Quotas: Enabling Conscientious Objection to Coexist with Abortion Access

Abstract

The debate regarding the role of conscientious objection in healthcare has been protracted, with increasing demands for curbs on conscientious objection. There is a growing body of evidence that indicates that in some cases, high rates of conscientious objection can affect access to legal medical services such as the abortion—a major concern of critics of conscientious objection. Moreover, few solutions have been put forward that aim to satisfy both this concern and that of defenders of conscientious objection—being expected to participate in the provision of services that compromise their moral integrity. Here we attempt to bring some resolution to the debate by proposing a pragmatic, long-term solution offering what we believe to be an acceptable compromise-a quota system for medical trainees in specialties where a conscientious objection can be exercised, and is known to cause conflict. We envisage two main objectives of the quota system we propose. First, as a means to introduce conscientious objection into countries where this is not presently permitted. Second, to minimise or eliminate the effects of high rates of conscientious objection in countries such as Italy, where access to legal abortion provision can be negatively affected.

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https://doi.org/10.1007/s10728-020-00419-5
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ORIGINAL ARTICLE
Quotas: Enabling Conscientious Objection toCoexist
withAbortion Access
DanielRodger1 · BruceP.Blackshaw2
Accepted: 11 November 2020 / Published online: 19 November 2020
© The Author(s) 2020
Abstract
The debate regarding the role of conscientious objection in healthcare has been pro-
tracted, with increasing demands for curbs on conscientious objection. There is a
growing body of evidence that indicates that in some cases, high rates of conscien-
tious objection can affect access to legal medical services such as abortion—a major
concern of critics of conscientious objection. Moreover, few solutions have been put
forward that aim to satisfy both this concern and that of defenders of conscientious
objection—being expected to participate in the provision of services that compro-
mise their moral integrity. Here we attempt to bring some resolution to the debate by
proposing a pragmatic, long-term solution offering what we believe to be an accept-
able compromise—a quota system for medical trainees in specialties where a con-
scientious objection can be exercised, and is known to cause conflict. We envisage
two main objectives of the quota system we propose. First, as a means to introduce
conscientious objection into countries where this is not presently permitted. Sec-
ond, to minimise or eliminate the effects of high rates of conscientious objection in
countries such as Italy, where access to legal abortion provision can be negatively
affected.
Keywords Conscientious objection· abortion· rights· quotas· professional
obligations· pregnancy
Introduction
The protracted debate regarding the role of conscientious objection in healthcare has
recently intensified [5, 10, 21–23, 36, 45, 51], and there have been few practical
solutions suggested likely to satisfy both opponents and proponents of conscientious
* Daniel Rodger
daniel.rodger@lsbu.ac.uk
1 School ofHealth andSocial Care, Allied Health Sciences, London South Bank University, 103
Borough Rd, LondonSE10AA, UK
2 Department ofPhilosophy, University ofBirmingham, BirminghamB152TT, UK
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objection. One of the primary concerns of opponents to conscientious objection is
ensuring that eligible patients have access to legal medical services that they need
or request. They see conscientious objection as an obstacle to this, and consequently
believe the right to conscientious objection should be removed [19, 50]. Conversely,
conscientious objectors typically have deeply held moral beliefs regarding cer-
tain services such as abortion, and do not wish to participate in their provision. Of
course, supporters of a right to conscientious objection are not necessarily objectors
themselves, but they are still concerned that those who do wish to object are able to
do so.
Our contention is that in a liberal society, the right of healthcare professionals
to conscientiously object to their involvement in the provision of certain healthcare
services such as abortion is of considerable value, both to themselves, and to the
healthcare system in general. However, if the proportion of objectors in the health-
care system is sufficiently high, the provision of these legal services could be com-
promised. We believe it is important that both of these competing concerns should
be accommodated. If a viable solution does not emerge, it seems likely to us that
the debate will grow increasingly entrenched, and current demands for curtailing
or removal of existing conscientious objection freedoms are likely to grow stronger.
Therefore, we have developed a pragmatic long-term proposal for a conscientious
objection quota system that we believe can, to a large extent, minimise these con-
cerns. It is intended primarily for use in two different contexts.
First, where the effect of conscientious objection is raising what seem to be genu-
ine concerns regarding service provision. For instance, in Italy it has been argued
that the high proportion of healthcare professionals who are conscientious objec-
tors to abortion is in some cases, hindering access to abortion. If this impact can be
convincingly demonstrated, the introduction of quotas would serve to limit the num-
ber of medical trainees with a conscientious objection to involvement in the provi-
sion of abortion services in specialties such as obstetrics, gynaecology, and general
practice.1
Second, in countries where conscientious objection is not currently permitted,
quotas could be used to help open up certain specialties to those whose moral beliefs
currently mean they are unable to consider these areas for potential employment.
Importantly, for critics of conscientious objection, this would come with little risk
of compromising access to those services if the quota remained low and was care-
fully regulated. One rationale for the introduction of conscientious objection in this
context would be to alleviate staff shortages without compromising patient care.
Another is to accrue the more general benefits of permitting conscientious objec-
tion that we will outline. We believe this is a novel proposal that has the poten-
tial to resolve much of the current deadlock, satisfying the concerns of the majority
of those involved in the debate. Importantly, our proposal provides a path in these
countries to bring individuals into specialities and professions such as obstetrics and
1 Whether or not this could be expanded to other healthcare professions or specialties is outside of the
scope of this essay. In principle, providing there is strong enough evidence that patients’ access to a legal
service is being compromised, then the wider use of quotas to ensure access may be indicated.
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midwifery, who at present feel they have no place in that profession because of their
moral beliefs and their inability to conscientiously object.
In countries where conscientious objection is permitted but is not currently
known to be compromising access to abortion services, our proposal will also serve
to moderate calls for its removal, by providing a viable alternative should it be
required. However, we believe the implementation of quotas must be predicated on
robust evidence that shows that legal access to abortion services is being impacted
by high rates of conscientious objection.
State oftheDebate
The volume of philosophical and medical discourse on conscientious objection
has increased rapidly in the last few years, [55] and grown increasingly intractable,
particularly regarding abortion provision. Certain ethicists have strongly rejected
any accommodation of conscientious objection. For example, Christian Fiala and
Joyce H. Arthur have described conscientious objection as ‘dishonourable disobe-
dience’ and ‘an abandonment of professional obligations to patients’ [19]. Along
similar lines, Udo Schuklenk and Ricardo Smalling assert that ‘medical profes-
sionals have no moral claim in liberal democratic societies to the accommodation
of their individual conscientious objections’ [54]. In the context of assisted dying
Schuklenk [53] espouses what Mark Wicclair calls the ‘incompatibility thesis’, [60]
whereby conscientious objection is understood to be incompatible with professional
obligations.
One of their main stated concerns is that the right to conscientious objection may
limit access to certain medical services [19, 54]. Another is the suspicion that some
conscientious objection claims are not genuine but are used to avoid any perceived
stigma or have other motivations rooted in self-interest [34]. Conversely, those in
favour of conscientious objection typically have moral beliefs regarding certain pro-
cedures such as abortion—euthanasia and assisted dying—and do not wish to com-
promise their consciences by being required to participate [6, 7].
There have been numerous attempts to develop criteria for determining what
conscientious objections should be permitted. Rawlsian public reason has been pro-
posed as one possible path: Robert McConnell and Robert Card’s public justification
approach requires reasons to be presented for evaluation according to a comprehen-
sive set of criteria [42]. The use of medical tribunals has also been put forward to
distinguish between justified and unjustified conscientious objections [32].
Savulescu and Schuklenk believe that conscientious objections should not be
permitted for procedures within the scope of professional practice [51]. Toni Saad
and Gregory Jackson argue that practices should conform to the norms of medicine,
chief of which is the restoration of health. Medical practices that are not aimed at
the restoration of health can therefore legitimately be objected to [49]. Others have
argued that any acceptable conscientious objection must balance the patient’s inter-
ests and the preservation of the health professional’s moral integrity [40]. David
Oderberg has suggested objections may qualify if there is a ‘history of dispute
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between recognised bodies of thought or over which reasonable people have disa-
greed or could disagree’ [47].
The difficulty with these approaches is that they do not address the primary con-
cerns of all the involved parties. Often enough, those who are opposed to conscien-
tious objection do not wish to see any procedures denied, irrespective of criteria that
might limit the scope of objections. Some are suspicious that individuals may lie or
exaggerate their beliefs [19] or base their objections on idiosyncratic or discrimina-
tory beliefs [50, 62]. These concerns are not unfounded—for instance, there have
been reports of doctors refusing to provide abortion services on grounds other than
legitimate conscientious objection [37], such as because of stigma or financial impli-
cations for their private practice [13].
For those who conscientiously object to involvement in abortion provision, the
prospect of having to meet certain criteria or publicly justify their objections is con-
cerning. If their objection does not qualify, they are placed in the difficult position
of having to comply or submitting to whatever penalty is mandated. Ultimately, they
may have to leave their position.
We believe a compromise is required. Ideally, opponents to conscientious objec-
tion need to agree that healthcare professionals should not be required to participate
in or provide services that they strongly believe to be morally objectionable—not a
major concession as long as service provision is unaffected, except perhaps for the
most strident opponents. However, advocates of conscientious objection also need to
agree that the practice should not prevent patients from receiving services they are
legally entitled to receive. If it can be shown that provision is being compromised,
they need to be willing to accept some restrictions to alleviate this. If their right to
object is to be maintained, then there needs to be a path to reducing the number of
objectors to levels where provision is no longer affected. We believe our quota sys-
tem meets these requirements. Before we explain the details, we will first examine
the current impact of conscientious objection on abortion services—one of the pri-
mary concerns of opponents of conscientious objection.
Is Conscientious Objection Aecting Abortion Provision?
At least 22 countries in Europe permit conscientious objection through regulation
[8], and in those with low prevalence of conscientious objection there is little evi-
dence that the provision of abortion services are being compromised. In England,
Portugal, and Norway where abortion is legal, it is generally accepted that access to
legal abortion is not compromised by permitting individual clinicians to exercise a
legal right to conscientious objection [8]. However, accurate data on the actual num-
ber of conscientious objectors in many countries remains scant and remains an area
requiring further research. A survey of 131 obstetrics and gynaecology trainees from
the United Kingdom (UK) in 1998 showed that 31% were conscientious objectors to
abortion in the first trimester, although 88% of the trainees would participate in an
abortion for fetal abnormality [48]. This adds an additional complication, because in
some cases a self-identified conscientious objector may still provide some abortion
services.
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A more recent study from Ghana provided a more detailed picture of the preva-
lence of conscientious objection from a sample of 213 healthcare practitioners [3].
The study found that 37.9% of the trained abortion providers self-identified as con-
scientious objectors. Interestingly, very few of the study’s participants—physicians,
midwives, nurses, and physician assistants—wanted to penalise conscientious objec-
tors, although a significant proportion of respondents supported increased regulation
that included mandatory confidential registration of objectors [3]. In a cross-sec-
tional survey of midwives in Ethiopia, over 25% of the 188 sampled were unwilling
to provide abortion services [30].
The situation in Italy is frequently cited as an example of where a high prevalance
of conscientious objection is compromising abortion provision [43]. Data from the
Italian Ministry of Health shows that close to 70% of Italian gynaecologists and over
50% of anaesthetists exercised their right to conscientious object to abortion, as well
as a significant percentage of non-medical staff, and this proportion has increased
over the last decade. Furthermore, in Italy, only 60% of hospitals with gynaecology
and obstetrics services provided abortions, and it has been stated that this is due
to the normalisation of conscientious objection [8]. The circumstances in Italy led
to the International Planned Parenthood Federation in 2012 and the Italian General
Confederation of Labour in 2013 to file claims with the European Committee for
Social Rights (ECSR) [15, 16]. In both cases the ECSR ruled that Italian women can
experience barriers and discrimination when seeking access to abortion services and
that the measures to ensure access are currently inadequate.
The Italian government disputed these conclusions on empirical grounds and
has stated that they cannot limit the number of medical personnel whilst respecting
freedom of conscience without contravening Article 9 of the European Convention
on Human Rights [17]. The Italian Committee for Bioethics subsequently argued
that despite the high numbers of conscientious objectors the available data does not
show that abortion provision is negatively affected [33]. For instance, in some Ital-
ian regions, the number of conscientious objectors increases while waiting times for
abortions decrease. Conversely, in other regions the number of objectors decreases
and waiting times increase. Bo etal. have responded by arguing that the commit-
tee’s approach is methodologically flawed, and that the data is insufficient to exclude
a causal relationship between the number of conscientious objectors and waiting
times, and that more research is required [5]. However, more recent evidence has
shown that the high rates of conscientious objection in Italy can compromise access
to abortion provision at the local level—affecting waiting times, travel distances,
and requiring many women in Italy to obtain an abortion in a different region [1].2
To summarise, there is evidence for a link between conscientious objection and
compromised access to abortion services, but it is limited to areas where levels of
conscientious objection are very high.
2 Nevertheless, the relationship between conscientious objection and abortion remains complex, and the
limitations of the study by Autorino etal. [1] show that the picture remains incomplete.
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Conscientious Objection Trends
Pressure is being exerted from various quarters with the curtailment of conscien-
tious objection as a goal. One example can be found in a 2018 report—produced
by an expert group of 45 activists, health professionals, academics, and lawyers
from 22 countries—called ‘Unconscionable: When Providers Deny Abortion
Care’ [59]. The contributors argue that the term ‘conscientious objection’ is a
misnomer that is more accurately characterised as a ‘refusal to provide services’
and should not be permitted [59]. There are several European countries such as
Sweden, Iceland, Finland, the Czech Republic and Bulgaria which do not permit
conscientious objection, and are often used as exemplars to demonstrate that con-
scientious objection is unnecessary [19, 26, 44, 59].
More concerning for supporters of the right to conscientiously object are the
laws being passed in countries that have recently decriminalised abortion. The
Australian states of Queensland and New South Wales have recently done so,
as has Ireland and New Zealand. In all these cases, conscientious objectors are
legally required to refer patients to another healthcare professional. This is prob-
lematic for objectors, because as Thomas Finegan has pointed out, referral is still
material cooperation: ‘the obvious, foreseen side effect of her making the referral
is that her patient’s plan to abort is aided in a significant way’ [20]. In the United
Kingdom, a 2014 Supreme Court judgement defined participation in a narrow
sense, so that medical staff working in ancillary or administrative roles who
object to abortion must still arrange abortions. The judgement also stated that the
conscientious objector is ‘under an obligation to refer the case to a professional
who does not share that objection’ [25]. During 2014, the Norwegian govern-
ment attempted to strengthen conscientious objection rights by permitting GPs
to refuse referrals. Popular protest ensured that the changes were withdrawn [8].
Similar issues are being encountered in countries which are legalising eutha-
nasia and assisted suicide. Typically, conscientious objection provision is written
into the laws or regulations for a specific procedure such as abortion, giving an
opportunity for different conscientious provisions to be employed for euthanasia.
For example, in Canada, the 2016 law regarding medical assistance in dying does
not mention conscientious objection. Physicians are not compelled by this law to
be involved, but they may be required to do so by other regulations. For example,
the College of Physicians and Surgeons of Ontario dictates that physicians must
provide the patient with an effective referral [9]. Similarly, in Maine in the United
States, the recent Maine Death with Dignity Act obliges physicians to provide
patients with information regarding assisted suicide, and ‘do everything prepara-
tory to the actual prescription of lethal medication’ [41].
Thus, the primary way conscientious objection rights are being eroded in var-
ious jurisdictions is when new legislation is enacted to legalise what was pre-
viously an illegal practice—usually abortion, euthanasia and assisted dying.
Because conscientious objection provisions are tied to specific procedures, when
this occurs there is a new opportunity to restrict the exercise of conscience. This
is not ubiquitous—for example, in Victoria, Australia, the conscientious objection
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provisions in the Voluntary Assisted Dying Act 2017 are strong. The Victorian
law is, however, very much the exception in a growing trend.
Why Keep Conscientious Objection?
Given the trend towards gradually curtailing the right to conscientiously object in
numerous countries, a question worth posing is why conscientious objection should
be maintained at all. If it does have the potential to compromise access to legal ser-
vices such as abortion, then the simplest solution would seem to be to eliminate
conscientious objection altogether. The numerous commentators we have cited who
describe conscientious objection in disparaging terms [19, 53] certainly imply this is
their preference—and some explicitly call for its removal altogether [18, 51]. Doing
so would avoid any economic investment and the resources required to establish the
quota system that we propose. As an anonymous reviewer suggests, it may be that
the resources required for these activities could be better spent on actual healthcare
provision. Similarly, Schuklenk and Smalling state that there is no reason that ‘any
healthcare system should burden itself, and ultimately patients, with these sorts of
logistical problems when there is an obvious, more efficient alternative: saying no
to the conscience-based accommodation requests of healthcare professionals’ [54].
There are, however, several reasons why permitting conscientious objection is
desirable. Firstly, as Mark Wicclair states, if a healthcare practitioner is forced to
provide services contrary to their core moral beliefs, their moral integrity is compro-
mised—and our moral integrity can be extremely important to us [61]. Critics may
reply that if performing certain legal medical services violates a practitioner’s moral
beliefs, then they should choose a different profession, but this fails to acknowledge
that the legality of certain procedures may change during the course of someone’s
career. For example, in 2007 Mexico City decriminalized abortion, and Ireland did
so in 2018. Requiring all healthcare professionals who object to involvement in abor-
tion services to leave the profession once it is decriminalised seems unfair if there
was no possibility of their involvement when they first trained for their profession.
Secondly, an uncompromising position on conscientious objection may result in
staff shortages by discouraging entry into certain healthcare professions. For exam-
ple, Sweden does not permit conscientious objection, despite having a chronic short-
age of midwives for several years [28, 29]. In some cases, women have had to travel
up to 200 km to give birth due to the closure of several maternity units [31].3 In
2017 two Swedish midwives filed complaints with the European Court of Human
Rights in Strasbourg after being denied employment to practice there. This resulted
in one of the midwives commuting to Norway where she was free to work and exer-
cise a right to conscientious objection [52]. It is worth noting that abortion provision
constitutes very little of the work of a midwife in Sweden—one study has shown
that 35% of midwives had never provided any abortion care [38].
3 This has been shown to negatively affect the health of mothers [2].
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Finally, Morten Magelssen argues that moral integrity is part of the common
good and is a particularly important quality for healthcare professionals. He points to
past atrocities in medical history which might have been prevented if those involved
had been more willing to object [40]. We have previously described how even critics
such as Savulescu and Schuklenk concede there are situations where healthcare pro-
fessionals must act on their conscience [4]. It is also conceivable that in the future,
some practices that are currently legal may come to be regarded negatively and
eventually be banned, and conscientious objection may be an important part of that
process.4 Holly Fernandez Lynch adds that prohibiting conscientious objection is
likely to reduce diversity in the healthcare profession, which is valuable to patients
[39]. She also suggests that if the right to object on moral grounds is prohibited, this
may contribute to public distrust of the healthcare profession [39].
Complete removal of conscientious objection, therefore, may harm individual
healthcare professionals, result in staff shortages in some areas, and make it more
likely that practices that are subsequently judged to be unethical are tolerated by the
healthcare community.
Introducing Quotas
Given the benefits of permitting conscientious objection, there seems to be no jus-
tification for its removal in countries where it has no discernible impact on abor-
tion provision, despite the demands of some critics [18, 51]. However, in countries
where there is clear evidence that abortion provision is being affected by high levels
of conscientious objection, some changes are obviously required if such services are
to be available to all. In these circumstances, it seems pragmatic for both sides to
compromise—to endeavour to preserve the right to conscientiously object, but to
address the primary concerns of critics regarding service provision.
Francesca Minerva outlines three practical suggestions to address the state of con-
scientious objection and abortion in Italy [43]. First, she suggests changing Italian
law to allow general practitioners to perform early term abortions, as currently only
gynaecologists and obstetricians can, thereby significantly increasing the number of
willing participants. Second, financial incentives or additional annual leave should
be provided to non-conscientious objectors. Third, hospitals should be required to
maintain a sufficient ratio of conscientious objectors and non-conscientious objec-
tors to ensure that abortion services are not compromised. Minerva suggests that
each hospital maintain a 50/50 split until empirical studies have been conducted to
demonstrate an ideal ratio. If a non-conscientious objector later becomes a conscien-
tious objector, this may require terminating their employment.
4 An obvious candidate to meet this criterion would be the practice of non-therapeutic infant male cir-
cumcision. Despite being legal, many bioethicists are now challenging the assumption that it is accept-
able for male infants to have parts of their sexual organs removed before they are able to understand the
consequences of doing so [14].
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We think Minerva’s suggestion of maintaining a certain ratio of objectors to
non-objectors is a step in the right direction. One concern is that in Italy, where
we have noted that a significant proportion of clinicians are conscientious objec-
tors, implementing a 50/50 split would entail many losing their positions, even
though up to the time of implementation they would have been legally entitled to
object. Again, this seems unfair, and the job market will likely remain saturated
with clinicians who are conscientious objectors. Additionally, imposing quotas
on clinicians in such a manner does not address the source of the problem—that,
potentially, too many of those entering a speciality may wish to conscientiously
object. Consequently, our preference is to intervene earlier, at the point at which
clinicians choose their speciality.
Provided parties to the debate can agree to respect their opponents’ positions in
this regard, we argue there is a practical and realistic approach that addresses the
primary concerns of all concerned: the use of a quota system for specialist medi-
cal trainees (or other relevant professionals such as midwives) as a means to reg-
ulate the proportion of professionals that are permitted to conscientiously object.
We believe such quotas would address the conflict between a woman’s legal right to
access abortion services and the right of healthcare professionals to conscientiously
object to providing these services.
The basic concept is to reserve a specific proportion of ‘conscientious objection’
places as part of an annual intake to a specialist training pathway. Once this propor-
tion is met, no more trainees with a conscientious objection would be able to enter
that specialist training pathway until a subsequent intake. The quota of conscien-
tious objection places does not need to be met in each intake; rather, it functions as
a maximum to preserve access to legal service provision. This ensures that train-
ees and later consultants maintain their legal right to conscientiously object whilst
minimising—although not completely removing—the risk of legal service provision
being compromised.
The advantages of such a system could be significant. The percentage of consci-
entious objection places could be set appropriately to prevent there being a short-
age of clinicians willing to provide legal services that are commonly objected to,
addressing one of the major concerns of critics. It would also permit an agreed pro-
portion of clinicians to practice with very little risk of being required or expected to
compromise their moral beliefs regarding services such as abortion—or having to
justify their objections to a committee or tribunal. A quota also reduces the theoreti-
cal risk of having a medical specialty constituted entirely of conscientious objectors.
A quota system could also be used as a conservative approach to introduce con-
scientious objection rights to the countries we noted above that currently do not per-
mit it. If set to low levels, there should be no impact on service provision, and yet
it would serve to open up certain medical specialties or professions to those who
were unable to commit to careers in these fields because of their moral beliefs. We
have already noted Sweden’s shortage of midwives. The use of a quota for access to
midwifery training in Sweden may help to relieve the shortfall in midwives to some
extent, with very little risk of affecting access to abortion services. This is likely to
result in a net improvement in care at childbirth without affecting abortion access,
and would seem to justify the introduction of such a quota system.
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Determining Quotas
One of the most crucial components of the proposed quota system is deciding what
healthcare practices warrant the introduction of a quota, and at what percentage they
should be set. The most obvious candidate—and our primary focus here—would be
specialties and professions involved in the provision of abortion because of its wide
legal availability and the ethical debate that surrounds the practice.5 These proposals
are tentative, and are primarily meant to initiate a conversation around the concept
of training quotas.
There are two scenarios we have proposed as being suitable for the introduc-
tion of quotas. The first is countries where conscientious objection has been shown
to have an impact on the provision of abortion services, such as Italy. The second
is countries that currently do not permit conscientious objection, and where it is
thought its introduction would be beneficial in some way, such as helping to alle-
viate staffing pressures. Doing so should increase the pool of applicants to certain
specialist training pathways and some healthcare professions such as midwifery and
nursing.
Keeping in mind that quotas on specialist training places will take some time to
have an impact on service provision, how might they be calculated in a case such as
Italy? We have noted that almost 70% of Italian gynaecologists are conscientious
objectors, so clearly—all else being equal—a lower figure is required for a training
quota, especially as our proposal does not impact existing practitioners. Surveying
existing trainees may suggest a figure—if, say, only 50% of existing trainees report
that they would be conscientious objectors, then perhaps 50% would be a suitable
quota. The key would be to enforce a quota that is significantly less than the existing
percentage of conscientious objectors that are affecting service provision. In time,
this will result in a lower percentage of overall conscientious objectors. There will
be a temptation to temporarily introduce quotas that are extremely low or even zero
for a short period to more rapidly alleviate service provision difficulties, but this
could well be counter-productive—in a society with high levels of conscientious
objection, it may result in a steep fall in applications to specialise in obstetrics and
gynaecology. This could then impact maternal care more generally in the future if
there were fewer qualified obstetricians and gynaecologists.
Implementation of quotas would be quite different for a country that currently
does not permit conscientious objection—for those in favour of its introduction, any
quota would be an improvement. Experiences of other countries that do not expe-
rience difficulties with service provision could be used as a guide as to what lev-
els of conscientious objection do not have adverse effects. Again, as training quotas
have little effect in the short-term, quotas could initially be generous enough that all
entrants who wish to register as conscientious objectors could be permitted to do
so—this might be a way of rapidly increasing the number of qualified practitioners if
there is an overall shortage in a particularly speciality or profession. Once the effects
5 Other candidates would be for specialties and professions involved with euthanasia or physician
assisted suicide.
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of this can be measured, a lower quota could eventually be introduced to prevent dif-
ficulties in service provision from arising in the future.
An important corollary to the introduction of a quota system should be to gather
detailed and accurate data regarding conscientious objection, so that an evidence
base of its prevalence and effects can be gathered over time. This should provide a
clearer picture of how conscientious objection is affecting service provision under
the quotas that have been set. If the effect is minimal or non-existent, then it seems
reasonable to grant that the current quotas could remain.
Let us now examine possible objections to our proposed quota system, including
some practical implementation issues. We conclude that none are insurmountable.
Imposition ofConstraints
Conscientious objectors are likely to regard the proposed quota system as an unnec-
essary constraint on their freedom to object. It does entail the imposition of some
form of monitoring for conscientious objectors, which could be perceived as onerous
and intrusive (and perhaps they would be). The quota system also applies restric-
tions on who can object. Compared to the current freedom to object in many juris-
dictions, it is obvious that such changes will be regarded as undesirable. We believe,
however, that they are a necessary cost of addressing the concerns of opponents to
conscientious objection, and form part of a solution that will preserve the right to
object in countries where high rates of conscientious objection are impacting service
provision. It is certainly preferable to the risk of conscientious objection provisions
being removed.
Religious Discrimination
A quota system for doctors—or other healthcare professionals—that hold beliefs
that lead them to oppose elective abortion could be accused of being discriminatory
by infringing on their freedom to hold beliefs deeply rooted in their religious tradi-
tion.6 For example, the Catholic Church opposes abortion in all circumstances, and
it is likely that a significant proportion of Catholic doctors will also, as is the case
in Italy. Similarly, in Sunni and Shiite Islam, abortion before 4-months gestation is
permissible under certain circumstances and after that to save the life of the mother
[27].
There does seem to be a correlation between healthcare professionals and stu-
dents with religious beliefs and an increased likelihood of conscientious objection
to practices such as abortion [11, 12, 46, 56, 58]. One study of practicing obste-
trician–gynaecologists in the United States showed that those with high religious
motivation were the least likely to provide abortion services [57]. Christopher
6 For instance, in the Christian tradition, the practice of abortion is described as morally licit as early as
the late first century and early second century in the Didache and the Epistle of Barnabas [24].
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Kaczor notes, however, that even though ‘religion is indeed connected in various
ways to the abortion debate … the links between abortion and religion are not sim-
ple and straightforward’ [35]. For instance, adherents of the same religion can often
be found on different sides of the abortion debate. Kaczor also observes that there
are also numerous atheists who are opposed to abortion, and so it is not clear that
claims of religious discrimination are sustainable, even if those with certain reli-
gious beliefs are disproportionally affected.
Ideally, the initial introduction of quotas should aim to minimise disruption. Quo-
tas should initially be set as high as possible to avoid communicating that those with
a conscientious objection are unwelcome in the speciality, whilst also reducing the
likelihood that access to abortion services will be compromised. In any case, we
have suggested that if a quota system is not introduced in some contexts, it is a real-
istic possibility that healthcare professionals’ right to conscientious objection could
become increasingly restricted or removed altogether. Moreover, if a quota was
introduced in a country that previously did not permit CO, the likely beneficiaries of
this will disproportionately be those with religious beliefs.
Belief Changes
It is possible that some trainees or even consultants may change their views during
their careers regarding abortion. For example, they might decide that they no longer
have any objection to performing abortions. We assume that the number of individu-
als that will change their beliefs in either direction once they are already training or
working would be small and unlikely to have a significant impact on service provi-
sion. A quota system would obviously not be able to account for changes in indi-
vidual beliefs—its purpose would be to preserve the right to conscientiously object
to abortion; ensure that a sufficient number of trained healthcare professionals are
available to provide legal abortion services; and to minimise any curtailing of access
to legal abortion services.7
Long‑Term Eects
Where legal abortion access is demonstrably affected by a high prevalence of con-
scientious objection, the proposed quota scheme is intended to operate over the long-
term—it will take time for its effects to manifest fully. This is not necessarily prob-
lematic for opponents of conscientious objection, however—where conscientious
7 It could be objected that by advocating a quota system we become more complicit in the provision of
abortion. However, unless the implementation of a quota system leads to an increase in the number of
abortions (which is not self-evident), it is not clear that this would make us (or anyone else) any more
complicit than we already are as participants in a democratic society that legally permits abortion. More-
over, our belief is that the system we have proposed will serve to prevent conscientious objection rights
from being completely removed in countries where it is clearly affecting service provision, and enable
conscientious objection to be introduced in countries which currently do not permit it.
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objection is legally permitted, a long-term scheme that addresses their concerns
regarding service provision would still likely be a significant improvement.
Geographic Disparities
Having a certain percentage of the healthcare workforce being permitted to consci-
entiously object may not be sufficient to alleviate shortages of medical professionals
willing to provide services in certain geographic regions. For example, it might be
that in a particular rural region there are too many healthcare professionals regis-
tered as conscientious objectors, and so abortion provision could still be affected.
One possible solution would be to limit the percentage of places available in certain
hospitals or regions for healthcare professionals who have a conscientious objection.
Of course, this may also limit employment options for conscientious objectors to a
degree, but again, we regard this as a necessary cost of ensuring that conscientious
objection remains available where it is impacting service provision or is introduced
to a country that did not previously permit it. For instance, not being able to work
in a particular hospital or region is far less onerous than not being able to practice at
all.
Conclusion
As defenders of conscientious objection in healthcare, our primary goal is to pre-
serve the right to conscientiously object in countries where it is under threat. A sec-
ondary objective is to demonstrate that there is a cogent pathway for its introduction
in countries where conscientious objection is currently not permitted. The proposal
we outline—quotas for specialty training—directly addresses the concerns of critics
who argue that the right to conscientious objection threatens the provision of legal
abortion services. By providing a practicable solution to this issue—one of genuine
concern in countries such as Italy—quotas undermine the primary argument for the
removal of conscientious objection. Of course, these concerns are also a significant
barrier to the introduction of conscientious objection in countries currently without
this right. By addressing them via our proposal for quotas and outlining the benefits
of conscientious objection, we have provided a strong case for its adoption.
Supporters of conscientious objection may judge this proposal to be a radical one
that reduces conscientious objection rights they currently enjoy. However, countries
where conscientious objection has no discernible impact on the provision of abor-
tion services are not the target of our proposal—it is aimed at countries where the
removal of conscientious objection is a serious threat, as well as countries where
the right to object is not currently permitted. Critics of conscientious objection who
would prefer that it be removed altogether may also find our proposal unsatisfactory.
However, given that it addresses their primary concerns regarding provision of ser-
vices, and may even help address staff shortages in certain areas, there seems little
reason for critics to oppose it.
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Acknowledgements We would like to thank Toni Saad and Nicholas Colgrove for their very helpful
comments. We would also like to thank the Bios Centre (Bios Centre, 107–111 Fleet Street, London EC4
2AB, info@bioscentre.org) for allowing us to present this paper for discussion, and for the very helpful
feedback provided by participants.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as
you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article’s Creative Commons licence and your intended use is
not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen
ses/by/4.0/.
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