Issue 19 / 2 June 2014

MANY years ago, a friend told me her GP, a man of strong religious beliefs, had repeatedly failed to act on her husband’s requests to be referred for a vasectomy.

The doctor never actually came out and said he wouldn’t do it. He just kept letting it slide.
Whatever you think of the vexed issue of health professionals allowing their personal views to influence the care they provide, it seems to me there is a problem if a doctor does not make his or her position clear.

At a minimum, a health professional who chooses not to provide particular services for ethical reasons needs to make a clear declaration of that fact — and preferably before a patient asks for the service (through prominent signs at the surgery, for example).

Similar issues arise when a pharmacy refuses to dispense contraception, as happened in Thurgoona near Albury in NSW a few years ago.

In that case, the pharmacists, a Catholic couple, were including a note with any contraceptive pills they dispensed.

“If your primary reason for taking this medicine is contraceptive then it would be appreciated that, in the future, you would respect our views and have your OCP (oral contraceptive pill) prescriptions filled elsewhere”, the note read.

More recently, website Mamamia published an article about a woman who was refused the morning-after pill by a pharmacist citing religious reasons.

In professional circles, the consensus has tended to be that health professionals should be able to refuse to supply a service for reasons of conscience, provided the patient can access that service from another provider.

But is it really that simple?

These stories often relate to reproductive issues but, as the woman featured in the Mamamia article asks, would it be acceptable for a pharmacist who was a scientologist to refuse to dispense antidepressants?

Even if the patient was referred to another pharmacy, you couldn’t guarantee they’d persevere in the face of a first refusal.

The same could well apply to some women seeking emergency contraception, especially if they were young and vulnerable.

And, of course, there’s the perennial question of what happens when the doctor or pharmacist is the only provider in a small country town.

In Italy, it has become increasingly difficult for women to access legal termination of pregnancy, with the percentage of gynaecologists who are conscientious objectors to the procedure now at nearly 70% (and as high as 80% in some regions).

Interestingly while the objection rate has risen among gynaecologists in recent years, it has declined among anaesthetists and auxiliary personnel.

In an article in the Journal of Medical Ethics, University of Melbourne ethicist Dr Francesca Minerva suggests not all the objections may be genuinely conscientious, with questions of professional advancement and the stigmatising of those who carry out the procedure possibly playing a role.

The country’s official abortion rates are low, but Dr Minerva suggests this may be because women travel to other countries for the procedure or turn to unauthorised providers.

I am not debating the rights and wrongs of abortion here (though, for the record, I believe the service should be safe and legal and that it is the woman’s right to choose).

Nor am I suggesting doctors should be forced to carry out the procedure if it is against their conscience.

Dr Minerva describes the question of health professionals’ right to conscientious objection as “one of the most puzzling and yet urgent topics” in bioethics. The AMA released a position paper last year that said conscientious objection might be exercised “in exceptional circumstances, and as a last resort”.

Balancing two conflicting rights is never easy, but it does seem to me the default position should be that anybody who chooses to work in, say, community pharmacy or reproductive health will be prepared to supply the full range of services allowed under our medical system.

A conscientious objection to doing that should be treated as a serious matter, perhaps requiring the approval of the appropriate professional board, and with strict guidelines around how the objection could be implemented.

Anything less would seem a failure of care.


Jane McCredie is a Sydney-based science and medicine writer.


Should approval of the appropriate professional board be required for a health professional to refuse service based on a conscientious objection?
  • No (54%, 51 Votes)
  • Yes (35%, 33 Votes)
  • Maybe (12%, 11 Votes)

Total Voters: 95

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9 thoughts on “Jane McCredie: Conscientious challenge

  1. Kay Dunkley says:

    Health care providers often have to make decisions which may conflict with the demands or expectations of a patient. For example prescribing antibiotics or narcotics. This is based on individual clinical judgment. Another prescriber may be willing to prescribe them in the same circumstances. Both treatments are considered to be standard medical practice and are readily available.  However individual clinical decision making is not put under the same scrutiny as personal ethics. I suspect that because personal ethics often relate to emotive topics such as contraception and abortion they are more widely scrutinised as criticised. 

    For the record I support the availability of oral contraception and legalised abortion. I do however feel that individual health care providers should be able to respectfully practice their personal ethics provided an alternative is available.

    In the case of the pharmacy in Thurgoona this had been their practice for many years before they were vilified. They did not refuse supply rather they discreetly advised anyone they supplied with the OCP by placing a note in the bag outlining their personal beliefs.

    It is always going to be very difficult to balance the rights of individuals but involving a professional board will only create more bureaucracy and scripted practices. Imagine if you had to state your conscientious objection to prescribing narcotics if you believe the patient is misusing them rather than being able to make this decision on a case by case basis. There are so many grey areas and decisions we make on a  day by day basis. 

    We live in a multicultural and multi-faith society and we need heath care providers from all backgrounds whatever their personal ethical stance.

  2. Randal Williams says:

    Every practitioner has a right to refuse to be involved in decisions or treatments which conflict with their ethics or principles. Involvement of Professional Boards would be cumbersome and undesirable, unless there is a a series of concerns or complaints.. To quote a couple of  extreme examples , imagine if German doctors in WWII objected to human experimentation but then had to refer it to the Nazi bureaucracy? -the response would have been swift and radical, I suspect.–  or if a patient requested a procedure which is clearly unnecessary or inappropriate?  My view is that if I do not wish to personally be involved ( and this is rare) I must state this clearly, document it and direct the patient to another practitioner .

  3. Philip Watters says:

    When non evidence based thinking ie religion stops interfering with evidence based medicine it will a great day for eveyone. Science and reason should overcome irrational mythology by the end of this century.

  4. Sue Ieraci says:

    Clearly there are different situations arising, demanding separate consideration. IN general, an overriding principle could be expressed as the relative risk of harm to the patient. At one end of the spectrum is life-saving emergency care, in which a provider’s personal values come second to the patient (unless the care would be futile). At the other end of the scale, where there is no urgency and there are many other providers, the patient can easily find another provider. More difficult is the small town situation, where the service is less urgent but the choice of alternative providers is limited. Of interest also is the situation where immunisation providers are requested to sign forms that they have counselled “conscientious objectors” to vaccination. It is easy to see the potential for harm to the unvaccinated children, and difficult for providers to be convinced that the objectors truly understand the risks.

  5. Paul Jenkinson says:


    Quote:’Balancing two conflicting rights is never easy, but it does seem to me the default position should be that anybody who chooses to work in, say, community pharmacy or reproductive health will be prepared to supply the full range of services allowed under our medical system.’

    Gosh,why stop at community pharmacy and reproductive health! I can’t find a general physician now as every RACP Fellow in our area has decided not to look after “general” patients.Where are their ethics?

    And even General Surgeons are getting scarcer.

    What a ridiculous proposal that only people who are abortionists and pro-abortionists can be obstetricians and gynaecologists.Give me a break!


  6. Communicable Disease Control Directorate says:

    I can’t find the specific proposal that only abortionists and pro-abortionists should be Obstetricians and Gynaecologists in the article, but whilst we are at it – it would be a bit silly for an intensivist to say – “oh, I don’t like providing  ventilation so much, so you can have inotropes and dialysis, but not intubation/ventilation”.  Termination of pregnancy is an important component of the suite of O+G therapies, and whilst the threshold for it’s use can vary according to personal beliefs – the beliefs that are relevant should only be those of the patient (not the professional practitioner.)  The issue with any professional’s personal religious beliefs impacting on their patient’s care is that we all sign up to an ethical framework predicated on using the patient’s value system to help decide what is the right course of action, rather than our own.  If professionals are unwilling to provide a valid service, they should at least have the human decency and respect to admit that it is a personal/religious belief that is impacting on the consult, to allow the patient to chose a better service elsewhere.  I find it curious that a community pharmacy can blatantly ask a patient to respect the personal beliefs of the professional, without offering the same human decency/respect in return. It seems very close to discrimination on religious grounds, which is bordering on illegal. I’d hope that most women requiring the OCP would chose an alternative pharmacy out of disgust/protest, as respect doesn’t seem to have been earned by the “professionals” involved….

  7. Kay Dunkley says:

    Re Dr Phil’s comment “When non evidence based thinking ie religion” . Medicine is so much more than a science. The belief systens of patients play such as important role in their management. Imunisation is a good example of a belief system which does not relate to religion and yet still seems to be controversial..
    Re: “I find it curious that a community pharmacy ………. It seems very close to discrimination on religious grounds…..”   In fact they did not refuse supply but disreetly enclosed written advice.  The pharmacists concerned  actually received significant support from their local community.
    I strongly believe that every health practitioner has the right to practice within their personal ethics and belief system otherwise they are being discriminated against. We live in a multicultural and multifaith society and we need health practitioners from all these backgrounds. Apropriate referral is the key and yes this is a problem in remote areas but not in regional Victoria.
    For the record I believe in immunisation and support the right of women to access contraception and abortion.

  8. Gabriel James says:

    This article and some of the comments are extremely shortsighted and lack an appreciation of bioethical and social complexity.

    First, to say that a patient’s value system should override that of their doctor is ridiculous. Any decision a doctor makes is ultimately one that must be in keeping with his or her beliefs at a scientific AND moral level. We are not automatons that simply do what patients, or the RACGP/RANZCOG says we should. We have to make our own decisions based on what we believe to be right. We value many principles such as patient autonomy. But autonomy does not override all others. That’s simplistic and poor logic.

    Second, the most fundamental right we uphold as doctors is the right of every person to be alive as a free and unique individual. For some doctors this right does not ‘magically’ begin as a baby’s head crowns at birth. It is completely logical in their ethical system to say it begins earlier and they want to uphold their life as that of any other patient. To somehow say that this viewpoint makes them unworthy to be doctors is tantamount to censorship and totalitarian suppression.

    This authors viewpoint is effectively to say ‘if you don’t agree with us, we will marginalize you in society’. She should be ashamed of herself.

  9. Paul Jenkinson says:

    Ah ,”respect ” Francis. We all want it don’t we ? Or do we?

    Why do I as a doctor not have the right to be respected as much as the patient? Does somehow being a doctor make me less human,less worthy?

    You see I would argue that my rights  are equal to that of the patient and the patient should,yes,respect that.

    So that if my conscience says that something is wrong,in a civilized community,no-one can force me to act in a way contrary to that.

    For example ,if the law in Victoria says  I must refer a patient requesting abortion to an abortionist or else commit a crime,I will not refer that person for an abortion.(unless that person’s life is in danger,a rare occurrence) because I believe in conscience that the foetus’s rights are being ignored(at any stage in pregnancy to term and beyond in Victoria).

    In fact I believe that in light of the reality of the massive numbers of pregnancy terminations that this issue is the real human rights issue of our time,albeit that slavery ,racism and other abominations of human rights still exist in this world.

    By the way,if Dtr McCredie did not mean O &Gs when she was saying that the default position for those working in reproductive health  should be prepared to do “the full range of services”,I stand corrected but ,silly me, I thought that O&Gs did that.

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