Letter of Protest from the Catholic Medical Association (USA)
Linacre Quarterly 75(2) (May 2008): 92-95.
Â© 2008 by the Catholic Medical Association.
All rights reserved.
Reproduced with permission
Official CMA Correspondence
On November 7, 2007, the American College of Obstetricians and
Gynecologists (ACOG) Committee on Ethics released an opinion, "The
Limits of Conscientious Refusal in Reproductive Medicine"-an
unprecedented attack on the conscience rights of practicing physicians.
After consultation with its membership and other leading national
organizations, the Catholic Medical Association responded in the letter
to ACOG Board President Kenneth Noller, M.D., reprinted below. CMA will
continue to engage ACOG, and the American Board of Obstetricians and
Gynecologists, until this issue is resolved.- Lancet Editor's Note.
February 28, 2008
Dear Dr. Noller:
On November 7, 2007, the American College of Obstetricians and
Gynecologists (ACOG) Committee on Ethics released an Opinion,"The
Limits of Conscientious Refusal in Reproductive Medicine" (the
"Opinion"), which attempts to resolve the issue of ethically appropriate
limits of conscientious judgments in reproductive medicine. This is an issue
that demands serious attention and sustained dialogue. Unfortunately,
however, the Opinion not only fails to provide helpful guidance, but is so
flawed that it threatens the reputation of ACOG itself. The Catholic Medical
Association urges ACOG to rescind this opinion immediately.
The Committee on Ethics' Opinion exhibits three fatal flaws:
(1) it is woefully inadequate in basic ethical theory
(2) the "considerations" advanced to limit
conscientious judgments are so vague and contentious that they cannot
meaningfully function as ethical or professional guidelines; and
(3) the solutions proposed are unjust, unworkable,
and harmful to the profession of medicine. We elaborate on these points
1. Flaws in Ethical Analysis.
The Opinion contains a seriously flawed and gratuitously condescending
approach to conscience. The Opinion describes conscience in limited,
negative, emotional terms, emphasizing such terms as "private," "sanction,"
"sentiment," and emotions such as self-hatred. At best, the Opinion notes,
"Personal conscience, so conceived, is not merely a source of potential
conflict." In fact, however, while conscience is a personal, subjective
judgment, it is not merely "private" or relativistic. Conscientious
judgments provide guidance both for good actions that should be done and
unethical actions that should be refused. It is true that conscientious
judgments are at times accompanied by emotion, particularly in conflict
cases. Still, conscience is not a matter of feeling, as the Opinion
suggests, but a judgment about moral truth.
In addition to providing an inadequate description of the nature and role
of conscience, the Opinion fails to do justice to the ethical issue of
cooperation in evil raised by providing referrals for abortion and, indeed,
dismisses concerns about complicity in gravely immoral actions.
This disregard for the harm caused by complicity in moral evil is
particularly hard to understand given the painful lessons the medical
profession learned from physicians' silent tolerance of, or complicity in,
the crimes against humanity in Nazi Germany. Here in the United States, in
the infamous Tuskegee Syphilis Study, U.S. Public Health Service physicians
denied treatment to patients with syphilis so they could study the late
stages of the disease. Moreover, physicians participated or acquiesced in
involuntary sterilizations under color of law in more than 30 more states
between 1907 and the early 1970s. All agree now that these practices were
unethical and a violation
of patients' rights and that physicians were wrong to cooperate, even
tacitly, or to remain silent, even when they were not direct participants.
The Opinion mentions, but fails to describe, what it means by the "set of
moral values - and duties - that are central to medical practice." Since the
Opinion goes on to list four "criteria" that ostensibly trump physicians'
ethical convictions, it appears that these are the moral values and duties
the Ethics Committee has in mind. Inexplicably missing in this section of
the Opinion is any mention of respect for human life, which has been
recognized by most physicians across centuries and cultures as a fundamental
value and duty that is central to the practice of medicine.
Finally, the Opinion attempts, in several ways, to legitimize a moral
duty to provide any requested "reproductive service." The Opinion appeals to
terminology such as "standard care," "standard reproductive services," and
"standard practices" without ever defining who or what has established these
standards. The Opinion attempts to conflate the duty to provide treatment in
an emergency with a new obligation - to provide "medically indicated and
requested care" where failure to do so "might" negatively affect a patient's
"mental health." This so-called obligation is unnecessary and completely
unfounded. Our position is that elective abortion is not healthcare, nor
does it qualify as an emergency. In a true emergency, where a pregnant
woman's life is in danger, physicians can and should strive to save the
lives of the mother and her unborn child.
2. Considerations Limiting Conscientious Refusal.
The "considerations" that the Opinion claims limit conscientious
judgments are so vague and contentious that they cannot meaningfully
function as ethical guidelines. For example, the Opinion cites the "degree
of imposition" as a criterion for overriding the ethical and professional
judgment of physicians. It is not clear at all what kinds or degrees of
"imposition" will trump ethical judgment, much less why they should. In
appealing to the criterion of "effect on patient health," the Opinion
unfairly assumes that all requested reproductive interventions (including
abortion or egg harvesting) are in fact good for the patient's health.
Moreover, it unfairly implies that physicians with ethical objections to
such practices are not motivated precisely by concern for the patient's
short and long term health. In appealing to the category of scientific
integrity, the Opinion overstates the certainty that current science can
provide about the mechanism of drugs (such as those used in Plan B). And it
fails to recognize that the real "possibility of postfertilization events"
inherent in the use of such drugs is a valid matter for a professional's
clinical and ethical judgment. Finally, in appealing to "matters of
oppression," the Opinion injects a dubious political criterion into the
heart of medical decision-making.
3. Solutions Proposed.
The Opinion proposes solutions that are unjust, unworkable, and harmful
to the profession of medicine. The Opinion unfairly dictates that only
physicians who oppose a specific set of medical "services" should be
required to provide patients with "prior notice of their personal moral
commitments." We think that all physicians should be ready to explain,
whenever appropriate, their ethical convictions with regard to medical
practice and care. To suggest that providers with pro-life ethical
convictions "practice in proximity to individuals who do not share their
views" is unworkable.
The solutions proposed in the Opinion are not only unjust and unworkable,
but harmful to the profession of medicine. First, by negatively and narrowly
defining conscience and by suggesting that judgments of conscience are best
left to "organized advocacy" groups, the Opinion tacitly discourages
physicians from thinking and acting in accordance with their judgment of
what is ethical or unethical. The demand that physicians provide
"professionally accepted characterizations of reproductive health services"
shows distrust of professionals and of the quality of the medical profession
as a whole. Second, in appealing to the vague criterion of past
discrimination allegedly suffered by some people, the Opinion allows values
and considerations extraneous to the practice and profession of medicine to
dictate treatment modalities.
Third, the Opinion invites lawmakers to enforce compliance with these
vague and contentious notions. This would run counter to AMA Code of Ethics,
"[I]t may be ethically permissible for physicians
to decline a potential patient when . . . [a] specific treatment sought by
an individual is incompatible with the physician's personal, religious, or
Moreover, this expressly contradicts ACOG's own Statement of Policy on
"The intervention of legislative bodies into medical
decision making is inappropriate, ill-advised and dangerous."
Such legislation could not help but undermine the freedom and integrity
of the profession of medicine and invite additional litigation and
legislation that have nothing to do with promoting the health of women.
Indeed, ACOG should be aware that legislation attempting to enforce this
Opinion would violate constitutional and statutory protections of
physicians' freedom of religion and conscience rights at federal and state
levels. Finally, driving out physicians who respect the value of every human
life - born and unborn - from the profession of obstetrics and gynecology
would harm the profession and the health of many women and children.
There is a great deal of work to be done in assisting members of ACOG to
practice medicine conscientiously, and to educate patients on what this
means and why it is important. We stand ready to assist in this task.
However, to be valid, any effort will have to be based on sound ethical
analysis, undertaken in a spirit of dialogue, with respect for diversity in
beliefs. The Committee on Ethics, Opinion No. 385, falls significantly short
in all these respects. Therefore, it should be rescinded immediately.
Kathleen M. Raviele, M.D., F.A.C.O.G.
President, Catholic Medical Association
John F. Brehany, Ph.D.
Executive Director, Catholic Medical Association