Genuineness View

The genuineness view states that a conscientious claim properly generates an exemption when it is based on a core moral belief that is genuinely held by the provider. This view is defended by Christopher Meyers and Robert Woods, and the following quote well represents their thinking: “We stress…that the principle of autonomy demands that society respect healthcare professionals’ genuine conscientious objection; we just seek confirmation that the conscientious objection is in fact genuine.” ^{Footnote 6}

Meyers and Woods discuss various criteria and suggest that a review board be established to ensure that the objection is sincerely held by the medical professional. Ultimately, however, priority is given to the values of tolerance and provider autonomy, and, therefore, this view seems to allow a very broad scope for granting an exemption to providers who possess conscientious objections. This point could be viewed as a primary advantage of this view: genuineness rightly seems to be an appropriate condition for any acceptable conscience objection. If the provider is refusing to do what would otherwise be his or her professional duty, in order to allow an exemption we would certainly want the refusal to at least be premised on a sincerely held moral belief. The genuineness view, however, seems to offer an exemption for any “legitimate” conscientious refusal—that is, as long as the refusal is based on a moral belief that coheres with the objector’s foundational ethical values. This view expresses a central insight; however, it also possesses significant difficulties. Given this view’s focus on tolerating conscientious objections founded on beliefs that are sincerely held, any moral grounds would seem to generate an exemption based on the genuineness view. A provider who held racist beliefs—for example, to not to treat patients of a certain race at a particular hospital—could properly receive a conscientious exemption based on this view, as long as those racist beliefs were genuinely held by the professional. This, of course, is a morally repugnant outcome of the genuineness view; such a position does not look at the reasons behind the objection in any way. Our discussion reveals, then, that this view does not lessen the burdens on patients at all—in fact, it seems that patients pay the price for providers’ conscientious objection either by being inconvenienced or (more significantly) being deprived of access to legally available medical services. This, however, seems backwards; as a point of reference, if one is granted a conscientious exemption in the military context, that individual must be willing to bear the consequences of his or her refusal to serve based on a genuinely held belief. Consequences can include having to serve jail time if one is not successful in getting one’s petition for a conscientious exemption granted and one refuses to enlist or to serve and engage in combat. Successful United States conscientious objectors (COs) in the military must perform alternative service (perhaps working in a hospital or driving a supply truck) to make up for not satisfying their duty; however, in the medical context, the CO bears none of the costs. This view is wrongheaded, because it places all of the burdens on patients who are subject to refusals that can be based simply on beliefs that are sincerely held by the practitioner.

Matching View

These points give us sufficient reason to explore another position, the matching view defended by Holly Fernandez Lynch. This view suggests that we should establish a physician–patient values-matching system; this system purports to preserve physician conscience and avoids scruples-based conflicts in society. She argues that state licensing boards should ensure that patient demand for various medical services is met by a sufficient supply of practitioners, and continues: “However, if access problems remain as a result of conscientious refusals, patients should seek compensation from these boards rather than from refusing physicians. Physicians should not be subject to individual liability or professional discipline for their refusals even when they stand as the last doctor in town.” ^{Footnote 7}

According to this view, liability clearly falls onto the state licensing board that is responsible for matching patients to physicians who possess a similar value system and will thereby offer the full range of services requested by a particular patient. Fernandez Lynch motivates the central idea behind her view as follows: “There may in fact be as many strains of medicine as there are value systems, and patients may prefer to be treated by physicians with similar values, who, while refusing to offer certain medical services normally within the ambit of their chosen medical specialty, are nevertheless capable of providing competent and valuable patient care. Rather than banning or sanctioning these physicians, the government, the profession, and society should allow both doctors and patients to seek out like-minded others.” ^{Footnote 8}

The matching view, then, consists in a sorting proposal that minimizes (or, if perfectly functioning, obviates) crises of conscience. A central advantage of the position is that it allows for a proactive method for providers to avoid having to act in ways inconsistent with their values, while minimizing access problems by patients. Such a system could well be established, although it would likely be costly to create and maintain. There are substantial practical difficulties with setting up this social mechanism based on providers’ and patients’ values, however. What happens when there are providers or patients whose values change over time? What about emerging technologies that have implications for one’s ethical values? If the conversation moves beyond practical problems, this view’s attempt to ensure that providers do not encounter patients whose ethical values do not mesh with their own is philosophically problematic, because this proposed solution does not examine the reasons behind a conscience objection when establishing the sorting system. If a provider has (for example) sexist beliefs and does not wish to allow women to have access to contraception because this physician is unduly paternalistic and does not think women should have control over their reproductive lives, the matching view appears to take that reason at face value. This position would aim to ensure that this provider will not have to write a prescription for birth control or counsel a rape victim and discuss emergency contraception (EC). ^{Footnote 9} Fernandez Lynch clearly states that her proposal is to allow “many strains of medicine” in a value-laden sense, thereby giving physicians the freedom to work with patients who are “like-minded others.” However, the idea that providers can simply avoid patients with moral beliefs that clash with their own suggests that this system does not give proper weight to the professional obligations possessed by medical practitioners. As discussed, physicians possess a prima facie obligation to provide medically appropriate and legally available medical care to patients, even if this care conflicts with their moral values; however, this system would allow providers to simply hide from the very real problem of toleration, of living with others who hold different worldviews. This view does not give appropriate importance to professional duty, because it removes the burden of proof from providers; they need not even demonstrate that a countervailing substantial reason exists that overrides their defeasible obligation to serve their patient. As Fernandez Lynch explicitly states, providers avoid all individual liability or professional discipline within the sorting system that is the hallmark of the matching view.

To bring this problem to life, imagine a provider in the United States who wishes to avoid patients for suspect reasons: for example, a Republican physician who wishes to not care for Democratic patients (or vice versa). This example seems outrageous; a patient’s political affiliation is hardly the sort of consideration that should constitute a countervailing reason to defeat the provider’s prima facie obligation to assist a patient. Fernandez Lynch might object to the hypothetical, countering that no physician would really do such a thing. However, the schematic example cited is drawn from the real case of Dr. Jack Cassell, a Florida urologist and registered Republican who strongly opposed “Obamacare” (the Affordable Care Act). In 2010, he posted the following sign on his office window: “If you voted for Obama….seek urologic care elsewhere. Changes to your healthcare begin right now, not in four years.” ^{Footnote 10} If this case is understood to be a kind of conscientious refusal, then Dr. Cassell aimed to establish a self-directed physician–patient values-matching system, seemingly in line with the matching view. It does not seem to be a stretch to think that Dr. Cassell possessed a relevant core moral belief that led him to pre-emptively announce that he did not want to care for patients with certain political affiliations or political beliefs—a result that again appears to be in line with the matching view. However, this result is unacceptable. Shielding physicians from moral diversity does not obviously improve medical practice, and it makes a mockery of professional ethical obligation in the healthcare field.

Incompatibility View

I will now move to the other end of the spectrum. The incompatibility view states that conscientious objections are incompatible with one’s role as a medical practitioner and for that reason are never justified. This position is defended by Julian Savulescu, who argues that invoking conscience in medicine is incompatible with the professional commitments of a physician. Therefore, conscientious objection in medicine should not be tolerated. As Savulescu states: “A doctor’s conscience has little place in the delivery of modern medical care….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.” ^{Footnote 11}

This quote makes it clear that the incompatibility view does not wish to countenance any conscience objections, and does not want to allow conscience any significant place within medical practice. Savulescu makes clear in this article his belief that “What should be provided to patients is defined by the law,” ^{Footnote 12} and that physicians must fully discharge their obligations to care for their patients. He summarizes his disdain for the inclusion of conscientious values claims in medicine in the following passage: “The door to ‘value-driven medicine’ is a door to a Pandora’s box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own.” ^{Footnote 13}

An advantage of this view is that it properly elevates the professional ethical obligations of physicians; as was mentioned, the matching view fails in this respect. The incompatibility view requires medical providers to separate their moral judgments from their clinical judgments. In fact, Savulescu states that medical professionals who disrupt the delivery of medical services based on their scruples should be punished by removal of their license or via some other such legal mechanism. ^{Footnote 14} This view has very clear implications: the answer to any conscientious claim is simply “No.” Although the view’s clarity and focus on professional obligation are virtues, the incompatibility view possesses serious shortcomings. This view treats all putative conscientious objections on a par, regardless of whether those who support conscientious exemptions actually wish to endorse doing so in any particular case. For example, most people think that a sexist or racist refusal is abhorrent, whereas a refusal founded on a genuinely held (nondiscriminatory) moral or religious belief is at least a more viable contender for a legitimate exemption. The incompatibility view, however, views all conscientious objections as equally (un)justified; it does not look to the reasons supporting the objection and considers all conscientious exemptions to be similarly unacceptable.

Further, this position is mistaken because it allows conscience no role in medicine; society might want to allow some role for conscience to spur moral progress in the profession. To support this claim, consider Bernard Dickens and Rebecca Cook, who argue that there should be a role for “conscientious commitment” in medicine: these are positive acts motivated by scruples that may violate religious tenets, institutional policies, or even law in order to safeguard women’s life and health. As Dickens and Cook say of objecting healthcare practitioners with regard to contraceptive products, contraception, and elective abortions: “Their modern claims to conscientious objection…reflect an earlier history of conscientious commitment to challenge the restrictive laws in regard to these practices that previously prevailed.” ^{Footnote 15}

The call for providers to engage in acts of conscientious commitment to women’s health arises in response to others’ failures to act, from conscientious refusals to provide care, or from repressive laws or religious doctrines limiting women’s reproductive freedom. ^{Footnote 16} Dickens and Cook offer a forceful case that both acts of conscientious commitment and scruples-based refusals deserve protection; however, the incompatibility view, by removing the concept of conscience altogether from medicine, cannot recognize the importance of conscientious commitment. The distinction between “positive conscience” (conscientious commitment) and “negative conscience” (conscientious refusals) is sharpened further by Lisa Harris within the context of abortion provision: “The exercise of conscience in health care is generally considered synonymous with refusal to participate in contested medical services, especially abortion. This depiction neglects the fact that the provision of abortion care is also conscience-based.” ^{Footnote 17}

Recognizing that abortion provision may be conscientiously motivated, Harris calls for the protection of both types of conscience-based actions in laws and policies. Harris’s point hits home, because moral integrity can be violated by not allowing positive acts in accord with one’s conscience just as it can by requiring performance of “contested” acts by those with conscientious scruples against providing the requested service. Harris’s discussion is particularly compelling given her focus on abortion; there is considerable evidence that abortion providers exhibit conscientious commitment and that society should allow a role for positive conscience on the grounds that laws may be in need of change and progressive thinking and action may be necessary. To cite just one historical referent, sociologist Carole Joffe discusses in Doctors of Conscience ^{Footnote 18} how United States physicians performed abortions before they were legalized by Roe v. Wade, ^{Footnote 19} risking loss of licensure or imprisonment. Joffe points out how not providing abortions made some physicians feel complicit in a system that, in the words of one of the interview subjects “was full of death and injury—all of it so utterly unnecessary” ^{Footnote 20} Joffe’s work also repeatedly shows how women from higher socioeconomic classes were able to secure abortions despite their illegality. Feeling complicit based on one’s participation in a system one believes is unjust and immoral is a hallmark of a conscientious claim; now, it appears that the same can hold true of failing to perform positive acts of conscientious commitment to women’s health. Savulescu thinks that allowing “values-driven medicine” will lead to bigoted and discriminatory medical treatment. He fails to realize, however, that if the appropriate authorities were to follow his advice and completely eliminate conscience from medicine, there would be a separate class of (presumably preventable) “idiosyncratic, bigoted and discriminatory” acts that would not be checked by the positive actions of other conscientious physicians.

To make this point more vivid, I will briefly discuss a tragic instance of a conscientious refusal. Consider the case of Savita Halappanavar, a 31-year-old woman living in Ireland who died in 2012 after being refused a uterine evacuation. Ms. Halappanavar, who was 17 weeks pregnant, presented at University Hospital Galway, and after it was determined that she was miscarrying, her repeated requests for a termination were refused. She found herself in pain and getting sicker and sicker. Her husband Praveen Halappanavar reported that his wife was told: “As long as there is a fetal heartbeat, we can’t do anything.” After another request, she was told that it was the law, that this was a Catholic country. ^{Footnote 21} Physicians said her child would not survive; after its death, the fetal remains were removed, but it was too late for the patient. Even though she was being treated with antibiotics, Ms. Halappanavar died of septicemia and multiple organ failure.

These actions were apparently in accordance with Ireland’s strict antiabortion laws dating back to the 1980s; these laws are vague in that they do not indicate when a threat to the life of the mother is sufficiently high to justify termination. The providers, then, were seemingly acting in accord with Irish law when they refused to perform the uterine evacuation while a fetal heartbeat could be detected. This case underscores the importance of allowing and encouraging conscientious commitment by medical providers to women’s health and safety; a conscientious commitment by a physician to act contrary to the law may have saved Ms. Halappanavar’s life. Should the appropriate authorities follow Savulescu’s advice to expunge conscience from medicine (instead allowing what patients receive to be simply “determined by law”) and thereby rule out conscientious commitment? The incompatibility view is mistaken to remove considerations of conscience altogether, because positive acts of conscience may be needed to promote moral progress in medicine, to advocate for needed changes in the law, and to avoid injustice and needless harm. ^{Footnote 22}

Referral View

The referral view states that a conscientious objection is acceptable as long as there is referral to a willing provider. In a prominent essay defending this view, Julie Cantor and Ken Baum focus on pharmacists’ refusals to dispense emergency contraception; however, their view seems to be generalizable to other sorts of healthcare professionals and contexts. Cantor and Baum weigh the arguments for and against a professional’s right to conscientiously object, and conclude:

Cantor and Baum clearly state that there should be no mechanism to legally require professionals to act in ways inconsistent with their beliefs. Their position is that objectors have an ethical professional duty to refer patients, and that there should be a legal duty to refer in instances of conscientious objection. This is their conclusion despite the fact (as Cantor and Baum discuss ^{Footnote 24} ) that there is no strong scientific evidence supporting the idea that EC is an abortifacient; however, the objection to EC consists in the claim that EC causes an abortion (or its moral equivalent) and that, therefore, dispensing this medication is participation in murder. Cantor and Baum instead suggest a number of creative policy alternatives such as requiring advance notice of an objection by signage posted at the pharmacy, asking physicians to fill gaps in care left by objectors, and advocating that physicians discuss EC during office visits and educate patients by pointing to web sites such as www.not-2-late.com that allow users to locate a willing provider in their area.

Referrals can make sense when they are practical. Both the provider and the patient may be more at ease and the patient may receive better care. The referral view is currently the status quo position, yet I am going to suggest that it is not a good solution to the conscience dilemma. One disadvantage is that access to particular services in rural areas may suffer. In fact, it is too generous to assume that only access in rural areas would be affected in cases such as abortion provision. In places such as Italy, 70% of gynecologist obstetricians are opposed to abortion, even though the law formally protects women’s access. ^{Footnote 25} In the United States, 89% of counties lacked an abortion provider in 2011. ^{Footnote 26} The referral view cannot ensure access in places where conscientious objection to the service in question is prevalent. Although this position may lessen the burdens on patients (as compared with, for example, the genuineness view), the costs of conscientious objection are again primarily borne by the patient and not by the petitioner for an exemption: the opposite of what should be the case in conscientious objection. Because the exemption is granted in the form of providing information or possibly referral to a specific willing provider, in either case the patient must spend additional time and resources to receive medical services that are legally available and have been deemed safe and effective. Further, a provider’s objection can be insurmountable in practice with respect to medications such as EC, because of the short window during which the drug can be effectively used (72 hours after sexual intercourse for Plan B). Objection in such cases can be tantamount to obstructionism; there are published cases in which women had to deal with the fallout of being placed on a conveyor belt of referrals that prevented them from receiving EC quickly enough for it to be effective. ^{Footnote 27} In such instances, the referral view privileges the provider’s beliefs over the patient’s beliefs and needs, and may place the patient in a morally precarious position. For example, imagine a case in which a provider refuses to dispense EC to a woman who finds abortion morally problematic yet is comfortable with using contraception, and the woman becomes pregnant. The provider has privileged his moral values over the patient’s values, and has placed the patient in the morally difficult position of having to face an abortion decision or carry an unwanted pregnancy to term: a position she tried actively to avoid by seeking out Plan B. This treatment is at the very least unfair, and at worst, an abandonment of the patient and an abdication of the practitioner’s professional ethical responsibilities.

The referral view privileges provider beliefs in this way; however, it does not examine providers’ reasons. What if they rest on false beliefs? A provider might, for example, refuse to dispense EC because he or she mistakenly thinks that its primary mechanism of action is to dislodge an implanted embryo. With the referral view, a provider’s false belief would be given precedence over a genuinely held and empirically correct belief of the female patient requesting Plan B. These problematic points constitute sufficient reason to not blithely adopt the referral view.

There is a clear theme in this discussion: None of the views in the literature that I have discussed consider the objecting provider’s reasons. The genuineness view looks only to ensure that the medical provider is acting on core moral beliefs that are genuinely held, and the matching view does not assess practitioners’ grounding reasons, but only sorts physicians and patients into pairs with values that mesh (regardless of the nature of the provider’s stated values). The incompatibility view denies that any conscientious objections generate an exemption, regardless of the grounding reason offered. Finally, the referral view does not seem to look at reasons, but simply states that in the case of a conscience objection, a practitioner’s professional duty is discharged by referring the patient to a willing provider. Cantor and Baum’s discussion makes this apparent: they still allow an exemption to objectors to EC whose objection is based on the empirically mistaken belief that EC is an abortifacient. Therefore, the referral view as it is developed by its most well-known proponents does not assess providers’ reasons in cases of conscientious refusals. Because failure to consider the reasons behind the objection causes major problems for these views, perhaps the spotlight should be placed on these grounding reasons. ^{Footnote 28} This observation leads to the view that I defend.

Reasonability View

The reasonability view states that medical professionals seeking an exemption based on a conscience objection must state the justification for their objection and allow this basis to be subject to evaluation in terms of its reasonability. First, the reasonability view both requires that practitioners publicly offer the reasons they hold to support their petition for a conscientious exemption and allows these reasons to be evaluated (the reason-giving requirement) and second, this view offers reasonability as the standard for assessing the justifications stated by medical professionals (the reasonability requirement). As I state in earlier work: “The beliefs on which conscientious objection is based must be reasonable and should be subject to evaluation in terms of their justifiability.” ^{Footnote 29}

I also offer a policy suggestion by which to deploy the reasonability view, that CO status be established within medicine: “The establishment of conscientious objector status with respect to certain activities would be a step forward by requesting that medical professionals state succinctly their reasons for refusing to serve and be open to these reasons being evaluated as part of institutional practice.” ^{Footnote 30}

If a conscientious claim satisfies the reasonability standard, then the exemption takes the form of granting the provider CO status with respect to the activity in question. ^{Footnote 31} The reasonability view possesses some significant advantages. First, it asks for a provider to make his or her objection and its basis public, and evaluates the reasons and the objection itself. I have argued that avoiding the evaluation of reasons causes major problems, and requiring publicity of the reasoned basis for the objection is not something that a medical CO should want to avoid. ^{Footnote 32} The other views lack this transparency. For example, with the referral view, it can become known that a provider possesses an objection because he or she continually refers patients who make a request for (say) EC. However, unless there is a requirement to create a repository to record conscientious objections, there is no enduring public record of the objection itself, and the basis for the objection is simply unknown. The reasonability view has the advantage of establishing a public record for providers’ conscientious objections, because a practitioner seeking a conscientious exemption must petition for medical CO status to a review board (perhaps a subsidiary of the licensing board) and state clearly both the objection and its basis. Providers who seek to be exempted from what would otherwise be their professional obligation, based on the fiduciary duties to their patients that they have willingly adopted, should at the very least be required to clearly state and explain their conscientious objection, allow it to be subject to evaluation, and, I further suggest, have the justification offered assessed in terms of its reasonability.

Another advantage is that my position is proactive, given its requirement to determine the reasonability of the objection in advance of a provider–patient conflict (by granting exemptions in the form of medical CO status). Part of the crisis generated by a clash of conscience is caused by time-sensitive circumstances such as those involved in conscientious refusals to dispense EC. Determining whether or not an exemption is appropriate in advance makes sense; the military does not adjudicate claims regarding CO status when the petitioner is on the battlefield. The matching view also possesses the advantage of being proactive; however, unlike this view, the reasonability view does not simply aim to avoid conflict (although in practice it can achieve this), but instead evinces a commitment to both tolerance and professional responsibility. The reasonability view acknowledges—out of a respect for tolerance—that there are cases in which a reasonable conscientious objection can defeat a provider’s professional ethical responsibility to give primacy to a patient’s interests.

Defining what constitutes “reasonability” with respect to conscientious objection is obviously a significant task in my view. I unpack the concept of reasonability in this context by proposing that a set of features that look to the reasonableness of the grounds for an exemption (intrinsic factors) and the reasonableness of granting an exemption given the specific circumstances (extrinsic factors) be examined. ^{Footnote 33} The account offered sets out only the primary factors to consider. The extrinsic factors are not intended to be a list of necessary and sufficient conditions, but should instead be viewed as possessing prima facie weight: there are cases in which the gravity of one or several of these factors may support granting an exemption in one circumstance and not in another. The first intrinsic factor states that a successful conscientious objection must be grounded in a core genuinely held moral belief. As discussed earlier, this is a sensible requirement to impose on a practitioner in order for that person to earn an exemption from what would otherwise be his or her professional obligation. The second intrinsic factor states that a successful conscientious objection must be premised on a grounding belief that is consonant with relevant empirical information. As discussed, a medical provider who objects to dispensing EC because he or she thinks that this is an abortifacient bases the objection on empirical misinformation, and as such, this objection does not earn an exemption. I will now turn to the extrinsic factors, the first of which is: A justified conscientious objection must not cause needless or unjustified harm to patients. In essence, the competing harms to providers and to patients must be weighed. A case analogous to that faced by Ms. Halappanavar in which the harm faced by the patient was life threatening would make it very difficult to justify a conscientious objection if one was sought. Second, a justified conscientious objection must not possess an uncontradicted self-interested appearance, and must respect the power inequality between medical professionals and patients. In this connection, it is disturbing that some who refuse to dispense birth control privilege their personal beliefs above their patients’ beliefs and categorically deny even considering any such request, even though as medical professionals they possess a state-sanctioned monopoly power over writing prescriptions for birth control. Third, a justified conscientious objection must not be based on a discriminatory belief. Fourth, a justified conscientious objection must not violate the duty of care by failing to assist patients in an emergency or time-sensitive case. Finally, a conscientious refusal requires a greater burden of proof, all things being equal, than a conscientious provision of care.

To see the force of this last criterion, I will (again) consider a uterine evacuation case. ^{Footnote 34} In some United States Catholic-owned hospitals, ethics committees have refused to approve uterine evacuations for miscarrying women because of moral opposition to abortion. Some medical staff have violated this protocol, thereby exercising conscientious commitment, because they felt that the protocol jeopardized the safety of patients. ^{Footnote 35} Given the clear and present danger faced by miscarrying women and the importance of women’s health, one can ethically distinguish between a uterine evacuation and an elective abortion, and, therefore, find a compelling case for providing such care to women despite institutional barriers. In this case, because the provision of care would conflict with a policy that wrongly classifies medical interventions to address miscarriages as intentional abortions, whereas the refusal of care conflicts with considerations related to safeguarding patient safety, meeting the standard of care, and requiring physicians to uphold their professional duties to patients, the onus is heavier for the defender of refusal. In general, because conscientious refusal goes against not only the conscientious beliefs of members of the profession who would provide the necessary care, but also against the stated wishes of the adult patient, conscientious provision in line with the patient’s request seems easier to justify with all other things being equal. Although the reasonability view would in all likelihood grant a conscientious exemption to a provider acting out of conscientious commitment in a case such as Ms. Halappanavar’s, I hasten to add that this should not be taken to imply that all conscience-based provisions of care will be justified. One can readily imagine cases in which a provider’s conscientious desire to continue life-preserving care against the wishes of a competent, terminally ill patient may not be justified after evaluating the practitioner’s grounding reasons and applying the foregoing analysis. This last criterion ties together the previous discussion and underscores my earlier point that an acceptable account of conscientious objection must make proper room for progressive change within the medical profession. The analysis I offer is contextual, given its inclusion of extrinsic factors, but it also offers foundational necessary conditions with its intrinsic conditions; this brief sketch of these combined factors comprises my view’s thin conception of what constitutes reasonability in the public sphere in relation to conscientious objection in medicine.

This view, of course, also possesses some putative disadvantages. One might say that the view is too restrictive; it allows for too little conscientious objection. Further, one might claim that it is asking too much to evaluate reasons; it would be too demanding or burdensome to ask practitioners to discuss their moral or religious views and the conscience objection based on these grounding reasons. In response, I consider these criticisms to be separable but closely related; therefore, I will discuss them together and make several observations to blunt their force. Medical conscientious objections occur in one’s employed, public life. In the public sphere, it does not seem unreasonable to ask for reasons when people fail to satisfy their professional obligations. It seems justified to ask for the reason why one missed work yesterday, as compared with actions in the private sphere, (for example) why one decided to stay at home during the weekend. Further, it is not unreasonable to assess reasons in this public context, treating a case in which one decided to stay home from work to catch up on watching favorite television shows differently from a case in which one was ill. Finally, protecting moral integrity constitutes the reasoning behind respecting conscience; however, we should keep in mind that integrity is a formal virtue. Integrity is a good within a life because it can be a positive thing to stick to one’s values (perhaps both intrinsically and extrinsically). However, if the value of respecting integrity applies to anyone or any set of beliefs, then it seems that we must respect the integrity of the white supremacist in the same way that we respect the sincere CO to abortion in medicine. I submit that we do not want to do that—we should not have to accommodate a white supremacist employed at a medical center as a matter of moral principle—therefore, this should drive all thinkers to look at the substance of the objector’s beliefs in determining whether to grant an exemption. Because decisionmakers must look in some way at the content of an objector’s beliefs and the reasons offered to support them, those decisionmakers are now engaged in a project of assessment; if they are to examine a person’s beliefs before extending a conscientious exemption, they need a standard for assessment. The view offered in this article says that the standard should be reasonability: only reasonable beliefs need to be accommodated within the public institutional structure of medicine. As Rawls ^{Footnote 36} argued convincingly, only reasonable conceptions of the good are admissible in the public sphere, and hence are the proper subject of toleration.

I suppose one could try to hone some of the other views in the literature to capture the essence of this point. One could refine the referral view to advocate referrals except in (for example) cases of discrimination or objections based on an empirical mistake. I would in fact be comfortable with allowing referrals when the putative conscientious objection satisfies a test of reasonability and a referral is workable. Yet notice this: the refined referral view has now become a reason-giving view. It holds that one discharges one’s professional obligations by referring to a willing provider except in cases in which one’s objection is not reasonable. This implies that assessment of reasons is logically prior to the referral requirement. On that sort of position, referrals are only justified in cases in which the objection is not deemed an instance of (for example) discrimination or misinformation, which means that this refined referral view is simply a species of the reason-giving view. ^{Footnote 37} The same holds true if one attempts to make a similar move with the other views discussed. A genuineness view could rule out exemptions in cases of discriminatory objections, as Meyers and Woods would likely suggest, or a matching view could refuse to create provider–patient matches for physicians whose objections are based on an empirical mistake. ^{Footnote 38} However, the same point applies: on such a refined version of each view, verifying genuineness or creating a values-matching system is subordinated to an assessment of the reasons behind the conscience objection, thereby making these positions a type of reason-giving view. ^{Footnote 39} The incompatibility view refuses to look at reasons, because it considers that no conscience objections properly generate exemptions, and it aims to remove conscience from medicine altogether. Therefore, it seems that one could not make this move with such a view. However, as I have argued, the incompatibility view possesses unique problems in virtue of its abdication of conscience because it cannot capture both the positive and negative aspects of conscience, hence it has further difficulties in addition to its failure to assess justifications. Based on the points established in this article, I think that all acceptable views on conscientious objection in medicine need to examine the reasons supporting an objection when determining whether or not to extend an exemption. Reasons ought to reign supreme in this debate. The reason-giving requirement properly places the burden of proof on the objector. In addition, it is eminently plausible to think that only cases in which objectors act on reasonable conceptions of the good properly generate conscientious exemptions within the public institution of medicine. I submit, therefore, that based on these considerations, a reason-giving position such as the reasonability view leads the pack.