The Doctor’s Conscience

By John Wyatt

Conscientious objection as a right is enshrined in law and in professional guidelines, but has recently come under attack. These arguments are described, but the concept of the conscience goes to the heart of what it means to act in a moral way, with integrity. There have been shocking historical examples of medical abuses after conscience has failed. The right helps preserve individuals’ moral integrity, preserves the reputation of the profession, safeguards against coercive state power, and protects from discrimination those with minority ethical beliefs.

The right of conscientious objection is enshrined in medical law. For example, the 1967 Abortion Act states that ‘…no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection’.1 Similarly, the Human Fertilisation and Embryology Act preserves an express right for health professionals to refuse to participate in any treatment authorised under the Act.

However, the right of conscientious objection is increasingly coming under attack from a number of prominent ethicists and writers.
Professor Julian Savalescu is a prominent bioethics:

A doctor’s conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and by the consideration of just distribution of finite medical resources, which requires a reasonable conception of the patient’s good and the patient’s informed desires…

…If people are not prepared to offer legally permitted, efficient and beneficial care to a patient because it conflicts with their values, they should not be doctors. Doctors should not offer partial medical services or partially discharge their obligation to care for their patients.

To be a doctor is to be willing to offer appropriate medical interventions that are legal, beneficial, desired by the patient, and a part of a just healthcare system… If we do not allow the moral values of self-interest to corrupt the delivery of the just and legal delivery of health services, we should not let other values, such as religious values, corrupt them either.2

A recent article in the New England Journal of Medicine stated:

As the gate-keepers to medicine, physicians and other health care providers have an obligation to choose specialties that are not moral minefields for them. Do you have qualms about abortion, sterilization and birth control – do not practice women’s health. Do you believe that the human body should be buried intact – do not become a transplant surgeon…conscience is a burden that belongs to the individual professional; patients should not have to shoulder it…3

Arguments against the right of conscientious objection

1. Conscientious objection leads to inefficiency and inequity in the provision of health care. It is inconsistent with modern healthcare systems.

The dominant vision for modern healthcare is that of the machine. Healthcare systems are conceived as highly complex, integrated, interdependent, standardised machines for treating healthcare consumers (patients) and for delivering healthcare. Healthcare managers have adopted the language of the service industry. Medial practice should be ‘cost-effective, evidence-based, time-efficient, consistent, high quality, and consumer-led’.

But in this vision of a well-oiled machine, it is essential that each element performs its function efficiently. Each cog must run smoothly if the machine is going to achieve maximum efficiency. So the doctor who refuses to fit in with the agreed protocol or care pathway because they have a conscientious objection to a particular type of treatment, for example, is seen as problematic and anti-social. There is no doubt that gynaecologists who have a conscientious objection to performing abortions create particular difficulties for healthcare managers who are tasked with providing an efficient abortion service. Doctors who are prepared to perform abortions may feel that it is unjust that they have to take on an extra workload because of their colleague’s personal convictions. Similarly, a general practitioner who is unwilling to refer one of their patients for an abortion on conscience grounds may cause delays and perceived inefficiencies in the flow of patients from primary to secondary services. So in modern healthcare systems it is all to easy for the doctor with a conscience to be seen as problematic, troublesome and disruptive.

2. Conscientious objection leads to logical inconsistencies.

It is generally agreed that doctors should not be allowed to refuse to treat patients because of their own self-interest or irrational prejudices. A doctor is not free to refuse treatment to people with AIDS because of the risk of infection. Similarly, a racially prejudiced doctor is not free to refuse to treat patients from particular racial minorities. So if self-interest and racial discrimination are not appropriate grounds for conscientious objection, why should certain minority religious beliefs be respected? It is argued that there is no logical basis to allow one sort of belief to be respected whereas other beliefs and values are regarded as inappropriate. If we allow doctors to claim the right of conscientious objection we open the door to discriminatory and idiosyncratic medical practice.

3. Religious and moral values belong to the private sphere of life and not to the public sphere.

Most people agree that privately held beliefs and ‘values’ are important parts of our lives. However, it is argued that these personal beliefs should remain in the private sphere of our personal lives, thoughts and relationships. Once we enter into the role of medicine we step into the public sphere. Particularly when we are employed within a state health system such as the UK National Health Service, we are acting as public servants. A doctor should not allow his or her personal beliefs to influence the care which is given to the patients. Religion belongs to the private and personal sphere of life. Public servants must act in the public interest, not in their own.

4. Conscientious objection discriminates against atheists and those without religious beliefs.

Since it is mainly religious believers who claim the right of conscience, it is argued that this discriminates against atheist and those who claim allegiance to no religious faith. Why should believers be allowed to escape from their contractual obligations as a doctor, while atheists have no such privilege? To treat people with religious values differently from those with secular moral values is a form of blatant discrimination.

5. Conscientious objection is always open to abuse by unscrupulous, lazy, bigoted, or self-centred individuals.

There is anecdotes evidence that many junior doctors who are training in obstetrics and gynaecology are claiming the right of conscientious objection in order to avoid participation in abortion services during their training. Because of the difficulty of finding staff prepared to perform abortions, it is said that some NHS hospitals have chosen to outsource these services to private abortion providers. But do all the doctors who claim the right of conscience have a genuine religious and moral objection to abortion, or is this simply a means for unscrupulous or lazy doctors to avoid their responsibility?

The practice of medicine enshrines moral commitments and required moral integrity

The argument above may seem persuasive, and in any case it is often assumed that the role of the conscience in medicine is relevant only to a few specialised and limited areas, such as abortion or contraception. But in fact the concept of the conscience goes right to the heart of what it means to act in a moral way, to act with integrity.

It is striking that the moral commitments underlying medicine can be traced all the way back to the Hippocratic roots of Western medicine. The Hippocratic doctors of the 3rd and 4th centuries BC went out of their way to differentiate themselves from the run-of-the-mill healers, herbalists and snake-oil salesmen who were offering their wares. The Hippocratic doctors were different because they had taken a solemn and binding oath which directed, governed and limited all their medical activities.4

The earliest version of the Hippocratic oath starts with an invocation to the gods: ‘I swear by Apollo Physician, by Aslepius, by Hygeia, by Panaceia and by all the Gods and Goddesses, that I will carry out, according to my ability and judgement, this oath…’ In the first centuries after Christ the oath was Christianised, and the introduction was changed to the words ‘I swear by Almighty God…’ but the basic structure is unchanged.

It is clear that the heart of the Hippocratic oath is a recognition that the individual doctor is practising before a higher power –
a power to whom he or she is accountable. But it is striking that Hippocratic doctors did not swear by the Emperor, by the State, or by local lords and authorities. Their oath was taken before the highest possible authority. In philosophical terms it is a recognition of transcendence, an appeal to ultimate authority. So doctors are not just paid artisans who do whatever their paymasters require. They are not just civil servants whose first loyalty is to the state. They are not just salesmen whose job is to keep the customers satisfied. They walk to the beat of a different drum.

Ever since Hippocrates, the practice of medicine has been founded in a number of core ethical values. Practising good medicine is a moral activity and not just a technical one. The foundational values of medicine are part of physicians’ understanding of who they are and they have provided the basis for historical codes of medical ethics, such as the Hippocratic Oath, the Declaration of Geneva, and the General Medical Council’s Good Medical Practice.

These core ethical values become part of the physician’s understanding of who they are and what they have entered medicine for. They are central to the doctor’s self identity. And when a person is coerced by employers, or by the power of the state, to act in a way which transgresses these core ethical values then their internal moral integrity is damaged.

It is interesting that the word ‘integrity’ is used in medicine to mean ‘intact’, ‘functional’ or ‘healthy’. Orthopaedic surgeon talk about the integrity of a joint, for example. So to have moral integrity is to be morally intact, to be internally healthy. Conversely, when I am forced to act in a way which violates my moral principles I am damaged internally, I become morally impaired.

Moral commitments of the doctors, from Good Medical Practice5

– Make the care of your patient your first concern
– Protect and promote the health of patients and the public
– Provide a good standard of practice and care

  • Keep your professional knowledge and skills up to date
  • Recognise and work within the limits of your competence
  • Work with colleagues in the ways that best serve patients’ interests

– Treat patients as individuals and respect their dignity

  • Treat patients politely and considerately
  • Respect patients’ right to confidentiality

– Work in partnership with patients

  • Listen to patients and respond to their concerns and preferences
  • Give patients the information they want or need in a way they can understand
  • Respect patients’ right to teach decision with you about their treatment and care
  • Support patients in caring for themselves to improve and maintain their health

– Be honest and open and act with integrity

  • Act without delay if you have good reason to believe that you or a colleague may be putting patients risk
  • Never discriminate unfairly against patients or colleagues
  • Never abuse your patients’ trust in you or the public’s trust in the profession

Read more: The Doctor’s Conscience (part 2)

References

  1. Abortion Act 1967
  2. Savalescu J. Conscientious objection in medicine. BMJ 2006; 332:294-7
  3. Cantor J. Conscientious Objection Gone Awry – Restoring Selfless Professionalism in Medicine. New Eng J Med 2009; 360:1484-5
  4. See Wyatt J. Matters of Life and Death. Leicester: IVP, 1998. Chapter II
  5. General Medical Council. Good Medical Practice. 2006

Christian Medical Fellowship (CMF) Files No. 39, 2009