Bioethics Forum Essay
Conscientious Objection and Abortion: Medical Students’ Perspective
A woman in her mid-30’s who was 23 weeks pregnant received devastating news: her fetus had a lethal diagnosis. Her pregnancy was not viable and would end in stillbirth. Her physician recommended dilation and evacuation, a type of abortion. The patient didn’t speak English and needed a translator. The translator explained the diagnosis but would not translate the recommended treatment because they objected to it. Two other translators also declined to do so. Despite the medical necessity of the abortion, it was delayed and rescheduled twice that day because individual anesthesiologists, technicians, and nurses did not want to be involved in, what several called, “this kind of procedure.”
After the procedure and still sedated, the patient was turned away by the post-surgical nurse on duty because she “doesn’t work with abortion patients.” The patient was wheeled around in a hospital bed for 30 minutes while we—medical students– desperately tried to find another nurse.
This is the care a patient received in a tertiary hospital located in a state where abortion is legal. However, state protections do not address the barriers to appropriate care that are posed by conscientious objection to abortion.
Another medical student in our cohort rotated at a tertiary hospital in a state where abortion is heavily restricted. Patients seeking abortion were required to undergo state-mandated waiting periods. Physicians had to read out loud state-mandated provider scripts with information about the gestational age of the fetus and the financial assistance available if they carried the pregnancy to term. The physicians were also required to show patients considering abortion graphic color pamphlets that displayed a fetus at various gestational ages. Finally, abortions were only performed at certain times on certain days to accommodate staff who were willing to even just be associated with abortion care. It became obvious to the rotating student that on top of the many legal roadblocks, conscientious objection was a prevalent unspoken barrier to abortion care.
Several of our other classmates have also encountered limitations and delays to abortion at the hospitals where they rotated. As medical students, we are often at the bedside, sitting with patients as they bear the harm of the downstream effects of conscientious objection. We do this without preparation from medical education and sometimes without the support of our clinical supervisors. There must be a better system, one that balances respect for individual staff members’ beliefs while ensuring that patients receive timely and quality care.
In health care, conscientious objectors can be doctors, nurses, and others involved in patient care who find themselves in situations where the proposed care conflicts with their beliefs. This term is used frequently in laws and policies governing abortion. A 2022 qualitative literature review of 36 papers found that conscientious objection impacts women’s access to abortion directly, when providers refuse care, and indirectly, when their community treats them differently because they have had an abortion.
Regardless of state laws that protect abortion, the current structure of our hospital systems fails to mitigate the consequences of provider refusal on our patients. Conscientious objection is undeniably a barrier to safe, quality abortion care. It is associated with significant delay in care and stigma from having had that care. These impacts pose danger and risk to patients. The WHO and United Nations have both called upon states that allow conscientious objection to ensure that objections do not undermine abortion access. The American health care system must rise to this challenge. Balancing patient autonomy and safety with the rights of staff to maintain their moral integrity demands a systemwide intervention–a way to integrate safety protocols for patients seeking abortion into institutional practice.
We believe that such change starts in medical school. When a law may conflict with a provider’s moral obligations or beliefs, values-based discussions need to be initiated early and occur continuously with students. As future providers who will soon take oaths to “do no harm,” we must talk about difficult topics like abortion care. If a provider decides that abortion is not something they can provide in good conscience, then the health care community as a whole must strive to agree on next steps so that patients do not fall through the cracks.
The International Federation of Gynecology and Obstetrics recognizes that conscientious objection to abortion is a global human rights issue. It acknowledges the stigma, burden, and lack of support that abortion providers face every day, destructively impacting their careers, and in some countries, risking their lives. It asserts that conscientious objection is not appropriate in the following situations: life-threatening emergencies, postabortion care, and when referral is not possible or would significantly delay treatment.
We believe that hospital systems in the U.S. should consider implementing similar guidelines and clarify next steps when a provider declines to care for an abortion seeker. Most importantly, we maintain that medical schools across the country need to support and educate students as they develop their own values. Future health care providers need to know what to do when their values conflict with patient care. They must determine for themselves what “do no harm” means and how to ensure that their moral conflict does not delay lifesaving treatment.
We as a medical community need to address conscientious objection and what it means for our patients. We urge our medical community to directly confront the consequences of conscientious objection and take the necessary steps to protect our patients.
Leah Chen is a fourth-year medical student at the University of Washington and an aspiring obstetrician and gynecologist who is passionate about access to reproductive health care. Tudi Le is a fourth-year medical student at the University of Washington and an aspiring emergency physician who is a passionate advocate for women’s health.
I am so sorry that this group of nurses behaved in this manner. The ANA Code of Ethics does address this issue and nurse do not have the right to deny nursing care to a patient post-abortion. This is considered unethical behavior and could result in loss of license. I do not know in which state this occurred but it appears that more education is required at this institution and state.
Yes, a refusal to provide care would be a violation of the code of ethics. It would be considered discrimination as the nurse was not participating in the abortion but refusing care based on a particular attribute of the patient. I am sorry that this happened. This would be reportable to the state nursing board.
I agree fully with the view from the two young soon to be medical practitioners. In Canada, at least in Ontario, those physicians who may be consciencious objectors, must refer the patient to an alternate professional who is able to provide that care. This is a reasonable view. I am now in the regulatory world. Years ago, when a drug considered an interceptor and another that would allow the provision of medically-induced abortions to be considered for market purposes, belonged to a group whose head was an objector for both instances. The head of that group did not want to touch the file, not even “with a ten foot pole”. I had to take that file in hand. While I do have issues with abortion, mostly because of matters of safety and potential consequences to subsequent fertility, I did take those files and navigated them successfully through the system. It was, what I viewed as an “elegant solution” to a multipronged dilemma… Where there is a will, there is certainly a way to solve moral issues. A wise ethicist, a physician, once noted that if and when we know enough about an issues to make us comfortable with the pros and cons of that issue, ethics is no longer a thorny consideration. That is not to say it should be discarded, but the viewpoints do shift, the more we know. Now that we know that there are few if any consequences to subsequent fertility if an abortion takes place, not offering that care is unacceptable, to me at least…
Thank you for sharing your experiences in this important essay – it is more than regrettable that patients suffer and are harmed when these moral objections interfere with safe and appropriate health care. We cover exactly this perspective in my Morals and Medicine course for our premedical students at Siena College and in the ethics education for medical students and clinical ethics consultants at Albany Medical College. I will share this essay in class this evening…I would be interested in how your preceptors/mentors advise you when this occurs (it seems that the preparation beforehand is lacking..???.)
Thank you for this thoughtful essay. Keep advocating for your patients and supporting your classmates. Proud to know people like you are the future of medicine!
Hi Leah and Tudi, thank you guys so much for sharing your story. It is so heartbreaking to hear about this patient’s unfortunate experience. It seems that the conscientious objectors did not care about the medical reasoning (and urgency) behind her abortion at all. The patient must have been heartbroken that her baby received a lethal diagnosis, yet the medical professionals’ attitude towards her situation must have made her feel even worse. Moreover, it is scary to think about how legal restrictions are not the only barrier for women to have access to abortion. Even in a state where abortion is legal, conscientious objection becomes yet another barrier for women seeking abortion to get the treatment they need. Conscientious objection has obviously become a pressing issue that greatly affects women’s access to essential health care.
On the other hand, it is difficult to determine whether conscientious should be honored or prohibited altogether. From the objector’s perspective, just because the law allows something does not mean that they should be obligated to perform procedures that are strongly against their moral codes or beliefs. A hypothetical example would be performing female genital mutilation in a (hypothetical) country where the practice is legal and widely accepted as a social norm. In this case, it certainly does not feel right to say that a medical professional has an obligation to perform FGM when it is strongly against their moral code. It also does not make sense to mandate a referral if they were to object to the procedure. A referral would mean that the physician still participated in the procedure, just indirectly. (However, the patient in this case is in a very different situation, as her fetus received a lethal diagnosis. Many patients in need of abortions as treatments for life-threatening conditions are still denied access.)
Abortion is not the only procedure that is made less accessible by conscientious objection. Many women are denied access to emergency contraception due to the conscientious objection by a pharmacists. As a result, many of those who are in remote areas without access to multiple pharmacies ended up with pregnancies (that are also difficult to terminate due to legal restrictions or conscientious objections as discussed). Institutions should think about how they could address or prevent conscientious objections, especially those that may delay or prevent treatment of medical emergencies. Bioethicists and legislators should think about whether conscientious objection should be prohibited or protected by law.