Five main topics emerged and will be presented in some detail: 1) carrying out conscientious objection in practice, 2) justification for conscientious objection, 3) challenges when relating to colleagues, 4) ambivalence and consistency, 5) effects on the doctor-patient relationship.
How conscientious objection is carried out in practice
Among the respondents two main approaches emerged. The first group of GPs attempted to prevent all consultations with women seeking abortion from taking place. This they did by having their secretaries schedule all such consultations for one of the GP’s colleagues. The colleagues in question had explicitly agreed to this general arrangement.
For this first group of GPs the issue of referral for abortion nevertheless sometimes came up in the consultation, mainly because not all patients disclose their agenda to the secretaries. In such cases the GPs then immediately conveyed that they would not refer for abortion. The GPs expressed this in different ways, but were united in placing the emphasis on themselves, rather than on the (morality of) the act of abortion or factors pertaining to the patient. The GPs told the patient that they were unable to comply with the patient’s request for a referral. These GPs would then help patients set up an appointment with a colleague.
In this first group, only one GP had openly declared his conscientious objection in the local community. Subsequently this doctor had not had any consultations where a referral for abortion was requested. An additional two doctors had gained acceptance for their practices by the municipality at the time of appointment.
The second group of GPs wanted to have the consultations with the women requesting referral, and the doctors did nothing to prevent these consultations taking place. These GPs performed the physical examination, history taking, and gave information, but ultimately would not provide the referral itself. One doctor would immediately inform the patient that she would not provide the referral, whereas the others in this group did not convey their refusal before the end of the consultation. The doctors in this group expressed their refusal in ways similar to the first group. The patients were then informed about how to obtain a referral; typically the GP would arrange for contact with a colleague, who would then refer the patient.
Two of the informants in this second group worked in areas where the local gynecological department did not require a referral for abortion, but could accept patients directly. One of these GPs nevertheless made a point of stating to patients that she could not provide a referral. The other GP only disclosed her objection in the case that the patient requested referral documents. This GP maintained that her objection would be considerably more practically difficult in other parts of the country where a written referral is required.
Several of the informants pointed to another possible solution: a written statement that the patient was pregnant, as an alternative to a referral letter. The patient could then bring this statement to the gynecological department. These informants saw this alternative as morally preferable to writing a referral – a practical compromise that would satisfy both the patient’s rights and needs, and the GP’s own need for not contributing in the abortion process in a morally problematic way. However, none of the informants used this method more than sporadically.
Common to all informants was the emphasis on not unduly obstructing the fulfilment of the patient’s legal right to abortion. The informants also claimed that the requests for referrals for abortion were uncommon occurrences in their practices. With one exception the doctors had not informed their constituency about their objections, and neither did they see any need for this.
Justification for conscientious objection, and associated emotions
Not contributing to taking a life
The informants maintained that unborn human life has moral value. Some explicitly stated that the embryo is valuable from conception. One informant’s expression was representative: ‘Human life is something very special, and we humans are not granted the option of taking a life’. All informants rooted this view at least partly in their Christian faith. Some also invoked the ethics of the profession: ‘I want to contribute to improving people’s lives, and to helping, soothing and comforting. Then it becomes self-contradictory to take lives’. Referral for abortion was portrayed as active participation in the process that leads to abortion. The informants emphasized the need to take responsibility for their own actions and contributions. Some informants had been opposed to abortion from their youth, whereas others had gradually changed their view of abortion towards a principled opposition. Similarly, some had refused to refer for abortion all through their careers as GPs, whereas for others the felt need to object had emerged gradually.
Unable to refer
Several described an inability to refer for abortions. If referrals had been demanded of them, these informants stated, they would not have been able to carry on as GPs. Some pointed to the importance of colleagues who could handle this task for them, and stated that they could not have been a GP in a rural setting without such colleagues. Two stated that they had referred on a few occasions, and that this lead to bad conscience and feelings of guilt. One said of this: ‘It felt like contributing to murder, in addition to breaking my own principles’. Two informants stated that they had previously lacked courage to refuse, but then had found that they could not handle referrals. One informant’s statement shows how the objection typically is tied to a Christian faith: ‘I am into spiritual counselling, I pray a little for people. I often place the hand that I write with on those I pray for. And then at one time it became clear that – I cannot sign this death sentence with the same hand that I use to bless’.
Being true to oneself
Informants maintained that having the opportunity to refuse referrals for abortion allowed them to be themselves. This was of great importance for most of our respondents. As one GP put it:
[The patients] meet actual persons during consultations. Being a doctor has a lot to do with the meeting between two or more people, and many come to you because you are the doctor […] personality is part of the package when you see the GP. And I also believe they want someone who talks back to them. I think it’s wonderful to be able to be allowed to be a whole person, to be allowed to be myself with my opinions.
Several also pointed out that patients appreciate that the GP is present with their own views and personality, and that patients profit from the GP giving his earnest view, sometimes also providing a little resistance. Several informants pressed that their refusals were not about communicating a stand against abortion, but were for the sake of protecting themselves and their own integrity. One GP stated:
With what I do, I do not have any missionary work in mind, I only have the thought of being able to survive as a doctor and a whole human being. My conscience is not a dress that I can put on or take off whenever I want to. My conscience must be there all the time, as a ballast, for me to remain a whole human being.
Uncertainty and respect for the choices of colleagues
Several stated that they were less than entirely comfortable with their chosen practice of refusals. Typically it was not seen as unproblematic, neither practically nor morally. A typical statement was, ‘There are many ways to do this, and I respect colleagues who choose differently’. Some also pressed that they were open to re-examining their current practice of refusals.
Inability to be neutral
Among the informants who avoided consultations with women seeking abortion, some stated that they would have liked to discuss the patient’s choice and options with them; however, the informants feared their opposition to abortion would preclude a stance of neutrality necessary for counselling. These informants thought that explaining their objections at the outset of a consultation and subsequently ending the consultation was necessary to avoid the impression of a moral condemnation of the patient.
The informants who performed the consultations with the women requesting abortion also thought it problematic to actively influence the patient’s choice. Rather, they described their role as aiding the patient in the decision-making through discussion and providing information. One informant said that he sometimes explained about fetal development, but would treat the topic sensitively, in order not to influence unduly. In addition, these informants thought that their potential influence on the patient’s decision was rather limited.
Some of the informants were careful to express respect towards the patient’s choice in the interviews. One said, ‘Even though I have a clear opinion about what I think is best, I feel humility towards the woman’s difficult choice. It is complex and in a way impossible’. Having to make such a choice was perceived to be very difficult.
Relations to colleagues
The informants found their relations with their local gynecological departments to be unproblematic. As for their GP colleagues, the informants all had experienced understanding and respect for their views of abortion and their refusal practice. Even though some colleagues had spoken critically of conscientious objection in the media, our informants had not experienced negative reactions from colleagues they cooperated with daily. Two of the informants stated that their conscientious objection had been an entry point to good conversations with their colleagues about ethical dilemmas pertaining to abortion. The informants had all found colleagues who were willing to take over the consultations with the patients requesting abortion.
The informants were asked whether they saw their refusal practice as morally consistent. Informants saw challenges to their consistency along three axes: the reason for abortion, other issues regarding early human life, and degrees of cooperation in referral.
The reason for abortion
Most, but not all the informants agreed that the reasons underlying the abortion request mattered for their refusal to refer. These informants would have referred for abortion in cases of rape or incest, or when the mother’s life was in danger, and sometimes in other cases as well. One stated, ‘I referred to abortion for a woman who had two handicapped children from before. Her situation was so overwhelming, and to me it outweighed my own conscience’. Another stated, ‘I referred a young woman with an incredibly difficult social situation. This gave me feelings of guilt and was a violation of my principles, but I thought that referring this woman was something I had to do’. Some also stated that even though they would not want to partake in abortion themselves, they were in favour of the current abortion law which allows abortion on demand up to pregnancy week 12.
Only one informant stated that the reason for the abortion request would almost not influence his willingness to refer. He stated, ‘pregnancy due to rape would give me greater anguish than regular pregnancies, but I do not think I would have been able to refer. I think that life is sacred and inviolable, I have to take the consequences of this, and I am able to do that in 99 per cent of cases’.
Other issues regarding early human life
Several of the informants emphasized that abortion belongs in a spectrum of moral issues regarding early human life. Some thought that full consistency would require conscientious objection on other issues as well, such as prescribing contraceptives that may have post-fertilization effects, and referrals for in vitro fertilization in which spare embryos are created. However, most informants did not refuse in these cases. Their inconsistency was, however, perceived to be a necessary compromise. One GP stated:
I am not entirely principled or consistent in my actions. I prescribe contraceptives, and most of them can lead to abortions, even birth-control pills and hormonal IUDs. I have found a compromise I can live with. If you are to be truly principled, it is in reality incompatible with being a GP. (…) If I were to object to IUDs, I had to object to the pill and other contraceptives as well, and that would be a bit too much. I have used the pill myself, and I think it would be contradictory [to oppose it]. If I object to contraceptives, then the women would have to return for an abortion a few weeks later.
One informant would refuse to refer for assisted reproduction for same-sex couples. But this was a decision he would be willing to reconsider, stating that ‘that argument does not run so deep with me’. Other informants did not think that their practice involved ethical inconsistency.
Degrees of cooperation in referral
Several informants reflected on the moral value of their chosen way of objecting to referrals. Did the actions they took to ensure that the patient’s right to treatment was fulfilled (e.g., ensuring that the patients were seen by colleagues) implicate the informants in morally culpable cooperation? Informants had no definitive answer to this. A typical statement was,
Then there is the question of where the line goes for what one ought or ought not to do. With the two or three I have had I have said that they can go to the gynecological ward without a referral letter. I could have refrained from saying that. (…) It is really an artificial line – I have put the line at not signing my name.
Burdens to patients and challenges to the physician-patient relationship
Refusal to refer as a potential rejection of the patient
A few GPs thought that their refusals could be experienced by the patient as a kind of rejection, causing disappointed patients, and perhaps damaging the doctor-patient relationship. One GP stated:
It is a problem, it does something to the relation with the patient – that I do not provide care fully, I feel that (…) I fail them a little bit in not taking part in the entire course – this is something that is harmful for the physician-patient relationship.
The informants assessed that physician-patient relations in the majority of cases had not been negatively influenced by the GP’s refusal. The informants all thought that it was unproblematic for them to relate to the patients concerned in future consultations. A few stated that they treated some of these patients for post-abortion grief in the aftermath of the abortion.
Some informants also stated that it is of the nature of the GP’s job to sometimes decline the patients’ requests. For instance, requests for certain diagnostic procedures, referrals, or sick leave certificates must sometimes be turned down. One GP stated, ‘As a GP … people come to us with many wishes we cannot fulfil, asking for sick leaves (…) and it is [often] completely out of the question. That is also a rejection.’
Furthermore, a few informants also stated that they had experienced understanding and acceptance for their attitude towards abortion referrals from the patients concerned. One stated, ‘I think people here have great respect for the fact that people have opinions. That is my explanation for why I have not encountered greater resistance’.
An established physician-patient relationship as a safeguard against the experience of rejection
Several informants pressed the point that a well-established and long-running physician-patient relationship would make the GP’s refusal to refer easier for both doctor and patient. One GP stated:
Our advantage [as GPs] is that we know patients for years. We have built a relationship in advance, which does not break just because of something that is not quite perfect. Refusals will be harder with a patient you do not know.
Some GPs said they had discussed just about everything with their patients, so a refusal to refer would not really mean a rejection. One GP stated that she was sure that a patient she had known for years saw her refusal as ‘just a parenthesis’ in their relationship.
Burdens to patients
Apart from the potential experience of rejection, mentioned by some informants, the informants did not think that their refusals led to burdens of significance for patients. One emphasized that although the patients do not receive the referral they want from their GP, they do receive proper health care as defined by the law, through being referred from another GP or being able to contact the gynecological ward directly. One informant stated, ‘I do not think my practice here is any more blameworthy than that I am not up-to-date on all medical fields at all times – which I cannot be as a doctor’. Speaking of a particular patient, the informant said: ‘If one views it as objectively as possible then I do not think she has suffered any burdens – the only potential burden must be to hear that others have different views on the principled aspects of her choice’.