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Protection of Conscience Project

Service, not Servitude

Conscientious Objectors: Canaries in the Ethical Mineshaft

Lay Witness, July/August 2001
Reproduced with permission

Maria Bizecki, B.S.P. *

. . . life and death issues facing the health care worker go far beyond abortion and physician assisted suicide, with conscientious objectors being the canaries in the ethical mineshaft. When they can no longer survive the moral environment in the workplace, others will soon find themselves in the same position.

Many professionals encounter varying levels of pressure to comply with proposed actions or deeds that are in conflict with their sincerely held code of ethics. This pressure to violate one's conscience is routine in health care. To alleviate this form of abuse, "protection of conscience laws" would ensure that health care workers could opt out - without fear of reprisal or other discriminatory coercion - of participation in medical procedures or referrals that offend their moral or religious convictions. Such procedures may include: abortion, artificial birth control, sterilization, artificial reproduction, use of abortificacients, genetic terminations, human embryo and human fetal research, human experimentation, human cloning, purely experimental high-risk research with the mentally ill, euthanasia and physician assisted suicide.

Freedom of conscience is an inalienable human right owed to everyone. Protection of conscience laws resist the development of a two-tier system of civil rights within health care professions, one tier being those who prescribe to a universal, unchangeable ethic, and the other tier being those who live by a relativistic, changing "majority opinion" ethic. As a consequence, such laws also reflect the ethics you prefer your health care worker to follow.

Obviously, there are members of society in need of health care workers who share the same views on ethics and morality as the conscientious objector. Should health care workers who do not subscribe to the ethical dogmas decreed by a handful of self-described ethicists in health care be treated as second-class citizens? Unfortunately, as medicine's philosophy is swinging from allegiance to the individual patient toward duty to the larger community, those who do not agree with these ethics are being forced out of the health care profession for thinking differently.

Working Out a Solution

Some object to conscience laws on the basis that they would allow health care workers to impose moral viewpoints on the patient. That is not true. Instead, conscience laws will ensure that the morals of the patient, professional associations and society cannot be imposed on the health care worker. Professional ethics should not contradict ethics in general and professional duty should not crush personal duty. Accommodating the interests of both parties is possible without suppressing the freedom of conscience of others, if we have the political will.

The interests of the patient and the health care worker are different -the former wants to obtain a product or service that they have no conscientious objection to, while the latter seeks to abide by his or her conscience, which is why, in the case of referral, their interests cannot be balanced. The patient and the physician operate from the concept of "good" that can be completely different from the concept of "good" held by the conscientious objector.

The patient may believe that he is being deprived of something to which he has a right, but in no sense is he made to do something that he believes to be wrong. The claim that the objector is imposing morality is quite wrong.

"Timely access" is a term that often encourages medical professionals to confuse the concept of medical necessity with avoiding patient inconvenience. Conscience laws would not interfere with timely access in a properly administered system; it would simply ensure that suppression of conscientious objection not be seen as an example of proper or competent administration. This concept applies to the profession of pharmacy, where economic self-interest appears to be a higher priority than protecting freedom of conscience. The refusal to cooperate in the distribution of morally controversial drug products, which make up only a small percentage of available products, has nothing to do with abandoning the patient's health care needs, but in many cases is about losing a patient's business.

A Matter of Integrity

Imagine you are a student in a school where cheating is endemic, and you are approached by Student X for the answers to an upcoming test. If you decline - for moral reasons - to supply the answers, should you be forced to direct Student X to someone willing to provide them? Most people would maintain that no one should be made to lie or facilitate cheating, because such things are wrong. To the extent that you sense or appreciate the wrongness of an act, you will defend the right to refuse to assist with it. It is an assertion of personal integrity, not an effort to impose limitations upon others.

Now consider something that you believe to be really wrong. Maybe it's bribery or stealing, or perhaps even something legal, like pornography. Do you think that you should be discriminated against or fired because you refuse to participate in or facilitate it? Even if other people do it, you still consider it wrong, and you refuse to be involved. That is how conscientious objectors in health care view forced participation.

Forced Participation

In Canada, the province of Manitoba has the only pharmacy association in the country which protects its pharmacists from forced participation in referral. Conversely, the College of Pharmacists of British Columbia (CPBC) openly - and with impunity, it seems - defies human rights legislation by demanding that conscientious objectors dispense or otherwise help the patient, even if this is contary to the objector's judgement of conscience. In the CPBC March/April 2000 College Bulletin, this ethics committee accused conscientious objectors of "dissuading patients under the guise of patient counselling," lying about the existence of services to patients," and attempting to "promote their own moral viewpoint." Not surprisingly, the CPBC failed to provide evidence for their prejudicial accusations.

In Holland recently, an elderly patient suffering from cancer had her life terminated without giving consent. She reluctantly agreed to be admitted to the hospital after being reassured the staff would not terminate her life. After she began to improve, another oncologist needed a bed for a patient and found this lady "blocking a bed," so he killed her. Soon after, upon learning of this news, her doctor was appalled, and created and scene and was disciplined for unprofessional behaviour. The "killer" was not disciplined.1How many health care professionals are to disciplined for so-called "unprofessional behaviour" when it comes to protecting and respecting a patient's life?

In Britain, health care professionals attempted to terminate the life of a severely disabled child. When the boy's pain medication began to cause respiratory arrest, the mother requested that the hospital staff discontinue it. They refused, so the family disconnected the boy themselves and a fracas ensued. The three relatives of the child were convicted of assault after saving his life.2 Imagine the position of a conscientious objector in this situation - called upon by an attending physician to repulse the efforts of the parents as they try to rescue their child.

A proposed statute concerning decisionally incapacitated human subjects was recently defeated in Maryland. A "decisionally incapacitated" patient, who was legally incompetent to give true informed consent, could appoint a surrogate or "research agent." That surrogate or research agent could then give his or her "substituted judment" that the patient would have wanted to participate in this research if that patient were competent.3 Imagine the psychiatric health care worker who does not want to take part in such procedures.

In Iraq, doctors have been forced against their conscience by their governments to be involved in non-medical procedures. For example, they were required by law to amputate the ears and brand the foreheads of deserters. Doctors were told that if they refused they would suffer the same fate. One doctor was executed and many were imprisoned for their refusal to exercise medicine punitively.4 Will conscientious objectors in other countries be condemned as "counter-revolutionaries"? What about those patients who want to be cared for by people whose attitudes are condemned by the establishment as "counter-revolutionary"?

Already, pharmacists in Alberta (Canada), California, Florida, Washington, and Indiana have been reprimanded or fired for their conscientious objections, as have other health care workers such as nurses, doctors, social workers and hospital aides. Although some health care professionals have successfully won lawsuits against their employers, they have endured psychological and financial stress in the process.

Clearly, life and death issues facing the health care worker go far beyond abortion and physician assisted suicide, with conscientious objectors being the canaries in the ethical mineshaft. When they can no longer survive the moral environment in the workplace, others will soon find themselves in the same position.


1. Christian Medical Dental Society, Canadian newsletter

2. McGovern, C., The Report Magazine (July 24, 2000), 48. See

3. Irving, D., "Biomedical research with 'decisionally incapacitated' human subjects: legalization of a defunct normative bioethics theory," Journal of Health Care Law & Policy, University of Maryland (June 30, 1998)

4. Mirzeaei, S. and Knoll, P., Letters in the Canadian Medical Association Journal (2000), 163(5):498-99



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