Abortion Provision, Refusal Both Exercises of Conscience, Commentary Argues

October 25, 2012 — Summary of "Recognizing Conscience in Abortion Provision," Harris, New England Journal of Medicine, September 13, 2012.

"The exercise of conscience in health care is generally considered synonymous with refusal to participate in contested medical services, especially abortion," according to a commentary by Lisa Harris of the Center for Bioethics and Social Sciences in Medicine and the Program for Sexual Rights and Reproductive Justice at the University of Michigan. "This depiction neglects the fact that the provision of abortion care is also conscience-based," she writes.

History of Conscience Legislation

The first conscience legislation, known as the Church Amendment, arose after the Supreme Court's 1973 Roe v. Wade decision.

The measure expanded the ability of health care workers to refuse to participate in procedures that violate their "religious beliefs or moral convictions" but barred discrimination against those who perform "a lawful sterilization procedure or abortion," according to the text of the amendment. However, Harris notes, it did "not recognize that moral convictions might drive such care." She adds, "Thus, opposition to abortion, and to fertility control generally, catalyzed the development of law, theory, and practice of conscientious objection in medicine."

Abortion-rights opponents in 2008 praised the George W. Bush administration's decision to expand protections to health care workers who refuse to participate in certain types of care, even indirectly, for moral reasons. Later on, abortion-rights groups lauded the Obama administration's move to rescind the Bush administration's rule. "The result is an ongoing false dichotomization of abortion and conscience, making it appear that all abortion opponents support legal protections of conscience and all supporters of abortion rights oppose such protections, with little nuance in either position," Harris argues.

Recognizing Motivations of Conscience in Abortion Care

Although abortion providers face "stigma, marginalization within medicine, harassment and threat[s] of physician harm," they "continue to offer abortion care because deeply held, core ethical beliefs compel them to do so," Harris writes.

Abortion providers "describe their work in moral terms ... and articulate their sense that the failure to offer abortion care generates a crisis of conscience," she adds.

Consequences of Neglecting the Role of Conscience in Abortion Care

Harris outlines the consequences of "neglect[ing] the compatibility between conscience and abortion provision" with regard to law, clinical practice and bioethics.

First, state and federal laws continue to protect only conscience-based refusals, while minimal legal protections exist for conscience-based abortion provision, she notes. For example, new bans on abortion after 20 weeks of pregnancy in Arizona and 22 weeks in Georgia include no protections for providers who feel a moral obligation to perform an abortion after the set limits. In addition, the so-called "global gag rule" forbidding workers at federally funded overseas organizations from discussing abortion includes no conscience exemptions.

Second, the notion that acting in "good conscience" is synonymous with refusal stigmatizes abortion providers by implying that they act in "bad conscience," Harris writes. These stereotypes can deter doctors from offering abortion care and exacerbate provider shortages. In addition, sociologists have noted that stigmatization contributes to harassment and violence against abortion providers.

Third, bioethicists largely have refrained from making a moral case for protecting the conscientious provision of medical care, even though "[m]oral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs," Harris states.

Conclusion

"Certainly, if abortion providers' conscience-based claims require scrutiny" as to their motives, "so do conscience-based refusals," Harris continues. Further, "[d]espite nearly four decades of debate about conscientious refusals, we have no clear path for operationalizing them -- no standard curriculum to teach health care professionals how to humanely conscientiously object, and no clinical standard of care for conscientious refusals," she adds.

"Health care workers with conflicting views about contested medical procedures might all be 'conscientious,' even though their core beliefs vary," Harris writes. "Failure to recognize that conscience compels abortion provision, just as it compels refusals to offer abortion care, renders 'conscience' an empty concept and leaves us all with no moral ground (high or low) on which to stand," she concludes.