Making Sense of Bioethics: Column 148: When Is It a Sin to Make a Referral?

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During World War II, if a contrac­tor had been asked to con­struct a building knowing that it would serve as a gas chamber in Ausch­witz, it goes without saying that he ought not agree to do it. By lay­ing the foundation and supervis­ing the plumbing, electrical and duct work, he would be contributing to, or enabling, the subsequent commis­sion of atrocities against prisoners in the concentration camp. 

But significant concerns would also arise if he were to reply: “I’m sorry, I have a moral objection to build­ing this structure, but let me put in a call to a colleague who is a contrac­tor, and he will do it for you.” By placing the call, he would still be a part of the causal chain leading to the building of the facility, and to the subse­quent evils that would be car­ried out in it. By making a referral to en­gage someone else’s services for some­thing immoral, we can still be in­volved in, and responsible for, the commis­sion of grave evils. 

Among medical professionals, situa­tions can likewise arise in which they may be tempted to make a refer­ral for an immoral procedure, suppos­ing that because they are not do­ing the procedure themselves, they are now morally “in the clear.” 

For example, a pharmacist who lives and works in a state or jurisdic­tion where physician-assisted suicide has been legalized may be asked to fill a prescription for suicide pills. By declining to fill that prescrip­tion, he or she avoids immediately cooperat­ing with a customer’s im­moral decision to commit suicide. But it would still raise moral con­cerns if the pharmacist said to the cus­tomer: “Let me pass this prescrip­tion to my co-worker, be­cause, although I cannot fill it, he can help you out.” The first pharma­cist remains a contributor in the chain of events leading up to the carrying out of the evil act, and he would be cooperating in evil by making the referral to his co-worker. 

A “referral” in moral terms is when the person who refuses to do the immoral procedure himself or herself directs the requesting per­son to another individual or institu­tion because the other individ­ual or institution is known or believed to be willing to provide the immoral procedure in ques­tion. The decision to offer the refer­ral indicates that the one do­ing it is choosing, at least implic­itly, to help the requester carry out the evil act, and such implicit will­ing of evil acts can never be mor­ally acceptable.

Making a referral can also con­vey a sense of tacit acceptance and approval of that evil, and there­fore the referring provider can also become guilty of wrongdoing by giv­ing scandal. Someone who gives scan­dal helps to form the immoral will of another. In fact, the term “scandal” in theology refers to any action, word or deed that leads another to sin.

Of course, a pharmacist could simply decline to fill a suicide pill prescrip­tion. He may have to pay the conse­quences for his refusal, but it cer­tainly would be a valid and coura­geous option for him to give witness to the injustice of assisted suicide laws. But that may not be the only way to ap­proach the situation. A conscien­tious pharmacist could also say to the cus­tomer, "There may be other pharma­cies around here that can assist you,” or even, “there may be others work­ing at this pharmacy who can as­sist you," and leave it at that. This would not be a referral, but a simple state­ment regarding commonly availa­ble public knowledge. The pharmacist could then return the prescription to the customer, rather than passing it to a co-worker, and the customer would then have to initiate a new "causal chain" or series of choices as he or she seeks to obtain the immoral medica­tions, looking around and inquiring about who might fill the prescription. This removes the original pharmacist from the causal chain, avoids making a referral to a colleague, and dimin­ishes or eliminates responsibility for any subsequent evils that the customer may end up committing. 

Regrettably, pharmacists and other health care professionals today are coming under increasing fire from the culture around them as they are be­ing told, as part of their job descrip­tion, that they have to ignore their well-formed consciences and fill prescrip­tions for suicide pills, the abor­tion pill or contraception. Yet a dou­ble-standard is clearly at work, for if the prescription were for something a pharmacist knew would be used as a date rape drug to take advantage of a woman at a party, everyone would de­clare the pharmacist to be a moral hero for refusing.

To sum up, then, a great deal of care, vigilance and determination is needed not only for us to avoid commit­ting certain evils, but also to avoid making a referral for those evils to be carried out by others.

Copyright © 2020, The National Catholic Bioethics Center, Philadelphia, PA. All rights reserved.

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