Conscientious objection to euthanasia: a qualitative study of palliative care physicians’ perceptions

Abstract

Abstract Background Conscientious objection (CO) in healthcare is a pressing issue, particularly in euthanasia, where legal permissibility coexists with moral disagreement. CO is commonly framed as a principled refusal based on moral or religious convictions, often emphasizing tensions between professional integrity and patient access. However, this framing may not fully capture how CO is understood and enacted in clinical practice. The present study therefore explored palliative care physicians’ perceptions of CO to euthanasia in Belgium, a country with more than two decades of regulated euthanasia practice. Methods Qualitative study using a constructivist grounded theory approach. Between March and December 2025, semi-structured interviews were conducted with 24 physicians trained in palliative care and working in Belgian palliative care units. Participants were purposively recruited, with theoretical sampling used to refine emerging concepts. Data were analysed using the Qualitative Analysis Guide of Leuven (QUAGOL), an iterative process of coding, constant comparison, and conceptual development. Results Physicians’ perceptions often diverged from conventional framings of CO. First, the term CO was experienced as contested and value-laden. Second, many participants distanced themselves from assumptions that CO entails refusal of care, opposition to law, or fixed moral positions. Instead, many refusals were embedded in ongoing care, involved interpretation of legal criteria, and were negotiated case by case. Third, CO to euthanasia emerged as a dynamic moral practice—evolving, interpretive, relational, and context-sensitive. Participants favored flexible, compromise-oriented approaches and expressed reservations about binary regulatory models. Conclusions Palliative care physicians perceived CO to euthanasia as a dynamic moral practice rather than a categorical refusal. These findings highlight the limitations of binary understandings of CO and support clinical and institutional approaches that balance professional integrity, patient relationships, and continuity of care.