During a quiet tea-break as a surgical house officer, I was summoned to the medical superintendent's office. My O&G colleague was busy. Would I please admit some patients for elective termination of pregnancy?

In accepting my appointment I had signed a form saying that I would be willing to take on extra duties from time to time at the medical superintendent's discretion. However, on this occasion, I politely refused and he accepted my right to conscientious objection.

Throughout Europe, the opportunity for such action may soon be over. The legal situation in several Western European countries has recently been reviewed in the Journal of CMF's Swedish counterpart, Kristna Lakare Och Medicinare i Sverige, and makes disturbing reading.[1]

Swedish law provides no right of conscientious objection to doctors and both doctors and other health personnel have contractual obligations to assist in the termination of pregnancy. In France, Norway and Italy, doctors are not legally required to perform abortions, but are obliged to participate in pre-operative care. In Denmark and the Netherlands one can conscientiously object to being involved in pre-operative care, but there is nonetheless a legal obligation to refer the woman seeking an abortion to another colleague.

The law in Britain

The situation in the UK is less clear and has been the subject of recent debate in the British Medical Journal.[2,3,4,5,6] The Abortion Act 1967 carries a conscientious objection clause which allows doctors to refuse to participate in terminations but which obliges them to provide necessary treatment in an emergency when the woman's life may be jeopardised. The British Medical Association (BMA), which is frequently asked for an opinion on the matter bases its advice[7] on two legal precedents.

The first of these was a Parliamentary answer on the matter[8] which made clear that conscientious objection was only intended to be applied to 'participation in treatment'.

The second was the Janaway case[9], concerning a doctor's secretary (Janaway) who refused to type the referral letter for an abortion and claimed the protection of the conscience clause. Lord Keith in his summing up of the case said that 'the regulations do not appear to contemplate that the signing of the certificate would form part of the treatment for the termination of pregnancy'.

The BMA document observes that 'it would seem that GPs cannot claim exemption from giving advice or performing the preparatory steps to arrange an abortion if the request for abortion meets the legal requirements'. At the same time it admits that 'the full legal position is not entirely clear, since it requires interpretation of case law, GP terms of service, good practice and the NHS Act 1977'.

What then should a doctor do? The BMA concludes that 'completing the statutory form'(HSA1) for abortion falls morally within the scope of the conscience clause, but that doctors who feel unable to sign still have an ethical duty to refer the patient expeditiously to another practitioner, and that unnecessary delay in referral is contrary to good practice. However it adds that 'other preliminary procedures such as clerking in the patient or assessing the patient's fitness for anaesthetic' are 'incidental to the termination' and are considered outside the scope of the conscience clause.

In other words, although specific cases have not yet been brought to court, (and there is disagreement over what will happen when they are[5,6]), the BMA regards the situation in the UK as similar to that in France, Italy and Norway. Doctors are not legally required to authorise or perform abortions, but are obliged to be involved in pre-operative care and referral.

Had my own case been brought to court in this present climate, I may well have been found guilty.

In my work among medical students, I am frequently asked about the practicalities of conscientious objection. The vast majority of students are not asking whether abortion is right and wrong. Rather they are asking: 'Given that abortion is wrong, how should I handle the situations where pressure is being put upon me to participate?' Let us consider the biblical principles relevant to the discussion and their practical implications.

Conscientious objection - Biblical principles

The Bible teaches us in both Old and New Testaments that it is God himself who institutes human authorities:

'..the Most High is sovereign over the kingdoms of men and gives them to anyone he wishes.' (Dan 4:25)

'The authorities that exist have been established by God.' (Rom 13:1)

Furthermore he expects us to obey them, not only because of possible punishment but also because of conscience. (Rom 13:1-7; Tit 3:1; 1 Pet 2:13-14)

This raises the issue of what we should do in circumstances where obeying the authority involves disobeying some other command of God. It seems in Scripture that there is a place for godly civil disobedience. Let us consider some examples.

The Hebrew midwives when ordered by the king of Egypt to kill all male Hebrew children refused to do so and as a result we are told that God commended and rewarded them (Ex 1:15-22). Rahab the harlot similarly refused to co-operate with the king of Jericho in handing over the innocent Israelite spies (Jos 2:1-14). She is later praised for her faith in so doing (Heb 11:31; Jas 2:25). The prospect of death as a consequence of disobedience to state law did not stop Shadrach, Meshach and Abednego refusing to bow down to the image (Dan 4:6-8), or Daniel persisting with public prayer (Dan 6:1-10). They were defiant and their obedience was rewarded when God intervened miraculously on both occasions to save them.

In the New Testament when Peter and John were commanded by the Jewish authorities not to preach the Gospel they replied 'We must obey God rather than men' and went right on doing it (Acts 5:29). Many of the prophets and apostles and of course Jesus himself were killed precisely because they chose to obey God in what they said and did, in situations where his commands and those of human authorities conflicted.

In John's vision described in Revelation 13 the beast which is given (by God) authority over every tribe, people, language and nation is clearly not to be obeyed in the matter of receiving a mark to enable buying and selling (Rev 13:15-16). To the contrary, those who take the mark ultimately share the fate of the devil himself (Rev 14:9-12).

So while recognising that we have an obligation to obey the governing authorities God has instituted, our obedience to God himself takes precedence when rulings conflict.

If we decide that as Christians we should not be shedding innocent blood (and personally I believe Scripture leaves us no other option; as previously argued[10]) it must follow that in spite of what governments and medical associations may decree, we must obey God first. Any suffering that may follow simply has to be accepted as part of the cost of following Christ in an increasingly godless world. To disobey God for fear of losing career, reputation or respect is surely to make idols of these things. We cannot say that in our hearts we worship God if our actions betray that we don't. Can we imagine Daniel, Shadrach or Jesus himself bottling out at the last moment on the grounds that the cost was too high?

What then of our involvement at other levels? If we decide that as Christian doctors we should not participate in the shedding of innocent blood, then surely this must have implications for other levels of involvement. If we fill out forms authorising abortions, prepare patients for the procedure or refer to others whom we know will do the same aren't we giving tacit approval to the whole process? Shouldn't we rather observe the apostolic directive:

'Do not be partners with them' (Eph 5:7)?

Hasn't the time come to:

'Come out of her my people, so that you will not share in her sins' (Rev 18:4)?

Taking innocent human life is contrary to the whole strategy of medicine. It runs not only counter to Christian ethics but to the Hippocratic Oath and the Declaration of Geneva, which the BMA not so long ago embraced. It is not we who are advocating change, but rather the legal and the medical establishment who have betrayed their own ethics. Why should we allow them to squeeze us into the same mould?

Practical implications

On the basis of the above, my own personal advice to medical students and junior doctors is as follows. Do what you can to persuade women not to choose abortion and be aware of all the excellent facilities that now exist in this country (such as those provided by LIFE and CARE for Life) to provide counselling, practical help, advice and support to those with crisis pregnancies. However, don't participate in the abortion process itself, by signing forms, admitting patients, helping in theatre or arranging for someone else to 'do the deed'. Whatever the cost to your career, conscientiously object. If, on the other hand, you have been asked to be involved in the care of patients with post-abortion complications, oblige willingly. I should add that it is wise (if possible) to make your position known to colleagues, before the event arises.

I am well aware that such advice, even if followed with tact and sensitivity, will bring some into conflict with medical, NHS and legal authorities. Many may find, as I and others have, that threats of reprisal often come to nothing. Authorities, be they persons or parties, frequently back off, fearing confrontation even more than we do.

However it is inevitable, given the slide in morals in society generally and the move towards medical care being yet another market commodity, that some of us will face discrimination, dismissal and even criminal conviction.

I am aware of a Christian general practice recently being denied certification for training purposes because the partners were not prepared to provide 'the full range of services' (see below) including abortion referral and contraceptive prescription for unmarried couples. Another CMF member was recently denied the Diploma of the Faculty of Family Planning and Reproductive Health Care of the Royal College of Obstetricians and Gynaecologists (RCOG) on the basis that he had refused to fit IUCDs.

When an enquiry was made on behalf of CMF the Chairman of the College Faculty concerned informed us that there was

'a considerable onus on the Faculty to ensure that its qualifications should be recognisable by service purchasers and patients alike as distinguishing doctors who were able to ensure that their patients had access to a full range of contraceptive services'. (Italics mine.)

Regardless of what personal convictions we may hold on the morality of IUCDs, or even for that matter abortion, there is a most worrying precedent here. Rather than being subject to an independent code of ethics and gaining qualifications purely on the basis of medical competence, doctors are being barred from practice in certain fields of medicine because they are unwilling to provide, for ethical reasons, what the market-place is demanding. The irony is that in the two cases cited doctors were discriminated against for insisting on abiding by the Declaration of Geneva[11] which enjoins 'the utmost respect for human life from the time of conception'. Just twelve years ago[12] they would have had the BMA and indeed the World Medical Association (WMA) on their side.

What of the future?

When further NHS trusts are under the control of non-medical interests, and market forces hold even more sway in an environment of diminishing health resources, one wonders whether 'the full range' of geriatric, psychiatric, intensive care or even general medical services might include euthanasia. Why not? What then?

One thing is certain. Junior doctors who hold Christian convictions are finding it more and more difficult to enter careers in certain specialties and the phenomenon is spreading. Convictions and disciplinary proceedings are inevitable if current trends continue and presently they show no sign of abating. The days of the Christian doctor with strong moral convictions may well be numbered. If the tide is to turn at all (it may already be too late) it will not happen unless those of us in positions of responsibility within the Royal Colleges, NHS Trusts and the BMA speak out. If such members of CMF remain silent, Christian witness in medicine, at least in the form it is practised in this country, may well come to an end. Mordecai's words to Esther, who occupied a position of privilege and responsibility at a similar time of national crisis, are a sober challenge to us:

'Do not think that because you are in the king's house you alone of all the Jews will escape. For if you remain silent at this time, relief and deliverance for the Jews will arise from another place, but you and your father's family will perish. And who knows but that you have come to royal position for such a time as this?' (Es 4:13-14)