Christian Bioethics, 18(1), 3040, 2012 Advance Access publication on April 2, 2012

doi:10.1093/cb/cbs006

The Physicians Right of Refusal: What Are the

Limits?

ROBERT D. ORR*
Graduate College of Union University, Schenectady, New York, USA

*Address correspondence to: Robert D. Orr, MD, CM. The Graduate College of Union
University, 80 Nott Terrace, Schenectady, NY, USA. E-mail: b.j.orr.vt@gmail.com.

A physicians long-established right to refuse to provide a requested

service based on his or her moral beliefs is being challenged. Some
authors suggest that physicians should not be licensed if they are
unwilling to provide all legal services. Others would grant them the
right to refuse, but require them to refer to a willing professional.
What are the limits of a physicians right to refuse? When such a
right is claimed on moral grounds, what residual obligations does
the physician have to the patient? How should the profession (or
society) decide when a moral claim to a right to refuse is justified?
Keywords:faith, moral complicity, refusal, right of conscience

I. INTRODUCTION

The right of an individual to refuse to do something requested by another

based on ones own conscience or religious beliefs is a well-established
societal precept. Probably the most easily recognized example is the consci-
entious objector who is conscripted into military service but is unwilling to
engage in combat, or sometimes even in a supportive military role, based on
his or her conscientious stance as a pacifist. It is generally accepted that this
individual should be assigned a noncombatant military role in the former
case or even be given an option for alternative (nonmilitary) service in
the latter.
It has been well-accepted in theological circles for millennia that an indi-
vidual believer was to resist imposed practices that were contrary to his or
her beliefs, though the obligation often carried potentially dire consequences
(e.g., Daniel chapter 6). While this right of refusal is most commonly
associated with the individuals religious beliefs, this is not exclusively
so. Most nonreligious individuals have well-developed consciences, many

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 The Physicians Right of Refusal 31

with deeply held moral commitments. It is of interest to note that, not infre-
quently, individuals who claim a right to refuse based on their religious
beliefs differ with other individuals from the same faith tradition, implying
that there is some degree of interpretation involved in ones conclusions.
The right of refusal began to gain credence in secular circles during the
Enlightenment and was clearly articulated by Thomas Paine in The Rights of
Man (1791) and even earlier in varying venues by Thomas Jefferson.1 The
right of conscience was a critical component in the founding of the United
States. It was clearly stated in early drafts of Madisons first amendment to
the US Constitution,2 though somewhat obscured in the shortened final version.3
From reading these early expressions of the right of conscience, it seems fair
to conclude that the right of refusal may be based on divine law, natural law,
or human reason.

II. THE RIGHT OF CONSCIENCE IN MEDICINE

The right of a physician to refuse a patients request similarly has ancient

roots. Hippocrates, in writing about the goals of medicine 2,500 years ago,
said Doing away with the suffering of the sick, lessening the violence of
their diseases, and refusing to treat those who are overmastered by their
diseases, realizing that in such cases medicine is powerless (Jones, 1923,
193). Though physicians practicing modern palliative care would quibble
with his assertion that medicine is powerless when a patient is dying, never-
theless the father of western medicine clearly articulated that there are limits
to what can be done and that physicians should be willing to just say no.
This Hippocratic admonition was assumed by physicians and accepted by
society for centuries. Until relatively recently, physicians took a paternalistic
approach to patient care:
This is whats wrong; this is what we need to do; lets go ahead and do it.
And conversely, they sometimes said, This will not work so we will not do
it. In the 1960s and 1970s, individual autonomy gained prominence in
western societyindividual rights, womens rights, minority rights, consumer
rights, and yes, patient rights. Patients rightly demanded a louder voice in their
own medical care, pursuing and establishing a patients right to refuse recom-
mended treatment. When the locus of decision making shifted at least partially
from physician to patient, many incorrectly thought that the patient could
not only refuse treatment but could also demand treatment. Only in this
autonomy-focused setting has the physicians right to refuse become an issue.

III. TWO KINDS OF PATIENT AUTONOMY

It is a common misconception that a patients autonomous right to refuse trans-

lates directly into a right to demand. But this is not so. Negative autonomythe
32 Robert D. Orr

right to refuseis nearly inviolable. There must be a very strong justification

for overriding a patients refusal. An example would be a young man injured
in a motor vehicle accident, sustaining a severe facial injury that threatens to
take his life if his airway is not immediately reestablished. If hypoxia and
panic cause him to physically resist intubation, it is ethically justifiable to
hold him down and insert an endotracheal tube over his objection in order
to restore his airway and save his life. Apart from such uncommon exceptions,
it is almost always unethical to override the refusal of even life-sustaining
treatment by a competent patient who has been adequately informed of the
consequences of refusal and has applied his or her own values in making
the decision to refuse. It is ethically permissible, sometimes obligatory, to
educate and try to persuade the refusing patient to accept critically needed
therapy, but it is only very rarely justified to impose it over his or her
refusal.
On the other hand, the case for positive autonomythe right to demandis
not nearly as compelling. The paradigm here is the professionals right to
refuse to provide a requested abortion if doing so would violate the profes-
sionals conscience. This right of refusal is well-established in US federal
law,4 state laws,5 and international law.6 In addition, this right of conscience
is upheld by several professional position statements, though with varying
positions on the physicians residual obligations to the patient.
The American Medical Association (AMA) says in its position statement on
abortion:
Neither physician, hospital, nor hospital personnel shall be required to perform any
act violative of personally held moral principles. In these circumstances, good medi-
cal practice requires only that the professional withdraw from the case, so long as
the withdrawing is consistent with good medical practice.7
The American Academy of Pediatrics (AAP) also supports the physicians
right of conscience, but with more clearly articulated limits: There are morally
important reasons to protect the individuals exercise of conscience even if
one disagrees with the content of the conscientious belief (AAP, 2009). The
AAP statement bases this right of conscience on the importance of personal
integrity and continues, they have a moral obligation to refer patients to
other health care professionals who are willing to provide those services
when failing to do so would cause harm to the patient. The AMA and the
AAP differ only slightly on whether and when the physician has an obligation
to refer. The AAP limits the duty to refer to those situations where the patient
would suffer harm if the service is not immediately available. The AMAs
right to withdraw when it is consistent with good medical practice is less
specific but amounts to a similar minimal limit.
In contrast to these position statements of professional organizations, some
individuals claim that professionals always have a duty to refer, or even have
an obligation to provide all legally available services, stating or implying that
 The Physicians Right of Refusal 33

a claim to a right of conscience should disqualify a professional from obtain-

ing a license to practice medicine. Alta Charo, an attorney and teacher of
bioethics at the University of Wisconsin, has written:
Should the public square be a place for the unfettered expression of religious
beliefs? . . . Until recently, it was accepted that the public square in this country
would be dominated by Christianity. ... Atheists, agnostics, and members of minor-
ity religions view themselves as oppressed ... Frustrated patients view conscience
clauses as legalized discrimination. She goes on to conclude ... [T]he states ...
give these professionals the exclusive right to offer such services. By granting a
monopoly, they turn the profession into a kind of public utility. (Charo, 2005, 24723)
Similarly, Julian Savulescu, Oxford philosopher, has written When the duty
is a true duty, conscientious objection is wrong and immoral. ... If people
are not prepared to offer legally permitted, efficient, and beneficial care to a
patient because it conflicts with their values, they should not be doctors. He
goes on to say, Conscientious objectors must ensure that their patients are
aware of the care they are entitled to and refer them to another professional.
... Conscientious objectors who compromise the care of their patients
must be disciplined (Savulescu, 2006, 294, 296). The stance of Charo and
Savulescu incorrectly grants a widespread right of refusal for patients but
denies any consideration of even negative autonomy for the health care
professional. This stance is defended by Rosamond Rhodes, Mount Sinai
(New York) ethicist and philosopher, based on social contract theory: the
covenant that empowers medicine is an agreement between society and the
profession (Rhodes, 2006, 77).
The conclusion of some of these objectors to the right of conscience is that
such physicians should not be allowed to practice medicine at all. Others
contend that a physicians right of conscience may allow him or her to refuse
to provide some treatments, but the physician still has an obligation to refer
the patient to someone who is willing to provide the service he or she
finds morally compromising. Lets look more closely at this supposed
duty to refer.

IV. THE SCOPE OF PHYSICIAN REFUSAL

There are at least five situations when I believe it is justifiable for a physician
to refuse a patients request for treatment. The first is based on a legal
standard. If a patient requests a prescription for a drug that has not received
governmental approval, the physician may, in fact, must, refuse to write the
requested prescription. For instance, if a patient is convinced that laetrile
might help his cancer, the physician should not prescribe this unapproved
drug and has no obligation to help the patient obtain the drug from another
country where it is legally available. No obligation to provide. No obligation
to refer.
34 Robert D. Orr

The second instance is based on a professional standard. If the requested

treatment is outside the bounds of professionally acceptable therapy for the
condition in question, the physician is under no obligation to provide it. For
example, if a patient who has residual neurologic deficit from a stroke that
occurred three years ago requests a referral for hyperbaric oxygen treat-
ments, the physician is justified in declining because this treatment is not
accepted by the profession of medicine as efficacious. This therapy is legally
available. And a few physicians may be willing to provide this type of ther-
apy for a patient with a completed stroke. However, since it has not received
a stamp of professional approval, the primary physician is under no obliga-
tion to help the patient find a willing physician. No obligation to provide. No
obligation to refer.
The third justifiable reason for refusal is a matter of clinical judgment. If
the physician knows the requested treatment is legally available and profes-
sionally acceptable, but he or she believes it is not in the patients best inter-
ests, there is no obligation to provide it. For example, if a patient who is sixty
pounds overweight asks his primary physician to sign a required insurance
authorization for bariatric surgery, but his physician believes he would be
better served with rigorous medical management of his obesity, thus avoid-
ing the risks and long-term sequellae of bariatric surgery, she is under no
obligation to sign the form. She may, however, know that another primary
physician has a lower threshold for such authorizations, and she might (or
might not), after sharing with the patient her reasons for declining to sign the
form, direct the patient to this other professional. She might even be willing
to provide an official referral. No obligation to provide the service (or sign
the authorization). No obligation to refer, but an allowance to refer if she is
not professionally uncomfortable with this degree of involvement.
The fourth situation is a matter of personal choice. A physician may have
chosen to restrict his or her practice. For example an orthopedic surgeon
may care for most orthopedic problems, but choose not to do spinal surgery,
or may even restrict his or her practice to a narrow part of orthopedics such
as hand surgery. Just because a physician is board certified in orthopedics
and licensed by the state to practice medicine does not mean that he or she
is obligated to provide a requested procedure that is outside his or her scope
of practice even if he is capable of providing that service. If he or she
believes the requested treatment is clinically appropriate for a given patient,
he or she should help the patient find a qualified and willing orthopedist. No
obligation to provide, but a clear obligation to refer.
The final situation, and the focus of our discussion here, is where the
requested treatment is legally permissible and professionally acceptable, but
participation would violate the physicians conscience. This represents the
professional expressing a right of conscience. The paradigm here is the
patient who requests an abortion; however, there are many other situations
where this might equally apply. Some health care professionals are unwilling
 The Physicians Right of Refusal 35

Table 1.Obligation to provide and obligation to refer

Reason for refusal Obligation to provide Obligation to refer
Legal standard None None
Professional standard None None
Clinical judgment None Optional
Personal choice None Obligation
Right of conscience None Optional

to participate in other gynecologic endeavors (contraception, sterilization,

assisted reproductive technology), end-of-life care (stopping life-sustaining
therapies, palliative sedation, lethal prescriptions), prisoner interrogation, capital
punishment, genetic research, and more.
Lets compare and contrast these five situations. Table 1 summarizes my
understanding of the obligation of the individual physician to provide and
the obligation to refer when he or she refuses a requested treatment based
on the five reasons for refusal I have outlined. How does the individual phy-
sician determine whether he or she should provide a referral in situations
where the refusal is based on clinical judgment or right of conscience?
In regard to refusals based on ones clinical judgment, the decision about
whether to refer or not will be determined by how strongly the physician
feels about the patient having or not having the requested treatment. Some-
times the physician may say, I am not comfortable authorizing this surgery,
but it you insist on having it even after hearing and understanding the rea-
sons for my unwillingness, then you should look elsewhere and I am willing
to direct you to a source that I trust. In other situations, he may say, I really
feel it would be unwise for you to have this procedure, and I am not willing
to compromise my standards to help you obtain it.
In regard to refusals based on the right of conscience, whether to provide
a referral will depend on the physicians perception of the degree of moral
complicity, that is, on the amount of moral culpability the physician would
feel if he or she were to facilitate the obtaining of a drug or procedure that
he or she believes to be morally wrong.

V. MORAL COMPLICITY

Some commentators on this issue, for example, Charo and Savulescu, have
concluded that professional refusal is justified only when it is based on a
legal or professional standard, that is, physician refusal should only be tolerated
if the action requested is illegal or professionally unacceptable. Physicians
who refuse based on their clinical judgment or their moral beliefs should not
be licensed or should be otherwise sanctioned.
Others, such as the AMA and the AAP, are more generous, allowing the
individual professional to refuse based on moral beliefs. However, many
who hold this position place various limits on the professionals right of
36 Robert D. Orr

conscience, for example, not justifiable in an emergency, requiring referral

to a willing professional, requiring the physician to give advance notification
to patients of his or her unwillingness to provide certain services, or even
requiring the professional with moral scruples to practice in close proximity
to another who is willing to provide the requested service.8
Many professionals find such limitations to the right of conscience to be
acceptable. In a large cross-sectional stratified survey of physicians in several
specialties, Farr Curlin and his co-authors found that 71% of physicians
believed that a physician who refuses a request for a legally available service
was obligated to refer the patient to a willing professional (Curlin et al.,
2007, 597). Even 56% of the physicians self-described as having high intrinsic
religiosity supported this obligation to refer compared with 82% of those
with low intrinsic religiosity. Though this represents a majority, does it mean
that the large minority is wrong? No, it means that different professionals
draw different lines for complicity in immoral actions.
Some professionals may have concluded that they are culpable of immoral
behavior only if they do the procedure themselves, for example, perform the
abortion, feeling no guilt for other layers of involvement. Others may feel
culpable for directly assisting (assisting in the operating room, filling a
prescription for an abortifacient). Still others may be unwilling to assist even
indirectly (sterilizing instruments that will be used for an abortion, checking
patients in at a gynecology clinic where abortions are performed). And some
may feel morally involved if they sign an insurance authorization for the
abortion, write a note of referral, instruct their office staff to make an
appointment for the patient at an abortion clinic, or even provide information
about where an abortion can be obtained. Comparable levels of involvement
(or noninvolvement) can be delineated for other actions/procedures that
raise the issue of moral complicity.
In addition, different professionals may be willing or unwilling to provide
a requested service based on the reason for the request. For example, some
physicians may be unwilling to perform (or refer for) any abortion, others
might participate if the womans life is threatened by the pregnancy, some
may be willing if the fetus has anomalies incompatible with extra-uterine
life, some for any fetal anomaly, and some for sex selection. On the other
hand, some physicians have minimal or no moral scruples about abortion
and would be willing to honor any request, even for what seems like the
convenience of the woman.
Why might different professionals draw different lines for their own
perception of moral complicity? I have previously proposed that many fac-
tors may enter into ones perception of moral complicity: timing, proximity,
certitude, awareness, and intent (Orr, 2003, 15). Similarly, others have
addressed criteria for moral culpability.9
Daniel Brock has written that since individuals, even from the same reli-
gious tradition, differ on what they believe is morally right or wrong, they
 The Physicians Right of Refusal 37

cannot all be correct (Brock, 2008, 189). Thus, he questions the basis for a
right to conscientious refusal, concluding that refusal can only be based on
the importance of the individuals moral integrity. He goes on to assert that
the medical profession as a whole does not have the unfettered autonomy
to exempt all of its members from having to provide a legally permissible
and beneficial service on the grounds that the profession ... had decided
that a particular service was deeply immoral (Brock, 2008, 193). He allows
individual professionals more space to protect their moral integrity based on
what he refers to as a conventional compromise that the physician is not
required to provide a service to which he or she has serious moral objection
if all of the following are in place: (a) prior notification, (b) obligation to
refer to a willing professional, and (c) the referral does not impose unrea-
sonable burden on the patient.
I am not convinced that his prohibition of blanket professional conscien-
tious refusal is justified. The AMA has taken a strong stance against physician
participation in capital punishment and has concluded that physician-assisted
suicide is fundamentally inconsistent with the physicians professional role.10
I support their authority to make such pronouncements. Physician involve-
ment in enhanced interrogation techniques is another issue on which it
seems reasonable to expect solid professional prohibition.11 Neither am I
convinced that Brocks conventional compromise is or even should be the
accepted norm as he claims. Though he admits I do not have, and so have
not provided, a full principled account of when the conventional compromise
should, and should not, be offered and available to physician/pharmacists,
he goes on to assert that state law should state clearly that any physician
who has a serious moral objection to providing a relevant and legal service
to one of his patients must meet the three conditions of the conventional
compromise (Brock, 2008, 194).
Brock continues with a discussion of moral complicity, recognizing that
there is relatively more complicity in referring than in informing. However,
he discounts the individual physicians concern about moral complicity since
the physician, he says, is obligated to discharge your professional obligation
to him or her. If the physician is unwilling, he or she should leave the
professional role that has these obligations (Brock, 2008, 198). Contrary to
Brocks willingness to assert that professional obligation trumps recognized
moral complicity, some elevate matters of conscience to a higher plane.
Daniel Sulmasy, physician/philosopher/ethicist at the University of Chicago,
clarifies that conscience is not an intuition (a still small voice) or a set of
feelings and is not to be confused with motives (Sulmasy, 2008, 1367). He
states that conscience involves a conjunction of will and judgment. At the
same time, conscience is not an infallible guide; moral error is still possible
through ignorance or through faulty reasoning, emotional imbalance, or
poor judgment. He states that judgments of conscience are prudential,
and he warns against unscrupulous claims of conscience (too lax) and
38 Robert D. Orr

scrupulosity (too strict) (Sulmasy, 2008, 142). While shaving off these two
extremes, he calls for tolerance based on moral realism and humility.
So Brock takes one polar position: follow his rules (which he has named
a compromise) or do not practice medicine. I take the contrary position:
concern about moral complicity is valid and persuasive; a physician should
not be legally or professionally required to participate in an action he or she
considers immoral. Is there a middle ground? Holly Fernandez Lynch, attorney/
bioethicist at the National Institutes of Health, has proposed what she calls
an institutional compromise (Lynch, 2008, Introduction). She suggests that
individual health care professionals right of conscience should be honored
and that the state licensing boards take on the responsibility of physician-
patient matching. At first blush, it seems unduly optimistic that this could
work, but she provides answers to objections and suggestions for policies
and statutes that just might allow it to work, still recognizing that there will
be some hard cases.
In arguing for his polar position, Brock offers some troubling examples.
He justifiably condemns a white physician who is unwilling to treat black
patients even in his part-time role in a public clinic and an emergency room
physician who newly accepts the Jehovahs Witness faith and thereafter ref-
uses to give blood transfusions to bleeding patients. Though these examples
could be perceived as straw men, they confirm his assertion that absolute
acceptance of a health care professionals statement that a certain action is
against his or her religious beliefs or personal conscience would not be
acceptable. In fact, some inappropriate claims of conscientious refusal have
likely fueled this debate, for example, the pharmacist who was not only
unwilling to fill a prescription for a morning after pill but also refused to
return the written prescription to the woman. There are other examples of
physicians who claimed the high ground of conscience when, in fact, their
refusal was based on personal distaste or immoral discrimination. Such egre-
gious decisions should not be allowed. Judgments about whether specific
instances are truly matters of conscience or not may occasionally be difficult.
These judgments should be made by professional bodies and should be
based on whether the belief in question is held by a recognized religious
tradition or philosophy.

VI. A RELIGIOUS RIGHT OF CONSCIENCE

In writing about the right of conscience in medicine, some authors frame the
issue as if it were unique to Christians (Charo, 2005, 2472). This is a distorted
view. Almost all religions have a moral code, some more stringent and pre-
scribed than others. In fact, the Christian moral code has many of the same
features as those of the other monotheistic faith traditions. Further, the Christian
moral code is not what distinguishes Christianity from other religions or
 The Physicians Right of Refusal 39

philosophies. It is the belief in the divinity of Jesus and His atoning work
that makes the Christian faith different from other faiths.
Perhaps it is my own familiarity with many strands of Christian faith and
my lack of familiarity with denominational differences in other religions, but
Christians are rightly recognized by Brock and others as having multiple
interpretations of their moral code. On issues like abortion, contraception,
reproductive technology, limitation of treatment at the end of life, use of
stem cells, and many others, there is a remarkable diversity of Christian
thought. This diversity of thought is not unique to the modern era. Those
men taught directly by Jesus, and filled with the Holy Spirit after His death
and resurrection, still had diverse beliefs about certain practices such as
circumcision. So, do we just throw up our hands and assert that anything
goes? No. Holy scripture does not always teach us what is right in every
circumstance. And, as Sulmasy has pointed out, individuals sometimes make
moral errors through ignorance, or through faulty reasoning, emotional
imbalance or poor judgment (Sulmasy, 2008, 137). In giving guidance how-
ever, scripture sets high standardsthat we should earnestly seek wisdom
and discernment (see, e.g., Proverbs 2). In addition, we are instructed that
we should Trust in the Lord with all of [our] heart and not lean on [our] own
understanding (Proverbs 3:5, New International Version).

VII. CONCLUSION

Physicians and other health care professionals may, on occasion, refuse some
patient requests on legal, professional, clinical and personal grounds. They,
like patients, are moral agents and may in addition conscientiously refuse to
be involved in actions they consider to be immoral. This latter claim is not
open-ended and absolute but may be constrained by denominational beliefs
and by professionally established boundaries such as those proposed by the
AMA and the AAP. The exact boundaries of allowable conscientious refusal
remain imprecise and should be adjudicated by the medical profession rather
than being legally imposed.

NOTES

1. The rights of conscience we never submitted, we could not submit. We are answerable for them
to our God. Notes on Virginia, Q.XVII, 1782. No provision in our Constitution ought to be dearer to man
than that which protects the rights of conscience against the enterprises of the civil authority. Speech to
New London Methodists, 1809.
2. The Civil Rights of none shall be abridged on account of religious belief or worship, nor shall
any national religion be established, nor shall the full and equal rights of conscience be in any manner,
nor on any pretext infringed. No state shall violate the equal rights of conscience or the freedom of the
press, or the trial by jury in criminal cases. First draft, June 1, 1789.
3. Congress shall make no law respecting an establishment of religion, or prohibit the free exercise
thereof. Final draft, September 1789.
40 Robert D. Orr

4. The so-called Church Amendment, part of the Health Programs Extension Act of 1973, Pub. L.
No. 93-45.
5. Forty-five states have statutes that address the right of conscience.
6. European Convention on Human Rights, Article 9.
7. AMA position statement H-5.995, Abortion.
8. The American College of Obstetricians and Gynecologists makes such a claim in its 2007 position
statement no. 385 (The Limits of Conscientious Refusal in Reproductive Medicine): in resource poor
areas, physicians who are unwilling to provide full reproductive services should practice in proximity to
individuals who do not share their views or ensure that referral processes are in place.
9. See, for instance, Keenan and Kopfensteiner (1995) or Grisez (1997).
10. AMA policy H-140-952 Physician Assisted Suicide.
11. For example, see Seltzer (2010).

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