All patients have a right to receive high quality clinically-indicated care in a supportive and non-judgmental manner.
The BMA recognises that some doctors and medical students may have a conscientious objection to participating in some procedures that are nonetheless lawful.
This guidance sets out the BMA's views on conscientious objection and the manifestation of religious and cultural belief for both doctors and medical students.
BMA view in summary
The BMA does not seek unnecessarily to restrict doctors and medical students seeking to exercise a conscientious objection, or in other expressions of their belief. We seek to balance doctors' freedom with the rights of patients to receive appropriate treatment in a non-judgmental fashion.
In the BMA's view, a doctor's primary obligation is to his or her patient. Where a conflict arises between the interests of a patient and a doctor's freedom to exercise a conscientious objection or to manifest belief, the conflict must be resolved in favour of the patient.
The BMA believes that:
- doctors should have a right to conscientiously object to participation in abortion, fertility treatment and the withdrawal of life-sustaining treatment, where there is another doctor willing to take over the patient's care
- doctors should be able to request that arrangements are made to accommodate their conscientious objection to participating in other medical procedures, provided that patients are not disadvantaged. All requests should be considered on their merits
- doctors should not claim a conscientious objection to treating particular patients or groups of patients
- doctors should not share their private moral views with patients unless explicitly invited to do so
- doctors should ensure that any manifestation of their religious or cultural beliefs (such as clothing or other religious icons) do not impact negatively upon the therapeutic relationship.
Supporting a 'limited right' to conscientious objection
The BMA recognises that opinions differ in relation to the proper scope of conscientious objection. Some commentators have argued that doctors should have no right to conscientious objection, that "to be a doctor is to be willing and able to offer appropriate medical interventions that are legal, beneficial, desired by the patient, and a part of a just healthcare system", and that such an obligation should be enforced.
We do not support this restricted position. Partly for the reason that the right to exercise a conscientious objection to participating in abortion and fertility treatment is already provided for in statute. In addition, the BMA would support a request by a doctor seeking to exercise a conscientious objection to withdrawing life-sustaining treatment from a patient lacking capacity - where another doctor is available and willing to take over care.
Although reasonable - and lawful - requests to exercise a conscientious objection in relation to other procedures should ordinarily be considered, the BMA does not believe doctors should have a 'right' to object in these circumstances.
The BMA distinguishes these procedures for a number of reasons. The first is their moral seriousness. Sincerely held views about when morally valuable human life begins differ in our society.
Another reason we distinguish these interventions is because they relate to specific acts. It is to the act of terminating a pregnancy, or, in relation to withdrawing treatment, the 'letting die' that the doctor objects to. The objection may also arise on the basis of genuine moral disagreement as to whether the intervention provides an overall benefit.
In our view this is very different to a doctor refusing to treat certain types or classes of patient. Objecting in principle to the termination of a pregnancy is very different to objecting to providing fertility treatment to same sex couples. In the BMA’s view, the latter would always be unacceptable.
At its 2008 Annual Representatives Meeting, the BMA passed a resolution stating that doctors should only have a right of conscientious objection to those procedures where such a right is recognised by statute (to participating in abortion and certain forms of fertility treatment) and to the withdrawal of life-sustaining treatment from a patient who lacks capacity, where another doctor is willing to take over the patient's care.
While only the former are legally recognised rights, the latter is given some support by the Mental Capacity Act's Code of Practice and the BMA would strongly support a request by a doctor to exercise a conscientious objection in the latter case, even though it is not a right directly protected by statute.
In addition, the BMA believes that there is no reason why reasonable and lawful requests by doctors to exercise a conscientious objection to other procedures should not be considered, providing individual patients are not disadvantaged and continuity of care for other patients can be maintained. In these circumstances, conscientious objection should not be seen as a ‘right’, but individual requests should be assessed on their merits.
Medical Ethics Today: The BMA's Handbook of Ethics and Law (Chapter 7) has more information on this topic in relation to abortion and fertility treatment .
Read the BMJ article 'Conscientious objection in medicine' - Julian Savulescu, Director (BMJ, 2006)
Conscientious objection and medical practice
The right to freedom of thought
An explicit legal right to freedom of thought, conscience, and religion is protected by Article 9 of the European Convention on Human Rights. This right is not absolute. It can be limited in circumstances where such limitations 'are prescribed by law and are necessary in a democratic society in the interests of public safety, for the protection of public order, health or morals, or the protection of the rights and freedoms of others.'
Medicine and diversity
The BMA is committed to promoting diversity and tackling unjustifiable discrimination in medicine. We recognise that in complex societies like ours there is a plurality of beliefs, backgrounds, and cultures. Although we do not seek unnecessarily to restrict doctors' freedoms to object, where the rights of patients to appropriate and timely treatment are at stake, we believe that the interests of patients must take priority and doctors should act with restraint in the manifestation of personal beliefs.
Patients' rights to care
Where it is available and approved by NICE, patients are entitled to timely, clinically-indicated care or treatment that is provided in a supportive, sensitive and non-judgmental manner. This right is enshrined in the NHS Constitution. Doctors seeking to exercise a conscientious objection must take care not to undermine this right. Doctors employed by the NHS are contracted to provide a public service in accordance with the terms and conditions of service.
Read about the NHS Constitution
You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.Paragraph 52 of Good Medical Practice
Conscientious objection and medical professionalism
Research suggests that many medical students would consider exercising conscientious objections to a broad range of interventions, extending, in some cases, to a refusal to treat patients of the opposite sex or those whose ill health derives from personal 'lifestyle' choices. This research is strengthened by a noted increase in inquires to the GMC from doctors seeking to exercise a conscientious objection. This also confirms the BMA's experience.
Medical professionalism refers to that set of values, behaviours and dispositions that underlie successful therapeutic relationships. An important aspect of this is developing an awareness of those areas where the expression of personal values might have a negative impact on patients or the therapeutic relationship. Of course, doctors will bring their own private values to their work, but it is vital that doctors exercise restraint where the expression of these values or beliefs might be detrimental to the interests of patients.
In addition to its inter-personal aspect, medicine and health in the UK are important public goods. The NHS is committed to the provision of health on the basis of need, however complex the concept of health 'need' might be. Pragmatically, were significant numbers of doctors to opt-out of providing certain treatments or treating certain types of patients, the NHS would struggle to function. Were doctors to opt out of treating classes of patient - those for example whose illnesses were thought to arise from their personal choices - the fundamental obligation to provide appropriate treatment in a supportive and non-judgmental manner could not be met. Doctors and their institutions could also be vulnerable to legal challenge for discrimination.
Discussion with patients
At times, doctors or other health professionals seeking to exercise a conscientious objection may need to discuss the matter with their patient, explaining, for example, their reasons for referral to another practitioner.
In these circumstances they should ensure that they discuss the matter as sensitively as possible, bearing in mind that the patient may be in a particularly vulnerable position. Sensitive handling should be designed to minimise any distress to the patient arising from a perceived judgment of the patient or the patient's values by the doctor or health professional.
Conscientious objection and medical students
In a 2006 position statement, the GMC's Education Committee addressed the question of whether students could omit parts of the medical curriculum and still graduate with a medical degree and practise as a doctor. The statement emphasised the GMC's commitment to a diverse medical student population but stated that its primary responsibility was to ensure the safety of patients. The Committee concluded that:
Medical students clearly have a right to freedom of expression and having a range of ethical and religious perspectives contributes to medical education and practice. However, these considerations cannot compromise the fundamental purpose of the medical course: to train doctors who have the core knowledge, skills, attitudes and behaviour that are necessary at graduation… Good Medical Practice already makes provision for doctors who object on moral grounds to providing particular treatments without prejudicing patient care. However, there is an important difference between performing particular treatments that many doctors would not, in any event, ever be expected to perform in the NHS and the core skills required of every medical practitioner at graduation.General Medical Council (2006) Core Education Outcomes: GMC Education Committee Position Statement. Para 10
The Committee also set its guidance in the context of the practical requirements of pre-specialty medical training:
Doctors who graduate in the United Kingdom enter a two year Foundation Programme which involves a range of clinical experience, much of it based in emergency departments and involving a wide range of unselected and acutely ill patients... it would not be possible for a doctor to practise in that environment while refusing to examine, for example, half of all patients on grounds of gender or the large number of people whose illness can be attributed to their lifestyle.General Medical Council (2006) Core Education Outcomes: GMC Education Committee Position Statement. Para 11.
The expression of doctors' personal moral or religious views
Although the BMA recognises the importance of frankness and openness with patients, this does not extend to doctors offering unsolicited opinions about their own moral views. Although all doctors have private moral views, they should not share them unless explicitly asked by patients to do so. In particular, doctors should avoid making pejorative or judgemental comments about patients' values or behaviour.
If doctors believe their personal moral views are likely to affect their advice or treatment, the patient must be given the option of seeing a different doctor.
'Lifestyle' choices can have a significant impact on health. Patients should be offered factual information about how to safeguard their health but the fact that their actions may have contributed to their condition should not give rise to moralising or delaying treatment.
In some cases, habits such as smoking, drug or alcohol addiction have clinical implications for the effectiveness of any proposed treatment. These should be discussed candidly, in a non-judgmental manner, as part of informing patients. Doctors must avoid language or actions that imply discrimination, including gratuitous comments about patients' lifestyles. NHS guidance makes clear that such behaviour in a healthcare setting could be construed as harassment.
In 2019, the Court of Appeal upheld the dismissal of a nurse for “improper proselytising” after she told patients they had a better chance of survival if they prayed; gave patients bibles; and asked a patient to sing a psalm with her. This issue was discussed at the BMA's 2009 annual meeting, which recognised that the NHS is committed to providing spiritual care to patients but that the initiative for it must rest with the patient.
Expressions of religious belief or culture
Some doctors may seek to manifest religious or cultural beliefs or views through the wearing of clothes.
Like the GMC, the BMA does not seek to tell doctors what to wear. As with other manifestations of religious belief or culture, the BMA anticipates that doctors will put the interests of their individual patients first and will adapt their manifestations of culture and belief accordingly.