Keeping the Patient at the Center of Conscientious Objection while Respecting Our Colleagues

For many Americans, the words “conscientious objector” conjure memories of an unpopular war and those who declined to fight, at the cost of freedom, careers, fractured family relationships, and hatred and threats. Yet the most famous conscientious objector, Muhammad Ali, explained that, in refusing to go to war in violation of his Muslim faith, “I have gained a lot…I have gained peace of mind. I have gained a peace of heart.”  Today, conscientious objection causes significant consternation in medicine. In this issue of Anesthesiology, Koganti et al.  discuss medical conscientious objections, and why anesthesiologists can and should accommodate them.

Federal rules and various state laws explicitly provide legal protection to physicians who refuse to provide care that violates their religious or personal moral beliefs regarding abortion, sterilization, contraception, physician-assisted suicide, and transgender care.  Many medical ethicist experts are concerned that vulnerable patient groups are particularly impacted by these issues: the poor, elderly, women, children, ethnic and faith-based minorities, and the LGBTQIA+ community.  Understanding why deserves our serious attention and study, but we set that aside for another time.

Understanding conscientious objection starts with defining what it is, and what it is not. Conscientious objection is more than a disagreement over medical treatments, discomfort with patient healthcare desires, or pragmatic difficulties in providing care. By definition, conscientious objections—whether due to religious beliefs or personal moral codes—are conflicts that threaten the core of a person’s moral identity. Conscientious objections, in other words, are about the soul. Being forced to provide care that creates deep personal moral dissonance presents real and serious dangers to the well-being of healthcare providers. 

Differences of opinion in health care are not uncommon. Physician refusals to provide patient treatments because of deep moral conflicts are fortunately more rare. And many conflicts termed conscientious objections are not.  Refusing to provide care that a provider believes is irrational, futile, or below professional standards is not necessarily a conscientious objection, for example, but a professional conflict that can be resolved through review of professional standards and treatment indications. Leaving individual providers to define “futility” or “lack of medical benefit” is highly subjective, and has been shown to invite discrimination, particularly of disabled patients.  Most conflicts in medicine do not rise to the level of conscientious objections the way that withdrawal of life-sustaining mechanical ventilation raises moral questions about killing versus letting die; that contraception and abortion raise moral questions about when human life begins or whether the life of a mother carries more or less weight than that of her potential child; or that transgender care raises moral questions about whether gender is a choice. Such questions are not medical ones, but moral ones, and present many physicians with deep conflicts over the answers, regardless of whether their ideologies arise out of religious tenets or personal moral codes, and regardless of whether they are “conservative” or “liberal” in nature. Sadly, the true nature of conscientious objection is becoming further obscured as it is increasingly co-opted by groups pursuing political ends rather than mutually respectful understandings.

Conscientious objections test us to respect our colleagues, and to manage their serious refusals with justice and compassion—but they do not absolve us from medicine’s foundational purpose and values: to set aside self-interest and put the patient’s needs first and at the center in our sphere of care. If a conscientious objection is impossible to accommodate without compromising patient well-being, precedence must be given to patient well-being over the provider.

Koganti et al. appear to take a position that only a medical emergency would justify not accommodating a conscientious objection. But vulnerable patients often face insurmountable barriers outside of emergencies in finding alternative caregivers, let alone negotiating significant limitations that will arise from broader healthcare workforce challenges created by institutional conscientious objections, even in major urban areas.

This latter concern is no longer hypothetical. In Washington state, for example, due to mergers of faith-based healthcare institutions, greater than 41% of hospital beds are held by organizations that conscientiously object to abortion, contraception, sterilization, many forms of transgender care, and some forms of end-of-life care. Even in large urban areas, such as Seattle and Bellingham, significant shortages and sometimes entire losses of these services have resulted.  As faith-based healthcare conglomerates grow, institutional conscientious objection will take bigger and bigger bites out of the availability of such care for patients who do not necessarily share their providers’ beliefs but have no place left to go.

The objector, too, has responsibilities: to avoid when possible situations in which they will predictably feel morally compromised, and also to provide alternative caregivers when they recuse themselves so that patient well-being is not compromised. Conscientious objectors should consider how their practice choices may impact their own well-being, just as such considerations have been examined by providers with strong convictions to provide abortion care who find themselves in settings with restrictions on reproductive choice, for example. These environments impact the provider’s ability to enjoy their work and have caused many to reconsider their location and practice setting. The Jehovah’s Witness Church calls upon believers to “carrying your own load of responsibility,” and seek alternative employment when they have moral objections related to their work.  In anesthesiology, we have broad flexibility in the focus and type of practice we decide to pursue, making many conscientious objections potentially avoidable. Whenever possible, conscientious objectors should provide known objections in advance.

The American Society of Anesthesiologists (Schaumburg, Illinois) Committee on Ethics has provided some guidance. The Guidelines for Ethical Practice of Anesthesiology adopts the American Medical Association (Chicago, Illinois) principles of ethics, which in turn were developed into multiple guidances, including conscientious objection.  The “Statement on Ethical Guidelines for the Anesthesia Care of Patients with Do-not-resuscitate Orders” requires conscientious objectors to provide a suitable alternative provider.  Granular details of how practices manage conscientious objections will necessarily depend on specific conditions of the practice: additional barriers to patient care should in no case be endorsed by the American Society of Anesthesiologists.

While threats to patient autonomy and reproductive justice are pushed in political and legal arenas, it is important to distinguish those conflicts from the more personal battlefields that physicians face, both in providing care to patients and addressing the very real moral concerns of their colleagues. Our specialty has been significantly impacted by burnout and issues concerning well-being. We would be remiss not to consider this when addressing the impact of care we provide in the context of conscientious objections.

We posit that diversity and inclusion within the physician anesthesia workforce will be critical in improving the impact of conscientious objection. Healthcare disparities are already well documented, and those who are members of vulnerable populations, whether they be racial groups, LGBTQIA+ communities, migrant populations, or those to whom English is a second language, would benefit from care provided by individuals with similar lived experiences, cultural humility, and shared values, and who therefore may have fewer conscientious objections to their care. Broader diversity and inclusion also create spaces for providers of true belonging and collegiality by helping us to experience and better understand our ideological differences. 

Our specialty is at a critical juncture as more is being asked of us despite workforce shortages. When leaders across the specialty consider short-term and long-term goals, we call upon them to prioritize the training of a diverse and inclusive anesthesia workforce to promote well-being among anesthesiologists who have conscientious objections. As our specialists occupy larger leadership roles within health systems, we must also advocate broadly for a diverse and inclusive physician workforce across the field of medicine.