Referral as Formal Cooperation with Evil
Johann Wolfgang von Goethe, Wagner and Mephistopheles, 1899.
Something often misunderstood by secular thinkers is that faithful Catholics and others with rightly formed consciences can never engage in formal cooperation with the evil actions of another person. Recently, a court in Illinois ruled that “if patients request abortions, at a minimum, the State can require medical professionals to provide information of other medical professionals whom they reasonably believe might perform abortions.” The same court decision struck down the constitutionality of other provisions of the Illinois state law that required medical personnel to discuss with patients the “benefits” of abortion if the subject arises. The judge saw that it was unethical to compel the speech of physicians when it forces them to lie by telling patients that abortion can be a good thing, but what was less clear to this judge was the wrongfulness of requiring referral when the medical professional refuses to cooperate with the carrying out of an abortion. These conscientious doctors believe that direct abortion is intrinsically evil and can never be morally or medically justified.
While researching my doctoral dissertation on conscience and health care I often ran into one particular false “compromise position.” Authorities frequently feel they are being magnanimous by not forcing medical workers to participate directly in abortions, but “only” ordering them to ensure “patient access” to procedures that they find unethical but which nonetheless are permitted by law. Some politicians and judges think it is reasonable to require referral of the patient by the objecting professional to a colleague who does not have a moral objection to performing the abortion or some other immoral act. The Catholic Church and many others have been quite consistent over the centuries, however, that formal cooperation with evil is never acceptable. In other words, a moral person may not intentionally assist another person in carrying out a sinful act. The National Catholic Bioethics Center (NCBC) provides more specifics, adding an explanation of what constitutes implicit formal cooperation.
Explicit formal cooperation occurs when someone wills the evil action of the principal agent, such as a doctor who openly encourages or recommends a direct abortion. Implicit formal cooperation happens when a person, for the sake of a good aim, establishes the structure (procedure, protocol, or contractual agreement) by which a specifically described immoral action will take place, grants formal approval to an immoral action, or wills the principal agent’s evil action as the means for achieving some other good.
Formal cooperation with evil, whether explicit or implicit, is involved in a medical referral. It is highly unethical to require it because even if the physician does not explicitly order the evil action with the referral, he or she implicitly wills the accomplishment of the unethical action by directing the patient to others known to offer the evil intervention.
This leads directly to the question of “transfer of care,” an area the NCBC has reflected upon as a means of avoiding formal cooperation. It is important to explain to the patient why the action is unethical and is not the right choice using one’s prudential judgement.
When all else has failed, if the patient is insistent on pursuing the immoral and harmful choice, health care providers and institutions may be unable to prevent this. Ultimately, the patient is an independent moral agent who is free to decide where and from whom he or she will seek care. The provider or institution may remind the patient of this, and may offer to assist the patient with accomplishing a transfer of care to another provider or institution of the patient’s choosing, without stating where the patient might go to receive the immoral procedure or otherwise directing the patient to it. A general list of other providers or institutions based on geographic vicinity or even area of specialty might be provided; however, the list may not be developed based on the criterion of whether they are known or believed to offer the immoral procedure.
It would be unethical to trap a patient in a doctor-patient relationship where a fundamental difference of opinion arises as to the recommended course of action. Facilitating the transfer of care of a patient to another medical professional is not immoral as long as it is not done in a way that makes the objecting medical worker formally cooperate with evil.
The judicial decision requiring medical referral for abortion in Illinois is being appealed to a higher court. It is earnestly to be hoped that wiser legal minds will ultimately prevail. The consequences of requiring formal cooperation with evil by medical professionals would be devastatingly far-reaching. Without robust conscience protections, soon the only persons remaining in the health care professions would be individuals without a strong moral compass. Medicine is fundamentally a moral enterprise, as the late Dr. Edmund Pellegrino never tired of insisting. To strip this vital area of the minimum ethical protections needed for moral individuals and institutions to function would cause all Catholic hospitals to close and bar Catholics from practicing medicine and many others. It is almost unthinkable, except in the settings of the most savage persecutions of the Church. Thankfully, when the stakes are explained and understood, the “compromise” of requiring referral for abortion will almost certainly be decisively rejected.
Joseph Meaney received his PhD in bioethics from the Catholic University of the Sacred Heart in Rome. His doctoral program was founded by the late Elio Cardinal Sgreccia and linked to the medical school and Gemelli teaching hospital. His dissertation topic was Conscience and Health Care: A Bioethical Analysis. Dr. Meaney earned his master’s in Latin American studies, focusing on health care in Guatemala, from the University of Texas at Austin. He graduated from the University of Dallas with a BA in history and a concentration in international studies. The Benedict XVI Catholic University in Trujillo, Peru, awarded Dr. Meaney an honorary visiting professorship. The University of Dallas bestowed on him an honorary doctorate in Humane Letters in 2022.