Edmund Pelligrino, who died in 2013, was one of the most respected medical ethicists in the United States. A recipient of 54 honorary doctorates, he served as President of the Catholic University of America, as Chairman of the President's Council on Bioethics under George W. Bush and as director of the Kennedy Institute of Ethics at Georgetown University.

In 2002 he published a perceptive article in the Fordham Urban Law Journal in which he discussed the future of conscientious objection in the medical profession. In the light of current controversies over abortion, euthanasia and contraception, we have excerpted a few relevant paragraphs.

Has the notion of conscience rights changed?

In the last fifty years, secularism has come to dominate much of medical ethics, despite the fact that most Americans personally hold religious beliefs. Secularism is a response to the plurality of moral and religious beliefs in our polyglot society in which there is wide disagreement on what a good conscience should dictate. Since no one moral system or religious set of beliefs is universally accepted, society reasons that none can, or should be dominant. All should be free to express themselves, and each should respect the other. So goes the credo of political liberalism.

On this view, decisions that must be made as a matter of public policy in areas such as abortion, euthanasia, and stem cell research, should be made democratically, universally, and equally binding. Conscience or exemption clauses presumably are devised to protect the freedom of the dissenter. Without dissecting its merits or demerits, this liberal democratic policy has functioned to avoid civil strife.

However, the recent erosion of the number of beliefs held in common, and the increasingly varied demography of our nation, has magnified the complexity and depth of our differences about what is morally right and wrong. The secular solution of moral or value neutrality has generated genuine conflicts of conscience …

Moreover, secular morality, which supposedly tolerates differences, does so only within a narrow range of so-called “values” that are supposedly “free” of moral or religious taint. But secular morality is itself an orthodoxy. Its “values” are based in democratic procedures, personal preference as the basis for moral choice, commitment to a free market economy, the commodification of health care, and an eschewal of religious belief. To deviate from this notion of moral “neutrality” in public policy is to be “undemocratic,” prejudiced, and intolerably sectarian.

What trends are behind the change?

Beginning in 1914, extending through both the Karen Ann Quinlan cases and related cases in the 1970s, and the accompanying trend to micromanagement, the right to refuse care has rapidly metamorphosized into a right to demand and dictate the details of care.

For some, the ends and goals of medicine are no longer defined solely by physicians, but by social convention or the demands of patients or their families. On this view, the physician practices by virtue of a social contract, which grants her profession the privileges of freedom to practice in return for provision of those services that society requires or demands. What constitutes the practice of medicine is societally determined. In Oregon for example, assisting suicide is defined as a normal part of the physician practice, whereas it is forbidden in other states.

These trends are exacerbated by the de-professionalization of medicine, which views health care as a commodity, and its delivery a matter of corporate enterprise, profit, and commercialization. A managed care organization now monitors and controls physicians' decisions. Corporate policy circumscribes the physician's judgments of conscience about the patients' welfare.

Recent professional organizations are trying to recapture professional commitment, but it may not be possible given the fact that most physicians are now employees of corporate entities.

In such a society, such profoundly religious issues as the morality of abortion, euthanasia, human cloning, and stem cell research are determined on grounds of utility, general consensus, or freedom of choice. In the secular philosophy, there is no other world beyond the immediate utopianism of a man-made heaven on earth. This vision determines secular society's decisions about what is permissible and what is not.

Is there such a thing as a value-neutral society?

The requirement of a secular society that physicians practice “value neutrality,” is impossible to achieve. First, it is a psychological schism that violates the integrity of the person as a unity of body, soul, and psyche. What it amounts to is the elevation of secularism to the level of a social orthodoxy; thereby, violating one of the major tenets of secularism itself-that no ideology would have preference over any other. It also violates a prized precept of the secular, democratic, constitutional social order by discriminating against a significant segment of the population, and the physicians who share certain religious beliefs.  

Why is it important to protect conscience rights?

In every belief system, fidelity to conscience is closely identified with the preservation of personal moral integrity. To arrive at a conclusion that something must be done or avoided, and to act accordingly, is to exhibit the kind of person one is, and wants to be. That act provides evidence that the individual is the kind of person she says she is.

Not acting in accordance with this conclusion is to incur the justifiable charge of hypocrisy. Often, to act against conscience is to violate personal identity so directly as to lead to severe psychosocial and emotional sequelae.

Therefore, conscience clauses are firmly rooted in what it is to be a human person morally, intellectually, and psychologically. Every individual, by virtue of being human, has a moral claim to the free exercise of conscience.

What happens if a physician does violate his conscience?

For a physician with deep religious commitments, a “value free” stance on certain issues is simply unthinkable. Certain matters are so clearly prohibited as inherently wrong that there is no possibility of compromise without compromise of moral integrity and danger to one's spiritual well-being.

For Catholics, Orthodox Jews, and Moslems, the teachings of the Gospel, Torah, or Koran take precedence in their lives and indeed inspire their healing vocations. For these major religions, healing the sick is ultimately a religious act and it comes ultimately from God. To practice medicine that contravenes religious teaching would be to subvert conscience to secular society and its “values,” to act hypocritically, and to violate moral integrity intolerably.

For Catholics this would also apply to the secular demand that those who must refrain from certain practice must refer physicians who will provide the disputed treatment or procedure would also be intolerable. To cooperate in an act which is regarded as inherently morally wrong, such as arranging for an abortion or assisted suicide, is to be a moral accomplice.”

What can a doctor with religious convictions do?

The only ethically viable course for the religious physician is to maintain fidelity to moral integrity and the dictates of conscience while practicing in a secular world. Catholic physicians and institutions have the same moral claim to exercise of conscience, as all other humans, even when the fruit of conscience is refusal and even resistance to accommodation of secular beliefs or the changing beliefs of their professional colleagues. This moral claim entails the right and obligation to use the methods available in a democratic society to protest morally objectionable practices by persuasion, judicious political action, and public debate, particularly in the most egregious situations