The idea of conscientious objections —objections based on a set of personal beliefs or morals —are a relatively recent concept in the context of healthcare. The practice initially arose as a consequence of the landmark decision of Roe v. Wade, which established a constitutional right to abortion—a procedure that many physicians objected to performing due to conflicts with their personal, moral, or religious beliefs (Morrison et al., 2023). Since then, due to medical advances and cultural shifts, the number of procedures considered morally controversial has expanded to include assisted suicide, euthanasia, mercy killing, certain kinds of reproductive technologies, gender-affirming surgeries, and many others (Magelssen, 2012). With its increasing applicability, the legality of conscientious objections has also come under increasing scrutiny, with many criticizing the prioritization of physicians’ moral integrity over patients’ rights. This is in part a consequence of the ambiguity in the current laws surrounding conscientious objections, which highlights a need for comprehensive reform that ensures patient welfare while respecting the autonomy of healthcare providers.
The first set of federal laws granting individuals and organizations the right to refuse services that went against their personal or religious convictions were the Church Amendments, enacted in the 1970s. These amendments were introduced in response to debates over whether entities who received federal funding were required to perform abortions or sterilization procedures. The Church Amendments outlined five key provisions, creating the first guidelines on conscientious objections (U.S. Department of Health and Human Services, 2024). The first and fourth provisions ensured that any entity receiving federal funding was not required under federal law to perform or assist in sterilizations or abortions, nor to participate in any health service or research activity that conflicted with their moral or religious beliefs (HHS, 2024). The second and third provisions prohibited discrimination against healthcare providers for either performing or refusing to perform such procedures (HHS, 2024). Lastly, the fifth provision prohibited discrimination against applicants based on their willingness to participate in abortion or sterilization procedures (HHS, 2024). These protections were then expanded in 1996 by the Coats-Snowe Amendment which prohibited discrimination based on a healthcare provider’s decision regarding the provision of abortion services in the process of accreditation or certification (HHS, 2024). A year later, in 1997, the Balanced Budget Act was passed stating that “Medicaid managed care-managed organizations and Medicare Advantage plans are not required to provide, reimburse for, or cover a counseling or referral service if the organization or plan objects to the service on moral or religious grounds” (HHS, 2024). This served to essentially expand conscientious protections from the provider level to the insurance level. These protections were further reaffirmed in both the Weldon Amendment of 2005 and certain provisions included in the Affordable Care Act of 2010 (Harris, 2024). The full scope of these protections was clarified in a mandate from the Health and Human Services Department (HHS) in 2008.
Prior to the 2008 Final Rule entitled “Ensuring that Department of Health and Human Services Funds Do Not Support Coercive or Discriminatory Policies or Practices in Violation of Federal Law,” there were no overarching, universal guidelines. However, in its attempt to make a set of blanket protections, the 2008 Final Rule was unclear and overbroad in its scope, resulting in public outcry (HHS, 2024). The rule was ultimately replaced and rescinded by the 2011 Final Rule which also stipulated that “enforcement of health care provider conscience protections will be handled by the Department's Office for Civil Rights [(OCR)]” (HHS, 2011). In 2018, the department proposed a new rule entitled “Protecting Statutory Conscience Rights in Health Care; Delegations of Authority “Protecting Statutory Conscience Rights in Health Care; Delegations of Authority.” This proposed rule sought to reinstate several provisions of the 2008 Final rule as well as “enhance the awareness and enforcement of Federal health care conscience and associated nondiscrimination laws, to further conscience and religious freedom, and to protect the rights of individuals and entities to abstain from certain activities related to health care services without discrimination or retaliation” (HHS, 2024). If this rule were to be formally enacted, healthcare providers' conscientious protections would greatly expand, resulting in a system that many protested against. The rule was challenged in multiple jurisdictions across the nation with activist groups claiming that the proposed rule exceeded the HHS’s jurisdiction and that it prioritized religious beliefs over patient welfare (Sheppard, 2023). Consequently, the 2019 rule was rescinded and the HHS continued to operate under the 2011 rule. That is until March 11, 2024, when the Department enacted the 2024 Final Rule entitled “Safeguarding the Rights of Conscience as Protected by Federal Statutes.”
The 2024 Final Rule clarifies the process for enforcing conscientious protections and reiterates the OCR’s authority to both receive and investigate complaints about any of the provisions laid out in the Federal Health Care Conscience Protection Statues, which include the Church Amendments, Coats-Snow Amendment, and Weldon Amendments. This makes it easier for individuals to file a complaint regarding a potential violation of the application of such laws. Though many of the aforementioned laws have a primary focus on abortion and sterilization services, the broad language of the 1970 Church Amendments extends many of the discussed protections to any potentially morally contentious procedures. However, the broad language of the Church Amendments is also one of its most controversial features as it does not explicitly regulate the extent to which a physician’s moral integrity could trump a patient’s right to care nor did it define what constitutes a moral or religious conflict. This, in turn, has led to many misconceptions surrounding conscientious protections as well as contention around whether or not such protections should even exist.
There are those who believe that the profession of a physician is to provide care which means acting in the interest of the patient irrespective of the physician’s own moral code. Many point out that health care providers enter the profession voluntarily and by doing so surrender their own personal autonomy to help serve “the greater good.” Some will go so far as to say that physicians who refuse to provide “accepted medical interventions” are not fit to carry the title of physician (Stahl & Emanuel, 2017). At the same time, “the right to refuse to act against one’s moral or religious convictions is central to a democratic society,” and is in fact protected under the First Amendment of the US Constitution (Magelssen, 2012). As such, a complete prohibition of medical conscientious objection would be a violation of one’s constitutional rights. However, some argue that these objections may use religion as a mere smokescreen to justify paternalistic and discriminatory practices.
At its most rudimentary level, conscientious protections allow for a physician to weigh their own values in the decision-making process of a patient’s care. This simplification has led many to believe that conscientious protections are merely euphemisms for protecting paternalism— where doctors, due to the asymmetric distribution of information, impose their personal beliefs on patients, thereby violating patient autonomy (Savulescu, 2006). This perspective inaccurately frames conscientious objections as something done to the patient, rather than something intended to protect the moral integrity of the physician. If a doctor opts out of doing a procedure based on personally held moral principles, they are not making a decision for the patient but rather for themselves. Thus the application of conscientious objections should not be confused with the problematic practice of paternalism. An additional argument against the practice of conscientious objections is that the inherent vagueness of the term makes these protections susceptible to abuse, potentially allowing individuals to exploit them for discriminatory practices.
The principle idea behind conscientious objection is that it grants physicians the autonomy to follow their own moral or ethical beliefs. However, there is no universally accepted definition of what constitutes a moral or ethical principle. Values themselves are also easily changeable, and “medical objectors are [not] subjected to a tribunal to assess their sincerity” and even if they were, “sincerity is impossible to verify” (Jones-Nosacek, 2021). This creates a crucial vulnerability in the nature of conscientious protections as there is no objective standard by which an objection can be measured. In a 2022 Yale School of Medicine panel, Mark David Siegel, a professor of pulmonary medicine at Yale, pointed out that “moral objections [could be used] as a smokescreen for discrimination” (Gwizdala, 2022). For instance, a physician could easily deny providing a given service to a patient citing a moral or ethical principle, when in reality they simply did not want “to take care of a person from a vulnerable group” (Gwizdala, 2022). In this regard at least, on a federal level, conscientious objection is ill-defined. One group that tries to remedy this within its jurisdiction is the American College of Obstetricians and Gynecologists (ACOG).
The ACOG has clear guidelines regulating the application of conscientious objections —ensuring that patient autonomy and well-being is insured. The guidelines consist of 4 criteria: potential for imposition, effect for patient health, the potential for discrimination, and scientific integrity (American College of Obstetricians and Gynecologists, 2007). The “potential for imposition” requires that physicians, regardless of their moral or religious objections, must inform their patient of all the possible options available. The “effect on patient health” considers the impact of conscientious objections on a patient’s well-being and stipulates that any objection should not negatively impact the accessibility of care, and that all patients have a right to receive timely, and appropriate treatment. This in turn emphasizes a physician’s duty to refer. Both the World Health Organization (WHO) and the International Federation of Gynecology and Obstetrics (FIGO) “have unequivocally recognized the obligation of health professionals to provide appropriate referrals to other health practitioners if they refuse to provide particular services due to personal beliefs” (Center for Reproductive Rights, n.d.). However, in the case of an emergency, a physician’s prima facie duty to the patient supersedes any moral misgivings. The third criteria, the “potential for discrimination” requires that conscientious objections take into account how consequent actions contribute to the “unfair distribution of the benefits of reproductive technology,” particularly for marginalized populations in resource-poor areas (ACOG, 2007). In this context, a physician's conscientious objection could indirectly restrict a woman's access to reproductive services, particularly if she lacks reliable transportation. The last criterion, “scientific integrity,” however, is arguably more radical than necessary —stating that any conscientious objection “should be considered invalid when the rationale for a refusal contradicts the body of scientific evidence” (ACOG, 2007). Such a stipulation however essentially invalidates the concept of conscientious objections as a whole —removing religion, which is often in conflict with mainstream science, as a valid reason to have a moral quandary with a given procedure. Although this particular criteria somewhat oversteps by defining religious objections as irrational and unworthy of protection, the other three criteria help to clarify the gray areas surrounding the protections established by the 2024 Final Rule. However, it's important to note that the ACOG only has the authority to set standards for its members and thus is limited in its scope.
Abortion and reproductive services are often at the center of discussions regarding conscientious objections, but the scope of this issue has expanded significantly in recent years due to advancements in medical technology. Gender-affirming care, euthanasia, physician-assisted suicide, and gene therapy are just some of the new fields that can raise complex ethical dilemmas, forcing healthcare providers to navigate their personal beliefs while considering the rights and needs of their patients. With increasing applicability, the rules dictating the criteria and usage of conscientious objections need to be reconsidered on a federal level. The double standard of conscientious objections, as Ronit Stahl, an associate professor at the University of California Berkeley, points out must also be addressed as “it protects those who refuse to treat [...] but not those whose conscience compels them to provide medically accepted by politically-contested care” (Gwizdala, 2022).
The language of Federal Health Care Conscience Protection Statutes fosters an environment of confusion, as it relies on inherently indefinable principles and creates gray areas in both the provision of care and the duties of physicians. It is important to recognize that a physician’s conscientious objection should not automatically be viewed as an act of discrimination; often, these protections are intended to benefit the physician rather than harm the patient. However, the current guidelines leave these protections vulnerable to manipulation, which could inadvertently affect patient care. While the 2024 Final Rule provides a clear process for filing complaints, the federal legal frameworks need to be better defined. Addressing such ambiguities on a national level rather than on a speciality basis, as seen by the criteria set by the ACOG, is essential for ensuring that both patient rights and provider beliefs are protected in a balanced manner.