Choice Joyce

Choice Joyce

Essays from a pro-choice feminist liberal skeptic infidel activist (and animal lover)

Sunday, May 22, 2016

Blasphemy Is Not Racism

May 22, 2016

Preface: I’m an atheist who firmly believes that religion is false and mostly harmful. I escaped from a Christian fundamentalist childhood, and that was my “oppression”. I spent many subsequent years researching, criticizing, and attacking Christianity, including the Bible, the Jesus story, and various doctrines. Does this mean I’m bigoted against Christians?  Of course not. I was one myself. Many of my family members and a few friends are Christians, and I love them. Criticizing ideas is not bigotry. 
The following article calls out Islamic terrorism as primarily a product of Islamic religious doctrine. It’s over a year old, but I’ve been too afraid to publish it. My past public comments on this topic have resulted in accusations of bigotry and racism – from my feminist and progressive “allies.”  However, recent encouragement to publish this has come from friends, former Muslims I’ve met, and from reading articles by other atheists, and reformist and ex-Muslims. Just today, Armin Navibi, an ex-Muslim and founder of Atheist Republic, gave me further encouragement, and I thank him. 

This piece was originally written for my former monthly column at in Jan 2015, a “progressive” political news site. They rejected it – the only submission from me they ever rejected. (They did eventually publish a different article that mostly avoided mentioning Islamic terrorism.) This draft represents a revised version that tried to answer their objections, which they still rejected. The final paragraph was just added today.
February 2015

In the aftermath of the January 7, 2015 Paris massacre of staff at the magazine Charlie Hebdo, many people on the left slammed the publication for its "racist cartoons," while few explained how they arrived at that conclusion. The French magazine's humour was frequently coarse and not necessarily funny. But that's not a crime, it's just part of free speech.

I absorbed a great deal of media commentary on the tragedy, and it became clear that the intent and context of many of the Charlie Hebdo cartoons were lost on people unfamiliar with French politics. The cartoons usually have multiple layers and meanings, combining two or three different issues at once. For example, the magazine frequently skewers the racism and xenophobia of France's right-wing party, the National Front, often taking the satire to absurd lengths such as equating the party with Boko Haram.

In fact, Charlie Hedbo is a left-wing, atheist magazine that often satirizes religion through the lens of French politics. It frequently targets Christianity and Judaism too, not just Islam. Its satire of Islam focuses mostly on Mohammed, Islamic clerics, practices such as the Islamic oppression of women, and Islamic terrorists – not Muslims in general.

It seems the critics of Charlie Hebdo were confusing satire of religion with racism. But Islam is not a race – it's a religion. Muslims are not a race either. They are part of a religious community and belong to every nationality and ethnic group imaginable, including white westerners. If Muslims are associated with Arabs, that’s a western bias (and probably a racist one).The majority of Muslims actually live in South and Southeast Asia, while only 20 per cent live in the Middle East and North Africa. Silencing critiques of Islam with accusations of racism is itself racist, because it holds Muslims to a lower standard than the rest of us – it defines them by their religion as if they can’t help themselves, and it assumes that all Muslims are the same. It fails to acknowledge their diversity and humanity, and it abandons oppressed and persecuted groups within the Muslim world, such as liberals, atheists, gays, and women.

On a feminist listserv, I once critiqued the Muslim burka (full body cover) and niqab (face cover) as symbols of religious oppression of women and their sexuality. To my astonishment, I was roundly attacked as “racist.” But I have always supported the right of all women to wear whatever they want for whatever reason. Regardless of the various reasons individual women wear these garments today, their origin is patriarchal and their justification comes from Islamic doctrine. The burka and niqab were designed to hide women so that men wouldn’t be tempted by their sexuality – especially non-Muslim men or foreign invaders. The intended effect of these garments is not only to invisibilize women, but also to put the onus on women for controlling both their own and men’s sexual behavior, and to send the message that women are valued primarily for their modesty – which means that Islam is defining women by their sexuality from a male perspective. These are factual observations that have nothing to do with judging individual Muslim women for their choices, which are usually not about kowtowing to men. 

I see a clear divide between blasphemy and bigotry. Blasphemy is a type of dissent or criticism against a god or religious doctrine, practice, or leader. Bigotry (or hate speech) disparages people based on an immutable or shared-group characteristic – colour, race, origin, gender, sexual orientation, disability, age, family or marital status, and religion. Yet, it seems that many people don't understand the difference, so they equate criticism of Islam with bigotry against Muslims and call it “Islamophobia”. That’s alarming, because it’s quickly starting to resemble the right-wing definition of anti-Semitism – any criticism of Israeli government policies. 

Of course, anti-religious satire occurs in a political and cultural context. But the reality today is that Islam has a strong radical minority that is engaged in a belligerent campaign that explicitly uses religious doctrine to justify violence. For example, despite all the western commentary about how the various sins of the French government and society were to blame for the Charlie Hebdo shootings, the only reason that the terrorists themselves gave for killing the cartoonists, as well as Al Qaeda which claimed responsibility, was to “avenge the Prophet.” If the killers were angry at the French government for oppressing Muslims for example, they could have targeted people in the government or even just the innocent public. But they didn’t – they specifically targeted cartoonists who made fun of their religion. 

We’re in a clash of ideologies. The liberal western tradition of freedom of speech (however tarnished) is anathema to fundamentalist Islam. To make matters worse, dissent is impossible within an Islamic state, since religion and politics are inextricably wed, and blasphemy and apostasy are punishable by death. Which means the main victims of radical Islam, by far, are other Muslims. A 2013 Pew Forum poll found that most Muslims don’t support terrorism, but that substantial minorities in some countries DO support it, while significant numbers – majorities in many countries – believe in the imposition of Sharia law and the death penalty for apostasy. 

Christians and Jews have certainly been guilty of terrible atrocities in the name of their faith too. But in the case of Judaism, the worst of it occurred over 2000 years ago (or at least was bragged about in an extensive catalogue – read the Old Testament book of Joshua if you can stomach it), while the Enlightenment put an end to most Christian violence like the Crusades and the Inquisition. Yes, modern Israel is guilty of violence against Palestinians on the basis of religious entitlement, some “pro-life” Christians have been bombing abortion clinics and assassinating doctors for several decades now, and you can find recent examples of Buddhist and Hindu terrorism too. But it’s Islamic fundamentalism that is in global ascendancy right now. 

The Institute on Economics and Peace found that: “Religion as a driving ideology for terrorism has dramatically increased since 2000.” And almost all of it is perpetrated by Islamic terrorists. In 2013, over 60% of terrorist incidents occurred in just five Muslim countries: Iraq, Afghanistan, Pakistan, Nigeria, and Syria. Those same countries experienced 82% of global deaths due to terrorism, and four Islamist groups were responsible for 66% of those deaths in 2013: Al Qaeda and its affiliates, Boko Haram in Nigeria, the Islamic State, and the Taliban. Another 21% of global terrorism deaths were caused by an assortment of other mostly Islamic groups. Further, out of nine organizations responsible for the most suicide attacks from 2000 to 2013, eight are Islamic (the ninth was Tamil Tigers) and the worst incidents all took place from 2008 onwards.

Religiously-motivated terrorism is only a subset of all terrorism, and one could argue that the United States and other western powers are guilty of political, state-sponsored terrorism. But there's a difference in intent, with western countries generally trying to avoid harming civilians, while Islamic terrorists make a point of it. Terrorism experts consider the phenomenon of “global terrorism” to be a recent one associated primarily with Al Qaeda and the Islamic State, whose main goal is existential and religious – to impose Islam on the world through armed conflict. Those adhering to radical Islam take literally the scriptural references that glorify military jihad (as opposed to spiritual jihad). As a result, they commit extreme, attention-grabbing violence to avenge real or perceived wrongs. However, their objective is not primarily to retaliate against political wrongs, but to exploit those in order to establish a global Islamic Caliphate

Factors such as the foreign policy and military imperialism of the U.S. and other western countries, and the social exclusion and discrimination experienced by immigrant Muslims in many countries, are no doubt contributing factors to terrorism. But those on the Left tend not to look past that. 

Because even when Islamic terrorists cite political factors for their deadly deeds, they almost always cite the defense of their religion too, or the Prophet Mohammed, or their vision of a global Islam.
Most oppressed people do not “martyr” themselves in suicide attacks unless they’ve been promised 72 virgins in heaven. And it’s hard to mobilize terrorist armies without a potent ideology to attract and hold them. After all, there are many non-violent ways to address political grievances that the vast majority of citizens in the modern world now opt for. But that’s often not the case for religious extremists. Radical Muslims in particular draw inspiration for violence from belief in literal readings of the Koran and hadith doctrines, as well as religious/political indoctrination by radical Islamists or at Al Qaeda camps such as in Pakistan

Further, terrorists motivated by religion choose to carry out particularly brutal types of retaliation that arise directly from their fervent religious beliefs. This makes religious terrorists much more dangerous than other types of terrorists, according to terrorism expert Bruce Hoffman: 
“[R]eligious terrorist violence inevitably assumes a transcendent purpose and therefore becomes a sacramental or divine duty… Religion, moreover, functions as a legitimizing force, sanctioning if not encouraging wide scale violence against an almost open-ended category of opponents. Thus religious terrorist violence becomes…a morally justified, divinely instigated expedient toward the attainment of the terrorists’ ultimate ends. This is a direct reflection of the fact that terrorists motivated by a religious imperative do not seek to appeal to any constituency but themselves and the changes they seek…are only to benefit themselves. The religious terrorist moreover sees himself as an outsider from the society that he both abhors and rejects and this sense of alienation enables him to contemplate - and undertake - far more destructive and bloodier types of terrorist operations than his secular counterpart.”

Journalist Glenn Greenwald wrote this 2013 piece claiming that Islamic terrorism is motivated by political concerns and not Islam. I spent several hours researching his claims and found that of the seven examples he cites, religious reasons were the primary stated motivation in the first case, and were equal or key underlying motivations in the other six. (I’m happy to share my research with anyone interested.)

Sam Harris is a philosopher and atheist who has extensively criticized religion, primarily Christianity and Islam, and the bad behaviours that dogmatic belief can lead to. Harris has a response to “…liberal apologists who have been saying that their behavior [of the Islamic State] has nothing to do with Islam. Rather, we’re told that burning people alive in cages, crucifying children, and butchering journalists and aid workers is an ordinary human response to political and economic instability. Even representatives of our own State Department assert this. I can’t imagine how comically out of touch with reality we appear from the side of the jihadis.”

Harris has also said: “Religions differ, and their specific differences matter. And the truth is that Islam has doctrines regarding jihad, martyrdom, apostasy, etc., that pose a special problem to the civilized world at this moment in history. We deny this at our peril.” Unfortunately, Harris has been widely misinterpreted and unjustly attacked as “racist” (including by Greenwald) for his criticism of Islamic doctrines and their violent consequences (which, again, are mostly inflicted on “errant” Muslims). He has voiced his frustration thusly:
In any conversation on this topic, one must continually deploy a firewall of caveats and concessions to irrelevancy: Of course, U.S. foreign policy has problems. Yes, we really must get off oil. No, I did not support the war in Iraq. Sure, I've read Chomsky. No doubt, the Bible contains equally terrible passages. Yes, I heard about that abortion clinic bombing in 1984. No, I'm sorry to say that Hitler and Stalin were not motivated by atheism. The Tamil Tigers? Of course, I've heard of them. Now can we honestly talk about the link between belief and behavior?

This is a deeply complex issue with no easy answers. For example, blasphemy and dissent against religion can sometimes be mixed with bigotry against its adherents, and may be hard to pull apart. Some religious believers take slights against their faith very personally, so perhaps one could argue that a devout person's religious faith is a reflection of their personal identity, and that criticisms of their beliefs cross the line into personal attacks. But that can't be our legal yardstick. The bad reaction of some religious believers to critiques of what they hold sacred is actually a reflection of their own doubts and insecurities. 

We are not obligated to treat Islam with kid gloves to avoid offending Muslims, or out of fear of being labelled “Islamophobic” (which is a false term, akin to being called “anti-Semitic” for criticizing the Israeli government). If we stay silent out of fear of instigating more terrorism, then we’re allowing fundamentalist religion to destroy our progressive values of free speech and critical inquiry.

To be clear, we must respect the right of religious believers to believe whatever they want, but we are under no obligation to respect their actual beliefs, especially when they inspire violent acts among a subset of believers. It should be remembered that Christianity and Islam in particular are proselytizing and conquering religions. When some of its adherents try to convert others or impose their religion on whole populations, they have placed their views in a public forum and we have every right – a crucial obligation even – to examine and critique what they believe.

Western liberals should respond to religious terrorism by strongly defending our modern secular societies and the democratic and Enlightenment values they are based on. For example, our immediate response to the Charlie Hebdo shootings should have been an act of defiant solidarity – the mass reprinting of the cartoons by media around the world. Instead, we mostly impugned the cartoons, the victims, and our own governments.

One of our key freedoms is the ability to use the tools of reason and science – as well as satire – to question traditional institutions and ideologies, including religion. It’s essential to preserving human rights and freedoms, which many fundamentalists and right-wing people ceaselessly try to destroy. The critique of any religion and its fruits is not “racist” or “Islamophobic.”

We must defend the right to blasphemy, not criminalize it, or silence ourselves out of fear or misplaced political correctness. Because doing so means excusing terrorism, and ignoring injustice in Muslim countries. It means abandoning women and oppressed minorities who live there, most of whom can’t speak out for fear of their lives. I’ve personally heard brave people like Armin Navibi, Ali A. Rizvi, Maryam Namazie, and Taslima Nasrin – former Muslims who used to live in such countries – ask westerners to please stand up for Muslims and rebut the “regressive leftists.” That’s a term coined by liberal Muslim Maajid Nawaz for people on the left who refuse to call out Islam even though it’s a primary motive for terrorism and oppression, mostly against people in Muslim countries. So I’m speaking up now. Because it’s not my comfortable life at stake, it’s theirs.

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Friday, December 18, 2015

How to Mansplain the Abortion Wars

I’ll start by giving Kurt Eichenwald the benefit of the doubt in one respect – he probably didn’t choose the inappropriate cartoon fetus on the cover of this week’s Newsweek to illustrate his cover article: America’s Abortion Wars (and How to End Them).  Abortion is not really about fetuses. It’s about women – what’s at stake in the abortion issue above all is women’s rights, lives, health, freedom, and dignity. 

Eichenwald’s article makes many strong arguments, but they are not original and his overall framing is offensively wrong. He paints both sides as extremists and complains about the “hypocrisy” and “flaws” in both sides. Yet, he fails to point out a single problem with the pro-choice position. Instead, he spends most of his article attacking the anti-choice side, while agreeing several times with the pro-choice side. I guess that makes Eichenwald an extremist too, just like the rest of us who defend truth and justice. 

Eichenwald does make an attempt to compare the twin evils of pro-choice and anti-choice rhetoric. A feminist calling a guy a “mansplainer” is just as hyperbolic as an anti-abortion person calling a doctor a “baby killer.”  Right, no difference there – they're both so incendiary. Although when’s the last time you heard about a deranged feminist going on a murderous shooting rampage against mansplainers? 

It’s not possible to find common ground with anti-choice fanatics and terrorists. They must be strongly opposed as a threat to our lives and freedoms. Let’s get a few other things straight, too:
  • Being against terrorists who kill people at abortion clinics is not an “absolutist” position.
  • Defending women’s lives and health is not an “absolutist” position.
  • Supporting constitutional freedoms for women (and everyone else), such as privacy, conscience, religion, speech, etc. is not an “absolutist” position.
  • Anti-choice ideology relies on religious dogma and doctrine, which are absolutist. The pro-choice view is steeped in the Enlightenment values of tolerance, secularism, autonomy, and universal rights.
  • Religious belief and fanaticism do not occupy the same playing field as evidence-based medicine.
  • The misogyny inherent to the anti-choice position is not morally equivalent to the respect and compassion extended to women and their families by abortion providers and the pro-choice movement.

There is also no “rational middle” in the abortion issue. Eichenwald probably means the “muddled middle”, a segment of the public that is unfortunately misinformed because it’s been fed too much anti-choice propaganda and tends to distrust women. Pro-choice is already the broad middle ground, the democratic position, the reasonable and rational position. Indeed, the pro-choice movement found the best solution to the abortion issue long ago and has been trying to put it into practice ever since: safe and accessible abortion without stigma and discrimination. 

The author expects people to open their wallets to help women have babies they can’t afford, but it’s delusional to expect private charity to prevent most or even some abortions.  Individuals can’t be financially responsible for helping a million women a year in the U.S. – on that scale, the problem becomes a societal and government responsibility. More importantly, many women having abortions don’t want to go through pregnancy or have a baby at all, regardless of finances. Not to mention that full-term pregnancy comes with medical risks and negative side effects and major disruptions to a woman’s life. And even when unintended pregnancies are carried to term, the vast majority of women won't give up the baby for adoption.

When the author recommends increases to the minimum wage, funded daycare, free healthcare and the like, he is simply talking about Reproductive Justice. Eichenwald seems to believe he conceived all this by himself just last week, which is offensive to say the least. Reproductive Justice was developed over two decades ago by Sistersong, a group of women of color in the U.S., and it has been widely adopted by the pro-choice movement in North America. It is the feminist movement’s solution to the "abortion wars", not the author’s.

Shame on Kurt Eichenwald for equating anti-choice extremist rhetoric and terrorism with the progressive, pro-choice values shared by a majority of Americans. Shame on him for being ignorant of history and feminism, and for failing to give credit where credit is due – especially to women of color. Dare I say it?  Eichenwald’s entire article is a classic example of mansplaining.

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Sunday, October 18, 2015

“Conscientious Objection” in Reproductive Health Care is Immoral and Should Be Abolished

Updated July 2, 2018

The topic of “conscientious objection” (CO) in reproductive health care is a fascinating one that has given me much food for thought. My position on CO is fairly well-developed and I’ve written or co-authored a number of pieces about it. In this piece, I discuss or expand upon a few aspects that have come up in informal discussions with researchers and academics, mostly around philosophical and epistemological issues. 

First, my position on CO

“Conscientious objection” is the refusal by a health care professional (HCP) to provide a legal medical service or treatment for which they would normally be responsible, based on their objection to the treatment for personal or religious reasons.

The majority of so-called “conscientious objection” is exercised today in reproductive health care and is not really about protecting the right to conscience. It’s about a person in a privileged position of authority (there by choice) imposing their personal beliefs on a vulnerable other in a dependent position (not there by choice). That is, physicians have a monopoly on the practice of medicine, and they voluntarily entered a profession that fulfills a public trust. They know they have obligations to provide care to patients without discrimination, and that patients are completely reliant on them for essential health care and can’t go elsewhere. These factors make the exercise of CO in reproductive health care a violation of medical ethics and an abuse of HCPs' position of trust and authority. It is also discrimination because it mostly affects women and the LGBTQ community.

The entire argument for CO in reproductive health care fails once it’s understood that the “conscience” excuse is a subterfuge that justifies class privilege and the “right” to control others. “Conscientious objection” is a propaganda term, not much different than “pro-life” in the abortion debate. CO is actually “Dishonourable Disobedience." It’s really unfortunate that the medical and human rights communities have been bamboozled by the CO term to the extent that allowing CO in reproductive health care is now considered a “consensus” position. They’ve accepted an anti-choice term as the starting point, which is the reason things are in such a mess today in terms of rampant CO abuse around the world and the near-impossibility of regulating and controlling it.

For further information on my position, please check out my previously published articles on CO, summarized and linked at the bottom of this article. (Most are co-authored with my colleague Dr. Christian Fiala of Vienna, Austria.)

Is CO ever justifiable in health care?

There are some valid cases where an HCP may conscientiously refuse to provide a legal treatment that is requested by the patient, but this should be done in the context of honouring their professional obligations and medical ethics. Doctors can refuse treatment on the principle of “beneficence” or “non-maleficence” to ensure the patient is helped or at least not harmed. This only applies in limited circumstances, such as a patient who requests a risky experimental treatment, or a mentally disturbed patient who wants an unnecessary procedure such as an amputation.

We (Dr. Fiala and I) also support refusal by HCPs if they are asked to perform illegal or quasi-legal activities that injure people and violate their rights, such as torture or genital mutilation of children (including circumcision of male infants, which likely has no health benefits but has plenty of harms). Such practices are not legitimate medical treatments and are not requested or needed by the patient; therefore, ethical HCPs should conscientiously refuse to participate in them.

However, these types of refusals are not grounded in the individual personal or religious beliefs of HCPs, so they do not actually qualify as CO as we have defined it.  Virtually all 'personal' CO occurs in reproductive health care (or medical assistance in dying) and does not stem from professional ethics.

This means that  personal conscientious objection to a treatment that a patient requests has no valid place anywhere in health care. Treatment decisions by HCPs must be patient-directed, not self-directed, and must be based on evidence, medical ethics, and professional obligations. If the treatment is legal, within the HCP’s qualifications, requested by a mentally healthy patient, and primarily beneficial (which abortion is), there is simply no excuse to refuse.

Downie and Shaw give an example of a Jewish doctor refusing to operate on a patient with a swastika tattoo. Another example is an abortion provider who refuses to do an abortion on a patient who calls him a murderer and treats him with contempt. It may be easy to sympathize with these doctors' refusals, but they are still not true examples of CO, because where does it end? Individual doctors may have personal moral misgivings on a lot of different things, but in the end, doctors cannot morally judge others and abuse their position of trust and authority by citing CO. Their responsibility is to treat.

What about physician-assisted dying?  Canada's Supreme Court struck down the criminal laws prohibiting this practice in 2015. A fight has emerged, with Catholic hospitals refusing to comply with the requests of terminally-ill patients to end their lives, even to provide them with information. Instead, these hospitals have taken to transferring these patients to another hospital. Unfortunately, this inflicts grave psychological and physical harm on patients who are already in a frail and weakened condition. Public institutions like hospitals should of course have no right to CO, since this can only be an individual right. It also violates the conscience rights of HCPs working at Catholic hospitals who want to provide the objected-to service. It's especially frightening that Catholic hospitals often have a near-monopoly on palliative care, such as in Alberta. In my opinion, special legislation may be needed to force Catholic hospitals to provide assisted-dying services – as well as abortion care and other medically necessary care such as sterilization services. If they refuse, provincial governments should step in and find a legal way to take control of these hospitals and secularize them. It's a radical move, but should be justifiable on the basis that Catholic hospitals are publicly funded, yet are systematically violating patients' rights and dignity and endangering their lives. Further, it's not realistic to defund or close these hospitals, as they are often the only ones in a particular community.

Coming back to why CO is not justifiable in reproductive health care, another reason is because it tends to become too broadly used, with providers citing CO for reasons other than a supposed moral objection, such as stigma, distaste, fear, personal preference, money, etc. I say “supposed” moral objection because the evidence is overwhelming and conclusive that safe legal abortion saves women’s lives and benefits their health and that of their families. The vital public health interests in keeping abortion accessible (as well as contraception) decisively trump any supposed moral concern for fetuses. Actually, I think it can be shown quite persuasively, by citing evidence on anti-choice policies, laws, etc., that anti-choice beliefs in general are not motivated by the desire to “save babies” but by the desire to control women’s sexuality and childbearing role. So treatment refusals in reproductive health care really do come down to harmful gender discrimination (see more below), and are not true CO because they’re based on a false ethical framework. People often assume we should respect the conscience of objectors, but why? I personally have zero respect for their beliefs against abortion because they are illegitimate and harmful. Their "conscience" denies respect to women, violates their rights, and risks their health and lives – all of which is demonstrable, not subjective.

Most anti-choice HCPs would claim they’re motivated by “respect for unborn life” or whatever, but that raises the issue of how we can’t trust peoples’ stated justifications anyway, since one’s personal or religious beliefs cannot be verified or falsified on a rational basis, including how genuinely such beliefs are held. It is also inappropriate and impossible for courts or governments to "decide" whether someone's religious beliefs are valid or sincere. Therefore, one reason that allowing CO is a bad idea is because it leaves us unable to challenge peoples’ justifications – we have to accept them at face value regardless of the harms they may cause to patients.

That said, many personal or religious beliefs are indeed empirically false or unethical in light of scientific evidence or accepted human rights standards (such as the inaccurate belief that some forms of contraception are abortifacients). Any justification of CO should therefore not rely on what individual HCPs claim, but instead on a broader social recognition of the benefits of the treatment in general and the harms of refusal (or perhaps vice versa in some cases). This means that true CO can happen only in unique individual cases as described above, or in cases where the patient would be harmed more with the treatment than without it, or at least not helped (the beneficence or non-maleficence principle).

Finally, on a practical basis, it may be acceptable to tolerate false CO in some limited and temporary circumstances. For example, a hospital may find it has only one objector amongst a larger group of doctors. Rather than fire or transfer the doctor, the hospital might decide to accommodate the objector if it can ensure that no-one is harmed or inconvenienced by it (except perhaps the objector). This does not mean that CO is 'okay' – it's still inherently wrong in principle and should not normally be tolerated. However, private and contingent decisions to accommodate CO on a case-by-case basis could be made by particular institutions, which also reflects the practical reality that things cannot be changed overnight. Indeed, my recommendations for ending CO (below) adopt a long-term, incremental approach, that "grandfathers" in existing objectors. 

Is CO in reproductive health care really discrimination?

Because the vast majority of CO takes place in sexual and reproductive health care, and because this care involves biological gender and sexual aspects that differently affect women, men, and LGBTQ communities in a way that’s not true for most other forms of health care, refusals of treatment constitute discrimination on the basis of sex/gender or sexual orientation. I believe that discriminatory treatment is by definition harmful, and can never be justified by evidence or ethics.

Similarly, HCPs cannot generally refuse to treat black people, gay people, obese people, smokers, injured drunk drivers, or other groups they may disapprove of, because that would be harmful and discriminatory (even if some such groups are not specifically protected under anti-discrimination laws).

Some might claim that discriminating by refusing to treat a class of persons is different than refusing to do a particular treatment like abortion – therefore, CO in reproductive health care is not discrimination. Or at least, the discrimination is an unintended byproduct of the objection to the treatment, and so is too indirect or removed to really be discrimination. However, when that treatment is something only women and some transgender people need, then it is indeed discrimination because it has a discriminatory effect.

The legal definition of discrimination in Canada is not about intention, but effect. The Supreme Court of Canada has defined it as (emphasis added): “a distinction, whether intentional or not but based on grounds relating to personal characteristics of the individual or group, which has the effect of imposing burdens, obligations, or disadvantages on such individual or group not imposed upon others, or which withholds or limits access to opportunities, benefits, and advantages available to other members of society. Distinctions based on personal characteristics attributed to an individual solely on the basis of association with a group will rarely escape the charge of discrimination, while those based on an individual's merits and capacities will rarely be so classed.”

It should also be clear that when objectors are not allowed to refuse treatment, they do not suffer discrimination themselves – they are prevented from discriminating against others. HCPs are free to hold and practice their beliefs in private, but their agreement and obligation to fulfill a public trust means they can’t bring their beliefs into their work and impose them onto patients (as per the principle of “public accommodation”).

Should patients’ rights be “balanced” with providers’ rights?

It’s sometimes implied by CO supporters (academics and doctors) that patients and doctors are on some kind of equal footing, so each bear some responsibility in cases of refusals and we should “balance” their rights. For example, the provider should refer appropriately while the patient is “responsible” for going to another practitioner. Or, the provider and patient have an equal obligation to be “respectful” of diverse views and values. (These examples come from a private email conversation I had in July 2014 with Dr. Owen Heisler, Assistant Registrar of the College of Physicians and Surgeons of Alberta.)

But this is absurd. Patients have an unquestioned right to health care and are in a dependent position with their doctor, so they bear zero responsibility for any supposed moral conflict or its consequences. And the patient’s values are irrelevant – they are there simply to obtain a required medical service, which might even conflict with their own values. The responsibility for CO is 100% on the objector, who should bear the burden of any refusals. Currently however, all or most of the burden falls on the patient, while the objector rarely has to answer for it and often even benefits from the refusal (e.g., by avoiding stigma, or freeing time for more lucrative health care). The harm to patients of allowing CO always outweighs any harm to doctors of disallowing CO – if there even is any.

Organizations and professionals that support CO often confidently state that providers have a right to conscience and patients have a right to health care. (For example, here.)  But which is it? These two things are entirely incompatible because when a provider refuses treatment, the patient has lost their right to health care, period. Giving doctors a blanket right to refuse treatment on questionable CO grounds contradicts the whole purpose of medicine – to care for patients. It usually also violates the fundamental values and policies of the medical organizations that espouse CO, with all their noble talk about physicians’ commitment to patient care and interests, evidence-based medicine, comprehensive care, and so on. But if you allow CO, health care is no longer comprehensive, it’s no longer based on science and evidence, it’s no longer in the patient’s best interests, and doctors are no longer committed to any of the above.

Can we really prohibit CO?

The solutions proposed by the organizations and professionals who want to allow CO, but who are nevertheless well aware of its systemic harms, seem (to me) to be clear evidence of the inherent unworkability and contradiction of allowing CO in the first place. The general objective in these proposals (such as those by Global Doctors for ChoiceFIGO, ACOG, and members of ESC) is to limit the injustice of CO as much as possible by requiring objectors to refer appropriately, impart accurate information on all treatment options, treat patients respectfully, and in urgent situations, provide the treatment they object to if no-one else is around to do it. The problem is that such concessions don’t work very well in practice because they assume that objectors will be rational and agree to compromise their stance against a particular treatment at some point in the process. But why should they, when they’ve already been given the right to practice “faith-based” medicine? It’s impossible to draw a line between that and evidence-based medicine, because they have nothing to do with each other. 

It is difficult for me to understand how medical groups and professionals can clearly see the many problems with CO in reproductive health care, but instead of recognizing that it is fatally flawed, they just want to put band-aids on the serious (often intractable) problems caused by CO, and continue to insist there is a provider’s right to refuse treatment on the supposed basis of conscience. Frankly, I don’t see any reason for this other than to protect the power and privilege of doctors over patients. But doctors are public servants, basically. They are no longer the paternalistic figures whom patients should just defer to when it comes to important life decisions.

I believe that a general ban on CO in reproductive health care is not only the right thing to do, but also would be simpler and much more doable than trying to accommodate and regulate CO on an ongoing basis. Empirically-based criteria could be developed that would be ethical and fair to all parties, with no need to navigate subjective aspects such as trying to decide if an objector’s reasons are valid. It also does not involve “forcing” doctors to do abortions, which is a red herring fear about banning CO. Below is my suggested protocol for carrying it out on an incremental basis:

  1. Disqualify objectors from entering certain disciplines at the medical school level (e.g., all Obstetrics/Gynecology applicants must be willing to provide abortions; all Ob/Gyn and family medicine applicants must be willing to prescribe birth control).
  2. Offer guidance to objecting students in terms of acceptable disciplines or specialties where their objection won’t be a problem. 
  3. At medical schools, provide compulsory training in contraception provision for all students in family medicine, and compulsory training in abortion techniques for all those in Ob/Gyn (and other things like vasectomies etc.).
  4. Include the requirement to participate in abortion in job descriptions at the point of hiring. 
  5. Require existing objectors to enroll in a Continuing Education course or Values Clarification workshop on the need for reproductive health care services (especially abortion) and why women request abortions. Expose them to patients requesting the services, educate them on the negative effects of CO on patients, and provide a clear understanding of their fiduciary duty to patients. This should decrease the number of objectors because many are arguably just misinformed, uncertain, or using the excuse of CO for the wrong reasons. 
  6. For those who continue to object, assist them and incentivize them to move to other disciplines or areas where their objection won’t be a problem. 
  7. Increase the burden on those who want to stay and continue objecting, with the goal of encouraging them to eventually transfer or quit. These measures would become mostly unnecessary over time as CO becomes rarer. For example, medical organizations could: 
a.      Require all remaining objectors to register so they can be monitored.
b.     Require all objectors to file a report every time they refuse services based on their moral or religious objections.
c.      Investigate any inadequate or problematic reports.
d.     Randomly conduct regular audits on objecting doctors.
e.      Discipline those who violate the policy, and develop a more robust disciplinary policy.
f.      Hold objectors financially liable for any harms done to patients.
g.     Prohibit existing objectors from working alone, especially in small communities where they are the only physician.
h.     Allow employers to prioritize hiring of non-objecting physicians.
i.       Pay objecting physicians less (a cut in wages for employed doctors, or a percent reduction in Medicare fees)
8.   To improve public accountability and transparency: 
j.       Medical organizations could make the complaint process easier for patients, including preventing the doctor from learning or discerning the complainer’s identity.
k.     Medical organizations could engage in public advocacy about the right to complain when doctors refuse care or referrals – e.g., create a brochure for doctors’ offices, publish an op-ed, write a position paper for their website, keep a permanent prominent link to it on their home page, etc.
l.       Governments could regulate public health systems to guarantee abortion provision, provide financial aid to hospitals to recruit abortion providers, engage in public education to reduce abortion stigma, implement buffer zones and various security measures to support doctors, and other initiatives.

Over time, such measures should reduce or eliminate the presence of doctors who refuse to deliver health care for which they would normally be responsible. 

Finally, it is crucial to point out that Sweden, Finland, and Iceland already do not allow CO – either it’s generally prohibited, or in the case of Iceland there’s so few objectors that requiring Ob/Gyns to participate in abortion care has not posed any problems. The assumption that CO is legitimate and must be allowed disregards the proven reality that it is indeed possible to disallow CO without any negative impacts on providers. They simply find other jobs or disciplines to work in, and they can be assisted (and even recompensed) to do so.

One might argue that these Nordic countries are a unique and unrepresentative case because they have high degrees of secularism and gender equality, and less abortion stigma. But isn’t that exactly the point? A strong commitment to secularism and gender equality makes CO unnecessary and even unthinkable, as it should be. And that’s really what our end goal should be – not trying to accommodate the ongoing oppression and stigmatization of women under the guise of “conscience.” CO is simply an ideological retaliation against laws that empower women, and it comes mainly from fundamentalist religion. It should not be defended or tolerated. 

(The End)

My previous articles on “conscientious objection”:

‘Dishonourable Disobedience’: Why Refusal to Treat in Reproductive Healthcare Is Not Conscientious Objection. Christian Fiala and Joyce H. Arthur. Woman - Psychosomatic Gynaecology and Obstetrics. December 2014 (first published online March 2014).

Synopsis: A comprehensive paper that uniquely delves into the underlying premises of CO to show that it is fundamentally contradictory and unworkable, and has nothing in common with the military CO from which it is supposedly derived. Current laws and practices in various countries around CO in reproductive health care show that it is frequently abused, with harmful impacts on women's health care and rights. CO in reproductive health is not actually Conscientious Objection, but Dishonourable Disobedience (DD) to laws and ethical codes. It should be dealt with like any other failure to perform one's professional duty, through enforcement and disciplinary measures.

Why We Need to Ban ‘Conscientious Objection’ in Reproductive Health Care. Joyce Arthur and Christian Fiala. RH Reality Check. May 14, 2014.

Synopsis: A criticism of the global consensus by secular medical and health organizations and human rights bodies that “conscientious objection” is a legitimate right of physicians. All such groups that accept CO simply assume without question that health care providers have a right to CO, while they contradictorily often devote considerable discussion and resources to documenting and trying to limit the systemic harms caused by the exercise of CO. Not a single statement, article, report, or study by any group that supports CO can cite any benefits of CO in health care, other than supposedly respecting clinicians’ “right” of conscience. But all groups fail to see that the term “conscientious objection” as applied to refusals of reproductive health care is fraudulent, and not true CO.

The CO debate: ‘Conscientious Objection’ is still dishonourable disobedience, Joyce Arthur and Christian Fiala. Bpas Reproductive Review. July 14, 2014.

Synopsis: A response to our critics, including Global Doctors for Choice. We paraphrase and respond to eight criticisms, most of which we feel ignored or misunderstood our position.

Synopsis:  Policies and practice around “conscientious objection” in reproductive health care in Canada, and a summary of the “Dishonourable Disobedience” paper by Joyce Arthur and Christian Fiala to show what’s wrong with CO.

Synopsis:  A critique of anti-choice views on “conscientious objection”, including in particular the views of the Christian Medical and Dental Society of Canada, which is suing the College of Physicians and Surgeons of Ontario for enacting a policy requiring objecting doctors to refer patients to someone who can provide the services.

Submission #1 to the College of Physicians and Surgeons of Ontario (see No. 731). Joyce Arthur and Christian Fiala. July 31, 2014.

Synopsis: We ask the Ontario College to amend its policy to prohibit or at least strongly discourage the practice of conscientious objection for contraception and abortion services in particular. We also ask the College to implement monitoring and enforcement against those who disobey CO regulations, including disciplinary measures and financial and legal liability for any patient harms. We provide arguments against allowing any degree of CO in reproductive health care, on the basis that it is not genuine CO, is a violation of medical ethics and patients’ right to health care, and is discrimination on the basis of sex. We also provide arguments against the typical compromise that requires doctors to refer appropriately, because it is contradictory, unfeasible, and systematically abused.

Synopsis:  The College’s new draft policy requires objecting doctors to make an “effective referral” to someone who can provide the service. I draw attention to the negative anti-choice reaction to this and the likelihood that most anti-choice doctors will flout the policy because they think referring makes them “complicit.” I urge the College to implement various suggested monitoring and enforcement measures, and to make the patient complaint process more accessible and confidential.

Synopsis: I critique the College’s draft "Conscientious Refusal" policy with similar arguments as in the above submissions to the Ontario College. (While the latter stuck to its “effective referral” policy, the Sask. College caved to anti-choice pressure and weakened its policy so that doctors only need to “make an arrangement” for the patient to see someone who can refer them to someone who can provide the service.)

Yes We Can!  Successful Examples of Disallowing ‘Conscientious Objection’ in Reproductive Health Care. By Christian Fiala, Kristina Gemzell Danielsson, Oskari Heikinheimo, Jens A. Guðmundsson, and Joyce Arthur. Feb 2015. European Journal of Contraception & Reproductive Health Care.  DOI: 10.3109/13625187.2016.1138458.

Synopsis: Three countries – Sweden, Finland, and Iceland – do not generally permit health care professionals in the public health care system to refuse to perform a legal medical service for reasons of CO when the service is part of their professional duties. We investigate the laws and experiences of these countries to show that disallowing CO is not only workable but beneficial for all involved.

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