revised Declaration.

However, this merely literal application of the text cannot be correct, since the WMA later reaffirmed its support for physicians who refuse to provide or refer for euthanasia and assisted suicide even where they are considered good medical practice [2]. A reading informed by the history of the document is necessary and consistent with the care taken in its revision [1]. This yields a rational and coherent account of the relationship of conscience and dignity to medical practice.

Murphy S, Coelho R, Violette PD, Goligher EC, Lau T, Harding SR, Leiva R. The Declaration of Geneva: Conscience, Dignity and Good Medical Practice . WMJ [Internet]. 2020 Aug; 66(4): 43-47.

Chilean medical and midwifery faculty’s views on conscientious objection for abortion services

Lidia Casas, Lori Freedman, Alejandra Ramm, Sara Correa, C Finley Baba, M Antonia Biggs

International Perspectives on Sexual and Reproductive Health
International Perspectives on Sexual and Reproductive Health

CONTEXT: In 2017, Chile reformed its abortion law to allow the procedure under limited circumstances. Exploring the views of Chilean medical and midwifery faculty regarding abortion and the use of conscientious objection (CO) at the time of reform can inform how these topics are being taught to the country’s future health care providers.

METHODS: Between March and September 2017, 30 medical and midwifery school faculty from universities in Santiago, Chile were interviewed; 20 of the faculty taught at secular universities and 10 taught at religiously affiliated universities. Faculty perspectives on CO and abortion, the scope of CO, and teaching about CO and abortion were analyzed using a grounded theory approach.

RESULTS: Most faculty at secular and religiously affiliated universities supported the rights of clinicians to refuse to provide abortion care. Secular-university faculty generally thought that CO should be limited to specific providers and rejected the idea of institutional CO, whereas religious-university faculty strongly supported the use of CO by a broad range of providers and at the institutional level. Only secular-university faculty endorsed the idea that CO should be regulated so that it does not hinder access to abortion care.

CONCLUSIONS: The broader support for CO in abortion among religious-university faculty raises concerns about whether students are being taught their ethical responsibility to put the needs of their patients above their own. Future research should monitor whether Chile’s CO regulations and practices are guaranteeing people’s access to abortion care..

Casas L, Freedman L, Ramm A, Correa S, Baba CF, Biggs MA. Chilean medical and midwifery faculty’s views on conscientious objection for abortion services. Int Persp Sex Repro Health. 2020;46:25-34.

Conscience and Compromise : Abortion and the Requirements of Justice in Medical Schools

Kevin Belgrave

McGill Journal of Medicine
McGill Journal of Medicine

The concerns of students opposed to abortion go well beyond simple personal preference, opinion, or even political leaning. Opposition to abortion rests firmly in the realm of one’s most fundamental beliefs and convictions about human life, human dignity and human rights. Together with this fact is the freedom of an individual to hold and manifest such fundamental beliefs and convictions and not be discriminated against as a result. It is well known that neither physicians, medical students, nor residents could ever be compelled to perform or observe abortions against their will. In this article, however, we have considered the closely related question: is it possible to require medical students to learn in detail the methods and procedures of a medical act that conflicts with their most fundamental beliefs and convictions? The answer has to be no. So long as the bona fide beliefs of an individual – explicitly grounded in conscience or religion – can be reasonably accommodated, they must be. We must respect this basic requirement of freedom in our community. Given the nature of the belief that underlies objection to abortion, it is not difficult to see how thin would be the line between performing an abortion and learning learning the procedure in all the detail required of a physician.

Belgrave K. Conscience and Compromise : Abortion and the Requirements of Justice in Medical Schools. McGill J Med. 2001;8(2):154-156.