By Dr Arianne Shahvisi, Lecturer in Medical Ethics, Brighton & Sussex Medical School

In the UK, a doctor is permitted to refuse to provide a signature for an eligible abortion on the basis of a conscientious objection, provided the conscientious decision is explained to the patient, who is then assisted in meeting a willing signatory without significant delay. This accommodation is made by virtue of a conscience clause, which permits doctors to honour the demands of their consciences.

As Ann Furedi asserts in these pages: “Clinicians should hold values and make value judgements, including that they will, in “good faith”, act in the interests of their patients.” This is redolent of a common line of reasoning in this literature: conscientious objectors to abortion are likely to be morally deliberative in other ways too, and that is a valuable quality in doctors, so we should permit those objections in order to retain virtuous doctors. I’ll now explain why this argument doesn’t pass muster.

Many conscientious objectors are religious, which provides no guarantee that that they’d be more likely to apply defensible principles of medical ethics elsewhere in their practice. Religions often require followers to observe scriptural directives, or pay heed to the guidance of religious leaders, rather than generating and refining their own moral views. It might be said that it is precisely this convergence of morals, owing to their common, unchanging source, that unites people within a religion. Further, since no religion was founded, nor religious leader trained, with medical provision in mind, it would be absurd to suggest that religion might be capable of offering guidance that would elevate their followers above non-religious colleagues as moral deliberators in this domain.

But even if objections do not derive from religious commitments, I don’t think the sort of conscientious objection which leads doctors to refuse abortions is the sort of piloting force that is likely to produce exemplary outcomes for patients in other situations. Doctors who refuse to provide decisionally-competent adult patients with the legal care they request do not strike me as more likely to make good decisions elsewhere in their practice. If anything, they strike me as people who are apt to undermine patients’ wishes in other ways too; as people who perhaps believe that good medicine is arrived at via their desires and beliefs, not the self-determined desires and needs of their patients, or the well-researched and ever-changing recommendations of law and professional good-practice.

In some senses, of course, consciences are helpful to medicine. They might lead doctors to provide additional, supererogatory care, going beyond the call of duty to complement and enhance health in in the best interests of each patient as she self-determines her needs, rather than restricting the legal care which they are in the unique position of having been trained or authorised to perform. Those who conscientiously object to abortion are not better-placed, or maybe even well-placed, to be such doctors.

Either way, matters are rarely so simple, and the specificity of doctors denying abortions to women demands careful attention along three particular strands which relate to the context of abortion provision.

 

  • Power

 

These days, one is rarely able to see a particular GP, but is rather referred to whichever doctor is available (often a locum who may be working at the surgery for just that day’s clinic). This means that a person seeking an abortion is very unlikely to know anything at all about the doctor she sees in advance. There is always some chance that the doctor she meets will refuse to sign off her abortion on grounds of conscience. If that happens, best-practice guidelines mean that the doctor will need to explain that the conscience clause is being invoked and ensure that the patient is able to see a willing provider.

So here’s the scene: in the highly-ritualised context of a consulting room, a patient who is likely distressed, worrying about the future, and acutely aware of the social stigma of abortion, has awkwardly requested an abortion after some deliberation. The doctor responds: “I’m sorry, I’m not able to carry out that request because I have a conscientious objection to abortion” or something to that effect. It’s very likely that that utterance, that refusal, no matter how gestural or temporary, produces distress in the patient, causes her to feel judged, or even prompts her to rethink her choice.

It is my view that no patient should be subjected to moral judgment by their doctor. Patients are vulnerable: need and illness make it so. Doctors in the medical milieu are not. To express moral views in the context of that power dynamic is a misuse of a doctor’s position.

 

  • Politics

 

Most importantly of all, abortion is political. Globally, women continue to be denied autonomy over their reproductive capacities. Families, religions, and governments wield power, defended and actualised by direct and structural violence, in order to maintain control over reproductive choices. In many places, abortion remains criminalised, and only 29 per cent of women globally can access an abortion simply because they do not wish to be pregnant, while 47, 000 women die from unsafe abortions each year.

Weigh this against the backdrop of the many ways in which our societies continue to police, penalise, and objectify female bodies to appreciate that this is not a neutral matter of doctors’ keeping their consciences unruffled and patients demanding seamless care, it is a case of bodies that have been under surveillance and control being fought back by their owners after centuries of struggle. When a group of people have been consistently denied rule over themselves, it is insulting, reactionary, and highly political when service providers’ personal views are considered to be in any way relevant, let alone important enough to pose an additional barrier or judgment.

 

  • Privilege

 

Doctors are some of the most privileged people in British society. Despite the government’s ongoing attempts to undermine the NHS, doctors remain well-paid, with excellent job security. They are educated at elite institutions, are well-respected within the broader health profession, and are held in high public esteem.

I graduated with a first degree in physics, and had the option of working for various military and financial sector companies, who seek the analytical skills of scientists. I find the work of such sectors unconscionable, which narrowed my employment options quite considerably, but it felt edifying to flex my conscience. Choosing to become an ophthalmologist or a paediatrician instead of a GP in order to avoid abortion provision ought not to leave one feeling wronged, but rather glad to be faithful to a set of principles, and grateful to have options in a world where so many have few or none.

Conscientious objectors should not train to become doctors, or should, after qualifying, select professional specialities in which they will not encounter abortion provision. They are privileged enough to shoulder concessions for the benefit of others, and their social power renders it an abuse of authority if they subject patients to their moral views in clinical contexts.

 

Women should have access to abortions when they need them, because all people have the right to exercise sovereignty over the uses of their bodies. That women continue to be denied that basic right, in ways both overt and subtle, is a pressing political matter.

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