Steve Fouch

Freedom of conscience in the new Nursing and Midwifery Council Code of Conduct

Steve Fouch is CMF Head of Communications. He has worked in community nursing, HIV & AIDS and palliative care. He serves on the International Board of Nurses Christian Fellowship International.
The views expressed do not necessarily reflect those of CMF.


A new year seems a good time to launch a new set of guidelines, and the NMC have chosen this January to launch their extensively re-written ‘Code of Standards of conduct, performance and ethics for good nursing and midwifery practice’ (usually just know as ‘The Code’).  While it has been published now, it does not come into effect until the end of March 2015.

This has been the subject of extensive consultation over the last year, mostly in response to some damming critiques of nursing practice and standards in the Francis Report. And most of it is good – we certainly felt very positive about the majority of the second iteration of the draft Code that went out to public consultation last June.

Now extensively re-written after that consultation, the new Code has finally gone public.  An interesting addition to the new Code has been the inclusion of a clause on Conscientious Objection which states:

4.4 [you must] inform and explain to colleagues, your manager and the person receiving care if you have a conscientious objection to a particular procedure and arrange for a suitably qualified colleague to take over responsibility for that person’s care.

(Footnote to 4.4: ‘Conscientious objection’ to participating in a particular procedure can only be invoked in limited circumstances. Please see our guidance at [weblink to guidance on conscientious objection] for further details.)

The recognition of freedom conscience within the Code for the first time is a welcome development.  However, the caveat in the footnote and the (as yet unseen) online guidance on conscientious objection raises some concerns.

Firstly, the requirement to arrange for a suitably qualified colleague to take over responsibility seems initially uncontentious, but in practice this means tacitly being involved in the procedure by making a referral – nullifying any real notion of conscientious objection.

Secondly, it is surely not appropriate in every circumstance to state a conscientious objection to a patient – certainly if one has not previously been involved with their care. To be brought in to the room only to say you have a conscientious objection to participating in a procedure seems harsh on both patient and nurse/midwife.  There should surely be some more leeway for professional discretion, integrity and reasonable accommodation here.

We wait to see what the specific online guidance will contain, but we are concerned that it will be very specific and prescriptive based on the published clause and footnote.

I suspect that this has been introduced since the United Kingdom Supreme Court ruling last December in the case of two senior Glasgow Midwives who had a ‘continued objection to “delegating, supervising and/or supporting staff to participate in and provide care to patients throughout the termination process”’ on the labour ward on which they worked.  The ruling effectively narrowed the definition of ‘participation’ in termination of pregnancy as defined by Clause 4 of the Abortion 1967 to mean being directly involved in clinical procedures.  The midwives’ objection was based on the belief that termination of pregnancy was harmful to the woman and lethal to the child.

This illustrates the problems the legal and medical establishment have in grasping what freedom of conscience actually is and is not.  It is not just about saying ‘I have decided that I believe X, and therefore I will no longer do Y’. Freedom of conscience is rather about a clear set of deeply held convictions (faith-based, world-view based or otherwise) congruent with the values and ethics primary to medicine and nursing, which value human life, human personhood, and individual human dignity.

Conscientious objection to conscription in time of war is probably the most widely recognised form. There are already well established standards for evaluating whether someone has a genuine reason for opting out of military service, allowing for a reasonable accommodation for freedom of conscience.

These standards state that there needs to be a clear reason for the conscientious objection – be it drawn from ‘universal’ ethics or from specific religious ethics – i.e. ‘I object to going to war on the grounds it is wrong to kill other people’ – this can be qualified because ‘all men are created in the image of God’ or ‘all human beings are genetic family, and it is just wrong to kill my kind’, etc. Morality is never purely individual, so these arguments stem from the wider debates and discourses of our society and culture – again be they religious or secular.  We have to recognise the gravity of what the individual is being asked to do– for instance violently ending the lives of other people in war is as grave as one can get.  Finally the person has to argue clearly that they hold these beliefs sincerely, and are not using them as an excuse to get out of some duty that they find unpleasant, arduous or dangerous – i.e. using conscientious objection as a smokescreen for ‘draft dodging’.

When it comes to abortion or euthanasia, we are looking at issues that have been widely and deeply debated in our society for centuries by both faith-based and secular thinkers – the arguments for and against are part of a wider, deeper public discourse.  Ending the life of a fetus or a mentally competent adult, regardless of the context, is a serious issue – there is gravity in what the health professional is being asked to do.

A doctor or nurse who takes a stand on these issues needs to make it clear that their priority is care for their patient, and that they are taking a stand that may put them at odds with colleagues and superiors precisely because they hold sincere beliefs about the value of the life of their patients, and sincerely believe that the fetus in the womb or the dying patient is a human being worthy of the same respect and care as any other young person or adult.

So, in laying down new guidelines on exercising freedom of conscience, the NMC needs to recognise these strictures.  Freedom of conscience is not to be exercised lightly, giving license to anyone to get out of doing something to which they have a passing discomfort or objection.  Nor should the right to reasonably object on grounds of conscience be forbidden, as some are calling for.  Any attempt to demand that all professionals should leave their conscience at the clinic door or get out of the profession should be strenuously resisted.  Instead we need guidance that will make reasonable accommodation for freedom of conscience, genuinely helping nurses and midwives act with the greatest professional and personal integrity, whilst neither violating their deepest beliefs nor threatening the wellbeing of the lives in their care.

Posted by Steve Fouch
CMF Head of Nursing



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