Content uploaded by Julian Savulescu
Author content
All content in this area was uploaded by Julian Savulescu
Content may be subject to copyright.
We thank Asim Ghouri for help with collecting data and the
many religious scholars and health professionals who have
shared their views with us. Thanks also to Scott Murray, Hilary
Pinnock, and Brian McKinstry for their helpful critiques.
Contributors and sources: This article is based on government
data, a Medline search, and searches of specialist Fatwa banks
and discussions with religious scholars and organisations repre-
senting a range of ethnic, linguistic, and ethicolegal perspectives.
AS conceived the idea for this review and oversaw data
collection, interpretation, and writing of the paper. NG and MA
undertook searches, extracted data, and drafted the paper. AS is
guarantor.
Competing interests: AS chairs the research committees of the
Muslim Council of Britain and the British Thoracic Society.
1 Central Intelligence Agency. The world factbook 2005. www.odci.gov/cia/
publications/factbook/ (accessed 19 Jan 2006).
2 GLOBALink. Tobacco control country profiles 2003. www.globalink.org/
tccp/ (accessed 15 Sep 2005).
3 Department of Health. Health survey for England, 2004. London: Station-
ary Office, 2005. www.ic.nhs.uk/pubs/hlthsvyeng2004ethnic/
HSE2004Headlineresults.pdf/file (accessed 13 Jan 2006).
4 NHS Health Development Agency. The financial cost of smoking.
www.hda.nhs.uk/html/improving/smoking_financial.html (accessed 15
Sep 2005).
5 Bush J, White M, Kai J, Rankin J, Bhopal R. Understanding influences on
smoking in Bangladeshi and Pakistani adults: community based, qualita-
tive study. BMJ 2003;326:962-7.
6 White M, Bush J, Kai J, Bhopal RS, Rankin J. A study to explore the feasibil-
ity and acceptability of smoking cessation interventions among Bangladeshi and
Pakistani men and women. Final report to Cancer Research UK. Newcastle:
University of Newcastle upon Tyne, 2002.
7 IslamicWeb. Muslim populations. www.islamicweb.com/begin/
population.htm (accessed 15 Sep 2005).
8 World Health Organization. Framework convention on tobacco control.
www.who.int/tobacco/framework/en/ (accessed 19 Jan 2006).
9 Ahmad KAB, Jafary FC, Jehan IA, Hatche JA, Khan AQD, Chaturvedi N,
et al. Prevalence and predictors of smoking in Pakistan: results of the
National Health Survey of Pakistan. Eur J Cardiovasc Prev Rehab
2005;12:203-8.
10 BBC News Online. Bollywood link to Asian smoking. http://
news.bbc.co.uk/1/hi/england/2995051.stm (accessed 15 Sep 2005).
11 Gatrad AR, Sheikh A. Medical ethics and Islam: principles and practice.
Arch Dis Child 2001;84:72-5.
12 Doi AR. Shariah: The Islamic law. London: Ta Ha, 1984:2-84.
13 Islam Online. Is the ruling on smoking still controversial? www.
islamonline.net/fatwa/english/FatwaDisplay.asp?hFatwaID = 116124
(accessed 15 Sep 2005).
14 Jibaly M. Smoking: a social poison. Detroit: Al-Qur’an was-Sunnah Society
of North America, 1996. www.qss.org/articles/smoking.html (accessed
15 Sep 2005).
15 Ask the Imam. Is smoking cigarettes haram? www.islam.tc/ask-imam/
view.php?q = 300 (accessed 3 May 2005).
16 WHO East Mediterranean Regional Office. Islamic ruling on smoking.
Cairo: WHO East Mediterranean Regional Office, 2003.
17 Kawach I. More evidence on the risks of passive smoking. BMJ
2005;330:265-6.
18 Mufti says. www.muftisays.com/index.php?viewpage = about (accessed 15
Sep 2005).
19 Ask the Imam. Please conclude as to whether smoking is Haram, Makruh Tan-
zihi or Makruh Tahrimi. www.islam.tc/ask-imam/view.php?q = 5634
(accessed 15 Sep 2005).
20 Rsipler-Chaim V. Islamic medical ethics in the twentieth century. Ledien: Brill,
1993:119-22.
21 Reynolds C. The fourth largest market in the world. Tobacco Control
1999;8(1):89-91.
22 Radwan GN, Israel E, El-Setouhy M, Abdel-Aziz F, Mikhail N, Mohamed
MK. Impact of religious rulings (Fatwa) on smoking. J Egypt Soc Parasitol
2003;33:1087-101.
23 Hameed A, Jalil MA, Noreen R, Mughal I, Rauf S. Role of Islam in
prevention of smoking. J Ayub Med Coll 2002;14:23-5.
(Accepted 8 October 2005)
Ethics
Conscientious objection in medicine
Julian Savulescu
Deeply held religious beliefs may conflict with some aspects of medical practice. But doctors cannot
make moral judgments on behalf of patients
Shakespeare wrote that “Conscience is but a word cow-
ards use, devised at first to keep the strong in awe”
(Richard III V.iv.1.7). Conscience, indeed, can be an
excuse for vice or invoked to avoid doing one’s duty.
When the duty is a true duty, conscientious objection is
wrong and immoral. When there is a grave duty, it
should be illegal. A doctors’ conscience has little place
in the delivery of modern medical care. What should
be provided to patients is defined by the law and con-
sideration of the just distribution of finite medical
resources, which requires a reasonable conception of
the patient’s good and the patient’s informed desires
(box). 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. Doctors should not offer partial medical serv-
ices or partially discharge their obligations to care for
their patients.
Problem of conscientious objection
Doctors have always given a special place to their own
values in the delivery of health care. They have always
had greater knowledge of the effects of medical
treatment, and this fostered a belief that they should
decide which treatments are appropriate for patients
—
Summary points
Smoking prevalence remains unacceptably high
among Muslim communities globally
Numerous religious scholars and institutions in
Middle Eastern and North African countries have
recently declared smoking to be haram
(prohibited)
South Asian religious authorities need to follow
the leadership shown by their Arab speaking
counterparts
Antismoking legislation is often poorly enforced
in Muslim countries
Religious rulings need to be backed up by
advertising bans and support to stop smoking
Analysis and comment
Oxford Uehiro
Centre for Practical
Ethics, University of
Oxford, Oxford
OX1 1PT
Julian Savulescu
director
julian.savulescu@
philosophy.ox.ac.uk
BMJ 2006;332:294–7
294 BMJ VOLUME 332 4 FEBRUARY 2006 bmj.com
that is, paternalism. Their values crept into clinical
decisions.
12
This has been squarely overturned by
greater patient participation in decision making and
the importance given to respecting patients’
autonomy.
3
More recently, doctors’ values have
reappeared as a right to conscientiously object to
offering certain medical services. Examples include,
refusal to offer termination of pregnancy, especially
late term termination, to women who are legally
entitled to it and refusal to provide reproductive advice
and help to gay couples, single women, or others
deemed socially unacceptable.
In the United States pressure has been put on
Catholic hospitals to allow obstetricians to ster ilise
women immediately after giving birth.
4
Alto Charo
notes that a recently proposed Wisconsin bill would
allow doctors to refrain from a broad range of
activities, including counselling patients:
The privilege of abstaining from counseling or referring
would extend to such situations as emergency contraception
for rape victims, in vitro fertilization for infertile couples,
patients’ requests that painful and futile treatments be with-
held or withdrawn, and therapies developed with the use of
fetal tissue or embryonic stem cells. This last provision could
mean, for example, that pediatricians . . . could refuse to tell
parents about the availability of varicella vaccine for their
children, because it was developed with the use of tissue
from aborted fetuses.
5
Indeed, one Wisconsin pharmacist refused to fill an
emergency contraception prescription for a rape
victim. She became pregnant and had an abortion.
5
Arguments against conscientious
objection
Inefficiency and inequity
In public medicine, conscientious objection introduces
inequity and inefficiency. In a survey I conducted
several years ago,
6
around 80% of clinical geneticists
and obstetricians specialising in ultrasonography
believed termination of pregnancy should be available
for a normal 13 week pregnancy if the woman wants it
for career reasons. However, only about 40% were pre-
pared to facilitate it. This implied that less than half of
doctors whose primar y job is to deal with termination
of pregnancy would facilitate a termination at 13 weeks
if the woman wanted it for career reasons. The service
that patients receive depends on the values of the treat-
ing doctor. Not only does this imply that patients must
shop among doctors to receive the service to which
they are entitled, introducing inefficiency and wasting
resources, it also means some patients, less informed of
their entitlements, will fail to receive a service they
should have received. This inequity is unjustifiable.
Inconsistency
Imagine an intensive care doctor refusing to treat
people over the age of 70 because he believes such
patients have had a fair innings. This is a plausible
moral view,
7
but it would be inappropriate for him to
conscientiously object to delivering such services if
society has deemed patients are entitled to treatment.
Or imagine in an epidemic of bird flu or other
infectious disease that a specialist decided she valued
her own life more than her duty to treat her patients.
Such a set of values would be incompatible with being
a doctor.
If there is any justification for compromising the
care of patients, it must be a grave risk to a doctor’s
physical welfare. But if self interest and self
preservation are not generally deemed sufficient
grounds for conscientious objection, how can religious
or other values be?
Commitments of a doctor
These examples show that people have to take on cer-
tain commitments in order to become a doctor. They
are a part of being a doctor. Someone not prepared on
religious grounds to do internal examinations of
women should not become a gynaecologist. To be a
doctor is to be willing and able to offer appropriate
medical interventions that are legal, beneficial, desired
by the patient, and a part of a just healthcare system.
If we do not allow moral values or self interest to
corrupt the delivery of the just and legal delivery of
health services, we should not let other values, such as
religious values, corrupt them either.
Discrimination
Sometimes religious values are considered special.
However, to treat religious values differently from
secular moral values is to discr iminate unfairly against
the secular, a practice not uncommon in medical
ethics.
8
Other values can be as closely held and as cen-
tral to conceptions of the good life as religious values.
Place for conscientious objection
The argument in favour of allowing conscientious
objection is that to fail to do so harms the doctor and
Conscience, for Shakespeare’s Richard III, was “but a word cowards
use”
©PHILIP MOULD, HISTORICAL PORTRAITS LTD, LONDON, UK;/BRIDGEMAN ART LIBRARY
Determinants of medical care
Law
Just distribution of finite resources
Patient’s informed desires
Not doctors’ values
Analysis and comment
295BMJ VOLUME 332 4 FEBRUARY 2006 bmj.com
constrains liberty. This is true. When a doctor’s values
can be accommodated without compromising the
quality and efficiency of public medicine they should,
of course, be accommodated. If many doctors are pre-
pared to perform a procedure and known to be so,
there is an argument for allowing a few to object out. A
few obstetricians refusing to perform abortions may be
tolerable if many others are prepared to perform these,
just as a few self-interested infectious disease doctors
refusing to treat patients in a flu epidemic, on the
grounds of self interest, might be tolerable if there were
enough altruistic physicians willing to risk their health.
But when conscientious objection compromises the
quality, efficiency, or equitable delivery of a service, it
should not be tolerated. The primary goal of a health
service is to protect the health of its recipients.
Certain constraints are necessary to ensure the
legal, equitable, and efficient delivery of health care:
x Medical students and trainees must be aware of the
commitments of the profession and be prepared to
undertake these or not become doctors
x The medical profession has an obligation to ensure
that all patients are aware of the full range of services to
which they are entitled
x Any would-be conscientious objector must ensure
that patients know about and receive care that they are
entitled to from another professional in a timely man-
ner that does not compromise their access to care
x Doctors who compromise the delivery of medical
services to patients on conscience grounds must be
punished through removal of licence to practise and
other legal mechanisms
x The place for expression and consideration of
different values is at the level of policy relating to pub-
lic medicine.
Legal uncertainty
In some areas of medicine, such as the hastening of
death and late termination of pregnancy, doctor s may
in good faith be uncertain as to whether an
intervention is legal. In 1990, the Human Fertilisation
and Embryology Act in the United Kingdom reduced
the limit for “social termination” to 24 weeks, but
placed no upper gestational limit on termination when
there is “substantial risk of serious handicap” or if it is
necessary to prevent “grave permanent injury to the
physical or mental health of the pregnant woman.”
Concern has been expressed about what constitutes a
substantial risk and a serious handicap. Lilford and
Thornton claimed that the issue might cause
significant public controversy and expressed their
“deep personal uncertainty.”
9
In 1993, Green asked 391
obstetric consultants in the United Kingdom how late
they would be prepared to offer termination of
pregnancy for anencephaly, spina bifida, and Down’s
syndrome.
10
She found that 89% of consultants would
offer termination for anencephaly at 24 weeks, falling
to 64% beyond 24 weeks. For Down’s syndrome, 60%
would offer termination at 24 weeks but only 13% after
this time. For open spina bifida, 53% would offer
termination at 24 weeks and 21% after 24 weeks.
In Australia, laws relating to late termination are
even more unclear and vary from state to state.
611
My
survey of clinical geneticists and obstetricians with spe-
cialist training in obstetric ultrasonography showed
similar variation in practice to that found by Green.
6
I
asked respondents to imagine that a pregnant woman
presents after prenatal testing with one of several diag-
noses at 13 and 24 weeks. These included anencephaly,
trisomy 18, hypoplastic left heart, spina bifida with
hydrocephalus, fragile X syndrome, Down’s syndrome,
achondroplasia, and cleft palate. I also asked respond-
ents about pregnancies in which the fetus was normal.
Some practitioners would not facilitate termination at
24 weeks even for lethal abnormalities. Fewer
practitioners supported termination or would facilitate
it at 24 weeks than at 13 weeks for all conditions. The
difference in opinion between 24 and 13 weeks was
greatest for pregnancies in which the fetus was normal
or had a relatively mild disorder. There was a lack of
consensus about which abnor malities were severe
enough to warrant termination and up to what
gestation termination is acceptable. For example,
around 75% of respondents believed termination
should be available for dwarfism at 24 weeks.
Such wide variation in practice around late
termination is due both to practitioners’ differing
values but also to legitimate uncertainty about the legal
status of late termination for “milder” conditions. I have
argued elsewhere that we urgently need to clarify the
law in this area.
11
In the absence of such clarification,
practitioners have a legitimate right to refuse to
provide a service which they believe to be illegal. How-
ever, they should make this reason clear to patients and
also the fact that the law is unclear. They should also
inform patients of the availability of other practitioners
who take a different view of the law.
Private elective medicine
Private elective medicine is different from public medi-
cine. Doctors have more liberty to offer the service of
their choice, based on their values. Nevertheless, for
patients to give valid consent to treatment, they must
be informed of relevant alternatives and their risks and
benefits (in a reasonable, complete, and unbiased way).
Summary points
A doctor’s conscience should not be allowed to
interfere with medical care
All doctors and medical students should be aware
of their responsibility to provide all legal and
beneficial care
Conscientious objection may be permissible if
sufficient doctors are willing to provide the
service
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
Analysis and comment
296 BMJ VOLUME 332 4 FEBRUARY 2006 bmj.com
Conclusion
Values are important parts of our lives. But values and
conscience have different roles in public and private
life. They should influence discussion on what kind of
health system to deliver. But they should not influence
the care an individual doctor offers to his or her
patient. The door to “value-driven medicine” is a door
to a Pandora’s box of idiosyncratic, bigoted, discrimina-
tory medicine. Public servants must act in the public
interest, not their own.
Contributors and sources: JS is a professional medical ethicist
with experience in practising general and emergency medicine.
This article arose from reflections on the literature and his
experience
Competing interests: None declared.
1 Hope T, Sprigings D, Crisp R. Not clinically indicated: patients’ interests
or resource allocation? BMJ 1993;306:379-81.
2 Savulescu J. Rational non-interventional paternalism: why doctors ought
to make judgements of what is best for their patients. J Med Ethics
1995;21:327-31.
3 Brock DW, Wartman SA. When competent patients make irrational
choices. N Engl J Med 1990;322:1595-9.
4 Collett TS. Protecting the health care provider’s right of conscience. Center for
Bioethics and Human Dignity, 2004. www.cbhd.org/resources/
healthcare/collett_2004-04-27.htm (accessed 23 Jan 2006).
5 Alto Charo R. The celestial fire of conscience
—
refusing to deliver medi-
cal care. N Engl J Med 2005;352:2471-3.
6 Savulescu J. Is current practice around late termination of pregnancy
eugenic and discriminatory? Maternal interests and abortion. J Med Ethics
2001;27:165-71.
7 Harris J. The value of life. London: Routledge, 1985.
8 Savulescu J. Two worlds apart: religion and ethics. J Med Ethics
1998;24:382-4.
9 Lilford RJ, Thornton J. Ethics and late TOP. Lancet 1993;342:499.
10 Green J. Ethics and late TOP. Lancet 1993;342:1179.
11 De Crespigny LJ, Savulescu J. Abortion: time to clarify Australia’s confus-
ing laws. Med J Aust 2004;181:201-3.
Ethics
Just a family medical history?
Dagmar Schmitz, Urban Wiesing
If you have a family history of inher ited disease, giving details could lead to discrimination
A recent case in Germany has highlighted the use of
genetic information obtained from family medical his-
tories in employment decisions. Although laboratory
genetic testing is rarely used in occupational health
medicine, prospective employees are often asked about
family medical history and may be unaware of the
potential consequences. We argue that information
obtained from family histories is similar to that from
genetic testing and consent procedures should be the
same.
Case
Teachers in Germany, like all civil servants, have to
have a medical examination before getting a perma-
nent job. In this case, a young female teacher was
examined by the occupational health doctor and found
to be in perfect health. But in response to questions
about her family medical history, she indicated that her
father had Huntington’s disease. She refused genetic
testing. Her risk of inheriting the disease from her
father and still being in perfect health is 50% at most.
At the same time, her chance of not having inherited
the disease from her father is at least 50%. The doctor
reported that she had an above average risk of future
absenteeism because of her family history. The Hessen
educational authorities then refused to give her a per-
manent job in the German civil service on the grounds
of this medical report.
12
The teacher has since success-
fully contested the decision in the German Administra-
tive Court.
Legal position
Although the German Administrative Court abolished
the decision of the Hessen educational authorities
because it thought the risk had been wrongly
interpreted, it explicitly approved the use of predictive
medical information from a family history. Civil
servants in Germany have particular privileges, which
the court believes justifies questioning the future ability
for performing the job.
3
The occupational physician is
therefore obliged to consider the future health of the
applicant and to give a prognosis based on a physical
examination and family history. The court also recom-
mended that genetic testing should be prohibited in
pre-employment medical testing because of the related
ethical problems and their lack of legal regulation in
Germany.
3
The approval of family histories and disapproval of
laborator y genetic testing in the workplace reflects the
current opinion and legal practice in most of Europe.
Countries such as Switzerland have implemented
restrictions on the use of genetic tests in the workplace,
and 22 US states have banned the use of genetic
screening in making employment decisions. Bills
Family history can sometimes be as revealing as genetic analysis
KEVIN CURTIS/SPL
Analysis and comment
See p 299
Institute of Ethics
and History in
Medicine,
University of
Tuebingen, 72076
Tuebingen,
Germany
Dagmar Schmitz
scientific assistant
Urban Wiesing
director
Correspondence to:
D Schmitz
dagmar.schmitz@
uni-tuebingen.de
BMJ 2006;332:297–9
297BMJ VOLUME 332 4 FEBRUARY 2006 bmj.com
