Conscientious objection arises within medicine when a doctor's conscience runs counter to a legal and socially accepted medical practice. This usually relates to 'controversial' practices, such as abortion, euthanasia, the morning after pill and certain contraceptives. It is expressed predominantly (though not exclusively) by those with religious convictions. For the Christian medic, it will become increasingly relevant as medicine departs further from traditional ethical boundaries.

The shift in relation to abortion is a useful place to start considering how conscientious objection developed and how modern Christian doctors manage practically. The current pressure on the UK Parliament to legalise assisted dying raises further questions about what the future may hold for Christian doctors. It is wise to know in advance your stance on such contentious issues so that you will be able to stand firm when conflict arises.

Medical tradition

The Hippocratic Oath states:

'I will not give a pessary to a woman to cause abortion'

This dates from 470 - 360 BC when Hippocrates, a Greek physician, developed a code of practice for the group of physicians he trained and practised with. Once the recognition of Greek deities is set aside, the oath accords well with a traditional Christian ethic - the preservation and respect of life and human dignity in all its forms. This oath became a standard of practice for doctors throughout the centuries that followed. In many ways this mode of medicine was 'taken as read' until the atrocities of the Nazi doctors during World War II shocked the World Medical Association (WMA) and other governing bodies into officially codifying acceptable medical practice in the 1948 Geneva Convention and the International code of Medical Ethics (1949), which requires adherence to the Geneva declaration. The original declaration,[1] as it relates to abortion, reads:

'I will maintain the utmost respect for human life from the time of its conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity.'

This was medicine that sat very comfortably with a traditional (evangelical) Christian ethic. In fact, the western development of medicine is largely built up around a Christian foundation.[2]

Abortion – the UK's first conscience clause

The legalisation of abortion in the UK was the first time the government took medicine away from this 'safe' ethic. I have covered the history of the 1967 Abortion Act elsewhere,[3] so will not review the details here. However it is worth noting that several factors; the sixties, a liberalising government, an active lobby body at Parliament, and the arguments from 'hard cases', were all effective in winning the debate for legalised abortion.

The original bill that was brought before Parliament in 1966 contained no allowance for doctors to opt out. However, it became clear throughout the parliamentary debates that some sort of conscience clause would be needed. Three intertwining threads forced this conclusion

• doctors' professional integrity - The 'social clause' of the bill requires doctors to make decisions about social factors - such as the woman's ability to raise a child, her family and financial situation, her age and future prospects etc. Many felt profoundly uncomfortable with this shift and argued that doctors would become mere 'technicians to the state' under such regulations.
• abortion 'on demand' - Although the original Act was not intended to introduce abortion on demand, many argued that it was inevitable that this would result. It was incoherent to expect doctors to restrict it - precisely because it was a social, rather than a medical, issue.
• doctors' moral integrity - This follows from the previous two: if abortion is on demand, and doctors are technicians of the state, what recourse is there for the doctor with a moral objection? Although the bill's proponents rubbished the first two threads, they couldn't avoid the moral convictions held by some of the medical profession. Thus, a special clause was introduced (see box) despite objections that, 'It seems quite wrong for any doctor to put his ethical reasons before the consideration of his patient.'[4]

The clause in practice

BMA guidance in relation to the conscience clause states: 'The BMA supports the rights of doctors to have a conscientious objection and believes that such doctors should not be marginalised... Some doctors have complained of being harassed and discriminated against... the BMA abhors all such behaviour.'[5] It adds that doctors should 'ensure that the treatment or advice they provide is not affected by their personal views.' In relation to the specifics of 'participation in treatment' BMA guidance indicates that the clause:

• definitely applies to participation in termination operations
• also applies to signing the form
• does not apply to advice
• does not apply to clerking the patient for abortion and may not apply to other preparatory steps
• definitely does not apply to referring to another practitioner or specialist
• does apply to students who want to opt out of witnessing abortions
• additionally, a doctor may explain their position to the patient if invited to do so

However, the exact extent of 'participation' is a grey area that has not been tested in law.[6] We know that the clause does not apply to treating a woman when the pregnancy is life-threatening (emergency abortion), or to treating a complication of abortion, such as infection or bleeding. Some argue that the clause doesn't apply to signing the forms.[7] However, it seems incoherent to ask someone to sign a legal document saying they agree with a woman's request for termination, when they don't.

Similarly there is still a question over the place of referral within the clause. The BMA requests that doctors refer but because it has never been tested in court we do not know whether referral is legally obliged. Mason and McCall Smith, in Law and Medical Ethics, indicate that because the doctor is under an obligation to advise, referral is his only recourse, whilst noting that this 'is only marginally compatible with a strong conscience and must damage the essential bond of trust between doctor and patient.'[8] The General Medical Council's (GMC) Duties of a Doctor says you must 'respect the rights of patients to be fully involved in decisions about their care' and 'make sure that your personal beliefs do not prejudice your patients' care'.[9] Put together these two suggest you could face a GMC hearing if you made it difficult for a woman to access abortion when she had decided in favour of it - and refusing to refer would be seen as just such an obstacle.

In reality, objection to termination may actually hang around the question of whether the patient fulfils the criteria of the Act. Kennedy and Grubb note in Medical Law: 'The situation contemplated by s(4) is one where the practitioner, but for the subsection, would be under a legal duty to participate in treatment under the Act. The effect of s(4) is to absolve that person of any such duty whether it be a duty owed to his employer because of the terms of his contract of employment, or to his patient.'[10] The abortion law sets out grounds on which abortion may be legally performed and the doctor is only under a legal duty to participate where the Act is fulfilled. In this respect the Christian GP or gynaecologist can face a strange situation: a sound medical or legal objection (ie a woman whose request does not satisfy the original intention of the Act), regardless of any conscientious objection the doctor may hold.

If a doctor is faced with a woman whom he judges does not fulfil the grounds of the Act, he can refuse to sign the forms based on clinical judgment rather than any conscientious reason. The woman could ask for a second opinion, and she would be entitled to this. Eventually - if a woman knows where to go - she will likely find a doctor who will sign her forms, if only on the basis of the statistical argument (for an early termination).[11] If he refers to a practitioner who will not object, what has he done to uphold the law? Is he in fact complicit in breaking the law? This is a pertinent question, as 98% of abortions are for 'social' reasons, and not the 'difficult cases' that the law was intended to provide for.

Implications for the conscientious doctor

A GP may ensure that patients know in advance not to raise the question of abortion with him (perhaps by a sign in the waiting room, or through the receptionists), and they will instead see a colleague who will sign the form, or perhaps be given contact information for the local family planning clinic. Many, however, prefer to see the patient so that they have an opportunity for discussion, and a chance to present the alternatives to the woman. Once discussion has commenced, however, the issue of referral is raised. Christian doctors tend to deal with the situation in a number of ways:

• 'It's your legal right if you meet the requirements of the Act... I don't think you do... you can seek a second opinion'
• 'I'm afraid I don't refer for abortion'
• 'You can ring...' [and provide, or not provide numbers directly / within the surgery]
• 'Here's a referral letter to another doctor, stating my reasons for not signing the form...' [to a doctor with similar or different views in the obstetrics and gynaecology department]

One effect that legalised abortion has had on medicine is a reduction in the numbers of Christians going in to obstetrics and gynaecology (O&G). A CMF survey in 1996 indicated that 25% of doctors who had chosen a career in O&G would not have done so again.[12] The issue of discrimination within O&G and difficulties obtaining promotions has also always been an underlying, if disputed, issue. The CMF survey found that 14% of doctors responding felt they had faced discrimination.[13] Various parliamentary committees have examined the working of the conscience clause in 1974, 1979 and 1990.[14] All recognised the inherent problem of employing someone in a job where they will not be prepared to fulfil specific job requirements.

It is possible that conscientious objection to abortion may also become more problematic for doctors. Evidence suggests an increasing number of doctors with an objection to involvement in terminations: a third of junior doctors refusing on moral grounds,[15] 10% of GP practices that won't refer, and one in four practices with a 'conscientious objector' in their midst.[16] With the continual rise in annual abortion numbers, this situation can only increase if it means women find it difficult to access services, those who will perform terminations are put under greater pressure, and the pro-abortion lobby get increasingly vocal in their annoyance with objectors. A recent Sunday Times article reported the campaigns of leading pro-abortion groups to intimidate doctors who refuse to particpate in termination referrals, encouraging women to make formal complaints to the GMC.[17]

Flexible and contagious ethics

In considering new legislation and how current laws function, it is common to look at how things are working in other countries that have similar laws. This is a pragmatic approach - any new law is in some ways a live experiment on the people and on society, but looking to other countries will give us an idea of what to expect. We can learn from other's mistakes to avoid making them ourselves, and hopefully improve on the pitfalls.

This is also significant in relation to the spread of medical practice and ethics between nations. Inherent in this approach is the feeling of 'they have done it, therefore it must be okay'... 'we are lagging behind'... 'introducing this law is progress'. It is interesting to see the way abortion was legalised throughout the countries of Europe over 50 years (see box below). Practical reasons, such as abortion tourism, would promote this spread as well as ethical contagion. The WMA has altered the Geneva Convention to fit in with this shift: where it used to require protection of life from the 'time of conception', this was changed to 'from its beginning' (a phrase that is open to differential interpretation) and has now been dropped altogether.[18]

A more recent development is pressure coming down through the European Union and the United Nations for more standardisation of practice across countries. There is not room to explore this fully here, but pressure may be experienced through the European Court, via reports at the European Parliament,[19] through the language of rights that inherently seeks equality across different jurisdictions and is being inserted into EU and UN declarations. Additionally, lobbyists are now operating internationally. Action has been taken against countries like Colombia, Poland and Malta to attempt to change their laws on the basis that 'international treaties establish abortion as a constitutional right in some cases'.[20] Similarly, Exit International[21] and the World Federation of Right to Die Societies[22] see assisted dying as something a person should be able to access whatever country they're in, and therefore campaign for countries' laws to be changed to enable that.

Euthanasia in the UK

The WMA's Declaration of Lisbon on the rights of the patient[23] asserts the patient's 'right to die in dignity', though there is no clarification of what death with dignity is. The Voluntary Euthanasia Society (VES) has cleverly adopted the phrase 'death with dignity' into their campaign for euthanasia and assisted suicide. So far, UK law doesn't recognise any 'right' to die,[24] and many would still see 'death with dignity' as something very different from euthanasia. However, our laws may soon face a change, and with it a shift in people's perspectives.

Lord Joffe, a human rights lawyer, has been working since February 2003 to get a bill legalising physician assisted suicide and euthanasia through the Lords. The bill has been through a number of adjustments, and went to a Select Committee in March 2004. The Committee's role was to examine the bill and make recommendations to Parliament. They released their report on 4 April 2005,[25] stressing that physician assisted suicide and euthanasia must be considered separately and that the whole of Parliament should debate the issues if a new bill emerges. Joffe has promised to introduce a new bill soon after the Lords' report is debated on 10 October this year.

Lord Joffe knew from the beginning that his bill would need a conscience clause. The text of this clause is in the box below. This aligns with a BMA resolution on euthanasia (adopted in 1977) affirming that medical practitioners with conscientious objection to euthanasia 'must be fully protected in future legislation should it occur and that no legal obligation in this respect should be allowed to be imposed unilaterally on any member of the profession at any time.' The assumption is very similar to that of the abortion law - that the doctor who objects can refuse to participate in assisting a patient to die, or signing the relevant forms. However, this clause demands referral to a physician who doesn't hold an objection - whereas with abortion it is merely considered 'good practice' by the professional bodies.

Interestingly, the Lords' Select Committee recommended:

'Any new Bill should not place on a physician with conscientious objection the duty to refer an applicant for assisted suicide or voluntary euthanasia to another physician without such objection; it should provide adequate protection for all health care professionals who may be involved in any way in such an application; and it should ensure that the position of persons working in multi-disciplinary teams is adequately protected.'[26]

Proponents of assisted dying will likely fight against removing the duty to refer.

At the moment we can only speculate over the kind of pressures that Christian doctors may find themselves working under if such a law were to be passed by Parliament. Can you imagine for yourself how medical practice might be affected? Also worth considering is that whilst abortion can be avoided by not choosing certain specialties, it is hard to find a specialty where death will not be encountered at some point. Among others, those expressing concerns about the effect assisted dying legislation will have on their work include GPs, anaesthetists, palliative care specialists, geriatricians, paediatricians (note the recent expansion of the laws in the Netherlands to include disabled babies)[27] and psychiatrists.

Biblical view - is referral enough? [28]

The Bible teaches us in both Old and New Testaments that it is God himself who institutes human authorities.[29] Furthermore he expects us to obey them, not only because of possible punishment but also because of conscience.[30] This raises the issue of what we should do in circumstances where obeying the authority involves disobeying some other command of God. Scripture is clear that there is a place for godly civil disobedience. Some biblical examples would be:

• The Hebrew midwives, who disobeyed Pharaoh when ordered to kill all newborn boys and were commended by God for their actions.[31]
• Rahab, who refused to co-operate with the king of Jericho and instead helped the Israelite spies, and is praised for her faith as a result.[32]
• Shadrach, Meshach and Abednego, who were prepared to face death rather than obey the king's decree commanding them to bow down to an idol - and were miraculously saved by God from the 'legal' punishment of death by fire.[33]
• Daniel, who persisted in public prayer against a royal decree at risk to his own life - and was miraculously saved by God from the 'legal punishment' of the lions' den.[34]

We should not necessarily expect the same intervention from God as Daniel and his friends. However, as Shadrach, Meshach, and Abednego replied to the king: 'If we are thrown into the blazing furnace, the God we serve is able to save us from it, and he will rescue us from your hand, O king. But even if he does not, we want you to know, O king, that we will not serve your gods or worship the image of gold you have set up.'[35] Even if death should result, our obedience to God remains the highest calling, and the threat of death or other suffering, such as a damaged career, should not stop us from attaining it.

The New Testament similarly upholds obedience to God where there is conflict between that and the human authorities. Peter and John refused to give up preaching when commanded to by the Jewish authorities.[36] Many of the apostles, and Jesus himself, died because they chose to obey God rather than the institutions of man. The Beast in Revelation 13 is clearly not to be obeyed by receiving a mark to enable buying and selling. Yet we can imagine how the lack of such a mark will cause suffering, and perhaps starvation.

In spite of what governments and medical associations may decree, the Christian doctor must obey God first - whatever the consequences may be.

Referral could be seen as complicity in the process, particularly referral to a doctor without an objection. Even without referring, the patient will likely still manage to access services eventually. Realistically, can a doctor make efforts to prevent such an outcome? How do our actions align with verses such as the following:

'Rescue those being led away to death; hold back those staggering towards slaughter. If you say, 'But we knew nothing about this,' does not he who weighs the heart perceive it? Does not he who guards your life know it? Will he not repay each person according to what he has done?[37]

Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy.'[38]

A conscience clause may work to alleviate our discomfort about a law, since we can protect our own conscience and still practise ethical medicine. But we may sometimes be in danger of hiding behind this, as if it were enough. God's sense of justice, wisdom and compassion revealed in the Bible indicate a desire for his people to do more than hide behind our own consciences. Are we not also called to stick our heads above the parapet to proclaim his truths, and to 'stand in the gap'[39] both to intercede for those who are lost, and to reach out to help them?

As modern western society increasingly permits medical practices that are unacceptable to Christian doctors, it is more likely that you will be called upon to take a stand - to protect both yourself and others.