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When I first entered medical school and heard the term “conscientious objection”, I was slightly confused. Having been a war history enthusiast in high school, a conscientious objector to me had always been associated with individuals refusing military service.
I quickly learned from ethics tutorials in medical school that the term had moved from the battlefields to our hospitals. In the context of reproductive healthcare (most often abortion), and now voluntary assisted dying (VAD), conscientious objection occurs when a doctor or other healthcare provider refuses to participate in these practices due to ethical, moral or philosophical beliefs.
As a human being, I can recognise that other human beings hold a conscience. Our conscience — that inner sense of right and wrong steering us to certain behaviours and away from others — is an essential part of being a healthcare provider. It is required for us to use our ‘gut instincts’ when treating patients and is the underpinning of the ethical pillars our profession is built on.
Within the medical profession, there is broad acceptance that individual practitioners who conscientiously object to abortion or VAD should not be forced to provide these services. However, despite legal safeguards, research I conducted at The University of Melbourne found that conscientious objection can still limit access for patients in Australia and globally.
Whilst conducting this research, I came across an unexpected finding. It is not only individual practitioners that are refusing to participate in providing abortion, but it is whole institutions.
What is institutional conscientious objection?
Now I don’t know about you, but I wasn’t aware of a hospital ever holding a conscience — I thought that this was something unique to humans (and possibly some other primates).
Institutional conscientious objection mainly occurs in religiously affiliated institutions and results in individual practitioners in these workplaces not being permitted to provide abortion or VAD, regardless of their individual views.
Many religious bodies claim conscientious objection does apply to institutions, arguing that institutions hold missions to protect life and therefore can oppose VAD and abortion. Catholic institutions in the USA interpret human rights protections such as freedom of religion to pertain to this issue also.
Researchers at The University of Melbourne found strong evidence internationally, that institutional objection to abortion led to reduced access for women in religious hospitals and prevented staff within these institutions from training in abortion provision.
In its guiding document on conscientious objection to abortion, the United Nations Human Rights Council’s Working Group on Discrimination against Women and Girls explicitly suggested that institutional conscientious objection should not be permitted, as it undermines access to healthcare and restricts women’s freedom of conscience.
Institutional conscientious objection in Australia
In Australia, the legislation is largely silent on institutional conscientious objection. In abortion legislation in Australian states and territories, there is no mention of institutional conscientious objection at all. In VAD legislation, however, the majority of States and Territories do explicitly address institutional conscientious objection. New South Wales and Queensland for example require institutions to explicitly publish information about their objection in a way that people will understand.
There is no research to date in Australia that looks at the prevalence of institutional conscientious objection, or its impact on individuals ability to access abortion or VAD. Research on individual practitioner objection in Australia has incidentally found evidence of private or catholic hospitals ‘opting out’ of providing services – including “maternity hospitals providing prenatal genetic testing services”.
With the paucity of research in this area however, there have been a number of news stories in Australia highlighting the challenges faced by people in accessing both VAD and abortion in Australian public hospitals, backing up these findings.
In July this year, a Brisbane couple went public with their experience in a Catholic-run hospital learning their baby had a high risk genetic abnormality and being denied termination in this facility. In Victoria, a woman with motor neurone disease was denied access to VAD due to receiving palliative care within a Catholic hospital, and shared her story with VAD advocates, sparking discussion about publicly funded hospitals denying legal care. Another aged care resident in Victoria was required to leave their facility which had been their home to access VAD for their terminal illness.
An issue of health access equity
Australia wide, despite most states and territories having legislation permitting abortion and VAD, individuals and families are still struggling to access these services. This is more pronounced for those with already reduced access to healthcare — people living in regional, rural or remote areas, people from low socioeconomic backgrounds, or Aboriginal and Torres Strait Islanders. Access is also more challenging for those who find difficulty in navigating the health system, such as people from culturally and linguistically diverse backgrounds or people with low health literacy.
Access issues are complex and multifactorial, but institutional conscientious objection is a growing concern that needs closer examination. Patients in publicly funded religious hospitals should not receive different access to care than those in secular facilities — particularly where no alternative service exists.
Where gaps exist in the legislation about institutional conscientious objection whether it be abortion or VAD, governments and health services should have clear guidelines of what the service and practitioners should do if their patient is seeking this care.
There also needs to be a strengthening of referral pathways from institutions that do object to those that do not, and these pathways need to be clearly outlined for patients and families.
Most importantly, research is urgently needed to understand how institutional conscientious objection in Australia affects access to abortion and VAD. Only then can we design appropriate policy and regulatory responses that safeguard both conscience and access to care.
Dr Jasmine Davis is a Resident Medical Officer working in regional Queensland. She completed her medical degree as well as a Master of Public Health at the University of Melbourne. She is a Board Director and Federal Councilor of the Australian Medical Association. She has an interest in how ethical frameworks influence health policy and how understanding these influences can help to improve equity in healthcare access.
The views expressed are the author’s own and are not affiliated with any organisation or association with which they are employed or volunteer. The author does not hold any academic appointments.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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