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The Intersection of Health Policy and Clinical Practice
of human in vitro fertilization (IVF) spread understanding that fertilization precedes pregnancy identified at implantation, with the consequence that prevention of implan tation does not constitute abortion. However, those who equate fertilization with concep tion, and believe that human life requires protection from fertilization/conception, will oppose techniques of fertility control that obstruct implantation. Addressing IVF, the Inter-American Court of Human Rights has rejected the argument that fertilization and conception are concurrent and synonymous, observing that “the term “conception” can not be understood as a moment or process exclusive of a woman’s body”, and ruled that conception “occurs at the moment when the embryo becomes implanted in the uterus”.24 Nevertheless, patients should be informed of the possible effects of methods of contracep tion, such as insertion of intrauterine devices (IUDs), and be allowed to reject any they find unacceptable as abortifacient.
CONCLUSION The greatest ethical challenges of con scientious objection and related referral are at the extremes. Acceptance of the view that conscientious objection to lawful procedures has no place in the voluntary assumption of responsibilities of clinical care of patients has credible support among some bioethics analysts, and is applied in a few national healthcare systems. However this approach, without practitioners’ voluntary surrender of their rights, risks offending human rights principles of reasonable accommodation of diversity in employment settings. Where practitioners conscientiously motivated by different ethical convictions are committed to professional collegiality, responsibilities of patient care can be distributed to main tain both patients’ appropriate care and practitioners’ conscientious values. At the
other end of the spectrum from absolute exclusion of conscientious objection is absolute refusal not only of any association with practices considered objectionable that patients are legally entitled to receive but also of referral of patients, for whom practitioners have accepted duties of care, to other practi tioners who do not object. Holding patients captive by refusal of referral, such as by invoking concepts of complicity in what other practitioners are willing to undertake, risks denial of patients’ rights to care, and to the information they require for protection of their health and well-being through access to appropriate service providers. At its extreme, conscientious objection has been unethically invoked by health facility administrators and facilities themselves to deny applicants for care admission to receive the range of medical services on which the facility managements have induced them, as community members, to be dependent. The commonly acceptable compromise between practitioners’ conscientious objec tion to direct, i.e. “hands-on”, participation in treatment and patients’ rights to care is through objecting practitioners’ duty of referral. This is almost universally endorsed in medical professional codes of ethics, and widely underwritten by legal provisions. Practitioners who invoke concepts of com plicity to refuse referral are objecting not only to their own patients’ receipt of care, but to participation in systems of clinical healthcare that are ethically and legally bound to ensure all patients’ access to such care. That is—they are refusing to participate in a healthcare system that must make available the clinical care in which they refuse to feel complicit. They thereby disentitle themselves from ethically inducing patients’ dependency on them for clinical care to which patients have ethical and legal claims. Patients’ dependency raises particular ethical concerns when practitioners liable to