The Doctor’s Conscience
By John Wyatt
read : The Doctor’s Conscience (part 1)
Examples of the corruption of medicine
Over the last century there have been many shocking cases when the core ethical commitments of medicine have been corrupted and violated:
- In stalin’s Russia, psychiatrists imprisoned, sedated and electro-shocked political dissidents.6
- In Nazi Germany, physicians performed barbaric medical experiments on prisoners and supervised the execution of millions of Jews and disabled people.7
- In Abu Ghraib and Guantanamo Bay, US military doctors were actively involved in the supervision of torture.8
- In the USA, physicians planned and carried out the infamous Tuskegee experiment in which hundreds of patients with advance syphilis were deliberately deceived and left untreated.9
- In China, doctors have been repeatedly involved in preparing prisoners for execution and subsequently removing organs for transplant purposes.10
So we must not be naive in thinking that medical practice cannot become morally corrupted. History teaches us that when doctors are subject to coercion from state power or other sources, they may act in ways which deny the fundamental moral values of good medicine. It is therefore an essential safeguard for the moral values of good medicine. It is therefore an essential safeguard for the moral health of medicine that legal and regulatory systems are maintained, to protect the rights of doctors to refuse to take part in practices which violate their most profound moral convictions.
There is no doubt that part of the high level of trust which doctors still retain in our society stems from their reputation as independent caring professionals who have an open and stated duty to act with moral integrity, in the best interests of their patients,
If doctors are perceived to be merely state apparatchiks, contracted and obliged to carry out the bidding of politicians, then why should we trust them to do the best for us?
Legal frameworks and the right of conscience
It is a fundamental principle of UK common law that doctors, like other professionals, should not be compelled by the state to act in a way which violates their conscience. The Abortion Act and the Human Fertilisation and Embryology Act both enshrine the right of doctors to refuse on the grounds of conscience to participate in treatments authorised under their jurisdiction.
Article 9 of the European Conviction on Human Rights states that ‘Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to manifest his religion or belief in worship, teaching, practice and observance’. However,
it is not yet clear to what extent doctors will be able to claim the right of conscientious objection under Human Rights legislation.11
Section 4 (1) Subject to subsection (2) of this section, 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:Provided that in any legal proceedings the burden of proof of conscientious objection shall rest on the person claiming to rely on it.
(2) Nothing in subsection (1) of this section shall affect any duty to participate in treatment which is necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman.
The UK General Medical Council guidance for doctors in Good Medical Practice5 reflects a balance between respect for the best interest of the patient and respect for the doctor’s right to conscience:
You must treat your patients with respect whatever their life choices and beliefs. You must not unfairly discriminate against them by allowing your personal views to affect adversity your professional relationship with them or the treatment you provide or arrange…
If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You must be satisfied that the patient has sufficient information to enable them to exercise that right. If it is not practical for a patient to arrange to see another doctor, you must ensure that arrangements are made for another suitably qualified colleague to take over your role.
Although the doctor has a right not to act against his or her conscience, this right must be balanced by respect for the patient’s concerns and interests. In particular there is a duty to make sure that patients are fully informed about their rights to see another doctor. Similarly, doctors cannot refuse to provide any care for a patient on the grounds that they have undergone or are about to undergo a procedure to which the doctors objects. Doctors still have a duty to act in the best interest of their patient. As the GMC has put it: ‘It is the procedure to which the doctor objects, not the patient’.11
Christian thinking about the conscience
In biblical thinking, the conscience is one of the most fundamental aspects of what it means to be a human being. The conscience is part of our created humanity and it is present in all, not just on those who are believers. The conscience is seen as, in some sense,
an internal reflection of God’s law for all mankind. The apostle Paul, writing of the Gentiles who did not receive the Mosaic law,
states that ‘what the law requires is written on their hearts’.12
But the human conscience as an internal moral compass is not an infallible guide to morality. As fallen human beings, our consciences are inevitability corrupted and contaminated by evil. It is possible for human beings to reach a point in which their conscience becomes completely insensitive.13 So the teaching of the New Testament is that the conscience needs to be constantly instructed, informed and realigned by Christian truth.14 The education of a godly conscience is an essential aspect of the growth into maturity of every Christian believer.
Abuse of conscientious objection
The right of conscientious objection is a precious privilege which our law and professional guidelines have granted to us. Like all privileges it is open to abuse, and there is a grave danger that selfish, misguided and thoughtless appeals to conscience may mean that the privilege is threatened and ultimately lost. There have been cases when doctors have claimed the right of conscientious objection,
when their real motivation was laziness, to avoid burdensome or boring duties. Conscientious objection may cause inefficiencies and delays in medical services, and doctors have a duty to ensure that their actions do not create avoidable problems for their patients and colleagues.
It is not always clear when an appeal to conscience is appropriate and when not. For example, it seems clear that a doctor who is a Jehovah’s Witness should not be allowed to refuse to treat with a blood transfusion a patients bleeding to death. But should a specialist in regenerative medicine be allowed to refuse to use a new stem cell therapy derived from embryos or aborted fetuses? Should doctors who hold religious beliefs forbidding the use of alcohol be allowed to refuse to treat patients with alcohol related illness?
The right of conscientious objection is not a minor or peripheral issue. It goes to the heart if medical practice as a moral activity. Current UK law and professional guidelines respect the right of doctors to refuse to engage in certain procedures to which they have a conscientious objection. However, the right of conscience is not absolute and doctors have a duty to preserve the best interest of their patients and to keep them fully informed.
The right of conscience helps to preserve the moral integrity of the individual clinician, preserves the distinctive characteristics and reputation of medicine as a profession, acts as a safeguard against coercive state power, and provides protection from discrimination for those with minority ethical beliefs.
John Wyatt is Professor of Ethics and Perinatology at University College London
5. General Medical Council. Good Medical Practice. 2006
6. Birley J. Political abuse of psychiatry in the Soviet Union and China. J Am Acad Psychiatry Law 2002; 30: 145-7. See also Wikipedia article Punitive psychiatry in the Soviet Union http://en.wikipedia.org/wiki/Punitive_psychiatry_in_the_Soviet_Union
7. See Wyatt J. Matters of Life and Death. Leicester: IVP, 1998. Chapter 9; and Proctor R. Racial Hygiene. Harvard University Press, 1998
8. Holmes D, Perron A. Violating ethics: unlawful combatants, national security and health professionals. Journal Medical Ethics 2007; 33:143-145
9. White R. Unraveling the Tuskegee Study of Untreated Syphilis. Arch Intern Med 2000; 160:585-598. Becker Human subjects investigation: timeless lessons of Nuremberg and Tuskegee. J Am Coll Radiol 2005; 2:215-7
10. Diflo T. Use of organs from executed Chinese prisoners. Lancet 2004; 364, Suppl 1:s30-1. Biggins S et al. Transplant tourism to China: the impact on domestic patient-care decisions. Clin Transplant 2009; Jan:10
11. Foster C. Conscience in the Consultation. Triple Helix 2008; Summer:10-11
12. Romans 2:15
13. Titus 1:15-16
14. Romans 14:1-23; 1 Corinthians 10:23-33; Galatians 2:11-16
Christian Medical Fellowship (CMF) Files No. 39, 2009