Recognizing conscience in abortion provision.

n engl j med 367;11 nejm.org september 13, 2012 981 provision of abortion care is also conscience-based. The persistent failure to recognize abortion provision as “conscientious” has resulted in laws that do not protect caregivers who are compelled by conscience to provide abortion services, contributes to the ongoing stigmatization of abortion providers, and leaves theoretical and practical blind spots in bioethics with respect to positive claims of conscience — that is, conscience-based claims for offering care, rather than for refusing to provide it. Pairing of “conscience” and antiabortion sentiment is an understandable consequence of the evolution of conscientious objection in health care. The first conscience legislation, the Church Amendment, arose in 1973 in the wake of Roe v. Wade. It declares that a health care worker cannot be required to perform or assist in the performance of abortion (or sterilization) procedures that conflict with “his [sic] religious beliefs or moral convictions,”1 and it prohibits discrimination against workers who refuse to provide care on the basis of their moral convictions. It also prohibits discrimination against those who do perform “a lawful sterilization procedure or abortion,” though it does not recognize that moral convictions might drive such care. Thus, opposition to abortion, and to fertility control generally, catalyzed the development of law, theory, and practice of conscientious objection in medicine. Conscientious refusals and opposition to abortion grew up together, so to speak. Over the past 40 years, the idea that conscience-based care means not providing or referring for abortion or other contested services has become naturalized. In 2008, the Bush administration extended the protections offered by the Church Amendment to workers who chose not to participate, even indirectly, in care that violated their moral beliefs. The Obama administration rescinded that rule. Antiabortion groups embraced Bush’s rule and criticized Obama’s rescinding of it; prochoice groups responded in the opposite manner. The result is an ongoing false dichotomization of abortion and conscience, making it appear that all abortion opponents support legal protections of conscience and all supporters of abortion rights oppose such protections, with little nuance in either position. Whether or not abortion proRecognizing Conscience in Abortion Provision