Professionals, Conformity, and Conscience

Laws, regulations, and ethical codes often address conflicts between personal beliefs and workplace demands. Such conflicts are common in the health setting, where work is intimately connected to matters of life and death, privacy, and dignity.

In the latest conflict attracting attention, pharmacists have expressed moral beliefs that interfere with women's reproductive health needs. Journalists and others have reported cases of individual pharmacists refusing to fill prescriptions for emergency contraceptives. Because emergency contraception can act to block implantation of a fertilized egg, people who believe in protection of human life after conception find it morally objectionable.

State officials have responded in two ways. Some have endorsed legal requirements that protect women's access to the drugs; others have sought to protect pharmacists' conscientious objection rights. The American Pharmacists Association "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 refusal."¹

In this and other contexts, we see disagreement over when to protect the professional's freedom to reject on moral grounds a practice that is ordinarily required of the professional. The dispute over pharmacist refusals and workplace demands offers an opportunity to examine this broader question.

The Varieties of Conscience Claims

Health care workers may seek to be excused from several medical services on grounds of conscience. Many laws protect health professionals from employment penalties if they refuse to assist with abortion or sterilization procedures. A few laws allow clinicians to avoid carrying out what they see as a morally objectionable decision to forgo life-sustaining treatment. Some laws excuse professionals from administering "futile" treatment that they see as morally inappropriate. And Oregon's law allowing physician-assisted suicide permits clinicians to refuse to supply patients with life-ending medication.

Many other types of conscientious objection may be asserted in health settings. Clinicians may cite disability rights as the basis for an objection to performing tasks associated with prenatal diagnosis, or gender equality as the basis for a refusal to assist with sex-selection procedures. They may claim religious or moral beliefs as the basis for denying a single person's request for infertility treatment. They may cite religious or cultural objections to retrieving organs from patients declared dead according to whole-brain criteria. Students may express moral opposition to using animals in training exercises.

In some circumstances, conscientious objection claims may mask self-interested or discriminatory motives. For example, professionals worried about disease transmission may refuse to care for an HIV-positive patient, claiming religious opposition to homosexuality or a duty to remain healthy for the sake of their families. An angry clinician may deny care to a disruptive patient, citing an ethical responsibility to protect other patients. Residents interested in lightening their work load may claim moral objections to avoid training sessions in abortion techniques.

Conflict Management Models

Because conscientious objection occurs in such varied circumstances, the acceptable resolution will be different in different situations. Nevertheless, there are several general models for handling such objections.

One is the contract model. At the outset of the encounter, the professional should disclose to patients any treatment limits. People in need of an excluded service may then seek that service from another professional. This model works in some contexts, but not when patients need care quickly or when no one else can take over the task of the objecting professional.

A second model imposes on the objecting professional a duty to refer or transfer patients to another professional willing to provide the contested service. The model shares some of the contract model's problems—namely, it fails to meet patients' interests when no one else is available. And this model may be unacceptable to professionals who see any assistance in securing the service as complicity in immoral behavior. One pharmacist expressed this view of referral: "That's like saying, 'I don't kill people myself but let me tell you about the guy down the street who does.'"²

A third model rules out the possibility of conscientious objection. According to this model, people who enter a profession agree to conform...