Against Conscientious Objection In Health Care: A Counterdeclaration And Reply To Oderberg

Alberto Giubilini (Wellcome Centre for Ethics and Humanities, University of Oxford) and

Julian Savulescu (Uehiro Centre for Practical Ethics, University of Oxford)

Conscientious objection in health care – that is, healthcare practitioners objecting to performing certain legal, safe, and beneficial medical procedures (e.g. abortion) that a patient requests by appealing to their personal moral values – is one of the most debated topics in medical ethics at present time. Although at the moment doctors’ private conscience enjoys a lot of legal protection – most laws that make abortion legal contain clauses that exempt doctors from performing the procedure if they so wish. We have provided reasons, both in this forum and in our academic work, for why we think that conscientious objection in health care is not morally permissible and should not be allowed in the case of procedures that are legal, safe, beneficial, autonomously requested by patients and, more generally, consistent with the standards of good medical practice (see e.g. Savulescu 2006, Savulescu and Schuklenk 2017, Giubilini 2014, Giubilini 2017). Some people disagree and advance reasons for the opposite view. One of the scholars who has more clearly and straightforwardly articulated the principles and reasons in support of conscientious objection in health care is Professor Oderberg of Reading University. Prof Oderberg was recently invited to debate the issue with Julian Savulescu at the Masters Course in Practical Ethics run by the Uehiro Centre here at the University of Oxford. On that occasion, Prof Oderberg’s defense of conscientious objection centred around a series of principles and considerations that he very effectively formulated in the 17 main points that constitute his “Declaration in support of conscientious objection in health care”, published on the University of Reading website and which is available for people who agree with him to sign.

We believe this declaration should be discussed because it presents in a clear, accessible, and rigorous way the reasons that often underpin positions in favour of conscientious objection in health care, but that are not always so clearly formulated. However, we want to explain why we think that each of the points of the Declaration fails to support the idea of a right to conscientious objection in health care. We are presenting here below each of Prof Oderberg’s points immediately followed by our reply.

  1. Freedom of conscience and religion are fundamental rights in any liberal, democratic society professing pluralism and tolerance.

OUR REPLY: We agree. Hardly anyone in our Western societies would deny that these are fundamental rights. However, needless to say – and Professor Oderberg certainly agrees – these are not absolute rights. There is hardly any absolute moral or legal right. In this case, there can be constraints both with regard to what kind of things a person can do or refrain from doing in the name of their conscience, and with regard to the circumstances in which they can legitimately do or refrain from doing these things. In particular, it remains to be established that a generic right to freedom of conscience entails, logically or ethically, a right to conscientious objection to certain specific activities within a specific profession that a person freely chooses. Professional standards and protection of other people’s right to health care, for instance, weigh heavily against extending a right to freedom of conscience into the domain of professional obligations. Individuals are free to choose careers that do not involve activities they morally object to, but if they choose otherwise, they should take on the responsibilities that their professional role entails. People can have their conscience, and eat it too. Just not in professions that require them to do what their conscience proscribes.

In other professions, and for many activities within the medical profession, professionals are not allowed to simply follow their conscience and ignore good professional standards. For example, they are not and should not be allowed to refuse to prescribe antibiotics, administer vaccines, deny blood transfusions, and so on. A general principle of freedom of conscience does not justify these objections.

  1. Article 18 of the U.N.’s Universal Declaration of Human Rights proclaims: ‘Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship and observance.’ The words of Article 18 of the International Covenant on Civil and Political Rights, and of Article 9 of the European Convention on Human Rights, are almost identical.

OUR REPLY: We wholeheartedly agree. But to the extent that these codes are inspired by the principle stated at point 1 above – as indeed they are – they are subject to the same considerations: the rights mentioned are not absolute ones and it remains to be established that they entail a right to conscientious objection to certain specific activities within a freely chosen profession.

Moreover, relying on codes is normally not a good way of making ethical arguments: codes can always be dropped, adjusted, updated. And they normally refer to general principles whose application to actual cases requires taking other values into account.

  1. In health care, conscience plays an essential role in the professional judgment – often subtle and delicate – that practitioners must exercise in their daily work. If health care workers are not to be reduced to mere functionaries (of the state, of the patient, of the legal system), they must be free to exercise their professional judgment and to allow their consciences to inform that judgment. This freedom of professional judgment informed by conscience must translate into the freedom not to be involved in certain activities or practices to which there is a conscientious objection.

OUR REPLY: We agree that “ conscience plays an essential role in the professional judgment – often subtle and delicate – that practitioners must exercise in their daily work.” Indeed medical practitioners, or anyone, must not be reduced to “mere functionaries”. However, one of us has argued that this role is fulfilled by doctors forming all things considered value judgements about what patients should do, and engaging patients in a free and equal dialogue about these (Savulescu 1995, Savulescu 1997) : if at the end of such a dialogue, where the doctor treats the patient as an equal whose moral view is deserving of respect, the patient opts for a course of action that is legal and within the scope of the doctor’s practice, and consistent with distributive justice, then the doctor should provide it, even if she disagrees ethically. That is what it is to be a professional.

But it could be argued that even this position gives too much power to the doctor and his or her conscience, at least according to certain understandings of conscience. Indeed, that one’s professional judgments require one to consult one’s conscience (e.g. Sulmasy 2017) is a problematic statement, because a lot depends on what one means by ‘conscience’. On some understandings of conscience, the statement is plainly false. Philosophically, the concept of ‘conscience’ has a variety of meanings and a complex history (one of us has provided an account here). Not all of them have relevance for professional judgments. For instance, in the Christian tradition ‘conscience’ is sometimes understood as the (imperfect) faculty through which we discover the law of God within our heart. Generally speaking, the voice of God is not essential to professional judgments – unless you are a minister of a Church – because what is good and bad professional judgement cannot be determined by religion. In the case of medicine, doctors and patients might have different religious views, and religious prescriptions can differ from commonly accepted standards of good medical practice (McConnell 2018).

Nonetheless, we remain “agnostic” as to whether religious values should enter the doctor-patient relationship. Provided the doctor is willing to express but not enforce his or her values, and respect the patient’s own values, such value pluralism is a justifiable part of liberal society.

  1. The rights of religion and conscience are, however, not absolute. Article 29 of the U.N. Declaration (with similar provisions elsewhere) states: ‘In the exercise of his rights and freedoms, everyone shall be subject only to such limitations as are determined by law solely for the purpose of securing due recognition and respect for the rights and freedoms of others and of meeting the just requirements of morality, public order and the general welfare in a democratic society.’

OUR REPLY: We agree on this principle. However, this formulation is quite vague.. For what exactly are the “just requirements of morality” against freedom of conscience? A moral obligation to act according to the professional standards of one’s chosen profession might count as a just requirement of morality against a claim to freedom of conscience. If it didn’t, then many professions would turn into mere anarchy. An ethical vegetarian waitress might want to be exempted from serving meat without losing her job; as a matter of fact, a significant proportion of Muslim medical students want to be exempted from medically inspecting patients of the opposite sex (36%) or intoxicated with recreational drugs (18.5%), in the name of their freedom of conscience (Strickland 2012). When assessed against professional standards and expectations, these types of objections are all equivalent: there is no reason to think that some (say, religious conscientious objection to abortion) have a stronger claim than others (say, conscientious objection to serving meat). It is important to note that the ‘just requirements of morality’ are not confined to respecting other people’s rights and liberties. It might still be wrong to fail to comply with professional standards and expectations even if other people’s rights are not violated (for instance because a woman to whom a doctor denies an abortion can easily get the same medical service elsewhere, or because a customer to whom a waitress denies a meat dish can get it from another waiter). One might appeal, for instance, to a duty of fairness towards one’s employer (including when the employer is the state) and towards one’s colleagues, e.g. a duty to perform the same professional activities as any other colleague who works on the same salary.

  1. We concur with the U.N. and other international bodies and conventions that freedom of conscience and religion should not violate the legally recognised rights of others and that the freedom can be limited by the just requirements of morality. This applies both to direct participation in various practices and to assistance or co-operation with them, such as facilitating them by means of referral to another practitioner.

OUR REPLY: We agree with this point, with the proviso we made in our response to point 4 about what constitutes a ‘just requirement of morality’. As said, it is not just about protecting other people’s rights.

  1. The rights of others, however, are not violated merely because they cannot be enforced against a person exercising their freedom of conscience and religion – for otherwise this freedom itself would be meaningless.

OUR REPLY: Nobody is forcing a conscientious objector to enter medicine or to continue in it. If conscience is important, one will incur significant costs to protect it. Conscientious objectors to conscription to war were incarcerated or experimented upon. Today’s conscientious objectors pay no such costs. A compromise position would be to deny conscientious objectors entry into medical specialties involving their objection (Savulescu and Schuklenk 2017). The cost would be minimal – choosing another career or even branch of medicine. But today conscientious objectors want to incur no cost for them imposing burdens on others.

Freedom of conscience and religion is not an absolute right; however, in this point 6 of the declaration, neither a duty to abide by standards of good professional practice within a freely chosen profession nor a duty to respect other people’s right to health care are taken to be strong enough to outweigh an alleged right to freedom of conscience and religion in health care provision. In a country like Italy with very high rates of conscientious objection to abortion – with peaks of 80% in certain regions – each conscientious objector poses a serious risk to the health of women seeking abortion and to their right to access safe and legal abortion because it is very difficult for a woman to find a doctor willing to perform the abortion (see e.g Minerva 2015); besides, doctors who are not conscientious objectors are overburdened for having to perform a disproportionate amount of abortions. In Oderberg’s view, these considerations are irrelevant because the alleged right to conscientious objection would trump such considerations. So one cannot help but wonder what would actually constitute, in Oderberg’s mind, an appropriate constraint on an alleged right to freedom of conscience in health care provision by health care professionals. Absent a valid answer, point 6 implies that this declaration takes freedom of conscience or religion to be absolute rights, which they are not.

  1. Moreover, the ‘just requirements of morality’ are precisely what are in dispute in a case of conscientious objection.

OUR REPLY: we agree: this is precisely the point we made above in our reply to point 4. The fact that people disagree about what the just requirements of morality are, however, does not imply that people should be free to stick to their own conscience. We will never get to agree on many substantial ethical issues, but disagreement does not give people a free pass to behave as they like in any sphere of public life, including professional life. 

  1. Furthermore, in a liberal, democratic society the state may not play favourites by choosing one system of morality to trump all others no matter what objections of conscience are made against it. Conscientious objectors must not be silenced or marginalised merely because of their unwillingness to participate in activities to which they object.

OUR REPLY: Choosing one system of morality over others in the regulation of professional requirements is indeed permissible and necessary. We should not let doctors refuse to examine patients of the opposite sex, as 36% of Muslim medical students in the UK would like to be allowed to do (Strickland 2012), just because their religion or any other value proscribes it. The state is not impermissibly ‘playing favourites’ if it merely requires professionals to abide by the recognized and socially accepted standards of good professional practice of a freely chosen profession. This point 8 relies on the false assumption that all systems of morality are on equal footing for the purpose of any policy making in a secular state: according to this point, as long as there is someone that holds a certain moral or religious view, that moral view should be considered on a par with any other moral view when it comes to deciding what people can and cannot do, or else the state would be ‘playing favourites’. This is radical moral relativism and a mistake. For many professions, there will be people who disagree ethically with some of its professional standards and requirements. Creationists will disagree with the professional requirement on teachers to teach evolution; racists will disagree with the professional requirement on doctors to treat patients of different ethnicities equally; vegetarians will disagree with professional requirements on waiting staff to serve meat; pro-life people will disagree with professional requirements on certain doctors to perform abortions.

The state would impermissibly play favourites if it excluded people from the public discussion about what represents good professional standard and policy and about changing professional standards and policies. By including people in this discussion and giving voice to their different views, the state discharges its obligation to be impartial. But it cannot allow everyone to object to everything merely on the basis of their personal moral views, just for the sake of treating all moral views equally. Once the laws are passed following the appropriate debate, we should abide by the umpire’s decision. Thus, a state may and indeed ought to choose certain systems of morality over others for the purposes of regulating different spheres of public life. Racist systems of morality ought to be excluded from any sphere of public life. Religious systems of morality or secular systems of morality that are at odds with the professional standards of certain legal and socially accepted professions ought to be excluded from such professions. And so on.

  1. In particular, the liberal, democratic state may not dictate that a secular, i.e. non-religious, system of morality trumps the rights of religious believers, or that one particular moral system trumps the rights of those with sincere, deeply held conscientious objections to some of its principles or requirements.

OUR REPLY: Again, this is question-begging: it all depends on whether certain things do constitute “rights” of religious believers. We have said that conscientious objection to activities that are consistent with good professional standards of a freely chosen profession is not a right that simply follows from a general principle of ‘freedom of conscience’. Liberal democratic states are secular states, and secular principles trump freedom of religion in many cases, and rightly so. For instance, in most countries Jehovah’s Witnesses cannot appeal to their freedom of religion to deny blood transfusions to their children: in a secular society, the best interest of children, which is a secular value, trumps religious freedom, and rightly so. Since, luckily, we live in secular societies, professional standards of good practice should be informed by secular values, and this does not violate any right to religious freedom.

The right to practice one’s religion implies freedom to believe and to practice that religion in one’s own life, but not to impose those religious values on others in professional roles. It implies the freedom to choose from a reasonable range of jobs and professions; it does not imply the freedom to choose any job or profession and modify it as one sees fit.

The law does not require people to participate in practice they consider morally objectionable. The law does not require a person to become a GP and prescribe contraceptives. One is totally free not to become a GP. Thus, we could grant conscientious objection to those already in professions which at some point change their professional standards, but there is no reason to admit people into professions requiring practices they do not wish to perform. This does not violate any fundamental freedom and it is necessary for social coordination.

  1. Freedom of conscience and religion in a liberal society does not entail that ‘anything goes’. A health care worker should not be able to find shelter under freedom of conscience and religion merely by claiming it. For the protection to apply, a person must have a deeply held, sincere adherence to a tenet or doctrine of their code of ethics or religion that forbids – expressly or by necessary implication – the kind of act to which they object.

OUR REPLY: This point is undermined by what we have said above. It proceeds from the assumption that there is a right to freedom of conscience in the fulfilment of one’s professional duties. This still requires justification. In any case, it would be almost impossible in practice to assess whether one’s objection is based on sincere and deeply held beliefs or is just a matter of opportunism (e.g. the desire to avoid unpleasant activities or, say, to please a Catholic director of a hospital so as to further one’s career).

  1. Moreover, the relevant religious or ethical code must be one that has current or historic popular acceptance across some significant portion of the society in which the conscientious objector resides, or in some other society where the code is readily identifiable.

OUR REPLY: This point is, from an ethical standpoint, completely arbitrary and discriminatory towards those who do not subscribe to any religion or that belong to minority moral groups, or who have moral views that others do not share. Why should it matter how many people share my own moral views for my right to freedom of conscience? We cannot privilege certain religious or ethical views in defining individual rights to freedom of conscience just because those views happen to be popular or have historically been predominant (often thanks to very objectionable strategies and relations of power). Historically, slavery, racism and sexism were supported by large sections of society but these should not serve as a basis for ethical practice.

The popularity of a certain ethical or religious code is normally not taken to be as a valid criterion for the definition of a right to freedom of conscience. As seen above, many Muslim doctors would like to be able to object to medically inspecting people intoxicated by recreational drugs or of the opposite sex; this is unacceptable, but according to this standard, this is not different from a Catholic doctor who doesn’t want to perform an abortion, since in both cases the religious code is one that has current popular acceptance across a significant portion of some society. And the same applies, for instance, to the creationist teacher who would like to be able to object to teaching evolution, or to the vegetarian waitress who would like to be able to object to serve meat. Vegetarians account for about 10% of the population in Europe, where vegetarianism can be considered a lifestyle choice rather than a necessity: undoubtedly, this makes vegetarianism an ethical code with popular acceptance across a significant portion of society. Still – to remain within the medical context – a vegetarian pharmacist should not be allowed to deny patients medications using animal products based on her own particular values.

  1. The strong presumption in favour of conscientious objection would be rebutted if it could be shown that the act or practice in question were such that no reasonable person could object to its performance in the particular health care circumstances at hand.

OUR REPLY: This point does not add anything because the concept of ‘reasonable’ here deployed is very unclear, as is in general in the academic debate on conscientious objection (see e.g. Marsh 2014). Oderberg is trying to connect the debate on conscientious objection to the debate about toleration of different comprehensive doctrines in a context of reasonable disagreement, but this does not take us very far. First of all, there is a general problem about whether, by any standard of ‘reasonableness’, it is reasonable to allow any person to object to any professional obligation as long as the objection is taken to be reasonable (and sincerely held, and having currency among a large portion of society): that reasonable objections within a freely chosen profession should be accommodated might itself not be a reasonable principle; toleration of reasonable views does not need to go that far. Secondly, and importantly, even if we accept that principle, what is ‘reasonable’? In one broad sense of ‘reasonable’, you can find at least one reasonable person who would object to pretty much any activity that falls within professional standards and expectations: abortion, vaccination, antibiotic prescription, inspecting patients intoxicated by recreational drugs, and so on. Appealing to the idea of reasonable disagreement to settle conflicts about different comprehensive doctrines is quite common in political philosophy, most notably in John Rawls’ Political Liberalism, and in the debate on CO as well (see eg Card 2007 and 2014), but it is very unclear what ‘reasonable’ means. The fact that John Rawls himself was reluctant to provide a definition of ‘reasonable’ and more often relied on what he took to be an intuitive sense of the term is quite telling of how fishy the concept is. In any case, we do not even need to go as far as to define reasonability to make our point. What we want – and we assume Oderberg also would want – is to apply the concept of ‘reasonable’ consistently even we assumed that reasonable objections should be accommodated. For instance, we could stipulate that a reasonable moral or religious comprehensive doctrine is one that does not involve any unjust discrimination and that is consistent with a certain degree of liberty of other people (so, for instance moral views that imply some form of sexism or racism are not reasonable and therefore should not be tolerated in liberal societies). But if we accept this broad understanding and we want to apply it consistently, why should we think that conscientious objection to, say, abortion, or contraceptives, or euthanasia, on the basis of religious or ethical reasons is more reasonable than conscientious objection to, say, prescription of antibiotics or vaccination or to medically inspecting patients intoxicated by recreational drugs? If the former is reasonable, then the latter are as well; and if the latter aren’t, then religious or moral opposition to abortion is not reasonable either. But if we are not prepared to allow the latter examples of conscientious objection, why should we allow CO to euthanasia based, say, on the religious beliefs that a our body and our life are not our property but God’s? Unless we resolve these substantial ethical issues, the appeal to the concept of ‘reasonable’ does not seem to take us very far in a justification of conscientious objection in health care. Other conceptions of ‘reasonable’ might be provided, but the burden is on the proponents to show that they allow to pick out just those few cases of conscientious objection that they think should be granted (and not, say, conscientious objection to providing vaccination). There might be substantial moral differences between euthanasia and providing antibiotics or vaccines, but if so, what we need to address is precisely such substantial moral issues. If people think that abortion is morally impermissible, then they should campaign to have it excluded from the domain of what constitutes good medical practice, trying to persuade people on the basis of public reason, and for consistency’s sake they should not take on professions whose recognized standards conflict with their own personal moral standard. If they succeed at showing, through public reason, that abortion is unethical, then the proper policy solution would not be that of allowing abortion and also allowing conscientious objection to abortion – which would presuppose a relativistic moral framework (Giubilini 2014) – but to exclude abortion from the proper scope of medical profession. Thus, as we have argued (Giubilini 2017, Savulescu 2006), we should stop focussing on the value of conscience and of freedom of conscience and shift our attention to substantial moral issues to determine what exactly should and should not fall within the proper scope of medicine (or indeed of any other profession)

  1. Conscience cases of recent concern nearly all involve beginning and end-of-life activities such as contraception and sterilisation, abortion, assisted suicide, and euthanasia. Reasonable people have serious disagreements over the legitimacy of some or all of these practices, and over whether participation in such activities should be compelled by law.

OUR REPLY: Reasonable people have disagreement also about practices that do not allow conscientious objection, such as vaccination, at least if we take ‘reasonable’ to mean something like “not discriminatory and consistent with other people’s freedoms”, and not something like ‘rational’ or ‘informed by evidence’ (given that religion-based objections are not informed by evidence either). In Italy some doctors have been expelled from the national association of medical doctors because of their opposition to vaccines. Vaccination is consistent with recognized professional standards as is abortion, so it is not clear why objecting to vaccination should imply expulsion from the profession and objecting to abortion should constitute a human right.

  1. That notwithstanding, it is abundantly clear that freedom of conscience and religion should notbe thought of solely, or even primarily, in terms of the practices that happen to be the flashpoints of current controversies.

OUR REPLY: Yes, we agree: if freedom of conscience justifies conscientious objection to abortion or euthanasia, it also justifies conscientious objection to many other practices that are not flashpoints of current controversies, such as IVF. However, for what we have said above, we take this to be a reductio ad absurdum: since we cannot accept that conscientious objection should be justified in cases such IVF or vaccination , we cannot accept the premise that a principle of freedom of conscience justifies conscientious objection to abortion or euthanasia where these practices are taken to be consistent with professional standards.

  1. Even if one disagreed with conscientious objection to some or all of the practices listed above, one should be concerned that controversies will soon also arise, as they are already beginning to, in cases such as: transgender surgery; extreme cosmetic surgery; various forms of artificial reproduction; cloning; gene editing and other forms of genetic engineering; cognitive enhancement; performance-enhancing drugs in sport and other areas; creation of chimeras; and much more.

OUR REPLY: Yes, and we agree that it might be difficult to determine whether some of them should or should not be considered consistent with good medical practice and included among professional obligations. But for what we have said above, the debate should happen at this level, not at the level of alleged rights to conscientious objection, given that the latter would be open to all the problems we have raised so far. Patients should not be held hostage to the values of an individual doctor, especially when that doctor has a monopoly power over the patient’s health or life.

  1. We will continue to see the list of controversial practices and activities increase at speed due to advances in biotechnology. If now is not the time to come out in strong support of freedom of conscience and religion in health care, we do not know when is.

OUR REPLY: We think this is not the time to come out in support of conscientious objection. This is the time to discuss whether and which of these new controversial practices should be part of the proper scope of medicine, and in what circumstances, in a rational, informed public discourse.

  1. Even if you feel sanguine about the controversies either actual or on the immediate horizon, you should be seriously concerned about what is over that horizon. If you are not prepared to make a stand now, whatever your opinion about this or that particular issue, then when the time comes that your own individual conscience is under threat, it will probably be too late. Who will be there, at that time, to come to youraid?

OUR REPLY: Reasoning ethically implies adopting an impartial, disinterested perspective. Whether conscientious objection in health care should be allowed is an ethical issue and, as such, should be discussed from an impartial point of view. The conclusion we reach should be valid regardless of who it is whose conscience will be under threat. If it was our conscience to be ‘under threat’ in the same way in which Oderberg thinks that the conscience of doctors required to perform abortions is ‘under threat’, we would still say that the ethical thing to do would be for us, or for anyone else, to choose a different profession.

 

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6 Responses to Against Conscientious Objection In Health Care: A Counterdeclaration And Reply To Oderberg

  • Owen Schaefer says:

    A very interesting read, Alberto and Julian! Something that struck me early on was your claim that CO should not be permitted for treatments that are “legal, safe, beneficial, autonomously requested by patients and, more generally, consistent with the standards of good medical practice.” I wonder if “beneficial” is actually the crux of disagreement, notwithstanding Oderberg’s emphasis on liberal principles and freedom of conscience. (indeed, I’ve always been sceptical of the consistency of such liberal arguments from conservatives who often would, when debating whether the interventions should even be permitted in the first place, deny the individuals’ privacy rights to seek out such interventions outweigh the purported harms/wrongs involved)

    Consider: for the main ‘problem’ cases Oderberg cites at point 13 (contraception, abortion, euthanasia and similar), I take it objectors would simply deny these are all-things-considered beneficial. They would say abortion decisively harms the foetus (whom they take to have moral status), outweighing any benefit to the mother, and for euthanasia, death is not a benefit. Contraception is maybe trickier, but objections could be that it temporarily debilitates (by taking away conception capabilities) or else it encourages harmful behaviour (promiscuity) that outweigh the benefits. And I think objectors would also deny overall benefit in the various cases raised in point 15.

    What about an alternate, benefit-dispute framework of CO, justified on the grounds that the fundamental aim of medical practice is to benefit patients? Where CO is only valid when there is genuine, reasonable dispute over whether an intervention would actually benefit patients (inclusive of reasonable disputes over who is a patient, in the case of foetuses). The opposite-sex and drunk cases would fall out of scope, as well as the vegetarian case, and (I think) vaccines as well. This wouldn’t fully answer your general denial of any right to freedom of conscience within a freely chosen profession, or the worry about definitions of ‘reasonableness’, but it would save Oderberg and similar from the implausible implications of CO you highlight. Importantly, dispute over harm to the *doctor* or to *third parties* could not justify CO, only dispute over harm (or lack of benefit) to the *patient*. (something like this is suggested at the end of Alberto’s 2017 paper in Bioethics, though that seems to rely on cases where intervention is related to objectively non-beneficial acts like execution, rather than cases where benefit is in dispute)

    Or maybe a narrower approach would be more viable: only allow CO where there’s reasonable dispute over whether a procedure is medically beneficial. This would be a little more contextually appropriate than the preceding, refocusing CO around the medical nature of the profession. Contraceptive CO wouldn’t be allowed, as I think the only reasonable objections to that would be non-medical. But abortion and euthanasia CO could be more easily permitted on this account.

    • Alberto Giubilini says:

      Thanks Owen, spot on! Indeed, this is exactly the type of considerations we wanted to raise: I think it is a mistake to focus on the value of freedom of conscience, liberty, or the like. This is not what is at stake. At stake are substantial moral issues, including whether certain interventions are beneficial (an issue that involves value judgments as much as medical considerations) – which explains why, for instance, many people tend to be in favour of CO to abortion but not to CO to vaccination. Whether the foetus is to be considered a patient or whether euthanasia is never beneficial to a patient turn on substantial ethical issues about, e.g., the moral status of foetuses or the value of human life. This is exactly what I argued for in one of the papers I have cited in the post: we need to shift the focus from the issue of ‘freedom of conscience’ to substantial ethical issues. But when we do this, we need to acknowledge that, as a matter of fact, the medical profession has in many places accepted that abortion is consistent with its ethical standards: the claim that the foetus is harmed by an abortion, or that a patient is harmed by euthanasia, is taken to be either not true or not strong enough to outweigh the value we place on other values, such as women’s autonomy or patient autonomy more in general. Of course this is debatable on ethical grounds and many would disagree with this view, but our point is that the disagreement should be made manifest not through conscientious objection, but at the level of public discussion.
      I agree that Oderberg’s case for CO – and the case of those who defend CO more in general – would be stronger if they emphasized the aspect of medical beneficence rather than focussing on the value of freedom of conscience, but this would require them to 1) engage with substantial ethical issues (e.g. does the foetus have a right to life?) and 2) argue on secular grounds through public reason.
      There is then the further problem you raise about whether there are ‘reasonable’ disputes over whether a certain practice is beneficial. But this encounters the same problems we raised with regard to “reasonable’ objections more in general, to the extent that determining whether something is beneficial implies endorsing certain substantial moral views about which the reasonability question can be asked.

      • Owen Schaefer says:

        Yes, that makes sense. I think where we disagree, though, is whether a benefit-based approach still leaves room for CO. I think it does. Maybe certain professional organisations have issued statements about whether abortion or euthanasia are all-things-considered beneficial, or maybe there’s professional consensus in some countries, I don’t know. But they don’t have authority on such matters, in contrast with other medical matters, e.g., a statement about the benefit of vaccines. In light of substantive disagreements over whether abortion or euthanasia are truly beneficial, and in light of the fact that professional consensus doesn’t offer much reason to think they are, I think a plausible case could be made for CO.

        • Alberto Giubilini says:

          Thanks. Yes, I think we disagree precisely on that point: whether the ‘benefit-based’ approach leaves room for CO. It is true that whether or not abortion or euthanasia are beneficial involves some value judgments over which doctors have no authority (qua doctors; they have some authority qua rational human beings with their own moral or religious views). That is a matter of substantive ethical disagreement that requires ethical, and not only medical considerations. But two things I would point out. First, once we bring in value judgments, then any medical intervention, and not only abortion or euthanasia, can be subject to the same considerations: vaccination is ‘beneficial’ in a strictly medical sense, but not necessarily in a value-based sense of the term ‘beneficial’, because that depends on the values we assume: I agree that the value judgments whereby someone would think that vaccines are not beneficial are very strange and anti-scientific ones (say, ‘vaccines impermissibly interfere with the natural harmony of our body’, or something like that), but to me, these are no more strange and anti-scientific than many religious views whereby abortion or euthanasia become non-beneficial (say, God instilled a soul in a foetus or embryo after a certain stage of development, or something like that). Second, even assuming that there is something special about the substantive disagreement on the beneficial nature of abortion or euthanasia, I do not see why this would be enough to warrant a right CO, as you suggest . It seems to me something else is required to take that further step in the argument. As we have argued, this ‘something else’ cannot be a principle of “freedom of conscience”. One might suggest that the two things are jointly necessary and sufficient for a right to CO: a principle of freedom of conscience plus substantive disagreement, taken together, do ground a right to CO in medicine. But I am not sure about these two conditions together being sufficient: it seems to me they would still imply a right to CO to anything, including vaccination, for what I have said above.

          • Mary Neal says:

            This is a really interesting exchange – I’ve a chapter forthcoming soon in John Adenitire’s collection which makes exactly this kind of benefit-based argument about the parameters of CO in healthcare. Good to see a version of the idea getting a degree of support here!

            • Alberto Giubilini says:

              Thanks Mary, yes I think that is possibly the stronger objection to our arguments here, although, as I have explained above, not strong enough I think. In any case, my view is that we need to shift the focus from the principle of freedom of conscience – which I think does not do any work – to a discussion of what counts as beneficial and whether and how the disagreement about this could be settled. I am not in principle opposed to ‘objections’ in medicine (in our papers referenced in the post both Julian and I provide examples of cases in which doctors should object); my problem is really with the appeal to individual conscience. I look forward to reading your chapter!

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