Exercising conscience in healthcare is usually defined as refusing to provide contested services, like abortion. But in an article to be published Sept. 13 in the New England Journal of Medicine, a University of Michigan faculty member says doctors can be "conscientious" providers of abortion.

Lisa Harris, M.D., Ph.D., assistant professor of obstetrics and gynecology at the University of Michigan Health System, highlights both historical and contemporary evidence that conscience motivates abortion provision. She cites sociologist Carole Joffe's study that shows skilled mainstream doctors offered safe, compassionate care before Roe v. Wade, risking fines, imprisonment and loss of medical license.

"They did so because the beliefs that mattered most to them compelled it. They saw women die from self-inducted abortion and from abortions performed by unskilled providers," Harris writes.

Harris says contemporary abortion providers are motivated by conscience as well: "Though today abortion providers work within the law, they still have much to lose, facing stigma, marginalization within medicine, harassment and the threat of (or actual) physical harm.….However doctors … continue to offer abortion care because deeply-held, core ethical beliefs compel them."

There are legal, clinical and ethical consequences of the false dichotomization of conscience and abortion provision, she says. Harris writes that federal and state laws continue to protect only conscience-based refusals to perform or refer for abortion, offering minimal legal protection for conscience-based abortion provision.

In addition, equating conscience with only the refusal to perform abortion continues to stigmatize physicians who are abortion providers.

"If physicians who offer abortion don't have a legitimate claim to act in 'good conscience,' as do their counterparts who oppose abortion, then the implication is that they act in 'bad conscience' or lack conscience altogether," Harris writes.

Harris says bioethicists have focused on moral claims to refuse care provision, largely neglecting that, as she writes, "moral integrity can be injured as much by not performing an action required by one's core beliefs as by performing an action that contradicts those beliefs."

Harris acknowledges that those who oppose abortion will likely argue that abortion providers have motivations other than conscience. While she disagrees, she says this highlights the importance of distinguishing claims of conscience from other types of claims:

"Certainly, if abortion providers' conscience-based claims require scrutiny, so do conscience-based refusals, to ensure that refusals are indeed motivated by conscience and not by political beliefs, stigma, habit erroneous understanding of medical evidence or other factors."

In addition to calling for recognition of "conscientious provision" of care, Harris calls for a standard curriculum and a standard of care for conscientious refusals.