Editor’s Note: This is the first entry in our short series of blogs reflecting on the medical conscience policy of the current US President and his Administration. See the Editor’s introduction to this miniseries for more background on both this issue and bioethical considerations of conscience claims.

The Trump administration has just announced that it will form a new division within the Department of Health and Human Services, called the ‘Conscience and Religious Freedom Division”. The new department will be charged with reviewing complaints by medical professionals about institutional failure to protect their freedom to refuse to perform procedures that violate the professional’s conscience.

The formation of the new department does not change the law. Physicians have had the right to choose who they will accept as patients since the 1952 decision in Findlay, and courts have recognized the right of all medical professionals, from physicians to nurses to pharmacists, to refuse to participate in procedures they find morally unacceptable as well. This right is limited—emergency treatment cannot be refused on the basis of conscience, and if a care giver is the only professional available (as when a pharmacist in a rural area has no substitute) and providing treatment is within the normal professional expectations of the job (imagine our pharmacist being asked to dispense birth control), then the professional cannot make it impossible for the client to access the requested treatment, and may be required to dispense it in spite of personal beliefs. But there is already extensive legal protection for conscientious refusal in medicine.

Nor does there seem to be a desperate need for an entire new department to handle cases of this sort—the Washington Post reports that during the entirety of the Obama administration, only ten cases were filed, though there have been 34 already in the first year of Trump’s administration. These numbers hardly seem large enough to justify the formation of an entire new department; forming the department, instead, is seen by many as a gift to religious conservatives, particularly the white Evangelical voters who provide solid support for the Trump administration.

Critics of the new department note that without a corresponding emphasis on the right of patients to equal access to care as well as access to needed treatment under emergency conditions, the emphasis on the right of religious believers to refuse treatment poses a real danger. In a 2011 case, for example, nurses in New Jersey filed a case arguing that they had the right to refuse pre- and post-operative treatment for women undergoing abortions, even when the women required emergency care. Religious conservatives have also claimed a right to refuse care to lesbian couples, transgender individuals, and others who offend their sense of morality. Because there are often limited providers in any particular geographical region, and because it is the provider themselves who decides what offends their conscience in any given case, patients seeking medical care can face serious harms to their health and to their dignity by caregivers who invoke conscience clauses.

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Public refusal to provide needed medical treatment to individuals considered immoral or otherwise ‘unclean’ would seem to be an odd choice for people who consider themselves followers of Jesus, and it does not fit well with the Christian tradition of providing medical service as a central part of their faith. Jesus famously prohibited loud public displays of piety to his followers (Matt. 6:3-6), advocated an ethics of service and assistance to all (Matt. 26:14-39, Luke 22: 24-27, John 13: 1-17), but especially to those seen as one’s enemies (Matt. 5:43-48, Luke 6: 27-36) and to the sick and poor (Matt. 25:31-46). Many contemporary health care systems signal their religious origins in their names (St Mary’s, Lutheran General, and so on) and were specifically founded to provide care to all those in need as a reflection of their Christian mission. So it seems paradoxical to see Evangelicals framing the refusal of treatment as essential to their personal conception of morality—one would expect that serious followers of Christ would demonstrate their Christian faith by assisting the sick, providing service to those with whom they disagree, and the like.

But as sociologists Michael Emerson and Christian Smith argued in their study of white Evangelicals in the US, certain strands of contemporary American Christianity have adopted a general framework for understanding moral purity that is problematic in a number of ways. While it is not characteristic of all Christians, white Evangelicals, particularly deeply conservative ones, define morality in terms of individualistic purity. Being a good person, on this view, involves keeping one’s self clean from moral contamination. Sexual misconduct, for example, is thought to taint the one who engages in it, but that ‘taint’ can rub off on any one associated with the impure individual. While Emerson and Smith do not address conscientious refusals by medical professionals, it is relatively easy to see how this view produces the phenomenon we see in the contemporary culture wars. If one begins with the assumption that one’s own moral purity depends on distancing oneself from with others one considers immoral, and if providing care or assistance for such individuals is seen as polluting, then the primary moral duty one has is that of remaining free from contamination. If one’s job involves providing care for other people, then it poses a constant risk of compromising one’s moral purity, Association with women seeking abortions, or with people whose sexual behavior one disapproves of, or transgender individuals, in other words, particularly association with them in ways that provide care or assistance, will generate a moral stain on the character of the assisting individual.

Ironically, this puts these Christians into precisely the position of the Pharisees, the only group of people consistently criticized by Jesus for privileging their own moral purity and observance of the finer points of the law over providing assistance to the needy or care for the ill (Matt. 23:1-39. Luke 11: 37-54). The New Testament provides little comfort for religious believers who focus so exclusively on their own moral purity that they are willing to see others suffer for it. And there are Christian group who have actively opposed this purity model of moral righteousness. The Sisters of the Holy Cross have been publicly recognized for their work providing care for those with HIV/AIDS, particularly in the early years when public prejudice was at its height, and Catholics provide extensive support for HIV/AIDS care worldwide. It is well within the bounds of standard Christian belief to recognize that while individual may need to refuse to participate in specific procedures as a matter of individual conscience (the right to refuse to participate in either abortion or physician assisted suicide are classic examples), they also have a moral duty to provide necessary health care to all individuals, regardless of whether or not those individuals comply with one’s own moral beliefs.

Refusing necessary treatment to an individual who holds views that differ from one’s own when the treatment itself is not morally problematic differs in important ways from what has traditionally been seen as protected by conscientious refusal clauses. American law generally does offer fairly expansive protection for behavior rooted in religious belief, and it may well be that the current expansion of conscientious refusal demanded by religious conservatives will be upheld by the Supreme Court. But the real question Christians should be asking themselves is not whether this can be enshrined in American law, but rather whether their demand for more rights to medical refusals is in deep conflict with the very faith they are invoking