Ethics of conscientious objection by the health professions.

Gonzalo Herranz, department of Bioethics, University of Navarra, Spain.
Session at workshop of Bioethics: Health conscientious objection.
University of Navarra
Pamplona, September 23, 1995
Greetings and perplexities

Index

Introduction

Permanent interest of the topic

The selective unpopularity of the health odc

topic professionally significant

Deontological regulation of conscientious objection

Corporate protection of objectors

Hierarchical relationship and conscientious objection

Institutional conscientious objection

A new field of health odc: the review of young people prior to joining the mandatory military service.

Boycotts of pharmaceuticals and medical devices

An uncertain future

In the end, I have decided to use the article published in Scripta Theologica as the main basis for the lecture, with the addition of some data and recent news, such as the accentuation in some sectors of society and political thought of the rejection of conscientious objection (CO); the emergence of a new object in the field of health CO, which is related to the recruitment of young people for military service; and the boycott of abortifacient drugs. This will help us to become aware of the reality of some of the problems and to prepare questions for the sessions at colloquium.

Greetings, with special thanks to reference letter to the doctoral students of the technical school of Industrial Engineers of San Sebastian.

Introduction

Probably the most significant achievement of modern ethics in the health professions has been to turn patients, physicians, nurses and pharmacists into conscious, free and responsible moral agents. And the most appropriate thing for a moral agent is to do things conscientiously, that is, with knowledge and freedom, with skill and deliberation, from agreement with certain rationally founded and deeply felt principles.

In general, patients and healthcare professionals, including public healthcare managers, are usually in agreement at agreement on what should be done to protect and restore health. And, in general, we are all used to living together in peace, obeying just laws and contributing to the common good.
It sometimes happens, however, that, because of the ethical pluralism of today's society, some people disagree with others on certain matters of greater or lesser importance. Such disagreement need not lead to insoluble conflicts or dilemmatic situations. When the disagreement concerns questions of preference or convenience, which are by their very nature negotiable, and does not go beyond the limits of the legitimate diversity of professional practices or styles, it is always possible to arrive, by making the appropriate concessions or adaptations, at a decision which, although less than optimal for all, can be accepted by all. No one is then obliged to renounce intangible ethical convictions or to betray seriously founded scientific reasons.

It happens other times, especially when authority-subordination relationships are at stake, that someone may refuse to carry out the order or demand of another, or not to follow a conduct admitted or imposed by law, because he feels a deep, invincible ethical repugnance towards those commands, so that submission to what is demanded would mean betraying or destroying one's own conscience, with serious damage to one's own dignity and identity as a moral being.

The rejection, for moral, personal or religious reasons, of what is ordered by authority or the law is a common feature of several attitudes of social dissidence, such as, for example, civil disobedience, conscientious objection or the evasive insubordination .¹.

What characterizes conscientious objection is its peaceful and non-violent nature; its religious-moral rather than political foundation; and its intention to bear witness against behaviors that, although socially permitted, are considered inadmissible or perverse by the objector. It is very important to retain in report and in action these specific features of conscientious objection. The objector does not intend with his action, and in an immediate way, to subvert or change the reigning political, legal or social status , as the civil disobedience activist does with his peaceful external manifestations, or the insubordinate does with his spectacular protest actions. The objector tries to exempt himself peacefully from certain actions, without, as a consequence, having to suffer discrimination or renounce rights.

There are not many actions to which health professionals have opposed odc and which, to a greater or lesser extent, have been recognized as legitimate by legislation, professional regulation or simple custom. They are induced abortion; contraception, especially post-coital contraception and voluntary sterilization; assisted reproduction, the destructive research of embryos and preconceptional sex selection; euthanasia, medical financial aid suicide and the suspension of life-sustaining medical treatments; force-feeding of hunger strikers, cooperation with the police in obtaining information, and participation in the execution of capital punishment; blood transfusion and organ transplantation; certain psychosurgical interventions; and certain experiments on humans or animals. Recently, the psychophysical assessment of young people for military service has been added to this list.

Decriminalized abortion is the paradigmatic form of health odc. It is logical that it should receive preferential attention.

Permanent interest of the topic

The right of health care professionals to health care odc is the subject of permanent discussion , both within the professions and in political bodies and among the general public. It is still far from being a peaceful possession or a definitively recognized and specified right. Objectors have suffered and will continue to suffer insistent harassment from social activist groups of various stripes, and from a large and influential sector of the healthcare bureaucracy. Public opinion is divided on the odc. Some believe that, once certain actions, such as abortion or sterilization, have been decriminalized, it is unfair for doctors to deny them to those who request them, especially when they are among the health services offered, and even subsidized, by the public health services: doctors, nurses and pharmacists are mere technicians, whose moral values must submit blindly or passively to legal dynamism. Others maintain that, in an advanced society made up of free and responsible men, and caring for the rights and freedoms of its citizens, no one can be legitimately forced to perform an action that is seriously repugnant to his or her moral conscience. 

In the never-ending and lively discussion on health odc, modern permissive laws and the ethical tradition of the profession, liberated behaviors and deep moral convictions, the functional efficiency of the managers of the health care attendance and the ethical fidelity of those who respect the life and dignity of people collide with each other.

Not only is there discussion: seriously unjust and discriminatory resolutions are taken against objectors. Intolerance of objection occurs in nations that consider themselves very liberal and advanced in the promotion of civil rights. A few examples will suffice. In Sweden, in 1993, the right of doctors, nurses, pharmacists and students to conscientiously object to abortion was still pending legal recognition: there, objectors form a professional underclass with fewer rights and opportunities.². In the United Kingdom, excluding Northern Ireland where abortion has not been decriminalized, serious abuses have been reported: some of them have been studied by the Social Services committee of the House of Commons. It has been found that, contrary to the provisions of the 1967 Abortion Act, serious impediments are placed there to the professional degree program of objectors, especially nurses and young doctors, and reluctant candidates to abortion have been prevented access to medical schools.³. In the United States, the American Medical association and the Joint Commission of accreditation of Hospitals prepared rules to impose the learning and internship of abortion as an inescapable requirement in the training of future specialists in Obstetrics and Gynecology.⁴. Fortunately, and according to recent news, the initiative met with very strong resistance and is about to be abandoned.

In Spain, too, there was talk many months ago about the odc of health professionals. The reason for this is well known: the Socialist government's advertisement decision to send to Parliament a project bill on the Voluntary Interruption of Pregnancy, the text of which contains a vague threat to doctors specializing in Obstetrics and Gynecology who, for reasons of conscience, abstain from the internship of the abortion.⁵. This legal project raised an energetic civil service examination both from the board Directive of the Spanish Society of Gynecology and Obstetrics, as well as from the Collegiate Medical Organization. The former has demanded changes in the text of the project and asks that the odc be regulated by means of an organic law, as was proposed by the Constitutional Court. The latter is committed to firmly and uncompromisingly defending the odc of physicians.⁶. But the ball is still in the court's court: on the one hand, the board Directive of the SEGO has changed and does not seem so energetic in its defense of the traditional ethical values of the specialization program; on the other hand, the WTO's advisory service Jurídica, a victim of the dominant legal positivism, has prepared an opinion on odc that is full of weakness and surrender.
We are also witnessing a psycho-social evolution that tends to surround objectors with antipathy and unpopularity.

The selective unpopularity of the health odc

The objector no longer always provokes reactions of civil tolerance or ethical admiration. On the contrary, he faces serious legal and professional difficulties. He encounters the incomprehension of politicians, administrators and a large part of the public.

The B of the case is that this antipathy is selectively directed to the odc based on respect for human life and the dignity of persons. The objector is often branded with the stigma of fundamentalist. In the most favorable circumstances, they are considered to be scrupulous, pharisaical, insensitive, anti-modern and installed in a cultural status already outdated. In contrast, the objectors to military service, including many times the refuseniks, those who demonstrate against the evil attention of animals, those who protest against the ecological passivity of governments, those who demand the increase of the financial aid to the developing countries of development, are considered, if not as saints or civil heroes, then as idealistic people who deserve support and sympathy.

It should be borne in mind that in the exercise of the odc there are not only ethical and political factors at work: there are some components of moral psychology that cannot be left out.

We cannot forget that the objector is a strong moral reproach for those who lack deep ethical convictions. The latter tends to feel insulted and offended by the unexpected and strong moral lesson that the objector's behavior is for him. The reaction of many to the objector is not one of simple annoyance, such as that provoked by an airline strike that spoils an important business or professional opportunity. The Username can, in the midst of the contrariness, pay some sympathy, even if distant, to those who aspire to improve their salaries or the conditions of their work. 

Never, the customer who goes in search of a certain product in a store reacts as if he were morally assaulted by the shopkeeper's reply that he does not have that product because, for example, he has decided, in response to his political convictions, to boycott French products until the nuclear tests on the Mururoa atoll are suspended, or because of the Paris policy towards Spanish agricultural products. The customer, if he wants that product, goes to the stores until he finds it: he knows that the satisfaction of his specific desire has a cost. And he also knows that, sometimes, he will have to resort to a substitute because the product of his choice is no longer marketed in that region: no shopkeeper has it. Our man will regret it, he will miss the good old days, but he will not be indignant or claim revenge: it does not occur to him to report the case to the Department of Commerce.

But what happens when the pharmacist refuses to dispense a contraceptive? The refusal is received as a moral slap in the face, which provokes, depending on the person, reactions ranging from mute rupture of relations, to angry and violent protest, to humiliating insult, to indignant denunciation before the authority of the one who unjustly deprives another of a service to which one has an absolute and inalienable right.

In particular, within health care facilities, the odc can be an occasion for serious conflict. The relationship between health care managers who are ideologically indifferent or pro-abortion and objectors is very complex. Managers are often fascinated by two aspirations: the machine-like efficiency of their management and the servile desire to please their superiors.

Fascinated by efficiency, they can never look with sympathy on those who break the regular rhythm of the uniform and programmed work . All the more so since hospital or health area managers, obsessed with reducing the economic cost of health care, have been invested with extensive organisational powers to keep the health care machine running at maximum performance level. This makes it necessary to consider any exception or exemption as a disturbing drawback of the supposedly homogeneous response.

The relationship between consumers and suppliers is just as complex in today's society. The associative movement of users and consumers has brought about clear improvements in the quality and uniformity of the industrial products that are purchased, the food that is consumed, the services that are used, the attention that is received. In order to attract consumers to certain lifestyles and to create urgent needs, advertising constantly flatters them and turns them, with its promises, into haughty people who are not satisfied with little. It is not easy for today's consumers to give up the immediate satisfaction of their aspirations, or to be satisfied with less than what they have promised themselves.

It is not surprising, therefore, that a doctor's refusal to consent to an abortion or a pharmacist's refusal to dispense a contraceptive is received with intolerable contempt. All the more so since it is not simply a matter of the inconvenience of not receiving immediately what is requested, of the inconvenience of having to go elsewhere to obtain what is sought. The objecting refusal of abortion or counter-abortion is taken as an insufferable moral insult. 

The rejection of the odc is accentuated as the so-called civil ethics gains ground in society, the idea that the law (the laws of parliaments, the sentences of jurisprudence, the decisions of ministries, the norms of directors) is the expression of the public morality of the civil community, that it speaks in the name of all, that we are all charged with the duty of complying with it. Being part of the community in which we live is achieved through compliance with the rules of the game, submission to the legal order in which we have to live peacefully, which politicians have agreed for all. The ethical peace of society is achieved through this consensus in which the principles of minimum legal intervention and the imposition of a common obligatory ethical minimum coincide. 

This idea is everywhere. In the preamble of the law 35/1988 on Assisted Reproduction, sample is shown how ethical pluralism is laminated under the steamroller of the common ethical minimum. It says: "From an ethical perspective, social pluralism and divergent opinions are frequently expressed on the different uses that can be given to Assisted Reproduction techniques. Their acceptance or rejection must be argued from the assumption of correct information, and be produced without interested motivations or ideological, confessional or partisan pressures, based solely on a civic or civil ethics, not exempt from pragmatic components [...] an ethics, in final, that responds to the feelings of the majority and to the constitutional contents, that can be assumed without social tensions and be useful to the legislator to adopt positions or rules and regulations".

It does not seem that the objector is going to find a generous shelter in the courts of justice or in the legal research . Soon, two years ago, the members of the group of programs of study of Criminal Policy, made up of some 50 professors and 50 magistrates and prosecutors, gathered at the Carlos III University of Madrid, approved a Manifesto in which they pointed out that our Constitution does not enshrine "an individualism incompatible with the social and democratic rule of law", and that, consequently, "the physician is obliged, in spite of his odc, to perform the abortion when there are no other professionals available to perform the termination of pregnancy" and that "the manager of the establishment or the staff health care provider may be held legally responsible for the consequences that his refusal to perform the intervention may have on the life, health and freedom of the pregnant woman". The Manifesto proposes that the legal euthanasia requested by the patient cannot be denied or limited, and that the physician must be held responsible for any obstructive actions, if this impedes the right of the patient who has requested financial aid to die. Paradoxically, the group proposes to suppress the obligatory nature of military service in order to solve the problem of the odc that this duty creates and criticizes the proposal of the Minister of Justice to apply the open penitentiary regime to the insumisos, because it considers that this measure is not only insufficiently liberalizing, but also a gratuitous exercise of political cynicism, because it perverts the sense and purpose of the open penitentiary regime, while avoiding the real solution to the problem, which is the decriminalization of the insubmissive. The great and libertarian freedom eats the small freedom of fidelity to conscience.

topic professionally significant

For members of the health professions, the odc has a special ethical significance and symbolic value.

Beyond the generic, religious or ethical dimension of any objecting attitude, by which the objector wishes to defend his identity as a moral person, the health odc expresses a position, a specific statement, on the intrinsically ethical nature of the health professions. It affirms that, in the complete professional, there is an indissoluble link that intertwines his or her technical skill with his or her moral convictions. The objector not only refuses to be a moral puppet operated by those who legislate or command, but, while objecting, proclaims that ethics is at the heart of his work.

The objection externalizes emblematic ethical-professional contents, such as maximum respect for the life of the deontological tradition, the area of legitimate freedom of prescription, individual independence in the face of gregarious fashions, and resistance to health consumerism. The odc is, therefore, more than a survival mechanism in an ethically fractured society, as it highlights many positive ethical-professional values. It requires the development and fine-tuning of new critical attitudes. It requires fine-tuning the mechanisms of negotiation - of agreement and of disagreement - between physicians, patients and officials. It uncovers the specific risk of commercial corruption of the private internship . It advocates fair legislation on odc and respect for individual freedoms, to prevent the risk that the objector may suffer moral damage and economic harm for bearing witness to the value of human life.

For their part, objectors are obliged to offer a social image of the odc that is consistent with its ethical dignity. They will never abuse it or exploit it to their own advantage. They will not seek privileges, but, even knowing that they will never be free from the inconvenience of swimming against the tide, they will not resign themselves to being victims.

In the permissive society, the odc stands as the defender of fundamental rights against the tolerant laws of controlled criminality. The doctor and nurse who are objectors to abortion are, in spite of the dictates of intolerance and lack of solidarity that some people hurl at them, the genuine defenders of the correct social-political order, because they loyally defend the right to life of the unborn, as enshrined in the Constitution. Their testimony prevents the silent and complacent narcotization of the social conscience.

The odc is a privileged manifestation of the medical and human virtue of integrity, the foundation of both trust and autonomy in the doctor-patient relationship and of the public credit of the medical profession.⁷.

Deontological regulation of conscientious objection

It is not easy to summarize the deontological rules on odc in the health professions. These rules vary from one country to another depending on whether or not they are recognized as a right and, above all, on the way in which they are respected or disregarded, both within and outside professional associations or corporations. Unlike what happens with the programs of study dealing with the comparative law of odc, there is no study of comparative deontology on the issue.⁸.

The treatment that odc receives in medical codes of ethics is very different. There are those that totally silence the topic, thus implying that the legal rules and regulations eliminates the need for a deontological regulation .⁹. Most often, however, codes of ethics include a article that proclaims the physician's right to refuse to participate in certain procedures and that outlines the conduct that the physician must follow when he/she objects.¹⁰. The same applies to the deontological regulations of the professions of Nursing and Pharmacy.¹¹.

What is the status in Spain? There is no legislation in Spain on health odc, and, according to Constitutional Court Ruling 53/1985 on abortion, it does not seem to be necessary.¹². The Spanish Constitution is sample, at least in theory, very generous in prohibiting any discrimination on ideological grounds and in guaranteeing the privacy of all citizens, since no one can be forced to declare their ideology and convictions, nor can they be discriminated against because of it.¹³. This being the case, the deontological rule takes on special importance.

It is therefore worthwhile to study the deontological doctrine in force in Spain. The article 27.1 of the Code of Medical Ethics and Deontology states that it is in accordance with the Deontology that the physician, because of his ethical or scientific convictions, abstains from the internship of abortion or in matters of human reproduction or organ transplantation. He/she shall promptly inform the reasons for his/her abstention, offering, if necessary, the appropriate treatment for the problem for which he/she was consulted. He/she will always respect the freedom of the persons concerned to seek the opinion of other physicians.¹⁴

This protective rule of the odc externalizes the institutional commitment to protect the professional independence of physicians, in its double ethical and scientific aspect. Deontologically, the objection cannot be a whim or a tactical and changeable, opportunistic position: it must have a solid base of ethical reasons and professional criteria. It is not difficult for the objector to refuse, as part of his professional work , abortion with a double argument: one ethical (the injury to the maximum respect due to human life); the other scientific (abortion is not a solution to certain medical problems, so superior to the other alternatives that the physician reluctant to abortion can offer, that its performance is never ethically obligatory).

The ethical argument can oppose all the legal "indications" (vital risk, fetal malformation, gestation following rape of the woman, hypothetical socioeconomic necessity) for abortion, but only the first two can be posed as problems that require genuinely medical knowledge. The scientific-professional argument must be applied, on the one hand, to the so-called therapeutic abortion, i.e., that which aims to save the life or avoid serious damage to the health of the pregnant woman, because it is considered that her life and health are threatened by continuing the gestation until the fetus is viable; and, on the other hand, eugenic abortion, which seeks to eliminate the fetus affected by infections or serious malformations, or by diseases that are transmitted to the offspring or that are accompanied in postnatal life by serious physical or psychological deficiencies.

The decision to treat the woman's illness without resorting to the destruction of the unborn human being represents a profoundly professional attitude, scientifically and ethically superior to its opposite. Faced with the mother-fetus dyad, the good physician owes an equal duty to his two patients: the pregnant woman and the unborn child. Today, given the formidable advances in the clinical attendance of diseases that can seriously endanger the life of the pregnant woman, no truly competent physician is obliged, based on scientific criteria, to accept that abortion is the treatment of choice for any disease of the mother, i.e. that it is such a superior and advantageous intervention compared to other therapeutic alternatives that not performing it would mean inflicting deliberate harm on the pregnant woman, and thus seriously violating the medical precept of doing no harm. Without the need to invoke moral objection, the physician, based on the medical art of the moment, can refuse the so-called therapeutic abortion on instructions strictly scientific grounds, since he can offer valid treatment alternatives that also respect the life of the unborn child .¹⁵.

The physician's refusal to abort fetuses with malformations or defects that seriously disrupt their subsequent physical or mental development is justified by the specifically medical respect for the deficient life. The Code of Medical Ethics and Deontology, in its article 25.2, confers to the unborn sick the full status of patient.¹⁶. 

Abortion is excluded as a treatment for the sick fetus, because the eugenicist idea that human beings must be free of imperfections is alien to medicine. The physician cannot be an agent of the "tyranny of normality": for him, all lives are equally worthy of respect. The sick man, before or after birth, is presented to him as someone who, however plagued by disease, is always worthy of his esteem and care. His patients are not perfect biological organisms, radiating a flourishing quality of life, but beings of flesh and blood, sealed by both dignity and frailty.¹⁷.

Corporate protection of objectors

Deontologically, odc is not only a private, individual problem of the objecting physician. It is something that concerns the entire medical corporation. It is the responsibility of the latter to guarantee, to the extent of its possibilities, the legitimate independence of physicians, an essential condition for the correct practice of medicine.

The corporation must defend the physician against any action that diminishes his freedom or discriminates against him, out of fidelity to the deontological rules and ethical principles seriously matured and sincerely lived. It does so not only because medicine must also contribute to a dignified social life, but also to fulfill the statutory duty to defend the independence and dignity of physicians.¹⁸. Specifically, article 27.2 of the Code of Medical Ethics and Deontology specifies the commitment of the Collegiate Medical Organization to provide moral support and advice to members who present odc. It reads as follows: The physician should not be conditioned by actions or omissions outside his own freedom to declare himself a conscientious objector. The Colleges of Physicians will provide, in any case, the necessary advice and financial aid .

Must they do so always and in all cases of objection? In order to deserve this institutional support, the objector's conduct, as such, must be impeccable, committed, not opportunistic, and proportionate in dignity and cleanliness to the ethical prestige of the objection. On occasions, when abortion objection is discussed in the media, reference letter is often made to the duplicity of some physicians who object during their hours of work in public services, but who do not do so when they devote themselves to their private internship . This is an extremely serious accusation, which has never materialized in formal complaints to the medical corporation or to the administration of justice. In the unlikely event of such conduct, those who engage in it would be deserving, not of the moral support and advice promised in the Code, but of serious moral censure, including a very severe disciplinary transcript . The conduct of objecting in a public center to the internship abortion of a woman and not objecting to that same woman having it performed in a private center is not only a painful example of moral duplicity, but a prohibited statutory offense: diverting, for self-interested purposes, patients from public consultations of any kind to the private enquiry .¹⁹

Hierarchical relationship and conscientious objection

Recent history sample that, at times, objectors to abortion can be discriminated against by those who govern health institutions. There have been some cases of gross injustice. But the most frequent is the subtle but painful punishment of those who do not bow to the wishes of those in charge.

In practice, the odc often presupposes a situation of inequality: the objector usually occupies a position of dependence. Sometimes because he or she is a subject, subject to the permissive laws of a country; sometimes because he or she is a subordinate, a member of a hierarchical team, receiving orders that may create conflicts of conscience. The problems of odc are most acutely and frequently encountered by health workers in dependent situations (young doctors, applicants for certain jobs, nurses and auxiliary staff).

The one who governs group will distribute the roles and responsibilities, taking care to respect the conscience of all. The leader must take into account the legitimate individual peculiarities of each one, including the ethical ones. In the case of physicians, there is one more reason to do so: they are colleagues who are part of a fellowship, who share a common vocation, who should treat each other with due deference, respect and loyalty, regardless of the hierarchical relationship that exists between them.²⁰.

The same conduct must govern relations with those who perform the necessary auxiliary functions alongside the physician: the same Code states that the physician shall respect and take into account the opinions of his non-physician collaborators regarding the care of the sick, even if they differ from those of himself.²¹. The ethical respect due to nurses and assistants implies respect for their freedom, their moral autonomy and their professional skill . Therefore, no one should be excluded from the right to object. In the United Kingdom, according to case law, this right is not enjoyed by those who are not immediately and directly involved in the abortion surgery: it cannot be invoked, for example, by secretaries who have to carry out, on behalf of the doctor, the administrative formalities prior to the abortion .²².

Whoever governs the group will see to it that the work is redistributed in such a way that respect for the odc does not produce unjust situations, neither of punishment nor of privilege, for objectors or non-objectors. Respect for consciences should never create resentment. It would be unacceptable cynicism for someone to invoke odc to avoid part of the workload he/she must bear: the objector must be willing to compensate with an equivalent work , in intensity, duration, inconvenience and schedule, the one he/she fails to do because of moral repugnance. Similar to what happens in civilian life with the substitute social service for those who object to military service, the moral integrity of the objector will predispose him to accept the work that equitably compensates for the one he has failed to object to.

The Code imposes on the leaders of work groups the duty to create an environment of acceptance and respect for the odc. It states that the person in charge of group shall ensure that there is an atmosphere of ethical demands and tolerance for the diversity of professional opinions, and shall agree to refrain from acting when one of its members objects to a reasoned objection of science or of conscience .²³. Thus, according to the Code, there is no place for moral violence in the work team, not even in the apparently mitigated form of implanting as official doctrine a minimalist civil ethics, which all must share. That would be the death of the ethical pluralism that we want to save. It is more humane and morally more dignified to live together in freedom, respecting, thanks to the odc, the convictions of all, than to impose, even if only on one, the withdrawal of his convictions.

Institutional conscientious objection

It is an interesting question whether, in a free society, not only individuals but also health care institutions are able to invoke odc, that is, whether a hospital, public or private, or a health insurance system publicly proclaims its attitude towards abortion (or any other practice that provokes moral disagreement).

The problem, apart from the theoretical interest of determining whether and to what extent a hospital is a moral entity capable of making decisions that affect the behaviour of all its members, has immediate practical consequences for health policy, public information, labour relations or the services and benefits offered.

Although there are contradictory opinions on topic, the most widespread view among those who have studied it is that the hospital, at least the private hospital, has the right to constitute itself as a collective moral subject. Thanks to this, over and above the relationships of individual physicians and patients and serving as an ecological envelope, the hospital can create an internal moral atmosphere, an ethical microclimate, in which both internal tensions and external pressures are regulated and integrated into an institutional creed, a professional style and a publicly proclaimed and voluntarily assumed ethical conscience.²⁴.

As far as the hospital odc is concerned, and by virtue of a long tradition carved out mainly by Catholic hospitals, it is considered a peacefully accepted cultural and social fact that hospitals have the right to define, at agreement with their own rules of governance, to declare the internship abortion as contrary to their institutional spirit. Even in a purely civil ethical argument, a truly democratic and pluralistic society should recognize the right to ethical pluralism of institutions, including public ones, by virtue of which hospitals could autonomously opt for odc at abortion.²⁵.

As with individual objectors, the objecting hospital may run the risk, and the harsh reality, of suffering discrimination and marginalization for proclaiming and practicing the utmost respect for human life. There is a long history of persecution, harassment and slow martyrdom of institutions reluctant to abortion.²⁶.

A new field of health odc: the review of young people prior to joining the mandatory military service.

Until recently, the review of young recruits was skill of the Classification and Review Boards of the Recruiting Centers, made up of Military Officers and Doctors. By virtue of and in accordance with the provisions of the 1991 Military Service Law, on December 5, 1994, INSALUD and the Ministry of Defense signed a partnership agreement for the performance of health examinations for the assessment of the aptitude Psychophysical for the Military Service of young people. Consequently, this assessment became a function of the INSALUD Primary Health Care Services, so that the doctors assigned to these Services are, from now on, in charge of this function.²⁷.

When the INSALUD authorities of a small provincial issue sent, in March 1995, to the physicians of the corresponding Services, together with the pertinent documentation, the order to go to contact with the young people who were to be evaluated for military service, there were some protests from some collegiate representatives due to the economic, functional and work overload that the new activity implied. But also, and this is what interests us, at least one physician refused, despite the explanations offered by the General Manager of Primary Care, to carry out the evaluations alleging odc.

The presentation of this odc had no effect, since the Management indicated that it was the opinion of the Chief Prosecutor of the Provincial Court that "no physician can be authorized as a 'conscientious objector' since the Law does not protect him as he is obliged to carry out the medical examinations at staff assigned to his quota". And the General Manager added that the same Prosecutor had informed him about "the administrative and criminal liabilities that the medical professional may incur by refusing to perform this examination and not issuing, therefore, the appropriate certification under the proper conditions".

The objection presented by the physician was based on two groups of reasons: some ethical-professional (the imposition of a fixed model of examination that annuls the freedom and independence of the doctor; the obligatory disclosure to third parties of the data of the clinical history, which includes information of the most intimate staff sphere, about lifestyles, orientation and sexual practices, testified through a certificate, the condition of minors of the young people at the time of being examined); others, of ethics staff and citizenship, consisting of the profession of pacifism and solidarity, and the social movement of rejection of compulsory military service.

It is obvious that, for the purpose of determining the legitimacy of the objection to these examinations, both the reasons stemming from the staff sphere and the more strictly ethical-professional ones are important. Is there continuity between the objection to the internship of military service recognized by the Constitution and regulated by law and the objection presented by the physician to the internship of the evaluations prior to the selection of recruits? In any case, can it be considered congruent with the pacifist attitude, constant and solidly based on ethical reasons, of a physician to refuse to cooperate in the selection of those who are to join the armed forces? There is a dual tradition of honor and dignity in the medical profession: that of military physicians who have contributed to humanizing wars and caring for the wounds of friends and enemies; and that of physicians who, after estimating the enormous cost of pain and death caused by wars between combatants and the civilian population, declare themselves pacifists and contribute, in humanitarian missions, to alleviating the tremendous impact that wars have on health and human rights.

The ethical and legal problem of this variant of objection has not yet been resolved. Personally, I am inclined to think that the deontological reasons supporting it are very solid. This is not the opinion of the legal experts, who either consider that no objection to such examinations can be made or consider the filing of such an objection to be of doubtful success, given the fluctuating jurisprudence of the Courts of Justice, including our Constitutional Court.

Boycotts of pharmaceuticals and medical devices

A boycott action against a pharmaceutical laboratory seeks to change the policy of this laboratory on the basis that the economic damage caused by the decision of many not to prescribe their medicines will be much more burdensome than that resulting from fail the manufacture or marketing of the product that provokes the boycott. The elements of the boycott are very simple: although other people (patients, journalists, other pro-life activists) can participate in it, the action is fundamentally aimed at health professionals who want to collaborate (doctors, pharmacists, pharmaceutical distribution centers, nurses). They are to be provided with a card, which is circulated by the pro-life professional group(s) promoting the boycott, indicating their address and telephone number. On one side of the card is written a concise explanation of the reasons for the boycott and an invitation to collaborate personally and to invite other colleagues to join the boycott. The reason for the boycott is given and a description is given of the coordinated actions that should be taken at internship: write to laboratory requesting the withdrawal of these products and refrain from prescribing or dispensing the other drugs produced by laboratory . To this end, a list of equivalent products is provided on the other side of the card , indicating the brand names or generic products that can replace the various drugs of the boycotted company. It is very easy, with a good drug vademecum or with the current year's prescription guide , to make this table of equivalents.

It is important to keep in mind that the boycotting action is part of a very broad way of life: that of changing the opinion of many indifferent people in favor of life, making them see that it is not a passing eruption, but a profound and permanent movement. There should not be "one" promoter, but many, very many, who spread the message. And they must do so in a positive, cheerful, encouraging, modern way, like ordinary people. Even the appearance of connecting the boycott with political, cultural or religious groups is not wise: they must have an open professional character. Sometimes an ill-advised gesture can be used by journalists to discredit the whole action in the eyes of public opinion. It is essential that, at all times, pro-life activists be courteous and friendly; that it be seen that, although they are suffering, they are not bitter; that they are confident that their aims will eventually appear reasonable and noble; that, although they are combative, they are not aggressive or violent. If they demonstrate in public, they will do so peacefully, with humor, carrying a kind and positive message. If they write letters, or make a campaign of phone calls to the central laboratory or to their local representatives, they must give their name, their professional degree scroll , and communicate with simplicity and in very different ways the message that, in essence, consists of expressing their pain for seeing that a laboratory that produces high quality drugs and that one has been prescribing or dispensing for a long time, or whose research one was proud of, has diverted its action in favor of health and life towards the destruction of innocent human beings. Add that one will boycott, for as long as the anomalous status lasts, their products, but that one is sure that this will be short-lived, as one expects a reasonable reaction.

In a hospital, a list of signatures can be opened to request the withdrawal of the product. Lists of shareholders and managers can be obtained from the relevant yearbooks and should be written to politely but clearly. 

It is up to the promoters to work seriously in the preparation of the boycott and of the satellite actions, so that at the moment of launching the operation all the immediate collaborators can be sufficiently endowed with moral reasons, with the capacity to attract new adhesions, to develop initiatives, to have access to the means of opinion. A boycott operation is short-lived, but it must be very intense.

An uncertain future

The right to abortion is not a right that is exercised peacefully. Despite the strong implantation of the dominant principle of autonomy in contemporary medical ethics, the general impression is that the autonomy of the woman who wants to have an abortion takes ^{precedence28, 29, 30}, in the minds of many health managers, judges and bioethicists, over the right of the doctor and nurse to refuse the internship abortion for reasons of science and conscience.³¹.

In Spain, while awaiting a legal rule regulating abortion, it does not seem that much reliance can be placed on the scarce jurisprudence available. Leaving aside the few cases that arose in the first weeks of application of the Ley del Aborto (Abortion Law), it would seem that there is little to rely on.³²it is worth citing here two rulings, emanating from the conference room of the Aragon High Court of Justice, in which two practically identical cases received diametrically opposed rulings .³³. The cases involved two anesthesiologists who had been working, with full efficiency, for 18 and 14 years in an Obstetrics and Gynecology Department of a Social Security hospital, and who had objected to the internship of anesthesia in abortion operations. On the occasion of a redistribution of staff of the Anesthesia Department, they were forcibly transferred to another Department of the same hospital, for the sole reason of refusing to participate in abortion cases. In the first case, the Court concluded that the transfer was a covert reprisal carried out in clear violation of the fundamental right to non-discrimination on ideological or religious grounds recognized in Articles 14 and 16 of the Spanish Constitution. By virtue of which, the Court revoked the resolution of forced transfer and ordered the reinstatement of the discriminated physician to his previous work space . In the second case, the same High Court of Justice of Aragon considers that the plaintiff, invoking constitutional rights, calls into question the organizational power of the hospital's managing body. And considering that such power is indisputable, it understands that the forced transfer falls within the School to organize the services to position in the way it considers most appropriate for the fulfillment of the purposes entrusted to it, and concludes that the general interest of the best provision of public service cannot prevail or oppose the rights invoked, provided that the exercise of the organizational power does not involve excess of power or imply a work different or superior to that established in the regulations. It is curious that in both cases different rulings of the Constitutional Court are invoked in favor of the different rulings issued.

It has been publicly acknowledged that the odc can close off physicians and nurses from work positions, whether it be the first employment, or advancement up the academic or professional ladder. internship If the project of the American Medical association and the Joint Commission of accreditation of Hospitals were approved to include training in abortion and abortifacient contraception in the programs of training for Obstetrics and Gynecology residents, a precedent of extraordinary gravity would be set, given the global leadership role of both institutions.

Professional authorities, often highly politicized or in the process of negotiating economic improvements with governments, tend to react very lukewarmly to cases of discrimination against physicians. And the passage of time tends to consolidate in the public mind that there is an enforceable and absolute right to abortion, which the physician cannot refuse. There are testimonies from non-objecting physicians that show the haughty Degree that some patients can exercise when they claim their alleged right to abortion.³⁴.

In point 73 of the recent Encyclical Evangelium vitae, John Paul II speaks to us with force and compassion of the moral obligation to object in conscience, of its testimonial value, of its evangelical root .³⁵. 35 Meditation on these lines reveals to us that conscientious objection is a grace, a charism, which gives strength to bear witness to the truth and to endure the modern forms of administrative martyrdom into which the willingness to go to prison or to die by the sword of the past has been transformed. The odc is, in addition to salt that prevents health professionals from the corruption of ethical relativism, a sign of hope.