Conscientious Objection and Emergency Contraception
by Robert F. Card
2007. The American Journal of Bioethics 7(6):8
This article argues that practitioners have a professional ethical obligation to dispense emergency contraception, even given conscientious objection to this treatment. This recent controversy affects all medical professionals, including physicians as well as pharmacists. This article begins by analyzing the option of referring the patient to another willing provider. Objecting professionals may conscientiously refuse because they consider emergency contraception to be equivalent to abortion or because they believe contraception itself is immoral. This article critically evaluates these reasons and concludes that they do not successfully support conscientious objection in this context. Contrary to the views of other thinkers, it is not possible to easily strike a respectful balance between the interests of objecting providers and patients in this case. As medical professionals, providers have an ethical duty to inform women of this option and provide emergency contraception when this treatment is requested.
I. Introduction
Decisions
regarding health policy frequently involve a volatile mixture of
medical science, politics, and ethical values. One of the most
contentious recent issues concerns prescriptions for emergency
contraception (EC), especially given the reticence of the Food and Drug
Administration (FDA) to grant over-the-counter (OTC) status to the
emergency contraceptive Plan B and the resignation of one of the FDA's
directors over this issue. On August 24, 2006, FDA announced approval
of Plan B as an OTC medication for women aged 18 and older , yet a
general moral question still remains: what is the scope of medical
providers' right to refuse treatment based on their own ethical
objections to this treatment? As it turns out, FDA's decision may
simply make the relevant ethical issues more subtle--imagine cases in
which a medical provider refuses to mention or discuss EC with a woman
expressing her concern regarding an unplanned pregnancy. The FDA's
recent plan still uses pharmacists as a gatekeeper, since women under
age eighteen must secure a prescription and women eighteen or older
must be able to prove their age to a pharmacist who keeps the drugs
behind the counter. As the Washington Post observes,
The
FDA decision does not resolve other controversial issues swirling
around the pills, including the refusal of hospitals run by
religious organizations to offer them, of some pharmacies to stock them
and of some antiabortion pharmacists to dispense them. "The FDA doing a
stupid thing doesn't change anything for those of us who need to do
the right thing," said Karen Brauer, president of the group
Pharmacists for Life International, which opposes the use of the
emergency contraceptive (Stein 2006, A06).
There
has been increased attention focused on this issue, given numerous
reports (Greenberger and Vogelstein 2005; Stein 2005) that medical
professionals have refused to honor women's requests for EC based on
conscientious objection. This discussion broaches a relatively
unexplored issue within biomedical ethics; conscientious objection
raises interesting questions in other contexts such as abortion and
physician-assisted suicide. A standard way to address this issue is to
advocate referral of care to a willing provider. To cite just one such
example, Dan Brock states in the context of active euthanasia that if
performing the associated actions “conflicted with a particular
physician's reasonable understanding of his or her moral or
professional responsibilities, the care of a patient who requested
euthanasia should be transferred to another” (Brock 2004, 215). This is
a popular approach to managing conscientious refusals, yet as I will
argue within this discussion of EC, it is not an unproblematic response.
I will understand conscientious objection as a refusal to comply with a
request based on personal moral or religiously inspired moral reasons
(Childress 1985). This general moral question applies not only to
pharmacists who refuse to dispense EC but also to physicians who refuse
to discuss EC on moral grounds. This paper focuses mainly on the former
controversy, since this is an issue of current relevance; fifteen
states have recently considered bills concerning conscientious
objection in the pharmacy (Greenberger and Vogelstein 2005, 1557). In
what follows, a critical examination will be conducted regarding the
ethical duties of professionals with respect to hormonal EC (e.g.
estrogen and progestin/Plan B). In contrast to other thinkers that
advocate the duty to refer patients, this paper argues that providers
have a professional ethical obligation to inform women of this option
and dispense emergency contraception when this treatment is requested.
The analysis presented is based on professional ethical obligations and
should not be construed as necessarily supporting or denying legal or
regulatory requirements. Professional ethics is a different and higher
standard as compared with legality. Since not every moral obligation is
(or ought to be) codified into law, the discussion of this paper should
be understood as centered on professional ethics.
II. The Moderate View on Conscientious Objection
In an influential paper, Julie Cantor and Ken Baum (2004) focus on the
objecting pharmacist's duty to refer patients requesting EC to another
willing pharmacist. They note that the American Pharmacists Association
(APhA) has endorsed referrals, and they hold that pharmacists do not
have an absolute right to object, nor lack a right to conscientious
objection (Cantor and Baum 2004, 2011). There is no absolute right to
object, since autonomy rights are limited in their scope. Clearly,
pharmacists cannot ethically refuse to provide treatment based on the
patient's (e.g.) race or ethnicity. Mark Wicclair (2000, 212) points
out that if a medical professional conscientiously objected to
participating in forgoing aggressive treatment on the grounds that it
would deny her an opportunity to test a new drug, then this type of
reason would properly be accorded no moral weight as a ground for
conscientious refusal. Pharmacists have a right to object since the
APhA has explicitly adopted a pharmacist conscience clause, this states
that
[the] APhA recognizes the
individual pharmacist's right to exercise conscientious refusal and
supports the establishment of systems to ensure patients' access to
legally prescribed therapy without compromising the pharmacist's right
of conscientious refusal (American Pharmacists Association, 2004).
As
I view it, this grants a (defeasible) professional right on the part of
pharmacists to engage in conscientious objection. Cantor and Baum
believe that a position in the 'vast middle ground' is most defensible.
This moderate position, while reasonable on its face, is problematic
upon closer inspection.
Referrals may not be possible for
economically disadvantaged patients and/or those who live in rural
areas, thereby leaving such patients with no true access to medical
treatment. In the case of emergency contraception, time is of the
essence, as such medication works best in the first 12-24 hours after
sexual contact and must be administered within 72 hours (Greenberger
and Vogelstein 2005, 1557). This position can therefore result in great
harm to women. Further, by exercising the referral option objecting
pharmacists are not fulfilling their role responsibility. The precise
role of pharmacists within the U.S. health care system is somewhat
murky, but some plausible suggestions include the following: (e.g.)
checking for drug interactions with the patient's prescription
medications and instructing patients on using a medication. A
pharmacist's role is not to second-guess an adult's decisions regarding
the use of an approved pharmaceutical, but is to provide convenient and
safe access to medications. Additionally, the publicity of
confrontations with objecting pharmacists, especially at the counters
of large chain pharmacies, compromises patient integrity and
confidentiality.
While the moderate view stresses a duty to
refer instead of a duty to dispense the medication as a way to strike a
balance between the interests of patients and pharmacists, it is
unclear what actual ethical difference exists between these two duties
for the conscientiously objecting pharmacist. Cantor and Baum state,
"[a] referral may also represent a break in causation between the
pharmacist and distributing emergency contraception, a separation that
the objecting pharmacist presumably seeks" (Cantor and Baum 2004,
2011). Is this really true, and do all objecting professionals support
the referral option? Referring the patient to another willing
pharmacist certainly does not remove the pharmacist from the causal
chain of events that leads to the use of emergency contraception, an
act that is considered morally wrong by such objecting pharmacists.
Supporters of pharmacists' right to conscientious objection such as
Karen Brauer, hold that such medical treatment violates the Hippocratic
Oath by doing harm to human life (Stein 2005). Brauer defends
pharmacists' rights to refuse to dispense medications themselves as
well as to refuse to refer customers to other willing pharmacists.
Brauer holds this position since she believes that referring customers
makes no intrinsic moral difference:
That's
like saying, 'I don't kill people myself but let me tell you about the
guy down the street who does.' What's that saying? 'I will not off your
husband, but I know a buddy who will?' It's the same thing (Stein 2005,
A01).
A staunch defender of pharmacists' right to
conscientious objection (such as Brauer) clearly sees no ethical
difference between dispensing the medication herself and allowing
another willing pharmacist to do so. This presents a serious challenge
to the moderate view. Since the proponents of the moderate view have
not defended an intrinsic moral distinction between 'doing' and
'allowing,' this argument by the staunch defender of conscientious
objection remains unchallenged. At the very least, referrals are not as
ethically unproblematic for objecting pharmacists as moderates think.
In fact, since referrals are equally morally troublesome for these
objecting pharmacists, Cantor and Baum have not provided the
'respectful balance' between the interests of pharmacists and patients
that they seek.
III. A Less Moderate View of Conscientious Refusals by Medical Practitioners
In
this section, I critically analyze proposed objections to the
dispensing of EC in order to arrive at a less moderate view on the
reasonableness of conscientious objection in this context. Before
beginning this task, however, I wish to briefly elaborate on how I have
framed the issue in order to set the stage for the weighing of reasons
that is to follow. From the outset of this paper I have viewed this
debate as involving the autonomy rights of medical professionals.
Valuable insight into this debate is gained by taking seriously the
notion that medical providers (e.g. physicians, pharmacists, nurses)
are members of a profession. Writings by numerous thinkers (Arras 1988;
Pellegrino 1987) suggest plausible characteristics of a profession that
are satisfied by the medical field. Edmund Pellegrino makes some
thought-provoking observations about why physicians (and, by extension,
other healthcare providers) are members of a profession. To discuss
just one of his points, Pellegrino views medical knowledge as a "public
trust." This knowledge was gained by invasions of privacy and
experimentation upon human beings, and these decisions were justified
since medicine should use this knowledge to reduce human suffering and
serve humankind. This suggests that there are social obligations on the
part of medical professionals that are not possessed by persons who are
simply members of an occupation. The distinction between a 'profession'
and an 'occupation' is rough around the edges, but it marks off a
useful and important distinction. The issue at hand requires balancing
the moral values of the medical professional and the patient. Medical
professionals are persons who possess autonomy rights, and hence may
refuse care in some circumstances, yet we cannot forget to take the
patients' moral values into consideration as well.
To
imagine just one concrete scenario, perhaps the woman seeking EC finds
using contraception to be ethically unproblematic but does not morally
agree with abortion at any stage. The professional's refusal may cause
a delay in care which, given the circumstances of the woman, may then
require her to have an abortion later. Are we then at a standoff in
this conflict between the moral values of the patient and the provider?
This is not the case, since refusals of care with respect to EC may
jeopardize the health and the well being of women. At the moral center
of medical professionalism is the requirement that practitioners give
primacy to their patients' interests. This is echoed in ethical codes,
for instance, in statements of research ethics (e.g. Declaration of
Helsinki) proclaiming a professional's duties to safeguard subjects'
well being and to not treat subjects merely as a means to advancing the
interests of society or medical science. Since EC must be used within
72 hours of sexual contact, time is of the essence. A refusal of care
in this context may amount, in practical terms, to a right to impose
their beliefs on their patients, yet professionals do not possess this
right. This follows from the fact that patients possess autonomy rights
and the point that providers should give primacy to patients'
interests. The position of this paper is that conscientious objection
is different with respect to EC as compared with (e.g.)
physician-assisted suicide; the extremely narrow time frame for care is
one such salient difference.
One may downplay the
importance of the discussion above by proposing that as long as
pharmacists refer patients to other professionals that will give them
timely access to EC, there is no significant threat to women's health
or well being. In response, I would ask the objector whether he or she
accepts the position that the professional must dispense EC if a
referral is not possible. I doubt this is the case. If the objector
does not accept this position, then he or she fails to safeguard the
patient's interests. If the objector does accept this position, then he
or she agrees with the argument set out above: that medical providers
can be under a professional obligation with respect to EC that
overrides their personal moral beliefs. Further, this objection is
clearly premised upon a hypothetical scenario. If, for example, war is
declared and there are so many able-bodied persons willing to enlist
that conscription is not necessary, then it may be thought that CO
becomes an issue that is of mere theoretical interest (so long as no
injustice or bad consequences occur in such a state of affairs). But
with respect to EC, unfairness and bad consequences do in fact occur,
and hence this objection is not realistic in the circumstances in which
the debate regarding EC occurs.
Physicians who
conscientiously refuse to provide EC object on the same basis offered
by pharmacists--yet a critical examination of this basis may lead to a
reconsideration of these reasons. This section focuses on examining
this basis in general; after all, physicians' greater stature within
the profession does not itself make their professed reasons more
forceful. What are these reasons? Professionals may object to
dispensing EC since (a) s/he considers emergency contraception to be
unethical since it is equivalent to abortion, or (b) s/he considers
contraception itself to be immoral. I will evaluate these versions of
conscientious objection to dispensing EC in turn.
The
first line of argument [(a)] is empirically questionable. There is no
evidence that Plan B and similar hormonal EC regimens have an effect on
an established pregnancy (Glasier 1997, 1060). Conception represents
the start of the process of becoming pregnant; as David Bainbridge says
regarding conception, it is “a term to include all the different
mechanisms that must act for a pregnancy to be established, of which
fertilisation is only one." (Bainbridge 2001, 278) His point is that
pregnancy is not equivalent to fertilization. Another source states the
following regarding EC: "By medical definition, the pills block rather
than terminate pregnancy." (Editors of Scientific American, 2005) The
scientific data suggest that hormonal EC operates mainly by inhibiting
or disrupting ovulation. (Glasier 1997, 1063) What this means is that
EC inhibits follicular development and the maturation and/or the
release of the ovum itself, (Glasier 1997, 1058) thereby preventing
pregnancy. As Anna Glasier puts the point, “it cannot be stressed too
strongly that if hormonal emergency contraception works largely by
interfering with ovulation, then it cannot be regarded as an
abortifacient” (Glasier 1997, 1063).
Why, then, would anyone
regard hormonal EC as equivalent to abortion? One hypothesis is based
on simple scientific ignorance of the mode of action of EC. A more
interesting hypothesis is offered by Glasier: "Although it seems likely
that the estrogen-progestin regimen works mainly by interfering with
ovulation, it is nevertheless regarded by many as an abortifacient
because it is taken after, rather than before, intercourse” (1997,
1063). This highlights a line of reasoning that is obviously mistaken
since it involves a causal or temporal confusion. It is worth taking a
moment to sort this out in order to see the mistake. If a woman has
unprotected sexual intercourse, she may become pregnant. Sperm can
remain in the female genital tract and are capable of fertilization for
up to five days; the ovum appears to be capable of fertilization for
only about twenty-four hours (Glasier 1997, 1058). If a woman's request
for this medication is satisfied, EC may interfere with ovulation and
hence fertilization does not occur. The point is that EC has lasting
effects and could thereby prevent a pregnancy that might have otherwise
occurred even after the 72 hour "window period"--the time during which
EC must be taken in order to be effective. EC is a form of
contraception, not an abortifacient.
An astute objecting
pharmacist might object to the definition of pregnancy used in the
previous discussion, suggesting instead that pregnancy is equivalent to
fertilization (or, at least, that fertilization marks the point at
which an individual with moral standing comes on the scene). On this
understanding, if fertilization had occurred then EC would terminate
the pregnancy and is equivalent to abortion. Since the mode of action
of currently available EC is not precisely known, it is possible that
EC may interfere with the transport of the embryo to the uterus or
inhibit its implantation into the endometrium (Dresser 2005, 9). A
review of the literature suggests that there is no solid reason to
believe that hormonal EC works in either the former or latter manner
(Glasier 1997, 1059); recent scientific evidence (Croxatto et al. 2004)
suggests that hormonal EC does not have post-fertilization effects.
Consider further that the astute pharmacist bases his or her objection
to EC on the fact that a pregnancy has occurred, but this is an unknown
within the 72-hour window period. Some basic facts about human
pregnancy make this clear. Pregnancy can be detected in women by the
presence of human chorionic gonadotrophin (hCG), a hormone produced by
the placenta in early pregnancy. Bainbridge makes clear that the embryo
has an aggressive approach to the maternal recognition of pregnancy
(relative to other species); he reports that "the embryo can form a
considerable bulk of placental tissue as early as five to seven days
after fertilisation" (Bainbridge 2001, 93). However, even given this
fact and the existence of sensitive and reliable pregnancy tests it is
not possible to confirm a positive pregnancy within the 72-hour window
period.
This is another way in which conscientious refusal
within the context of EC differs from other cases in which medical
professionals invoke such objections. In a case of conscientious
objection regarding abortion, a physician knows whether or not a fetus
exists. The same is true, mutatis mutandis, in cases of conscientious
objection regarding assisted suicide. Yet there is a small and
unknowable probability that dispensing EC during the window period
would cause something morally wrong to occur (by the objecting
professional's own lights). Since the objecting professional lacks
relevant evidence for the very foundation of his or her conscientious
objection, there is not sufficient reason to grant substantial weight
to a refusal on this ground.
A very astute professional
might accept the foregoing discussion, but respond by arguing that
while this is an unknown, there is a non-zero probability that
pregnancy has occurred. If the professional dispenses EC, then there is
a possibility that he or she has contributed to the commission of a
morally wrong action (by his or her own lights). Or, in a slightly
revised version, an objecting professional might state that by doing so
in numerous instances, there would be a non-zero probability that he or
she has contributed to the commission of a morally wrong action (by his
or her own lights).
I will call this the zero probability argument:
persons should not perform an action unless it is true that there is a
zero probability that their action (or their contribution to an action)
will issue in immoral results. The zero probability argument leads to
absurd results, since the mere possibility of contributing to immoral
results exists with virtually anything a human being does--given the
existence of spurious causal chains, this may be true of acts such as
(e.g.) taking a walk or brushing one's teeth. More specifically, the
mere possibility of contributing to wrongdoing applies to many acts
performed by a medical professional (e.g. dispensing cold and sinus
medicines that might be abused in various ways) and would suggest that
such professionals should stop assisting patients in general. This is
unacceptable; it is simply unreasonable to withhold medication because
of the mere possibility that this may contribute to an immoral result.
In this portion of the paper, we have discovered a general problem with
conscientious objections to EC based on a comparison to abortion. If
fertilization has occurred, since there is no evidence that EC has
post-fertilization effects, dispensing EC will not change the outcome.
On the other hand, if fertilization has not occurred and EC acts to
inhibit ovulation, thereby preventing a pregnancy that would have
otherwise later occurred, nothing immoral happens even granting the
objecting professional's beliefs as discussed. In either case, the
basis for the professional's conscientious refusal with regard to
dispensing EC is called into question. EC causes something ethically
problematic to occur only if contraception itself is considered morally
unacceptable.
Perhaps members of Pharmacists for Life
represent this remaining type of objecting professional; recall, they
stated above that EC constitutes "doing harm to human life." If this
notion is taken literally, then this implies that medical treatments
such as (e.g.) chemotherapy are morally wrong in themselves.
Chemotherapy destroys human cells and hence seemingly counts as doing
harm to human life in some way. Yet it is absurd to think that
chemotherapy is morally wrong in itself. It is more plausible to
suppose that the objecting professional believes that the human life in
question is somehow limited specifically to individual sperm and ova.
This professional might argue that reproductive cells are special,
since they possess the potential to become persons. Sperm and ova that
are not given at least an opportunity to become persons are harmed.
The fact that this claim lacks a sounds basis is made clear by
referring to a version of the non-identity problem. Contraception, if
effective, prevents conception; yet does not being conceived constitute
a moral wrong to one who otherwise would have come into existence?
Laura Purdy discusses the non-identity problem and addresses this
question in the negative:
[T]here
seems to be no reason to believe that possible individuals are either
deprived or injured if they do not exist .. .[if we had not been
created] we would not exist and there would be nobody to be deprived of
anything (Purdy 1978, 258).
This argument states that if
an individual never comes into existence, then there is no one that is
harmed, since no one exists who is a subject of harm. This general
argument is not beyond dispute; Dan Brock (1995) questions the
dismissal of harms to "possible persons" by referring to the
non-identity problem. Yet Brock's discussion centers on the case of
genetically transmitted handicaps and his point is that the possible
harm to a potential offspring should not be dismissed if one could have
a different child without comparable burdens (Brock 1988, 313). Hence,
the foregoing argument is not directly affected; even a critic of the
non-identity argument such as Brock does not accept that being deprived
of existence itself constitutes a moral harm. After all, if not being
brought into existence was an injury and we were committed to a
principle of minimizing harm, this would imply (in certain
circumstances) the absurd result that failing to reproduce at a maximal
rate is a moral wrong. In sum, before one is conceived, there is no
individual of which to speak. If one was never brought into existence,
it is not the case that harm occurs by virtue of the deprivation of
'actualizing' the potential to become a person--there is no one who
could be said to have been deprived of anything.
One
may object that I have not properly interpreted the moral objection to
contraception. One may instead think that contraception is wrong
because intercourse is ethically acceptable only if the goal is
procreation. In response, I call attention to the ambiguity of the word
'goal' and critically analyze this proposed reason. If this is to be
understood as "intercourse is ethically acceptable only if the natural
'goal' is procreation," (or some such) then on this argument no
contraception is morally permissible. This position is unreasonable
since it is inconsistent with the compelling fundamental idea that
adults possess a moral reproductive right founded in autonomy. This
notion was first articulated as a legal right in Griswold v.
Connecticut (1965). If the word 'goal' is to be understood as
"intercourse is ethically acceptable only if a person's 'goal' is
procreation," then we must determine the subjective intentions or
circumstances in which potentially procreative activity occurred. If a
woman requests EC due to contraceptive failure, then obviously her goal
was not procreation and EC should be dispensed. Yet this does not
support the objecting professional's position. What if, instead, a
woman who is a rape victim requests EC? Was the goal in the activity
procreation? It is reasonable to say that she had no positive goal with
respect to the intercourse, as she was an unwilling participant. Notice
that objecting providers do not distinguish cases of sexual assault
from other cases in which women request EC, so this subjective
understanding of the reason is not applicable to the situation at hand.
This proposed reason based on the wrongness of contraception does not
successfully support conscientious objection on the part of
professionals with respect to EC.
IV. Further Thoughts
The
discussion in this paper has proceeded using the rubric of
"conscientious objection" in medicine, though it is not clear that this
term is entirely fitting. In an early paper, James Childress discusses
the refusal to meet a professional demand in precisely these terms; he
states that "I will use "conscientious objection" to refer to public,
nonviolent, and submissive violations of law based on personal-moral,
often religious, convictions and intended primarily to witness those
principles or values" (1985, 68). Civil disobedience, by contrast, is
a refusal to obey a demand instead on moral-political grounds as a way
to make an open public statement of advocacy for change (Childress1985,
67-68). Notice, however, that an act of conscientious objection need
not necessarily involve a violation of law, contrary to Childress's
conception. There are instances in which state law grants medical
professionals a right to conscientious objection (Greenberger and
Vogelstein 2005, 1557). More importantly for our purposes, a person who
engages in conscientious objection typically undertakes the risk of
suffering any negative consequences stemming from that decision, yet
with the presence of the APhA conscience clause, the risk of negative
consequences disproportionately falls on women in need of EC. One may
wonder whether the medical professionals in question are engaging in
conscientious objection or civil disobedience. Using Childress's
conception, I would say both. Their acts are guided by moral beliefs,
and they are public--these professionals do not attempt to be evasive
by (e.g.) falsely informing patients that EC is not in stock or is
contraindicated in their case. Perhaps the framework of conscientious
objection is not the best or sole one in which to conduct this
discussion.
If we take the rubric of conscientious
objection seriously and apply it to the context of health care, then
perhaps we should establish CO status for medical professionals. This
is an idea worth considering, since at the very least it would put
women on notice with regard to their practitioners' views on EC. Yet,
as a general matter, to which sort of medical treatments can a
professional properly conscientiously object? If objecting to
participation in abortion is on one end of the continuum, can the
practitioner acceptably refuse providing infertility treatments for an
unmarried individual or removing organs from patients declared dead
according to whole-brain death criteria? (Dresser 2005, 9). The
establishment of CO status with respect to certain activities would be
a step forward by requiring that medical professionals state succinctly
their reasons for refusing to serve and be open to these reasons being
evaluated as part of institutional practice, similar to the manner in
which determinations of CO status work within the military. In a
powerful narrative recently published in the Washington Post, Dana L.
finds it particularly frustrating that medical professionals "...aren't
even required to tell the patient why they won't provide the drug..."
(2006, B01). In present circumstances, since professionals need not
even state their reasons for the decision to not provide care, their
right to conscientiously object is unlimited in practice.
An alternative proposal would attempt to dissolve the conflict by
noting that women could take regular birth control pills and achieve
the same effect, since the EC regimens focused upon in this paper
essentially contain a greater amount of the same (or similar) hormones.
The appeal to such "off label use" of regular birth control is a
diversionary tactic that avoids the central ethical issue, that of
whether and when a professional has a right to conscientiously refuse
medical treatment. This "off-label" use solution is not necessarily
available in all cases (e.g. physician-assisted suicide where legal)
and does not work in the context of EC if the pharmacist objects to
filling prescriptions for birth control pills themselves. Advocating
such use of drugs in order to achieve the same effect as an
FDA-approved medication indicated for precisely such circumstances is
disingenuous at best; refusals to dispense EC based on an appeal to
"off-label" use fails to make patient safety and well-being the first
priority.
One might object to my discussion in this paper by
granting my criticisms of the reasons offered against dispensing EC yet
arguing that the right to conscientious refusal is not limited to
ethical beliefs thought to be justified or reasonable. I find this
general line of criticism to be implausible. The beliefs upon which CO
is based must be reasonable and should be subject to evaluation in
terms of their justifiability. This is assumed in the discussion above
relating to CO in the military: an individual's reasons are to be
clearly stated and evaluated in a public forum. If an individual sought
CO status within the military because (e.g.) s/he had the moral belief
that wearing green in battle was morally evil, this should not serve as
a sufficient reason in itself for granting CO status. Further, the
proposed line of argument stemming from this criticism has troubling
implications. If a professional's reasons for seeking CO status need
not be limited to those that are reasonable or justified, then on this
understanding a provider can acceptably refuse EC based on (e.g.)
sexist beliefs that women are inferior and should be pregnant as often
as men wish them to be. As emphasized above, critical evaluation of the
reasons for proposed CO status is essential.
V. Conclusion
Initially,
there seem to be three relevant alternatives regarding this issue: an
absolute right to object, no right to object, or a limited right to
object. This paper has argued that there is no absolute right to
object, since it would be immoral for a provider to deny medical
treatment to a patient based solely on (e.g.) his or her race. There is
a prima facie right regarding conscientious objection, founded in the
notion that providers are persons with their own ethical values who
exercise moral judgment, yet this right may be defeated in certain
cases. Working strictly within the context of conscientious refusals to
dispense EC, the argument in this paper suggests that fewer options
exist than appear on the face of things. A limited right to object, if
it is manifested in a professional obligation to refer the patient to a
willing provider, can be viewed as philosophically indistinguishable
from the case of dispensing EC by the staunch objecting professional
him- or herself. This is the case if no stock is put into an intrinsic
moral distinction between 'doing' and 'allowing;' the defender of the
moderate view on CO with respect to EC has not adequately recognized
this point nor attempted to rebut it. For the staunch defender of the
right to conscientious objection discussed in this paper, either such
providers have an absolute right to object, or no right to
conscientious objection regarding EC. As argued above, providers are
medical professionals who lack an absolute right to object. Further, I
have argued that the reasons offered for refusals regarding EC do not
withstand critical scrutiny. Hence, it is reasonable to think that even
given their moral reservations, providers have a professional ethical
obligation to dispense EC.
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