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Eleven principles for medical conscientious objection

Eleven principles for medical conscientious objection

What has been missing from the on-going controversy over contraception and conscience–beside the voices of women–has been a useful way of thinking through how to balance equal and competing claims. In this case, the claim to equal and quality access to health care has run into the claim that the caregiver should violate ones own conscience in providing care.

Part of the problem is that not only have Catholic Bishops have not only politicized the issue, they refuse to apply their own standards of debate within Catholic moral theology. Part of this is that they refuse to see access to contraception as a competing good, and they refuse to recognize the validity of other views–even within Catholicism. Consequently all they do is complain and criticize. They, and the politicians who have jumped on this bandwagon, have refused to recommend any solutions that can move the conversation forward, settling instead to label the President and call their opponents names.

There has to be a better way.

William A. Galston and Melissa Rogers of the Brookings Institution have written a useful guide, “Health care Providers’ Consciences and Patients’ Needs: The Quest for Balance” that walks the reader through the questions of conscience, the law and medical ethics and have suggested some principles that policy-makers, health-care providers and religious leaders might use in figuring out how to balance those who want to refrain or withhold treatment for reasons of conscience and the need to provide equal and quality access of care.

The paper is well written and provides a very good framework for ethicists, policy-makers and laypeople to begin discussion.

They know that by itself no paper will solve the problem. People have to come together and work through the hard issues together.

…These…controversies raise fundamental—and politically consequential—questions…. But they take place against a backdrop of longstanding tensions between claims of conscience and laws of broad scope and application—tensions well-known to experts but less so to public officials and most citizens. Knowing that the implementation of federal health care reform was bound to expose these tensions, the Brookings Project on Religion, Policy and Politics convened a day-long, off-the-record consultation in June 2011 (participants are quoted herein only by specific permission) involving theologians, moral philosophers, legal scholars, health practitioners, and advocates reflecting perspectives on all sides of these issues. This report is informed by that discussion as well as research the co-authors independently conducted. It is not an attempt to reflect a group consensus on these issues. The report sets forth the thoughts and conclusions of the authors.

While the co-authors are under no illusion that this or any report could settle controversies that have been raging for centuries, we hope that it can contribute to a better informed and more open-minded discussion about how to proceed. Although there is no way of resolving clashes over first principles, we believe that good will on all sides can often open a path to balanced approaches that respect and, to the greatest extent possible, accommodate competing claims.

Galston and Rogers conclude with eleven principles that can help move the conversation forward and which, if followed, could make for sensible, balanced policy and practice.

1. Don’t spend much time looking for bright-line solutions.

2. Accept the presumption of non-discrimination and equal treatment of individuals as a basis for public policy

3. Whenever possible, move the debate from principles to specifics.

4. Distinguish between what matters and what doesn’t.

5. Take the logic of institutions seriously.

6. Recognize that the right of conscience includes a right to decline to participate in the delivery of services, but it does not include a right to attempt to block a patient’s access to those services.

7. Make early and full disclosure of conscientious objections to the patient the rule, as well as complete and prompt disclosure of available alternative for service.

8. Recognize that the right to conscientious objection does not encompass a right to proselytize, condemn, or harass patients.

8. Acknowledge that defending the right of conscientious objection isn’t the same as defending the merits of the objection itself.

10. Recognize that moral diversity in the health care profession is a public good.

11. Always look for ways of including competing principles and divergent interest.


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A few points.

1) This is not a new mandate from Obama. As has been pointed out numerous times, the mandate dates from the Bush administration, and Catholic institutions have complied with it under state law in 28 states. What’s different now? Politics.

2) The Bishops indeed want every employer, not just Roman Catholic affiliates, to have the right to choose what medical coverage their employee receives.

Really? If you are a Jehovah’s witness, you can block transfusions? If you are Muslim, you can forbid your employee to take the money you pay him, and buy a ham sandwich? A fundamentalist can refuse to promote a woman over a man? What about benefits for the legal spouses of previously divorced people (marriages the RC consider sacramentally invalid). Do they get coverage? Should they be able to “opt out”? Why not? If religious belief gets a “bye” from adhering to employment laws….

Of course not. If you choose to participate in the public sphere you have to adhere to public mores.

3) No one is being forced to use contraception; that is a matter of personal conscience. It makes good medical sense to prevent unwanted pregnancies (let alone having medical uses outside of pregnancy prevention). Indeed, one might easily argue that the knowledge of what health care benefit is used by an individual should be under the privacy laws and no business of their employer.

4) Finally, as to “the women can buy it themselves”: a claim that is generally spoken by men. First, contraception is expensive. Second, not all formulations are the same or have the same side effects. Some women can’t tolerate certain pill formulations, for example– but may not be able to afford the newer, non-generic drugs that suit them better. So what? say the men. Tough luck. Get a new job for someone with a different religion.

Seriously? That’s a solution?

Andrew Gerns

The thing that I find strange is that in the years I worked as a Chaplain in a Catholic institution (even before it partnered with a for-profit–and even then we functioned according to Catholic ethical and religious directives) the hospital offered birth control through it’s health insurance plan to their employees.

It is well documented that several Catholic Universities and at least one large Catholic hospital system does right now. If these institutions can do it on their own and still be abiding by the ethical and religious directives for Catholic healthcare, I don’t know what the problem is if the government mandates the exact same practice.

Maybe these institutions provide these because they choose to or because their states mandate the coverage. In either case, they either chose to provide the coverage or chose not to complain about their state’s mandate.

Why scream now?

Let’s look at this situation from the standpoint of how to balance two competing goods: providing full and free access to quality healthcare that the patient is in charge of versus the need of a religious hospital not to undertake procedures or provide services they find objectionable.

My example comes from real life, the Catholic hospital where I worked. Here is how they handled it.

This hospital did not provide certain services, full disclosure was made and arrangements were made for patients to go to a neighboring facility for the procedure. This was normal practice.

Our hospital covered medications and procedures that our hospital did not–and would not–provide.

In this way the employee’s conscience was not penalized if she wanted birth control pills even if the sponsors–the Catholic Church–was opposed to it. The employee and the insurance company worked out where she got her pills, if that was her conscience and her choice.

At the same the hospitals “conscience” was not violated because we were not forced by the state nor the insurer to directly provide medications or procedures the hospital would find objectionable.

In other words, we as both employer and as health care provider pretty much followed what Galston and Rogers write above as a matter of course. Both goods were balanced.

Now, I’ve been away from the place for ten years so who knows what they do now, but based on both my experience and my reading of Catholic moral theology, I am having a hard time seeing how this policy actually, functionally impinges on any religious hospital’s right to do or be anything.

I disagree with John Chilton that the conscience of a Catholic institution is being impinged upon by this mandate.

I do think the Catholic employer who refuses the mandated coverage–who wants a “bye” from the accepted standard of care– is inappropriatly impinging on the good-faith conscience of another free moral agent, namely the employee.

The objecting employer is also making a false case that any money he spends should only be used for service he approves of.

To me, that is like saying that since public roads are being used by SUV’s, and I think Hummers are bad for the environment, I want the gas station to not charge me the portion of my gas tax that pays for the wear and tear caused by SUVs.

What if I told my grocery store to discount the part of my purchases that goes to pay for the stocking, sale and marketing of white bread and cigarettes?

The whole point of insurance, like taxes, is that it creates a pool of money that pays for the care for all the insured.

As David Brooks points out in todays NYTimes, we in the USA use tax breaks to employers to promote public policy in all kinds of ways. That means that if insurance companies want to be in the health insurance business they should do certain things for everyone regardless. In this case, preventative care and, yes, the pill.

Christopher Johnson is wrong that this is somehow a new, oppressive invention. This “right” was not invented out of thin air. Government, insurance companies and the public health system have been using insurance regulation and tax law to promote public health for decades.

The Affordable Health Care Act standardizes what is a now a crazy quilt of mandates across the fifty states. The attempt is make preventative care on a whole host of issues consistently accessible. It’s the pill that’s getting all the attention. In any case, these issues are not new. Hospitals, insurers and employers have been dealing with these questions on a state by state basis for years.

Back to the question at hand.

The truth is that once we let go of our money either for taxes or insurance (or for that matter buying any good or service) it might be used for something we don’t like.

Should I object and demand a refund from my insurance plan that pays for the services of a Christian Science practitioner for an employee of that faith even though I disagree with their theology and medical practice? In many states insurance plans have to pay for that service.

In many states, insurance companies have to pay for the pre-packing of a patients blood if their religion prohibits transfusion from another donor. It’s expensive, but they do it. Should I object and demand a discount because I’m not a Jehovah’s Witness?

What if I found out that my insurance pool includes people who use in-vitro fertilization or use morphine for palliative care that may also hasten death and what I diapprove of these procedures? Should I insist that I be discounted from paying for these, too?

Where will this logic end?

For one thing, insurance would stop being insurance because you could no longer underwrite groups of people on the off change that some member of the group might object to one part or another of someone else’s coverage.


@ ChristopherJ

Let me see if I have this straight: (1) Barack Obama invents a “right” to free birth control.

No, that would have been one . . . Yahweh!

So God created humankind in his image, in the image of God he created them; male and female he created them. [Gen 1:27]

HTH! 🙂

JC Fisher


you are not compelled to work for a Catholic institution

Seriously, JohnC?

To a (non-Catholic) receptionist at “St Joe’s Hospital”—in 2012, in THIS economy, w/ THIS unemployment rate—the best you’ve got to offer her (and her family) is “There’s the Exit”?

If the government wants these women to have contraceptives the solution is to hand them out.

Which I’m sure is Just A-OK w/ the Republicans in the House!

I’m for Single-Payer Health Insurance/”Medicare for All” as much as next bleeding-heart liberal Episcopalian. But let’s not make the Perfect the enemy of the Good here, OK?

Birth control is not just another discretionary-spending item, to come from one’s paycheck. Birth control is health care, and that’s why we have health insurance. The important thing is that it BE COVERED, not who pays. Obama’s compromise is a perfectly reasonable approach, w/ the health insurance system we have NOW (not the Single-Payer Future Perfect!).

JC Fisher

John B. Chilton

I’m with Paige that if you tax dollars, then live by the rules our democratic system has created. That means get out of the hospital business if you can’t in good conscience abide by the rules. Period.

As to blocking, I’ll concede the bishops are trying to broaden the contraceptives argument to Catholic business owners. I presume of them are not corporate welfare recipients. Is it so clear they can’t have conscience objection? I’d have to see details. But even there, how is not buying contraceptives for employees blocking them from obtaining them?

With Catholic institutions making up so much of the field I concede that can impinge on the alternatives available to some in the healthcare field, especially for whom a move would be a sacrifice. But even in the case where you have little choice but to accept a job with a Catholic institution, none of those institutions to my knowledge are dictating reproductive choices as a condition of employment.

An argument that cost is a barrier, a denial of access has to be backed up with more details: is it so much cheaper for employers to buy, is it true insurance companies will be glad to give it for free because it’s a savings, why not government provision, won’t the cost of the mandate simply be shifted to the employee through a change in the wage?

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