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.