Medical Ethics and the Faith Factor: The Endangered Right of Conscience

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Julian Savulescu, Oxford philosopher, has written “When the duty is a true duty, conscientious objection is wrong and immoral. …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. …Conscientious objectors must ensure that their patients are aware of the care they are entitled to and refer them to another professional. …  Conscientious objectors who compromise the care of their patients must be disciplined.”[16]

American College of Obstetrics & Gynecology (ACOG) proposal to limit the Right of Conscience

In November 2007, the ACOG Ethics Committee issued position statement #385 entitled “The Limits of Conscientious Refusal in Reproductive Medicine.”  In the statement, they define conscience, define limits for conscientious refusal, delineate institutional and organizational responsibilities, and make seven recommendations.  Some of the recommendations are not unreasonable (about accurate and unbiased information[17], obligation for prior notification), but others are clearly contrary to the longstanding understanding of physicians’ right of conscience.

Recommendation #1 includes “…Any conscientious refusal that conflicts with a patient’s well-being should be accommodated only if the primary duty to the patient can be fulfilled.”  According to ACOG, the patient’s wishes trump; her “well-being” is self-defined.  Thus, by their assessment, each physician is obligated to provide all services requested by a patient.

Recommendation #4 insists the refusing physician has a duty to refer the requesting patient to a willing physician.  They display no regard for physician concerns about moral complicity.

Recommendation #5 includes “In an emergency in which referral is not possible or might negatively affect a patient’s physical or mental health, providers have an obligation to provide medically indicated and requested care regardless of the provider’s personal moral objections.”  Though the underlying premise is valid, the services in question are rarely life or death emergencies, and inclusion of a mental health provision boundlessly expands this requirement.

Recommendation #6 says that in resource-poor areas, physicians who are unwilling to provide full reproductive services should “practice in proximity to individuals who do not share their views or ensure that referral processes are in place.”  In no other area of medicine is it assumed that every patient must have convenient access to all services.  Living in a resource-poor area may mean that a patient does not have access to a dermatologist or a neurosurgeon.  Certainly a physician practicing in such an area must be willing to provide all emergency services in which he or she is adequately trained.  However, there is no such obligation for elective procedures, even if he or she is capable.  In no other area of medicine am I familiar with a professional requirement that a physician must limit or move his or her practice location to satisfy patient requests.

Response to ACOG

I believe the ACOG statement asserting limits to the healthcare professional’s right of conscience is seriously flawed in several areas:

  • ACOG maintains that patient autonomy is the final arbiter of treatment decisions. This is not always true. There are clearly times when patient autonomy is not the determinative factor, such as imposed immunizations, imposed quarantine, imposition of life-saving treatment when a patient has made an irrational refusal, treatment and prevention of suicide.
  • ACOG asserts that whatever is legal is socially acceptable, and thus licensed professionals are obligated to provide such services. Acceptance of this flawed precept would require a physician to provide or facilitate each patient request for a legally available service, e.g., every Oregon physician would be required to assist a patient with a request for suicide.
  • ACOG erroneously maintains that negative patient autonomy (the right to refuse a recommended treatment) and positive patient autonomy (the right to demand a treatment) are morally equivalent. It is a well-established and longstanding tenet of medicine that the patient’s right to refuse is nearly inviolable, but a patient’s right to demand a specific treatment is subject to physician discretion and veto. Were this not so, patients could demand unnecessary surgery, and they would not require prescriptions for antibiotics or narcotics. Society has supported such professional refusals of procedures or drugs the physician believes to be deleterious to the patient based on patient beneficience [beneficence?]. Similarly, society has until recently supported physician refusal based on his or her right of conscience.