Catholic Medical Quarterly

The Journal of the Catholic Medical Association (UK)

Building knowledge. Building faith. Protecting the vulnerable.

Catholic Medical Quarterly Volume 63(3) August 2013

The NHS – No Place for Conscience

Trevor Stammers, St Mary's University College, London TW1 4SX

Photo of Trevor StammersAs an academic who teaches bioethics and medical law, it is my privilege also to learn from my students – undergraduate and postgraduate alike. Just recently one of my MA students based in Australia, posted the following contribution on our online discussion board - “ The politics of abortion make it incredibly difficult for those who are critical of current practices to be heard in the public square. In the case of conscientious objection, what should be a straightforward moral appeal for freedom to perform acts that are not morally objectionable to the individual (and not to perform acts which are morally objectionable), becomes a question of the rights of women in general. This becomes doubly difficult if, as a critic, one is also a man. Nevertheless, the notion that such conscientious objection can be called into question is a spurious idea that betrays a bizarrely modern commitment to autonomy”.

The autonomy referred to here is of course that of the patient (as the student rightly goes on to comment), but one wonders from recent events in the UK, what place will remain in a few years time for the autonomy of health care professional to be exercised in expressing conscientious objection ?

The United Kingdom’s National Health Service (NHS) is the largest, publicly-funded health service in the world. Serving a population of over sixty million people, every year the NHS receives over £100 billion of tax-payers’ money. Furthermore, it employs more than 1.7 million people, including 120,000 hospital doctors, 40,000 GPs, 400,000 nurses, and 25,000 ambulance staff. Given the NHS’s social, political, and economic importance, the large numbers of people it both serves and employs, and the gravity of the matters with which it deals, it is not surprising that the place of moral concerns within it have been subject to considerable, and often heated, discussion and argument. Not surprisingly, secularist voices have been prominent here — and nowhere more so, than on the question of conscience in healthcare provision.

There is good evidence that a doctor’s beliefs influence patient care. This is especially true with regard to for example sexual health and end-of-life issues. A carefully designed study of the influence of doctors’ religious beliefs (or lack of them) on their care of the dying, for example, showed that ‘doctors who described themselves as non-religious were more likely than others to report having given continuous deep sedation until death, having taken decisions they expected or partly intended to end life.’ [1, p. 677] Conscience is not, of course, the sole preserve of religious people — there are a great many doctors who identify with secular spiritual traditions, or who have no religious or spiritual tradition at all, who would equally refuse to authorize or participate in particular (legal) medical procedures on the grounds of conscience. Nevertheless, such objections are indeed frequently influenced and justified on the basis of specifically religious convictions.

Although misleading, it is perhaps not surprising that conscientious objection in healthcare is frequently discussed as though this were an exclusively ‘religious’ issue. In 2006, the Oxford ethicist Professor Julian Savulescu published an article in the BMJ (formerly the British Medical Journal ) on ‘Conscientious objection in medicine’. He opens with a tone-setting, though perhaps ironic, quotation from Shakespeare’s Richard III : ‘Conscience is but a word cowards use, devised at first to keep the strong in awe’.[2, p. 294] Savulescu, clearly not in awe of anything and anyone, proceeds to argue: A doctor’s conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient’s good and the patient’s informed desires. 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. (Ibid.) Furthermore, in a system where ‘less than half of doctors whose primary job it is to deal with termination of pregnancy would facilitate a termination at 13 weeks if the woman wants it for career reasons,’ [p. 295] conscientious objection results in both inefficiency and inequity. While Savulescu is careful not to depict conscientious objection as an exclusively religious ‘problem’, the reader is left in no doubt that it is primarily so. The article’s subheading begins ‘Deeply held religious beliefs may conflict with some aspects of medical practice,’[p. 294] and at several points ‘religious values’ are unfavourably contrasted, explicitly and implicitly, with ‘secular liberal values’. Moreover, religious values ‘corrupt’ the delivery of health care and to allow conscientious objection on the basis of them is clearly discriminatory when ‘other values can be as closely held and as central to conceptions of the good life as religious values.’[p. 295]

This position has clear affinities with secularist modes of thought. While for Thomas Hobbes, religious reasons or arguments have no place in public life, for Julian Savulescu, they have no place in a publicly-funded health service. Doctors may have private religious convictions, but as public servants they must conform to a shared set of (secular) values and practices, defined and regulated by law and governmental policy. Those unable or unwilling to do this, thereby forfeit the ability to do their job: ‘Doctors who compromise the delivery of medical services to patients on conscience grounds must be punished through removal of their license to practice and other legal mechanisms.’[p. 296] Explicitly motivating Savulescu’s arguments is a concern for patient care, and the worry that conscientious objection can, at least in some instances, either prevent or delay patients from receiving medical service to which they are legally entitled.

Savulescu’s article sparked an avalanche of responses, many of which are available on the BMJ website.[3] The vast majority of these — from doctors, patients, and medical ethicists — are strongly negative. The most common criticism is of the suggestion that conscience, however informed, has no legitimate role in medical practice. Without necessarily agreeing with, and perhaps even actively opposing, the specific reasons (and/or their religious or non-religious foundations) put forward by objectors to particular procedures, the idea that such reasons are, in principle, ‘out of bounds’ was condemned by many respondents. Not only were doctors themselves disquieted by a medical profession that leaves no room for personal moral conviction, several of them raised the important point that patients would likely be so too. Patients do not view doctors as functionaries, devoid of human feeling or conviction.

I often ask medical students what qualities they would look for in the ideal doctor looking after their elderly mother with a terminal illness. Never yet has technical competence, being an exam prize-winner, or anything remotely ‘scientific’, been the first item in their list. The intial replies are usually ‘compassion’, ‘kindness’, ‘empathy’, ‘humanity’, and even ‘tenderness’. The next question I will sometimes follow up with is: ‘On balance, is your mother likely to receive better treatment from a doctor who believes that after his or her own death they will have to give account to God of how they have lived their lives, including of how they have practiced medicine?’ To this question there is, of course, no right or wrong answer. However, it is arguably a vital part of good medical training to encourage students as well as patients to think about the importance of spiritual values.

In early 2009, Caroline Petrie, an NHS nurse in north Somerset, was suspended by her Primary Healthcare Trust for offering to pray with a patient

Savulescuan secularism is, however, by no means without its supporters. [e.g. 4] Indeed, many of his BMJ critics, while upholding the general right to conscientious objection, would presumably themselves disagree strongly with the — in many cases, religiously-informed — objections of their colleagues to specific practices. It is one thing to uphold the value of conscience in medical practice, quite another to believe that an appeal to it is, in every instance, a ‘trump card’. Nevertheless, Savulescu’s article evidently struck a chord. Even without conflating ‘conscience’ and ‘religion’ (another common theme in the BMJ responses), the role of religious conviction in a publicly-funded, state-run health service is clearly a significant issue; even those disagreeing with Savulescu may be thankful to him for opening up the debate.

In fact, the ongoing debate over conscientious objection can be viewed as just one aspect of a wider controversy concerning religion in the NHS. This much is clear from a number of recent cases, and the coverage and comment which they have received. In early 2009, Caroline Petrie, an NHS nurse in north Somerset, was suspended by her Primary Healthcare Trust for offering to pray with a patient for healing of her leg ulcer which she was regularly dressing without any rapid signs of improvement. The patient declined, but did not mind nor complain, though she did mention the offer to another nurse, who then reported Mrs Petrie to the Trust. They then suspended her. The story culminated in a Daily Telegraph headline on 6 February 2009 that ‘NHS staff face sack if they discuss religion.’[5] The subsequent public outrage at the way Mrs Petrie had been treated was such that she was reinstated shortly afterwards, though not without ongoing pressure applied to prevent her from ‘reoffending’.

Later that year, the case of another NHS nurse, Anand Rao, also made the papers. He had volunteered to take a postgraduate course in palliative care organized by the Leicestershire and Rutland Organization for the Relief of Suffering (LOROS). During one of the course sessions, Mr Rao was placed in simulated consultation with actors playing the part of married couple. He was told the wife had a serious heart condition and was suffering from stress after a doctor had told her she would not live much longer. Mr Rao ‘advised the patient to refrain from smoking, change her lifestyle and try not to dwell on what the doctor had said, because worry in itself can overload and damage the heart further. In addition, I said that she should try to visit a church if possible, because it can sometimes relieve stress.’[ 6] Unhappy with this suggestion, the course organizers reported him to his employer who subsequently suspended, and later dismissed him. He stated to the press: ‘They told me I had breached the [Nursery and Midwifery Council’s] code of conduct because I had used the word “God”, and that I might use it again in the future and that they would be notifying my employers at the Leicester Royal Infirmary with a view to terminating my post.’ Asked whether he wants his job back, he replied: ‘Of course, nursing is all I’ve ever known.

Both these well-publicized cases attest to a genuine unease about the role of religion — or, more to the point, religious people — in healthcare. As with Savulescu’s stance regarding conscientious objection, there are again clear parallels to a version of secularism that would confine religious beliefs and convictions to a purely private sphere. Such things are presumably fine for a doctor or nurse’s leisure time, but must not ‘interfere’ in any way with their professional, secular lives. Such views ought not, however, to be caricatured: in many cases, they arise from a sincere concern for patient care. Behind the disciplinary actions against Petrie and Rao, for instance, is the reasonable desire that vulnerable people not be troubled by unwanted proselytism or religious harassment. This is a worry expressed in the Department of Health’s 2008 Religion or Belief: A Practical Guide for the NHS : ‘Members of some religions [ … ] are expected to preach and to try to convert other people. In a workplace environment this can cause many problems, as non-religious people and those from other religions or beliefs could feel harassed and intimidated by this behaviour’.[7, p. 22] However, it is difficult to see how exactly the actual actions of Petrie or Rao would count as either proclamation or proselytism. Instead, both cases may be viewed — and were popularly received — as being grave overreactions on the part of the nurses’ managers to any intimation or expression of a religious commitment. Note too that in neither case was any complaint made by a patient.

Arguably, the attempt to drive all expressions of religious belief, practice, or conviction out of healthcare will itself lead to a sharp decline in patient wellbeing. It ignores the fact that all healthcare professionals, regardless of their spiritual tradition or lack of one, possess beliefs and commitments, which in turn influence their actions. This much is recognized in the well-balanced advice of the 2008 General Medical Council (UK) guidelines Personal Beliefs and Medical Practice: Guidance for Doctors.
All doctors have personal beliefs which affect their day-to-day practice. Some doctors’ personal beliefs may give rise to concerns about carrying out or recommending particular procedures for patients.

Discussing personal beliefs may, when approached sensitively, help you to work in partnership with patients to address their particular treatment needs. You must respect patients’ right to hold religious or other beliefs and should take those beliefs into account where they may be relevant to treatment options. However, if patients do not wish to discuss their personal beliefs with you, you must respect their wishes.[8]

This applies just as much to a utilitarian seeking to encourage patients to pursue assisted suicide as a possible option, as it does to the Muslim, Christian, or Jew seeking to dissuade them from it. Both groups could give rise to concerns if undue pressures are exerted, but to try to discriminate against one set of values alone is hardly compatible with any meaningful concepts of equality and diversity — which are, of course, precisely what secularism sets out to safeguard. No wonder my student was puzzled.


  1. Seale, C. ( 2010 ). The role of doctors’ religious faith and ethnicity intaking ethically controversial decisions during end-of-life care. J Med Ethics 36 : 677 – 82.
  2. Savulescu J. ( 2006 ). Conscientious objection in medicine . Br Med J 332 : 294 – 7.
  4. Cantor, J. ( 2009 ). Conscientious objection gone awry — restoring selfl ess professionalism in medicine . N Engl J Med 360 : 1484 – 5.
  5. Beckford, M. , Gammell, C. ( 2009 ). NHS staff face sack if they discuss religion . Available at:
  6. Alderson, A. ( 2009 ). Nurse loses job after urging patients to find God during a training course. Available at: nd-God-during-a-training-course.html
  7. Department of Heath ( 2008 ). Religion or belief; a practical guide for the NHS. Available at:
  8. GMC ( 2008 ). Personal beliefs and medical practice: guidance for doctors.


Dr Stammers is programme director in bioethics and medical law, at St Mary’s University College,Twickenham, London, UK

This article is taken from the chapter on secularism in The Oxford Textbook of Spirituality and is reproduced with permission