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Conscientious objection is an important medical principle

Doctors are expected to have integrity. Does this not entail that they should do what they think is right?

23 February 2018

12:31 PM

23 February 2018

12:31 PM

Something interesting is happening in the House of Lords. Baroness O’Loan’s Conscientious Objection (Medical Activities) Bill, now at the committee stage, has put on the agenda an issue which well-deserves to be there. Its point is simple: all healthcare professionals should have a legal right to opt out of certain procedures which they find objectionable. It specifies three areas: abortion provision, withdrawal of life-saving treatment, and actions relating to certain reproductive technologies.

This is not particularly radical; the 1967 Abortion Act already explicitly protects conscientious objection. Indeed, it could even be asked why this should, in a country with a tradition of liberty like ours, even be up for debate. Do we really need law to protect the right to conscience?

Sadly, it has become clear that we do. Armchair philosophers have been discussing the merits of forcing doctors and nurses to act against their conscience (or lose their jobs) over the last few years. Many papers against conscience have been published. At the vanguard of this hostility is a small group who have drafted a ‘consensus statement’ against conscientious objection. (Of course, it is no more the consensus of all doctors and medical ethicists than Das Kapital is the consensus of all economists). The basic contention is that patients are entitled to anything which can legally be provided, and doctors have no right to let their own personal and (especially) religious values interfere.

But has anyone ever met a doctor without values? Every decision a doctor makes entails a value judgement about seeking good and avoiding harm, whether he is considering ligating haemorrhoids or performing a heart transplant. Doctors are expected to have integrity. Does this not entail that they should do what they think is right? I doubt many of us would trust a doctor willing to do something he believes to be seriously wrong. How could we place our confidence in such a person in our moment of greatest need? (This perhaps explains why patients support their doctor’s right to conscience.)

Moreover, patients are entitled to everything that is legal, in a qualified sense. We do not have à la carte medicine where therapies are chosen like starters and mains. Doctors rightly have a gatekeeping role because of the responsibility they bear, and so retain the right to withhold something futile or excessively dangerous (more on this here). No surgeon is forced to amputate someone’s leg to cure their gouty toe. Likewise, none of us is forced to take medication against our wishes. The fact that entitlement is qualified is not at all controversial. It will not do to ignore it in order to undermine conscience.

The point about the gouty toe proves that professional clinical judgment is a good thing. Those who oppose conscience typically frame it as religious or moral prejudice rather than concede that it is just a species of professional judgement. Calling it moral or religious makes it seem arbitrary, but I doubt there is any conscientiously objecting doctor who believes he is not acting according to his patient’s best interests. Hence, if conscience in ‘moral’ matters is done away with, there is no good reason why the rest of professional judgment should not go the same way—that is, unless those who oppose conscientious objection only care about excluding certain views they disdain and dismiss as ‘religious’ or ‘moral’.  If so they are making a distinction without a difference, albeit a convenient one. Ethical judgment is of apiece with clinical judgment because both are ways of answering the question ‘what is the right thing to do’? Swing at one and you will hit both.

It’s also worth noticing the supreme self-confidence of this attack on conscience. To say that healthcare professionals must participate in such-and-such or seek alternative employment means that some people in power are so certain that current practice is ethically perfect that it is not up for debate. There is not room for self-doubt or self-reflection here, let alone agreeing to disagree. But history proves that the medical profession has got it badly wrong in the past. Might history not judge us for fossilising our practices by excluding a mechanism by which problems can come to light? Are we completely certain that what we are doing is always and inevitably good? And, if so, does this justify shutting down all dissent at the outset? Only strongly motivated reasoning could justify a positive answer.

In practice no one is harmed by conscience (unless rare inconvenience constitutes harm). But many would be harmed and wronged if there were no conscientious objection. Those who wish to register conscientious objection will be forced to sacrifice either their career or their own ethical sense and become medical marionettes.  And this at the further cost of excluding several tranches of society on the sole basis of a handful of highly contentious issues. Surely this makes a mockery of genuine pluralism.

No one is suggesting that conscientious objection should be an abracadabra to evade genuine duties or baptise prejudices (I write about this here). But it should be clear that the liberty to engage in personal reflection and act accordingly is basic to good medical practice. Its benefits so vastly outweigh its occasional inconveniences that only badly disordered priorities could suggest its termination. Perhaps this is precisely what the attack on conscience stems from, a view that the gravest sin disagreement with a certain ‘enlightened’ consensus.

If we are willing to contemplate a situation where certain issues are so far past debate that participation in them becomes coercive, we have yet to learn the meaning of tolerance, that perfect uniformity of opinion is not necessary for unity and co-operation. Baroness O’Loan’s Bill is a sophisticated application of this simple principle. It deserves the attention and support of all those interested in liberty and tolerance, and those in a position to establish these in our statute books.

Toni Saad is a final year medical student at Cardiff University

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