By Steve Clarke

The ethics of conscientious objection (CO) in healthcare is an important and controversial topic in bioethics and much has been written about it. I first published on the ethics of CO in healthcare in 2017 and I’ve had several other pieces published on the topic since then. I’ve also edited a special issue of this journal on Conscientious Objections (Volume 43, Issue 4), co-authored a paper on CO and vaccination, and authored a paper on the conception of conscience advocated in Mark Twain’s The Adventures of Huckleberry Finn. Despite all this activity I’d never committed to an overarching view about the ethics of CO in healthcare. What I had published was either about specific issues that arise in debates about CO or was criticism of other people’s work.

Given my level of engagement with issues around the ethics of CO in healthcare it started to feel odd that I neither adhered to a recognized account of the ethics of CO in healthcare nor had attempted to develop one. The problem I had was that I consider myself to be a consequentialist but the leading consequentialists who write on CO in healthcare advocate a view that I don’t warm to – the view that CO should never be permitted in healthcare. The best state of affairs, from a consequentialist point of view, is to permit healthcare professionals to express COs and also ensure service provision – to ‘have your cake and eat it’ as Giubilini et al. recently put it, in Rethinking Conscientious Objection in Healthcare. Leading consequentialists who had written about CO in healthcare – Julian Savulescu and Udo Schüklenk – don’t dispute that this would be the best possible state of affairs. They just think that it is impossible to attain.

The absence in the literature of a view that I wanted to exist was exasperating but it also presented an opportunity. There was uninhabited and attractive conceptual territory to be staked out – a consequentialist ‘have your cake and eat it’ compromise position – if only I could figure out how to get there. I had a ‘light-bulb moment’ in early 2025 when I realized that what is really problematic in the literature on CO in healthcare, when considered from a consequentialist point of view, is the heavy reliance, by influential advocates of compromise positions, such as Brock, on referral as a means to reconcile permitting healthcare professionals to exercise COs with ensuring that patients receive needed healthcare services. Referral is a poor means of compromise because it can lead to several forms of harm. The referral process can introduce potentially harmful delays to the provision of healthcare services, and if handled incorrectly can lead patients to experience dignitary harms. Also, healthcare professionals who are required to make referrals, to procedures they conscientiously object to, can experience harmful feelings of moral complicity.

Referral is only necessary when a prospective patient who requires a particular medical procedure interacts with a healthcare professional who has a CO to that procedure. It occurred to me that rather than focusing on what to do when such interactions take place, we should look to minimize their occurrence. A register system offers a way of doing this and in an early version of A consequentialist case for permitting conscientious objection in healthcare, I proposed keeping a region-based register of healthcare professionals with COs to particular procedures that patients could consult so that they might be able to avoid encounters with healthcare professionals who have COs to those procedures.

Region-based registers of healthcare professionals with COs to euthanasia have recently been set up in Spain, although these are not intended to be accessed by patients. As I found out more about the Spanish experience, I discovered that these registers had aroused strong opposition, as healthcare professionals with COs were very uncomfortable having their names listed on them. I soon realized that there is a better way to go which is to keep region-based registers of healthcare professionals who lack COs to procedures for which COs are permitted. A patient who needs a procedure for which COs are permitted can consult such a register, thereby enabling them to avoid interactions with healthcare professionals who have a CO to that procedure. In most circumstances it should be a default assumption that healthcare professionals are willing and able to provide the services they have been employed to provide, so it is hard to see why there would be any serious objections to taking this approach.

By maintaining region-based registers of healthcare professionals who lack COs to procedures for which COs are permitted, we enable healthcare professionals with COs to those procedures to act on COs, and this is beneficial for them. We also help ensure that patients can access required healthcare services without interacting with healthcare professionals with COs, and this is beneficial to those patients. We obtain the best overall combination of benefits for all those concerned, which is an outcome that consequentialists should welcome.

Article: A consequentialist case for permitting conscientious objection in healthcare

Author: Steve Clarke

Affiliation: School of Social Work and Arts, Charles Sturt University

Conflicts of Interest: None to declare