Conscientious objection in health care: A principlism-based compromise position

Conscientious objection (CO) is a complex topic of great clinical and philosophical importance which recently came again under fire. Both the so-called absolutist and pro-choice extreme positions (pro and against CO, respectively) cannot stand up to arguments. Moreover, there is not satisfactory compromise position between the conflicting rights.

The conflicting claims (objectors' and patients') are (almost) equally strong and as such should be accommodated at the same time, when the following conditions are met: objectors' claims are entrenched in society, no anti-democratic values are manifested, and patients' claim is incontestably de lege lata legitimate. The judgment about the de lege lata legitimacy of any given patient's claim should result from the dynamic process of an ongoing dialogue in accordance with the rawlsean "reflective equilibrium" held against a background of shifting sand: people change, medicine changes, society changes. The dialogue should be informed by the ongoing universal dialectic between absolutism and relativism. In accordance with the principle of mutuality, the state and other involved stakeholders (i.e. institutions) have the moral obligation to investigate all the "alternative options and circumstances" under which the conflict can be eliminated, circumvent or a true compromise can be achieved. With this path locked, the conflicting parties should find a fair mutual concession accommodating both the conflicting claims to the greatest extent possible, at the same time. Both the conflicting parties are placed under the obligation to tolerate a "reasonably" minimal harm. This may be the case with referral obligation. If an objective (not personal) referral obligation would be recognized the right to CO would be limited without, however, losing its core physiognomy, provided that the right to CO is a flimsy subjective right that is structured like a molecular aggregation. Besides, a very low amount of wrongness can be conferred upon the act of referral. Who makes it is an in-the-rear-actor in a "wrongdoing" which, in addition, is preparatory act of the principal moral wrongdoing.

On the basis of the bioethical principle of mutuality the paper provides a proposal in two steps for obtaining a normatively reasonable (if not true) compromise position.