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.