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Rapid Responses: Rapid Responses published:
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benefits
- Karen Palmer (4 February 2006)
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Six objections to Savulescu's salvos
- Trevor G Stammers (4 February 2006)
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Lack of debate
- Jose J De Murtinho-Braga (5 February 2006)
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Objections to conscientious objection
- T Everett Julyan (5 February 2006)
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Should conscientious objection be tolerated?
- David R Clegg, None (5 February 2006)
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Savulescu on Conscience
- Michael Gillan Peckitt (5 February 2006)
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A personal moral code
- Anthony Papagiannis (5 February 2006)
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Conscientious objection: Savulescu's illogical arguments
- Michael Jarmulowicz (5 February 2006)
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Execution by lethal injection
- rb jones (5 February 2006)
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Good and evil- its recognition
- John. H Scotson (6 February 2006)
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Doctors have rights too
- Charles A. Foster, Dr. Mary McCullins (6 February 2006)
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Conscience is our safeguard
- Andrew F West (6 February 2006)
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Please protect me from intolerance
- Tom Van der Linden (6 February 2006)
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Concientious objection is a manifestation of free choice
- David Lewis (6 February 2006)
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Is there a real difference between a 'secular' and 'religious' value?
- Stuart J Fergusson (6 February 2006)
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The path of Savulescu's logic leads to strange places.
- James D Stevenson (6 February 2006)
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Savulescu's interesting take on Law
- Peter KK Au-Yeung (7 February 2006)
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Conscientious objection
- Edmund J Dunstan (7 February 2006)
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So sprach Superego
- Adrian Blaj (7 February 2006)
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Wholesomeness is crucial to ethical care
- Paul D Kelly (7 February 2006)
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A higher duty
- Frank H Bloomfield (7 February 2006)
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Conscientious objection in medicine
- John B Zachary (7 February 2006)
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Autonomy is never absolute
- Surendra I Deo (7 February 2006)
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Objections to objecting to objection
- David J Shepherd (7 February 2006)
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Legal or decriminalised unproven benefit
- Anne M Williams (7 February 2006)
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Please reconsider this unfortunate position
- shimon M. Glick (7 February 2006)
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"Conscientious objection...wrong and immoral"?
- Alasdair H B Fyfe (8 February 2006)
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Analysis and learning for all
- Stephen Bamber (8 February 2006)
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Autonomy and Conscience
- Ian McD Jessiman (8 February 2006)
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Conscientious objection in medicine: the ethics of responding to bird flu.
- Elizabeth Murray, Paquita de Zulueta (8 February 2006)
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The value of conscience
- Amitava Banerjee (8 February 2006)
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Failure to Meet Standards of Argument-Based Ethics
- Laurence B McCullough, Frank A Chervenak (9 February 2006)
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Conscience and society
- Ronald J Clearkin (9 February 2006)
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Poor analysis, setting rights against law
- Adrian K Midgley (9 February 2006)
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Doctors' freedom of conscience
- Vaughan P Smith (9 February 2006)
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The Priority of Professional Ethics Over Personal Morality
- Rosamond Rhodes (9 February 2006)
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Discussion warrants more careful precision
- Alexander C. Tsai (9 February 2006)
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Avoid selective use of law
- Peter Gooderham (9 February 2006)
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What are the editors doing?
- Steve Kelly (9 February 2006)
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ethical rules
- benjamin dean (10 February 2006)
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Re: What are the editors doing?
- John P Heptonstall (10 February 2006)
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Is Savulescu displaying double standards?
- Christopher J Harrison (10 February 2006)
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Are Objections to Conscientious Objectors Unconsciously Unconscientious?
- Andrew Ashworth (10 February 2006)
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There will be no loyalty, except loyalty towards the Party
- Giles N Cattermole (11 February 2006)
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Poor example of editing standards at BMJ
- Kelly A Markham (12 February 2006)
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"Beneficial" is a value judgement.
- John P. Watson (13 February 2006)
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Re: Six objections to Savulescu's salvos
- Stephen Hayes (14 February 2006)
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Conscientious objection is not cowardice
- Eldad J Ben-Eliezer (15 February 2006)
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Conscientious objection and the difficulty of consensus
- Piers M W Benn (16 February 2006)
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In defence of conscientious objection
- Hugo van Woerden (16 February 2006)
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Re: Conscientious objection and the difficulty of consensus
- Tom G Heyes (17 February 2006)
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Conscientious objection in medicine
- Tom R C Boyde (21 February 2006)
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Re: Re: Six objections to Savulescu's salvos
- Peter KK Au-Yeung (21 February 2006)
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Re: The difficulty of consensus in real cases
- David Jones (21 February 2006)
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Truth in Unity
- Philip G. Ney (24 February 2006)
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Conscientious objection in medicine
- Sylvia M Watkins (9 March 2006)
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Conscientious objection in medicine: Quoting the Villain in Shakespeare
- Brian J Bane (13 March 2006)
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Without conscience and without wisdom - towards the abolition of man
- Marta Munzarova, Komenskeho nam. 2,CZ-60200, Brno, Czech Republic (31 March 2006)
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A bit more context
- John Stone (31 December 2008)
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freedom of conscience: a core of medicine and of the practice of ethics
- Paula R Boddington (13 April 2009)
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Karen Palmer, staff grade psychiatrist ICT team, Glasgow G43 1RR
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"To be a doctor is to be willing and able to offer appropriate medical interventions that are legal, beneficial, desired by the patient, and a part of a just healthcare system." The word "beneficial" is important. It is interesting that this week's issue also has mention of a study from the Journal of Child Psychology and Psychiatry - "young women who terminate their pregnancies are at increased risk of subsequent mental health problems, according to a 25 year cohort study from New Zealand". See Minerva p312. Maybe termination of pregnancy is not as "beneficial" as Julian Savulescu is in danger of assuming. Competing interests: None declared |
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Trevor G Stammers, Senior Tutor in General Practice, St George's University of London SW17 0RE
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Savulescu has several fatal flaws in his case against conscientious objection in medicine. First, he assumes that what is legal is just; a moment’s thought shows this is not so. The Nazis would have applauded his assertion that we should not “allow moral values to corrupt the delivery of a just and legal health service” It was doctors' compliance with the law they saw as just, that facilitated the Holocaust. I wonder if Savulescu has carried out a survey to determine how many patients would prefer to be treated by his ideal doctors whose “conscience has little place in the delivery of ..care”? 1 Secondly, he appears to conflate conscientious objection with religious belief. There are many medical students and doctors today with no religious belief who consider euthanasia and abortion are intentional killing of the innocent and should have no place in the delivery of medical care. The recently launched “Care Not Killing” alliance makes the point powerfully enough.3 Third, he fails to recognise the irony of his reluctant acceptance of conscientious objection only in situations where there are enough other doctors to do the killing (or whatever is objected to). I believe the current recruitment crisis in obstetrics is in part due to the fact that an increasing number of young doctors do not want participate in the abortion industry. If, as Savulescu suggests, they don’t become gynaecologists,then the crisis will just deepen. Some patients only want to be cared for by obstetricians who will not do abortions. It is surely not paternalism to allow them that choice where possible? Fourth, it is because conscientious objectors share Savulescu’s belief that “the primary goal of a health service is to protect the health of its recipients” that they are objectors. I can’t see how the abortionist’s curette benefits the recipient fetus. Fifth, if objectors have to openly declare their hand to their patients should not those doctors willing to carry out euthanasia or assist their patients' suicide also have a notice in the waiting room to this effect in countries where this is legal? Finally, if values have no place in determining medical care, on what basis does Savulescu attempt to impose his own moral values on conscientious objectors? The paternalism he so despises is only matched by Savulescu’s own and his ideal of “statute-driven medicine” seems to me more ‘idiosyncratic, bigoted and discriminatory’ than the moral values he is so intolerant of. 1.Savulescu J Conscientious objection in medicine BMJ 2006 332 294-7 2.Lifton Robert Jay The Nazi Doctors ; Medical Killing and the Psychology of Genocide Papermac 1986 3.http://www.carenotkilling.org.uk/ Competing interests: None declared |
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Jose J De Murtinho-Braga, General Practitioner Northdown Surgery CT92TR
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Yet again the BMJ seeks to place opinion before fact ideology before reasoned debate. The whole tenor of the BMJ reflects a neo-liberal ideology which it assumes all doctors should and must buy into from obituries that laud euthanasia to diatribes against conscientious objection. This is the last straw therefore I am withdrawing my BMA membership and my BMJ subscription. Competing interests: None declared |
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T Everett Julyan, SHO in Psychiatry Dykebar Hospital, Grahamston Road, Paisley PA2 7DE, UK
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Julian Savulescu believes that doctors who seek to practice medicine ethically with a clear conscience should be excluded from the profession. I wonder how many patients would agree with him? Savulescu states that “conscientious objection is wrong and immoral” when there is a true duty of care. He bases his arguments on the belief that there is right and wrong, moral and immoral. However, he does not apply this consistently. Unfortunately his condemnation of those with conscientious objections fails to acknowledge why they object in the first place. Doctors with consciences are only trying to care for their patients in a right, moral and ethical way. Savulescu argues that those who do not participate in certain practices (such as abortion) on the basis of conscience are immoral. The underlying assumption appears to be that it is wrong to believe that something is wrong – a self-refuting argument. Is it wrong to opt out of practices which many consider to be immoral and unethical? Extending the logic of Savulescu’s argument suggests that if, for example, physician-assisted suicide was legalised, then all doctors would have a duty to help their patients kill themselves. Only those individuals who agree (or acquiesce) should be allowed to practice medicine. Extrapolating this, the medical profession would be made up of individuals without a conscience whose collective morality is markedly different from that of the patients they serve. British doctors are part of a pluralistic culture which values tolerance. It seems ironic, therefore, that Savulescu expresses his intolerant beliefs in such extreme terms. There are diverse views on a wide range of ethical issues in our society. Should the medical profession not reflect this? Competing interests: None declared |
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David R Clegg, retired obstetrician NA, None
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Should conscientious objection be tolerated?1 Editor - To make an action that was once criminal now a legal obligation would show the emptiness of today’s situation ethics. If the action is genuinely controversial and important to both patient and doctor both should have freedom of choice. If cowards may abuse conscience to avoid duty may not dictatorial legislators abuse power for a political agenda? Liberal legislation introduced under cover of autonomy may pressure patients to conform reluctantly to what is suggested to be in the public interest. The history of modern medicine has many examples of doctors faced with pressure to do harm. Some have stood against it for the common good at personal cost. Patients have a right to choose a doctor they trust, whose values they know and with whom they feel comfortable – “the medical profession have an obligation to ensure that they are aware of the full range of services to which they are entitled” and also the controversial values on which some of those services are based. Bias in the selection of medical students may threaten patients’ future freedom of choice. The author misrepresents history when he compares a “- obstetricians refusing to perform abortions” with “self-interested infectious disease doctors refusing to treat patients in a flu epidemic”. His penultimate emotive sentence “- value-driven medicine is a door to a Pandora’s box of idiosyncratic, bigoted discriminatory medicine” suggests that he has a problem of conscience in writing the article. If medicine is not driven by values there is nothing left to drive it but money. David Clegg obstetrician hclegg@fish.co.uk 1 Savulescu J. Conscientious objection in medicine. BMJ 2006;332:294-297 (4 February) Competing interests: None |
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Michael Gillan Peckitt, University Tutor University of Hull, c/o Philosophy Dept, Hull, E Yorks, HU6 7RX
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Imagine the scene: A student hands me an essay - which I am duty to mark as a tutor, but I find the student’s ethical views expresses in the article objectionable. So I refuse. Such a scene could never occur, I am duty bound mark the essay whether I agree with it or not. According to Hippocrates, the doctor’s remit is to “prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.” There is not mention of sentiment or conscience here, a doctor’s gives the advice or acts in manner which is medically sound. I don’t like taking pain killers, my doctor may not like prescribing them, he knows the side effects, so for all I know he may not like prescribing them, but in his judgment, it is a medically sound course of action, therefore I take tablets. Doctors and all health care workers can object to lawful practices and policies, but this is a debate to be had with the wider public, the government and unions and not just the individual patient. Ultimately, without an agreement on policy beteen doctors it is simply unfair if one doctor believes action x to be sound and another does not. Thus I agree with thrust of what Julian Savulescu is arguing but with a qualification. Whilst establishing a moral principle is a good idea, to whom does to apply? Have an immeasurable amount suddenly stopped acting in accordance with their duty and chosen conscience instead? Competing interests: None declared |
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Anthony Papagiannis, Respiratory Physician St Luke's Hospital, Thessaloniki, Greece
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Trevor Stammers has stated the case for conscientious objections in medicine so well that it would be unnecessary to add anything to his solid arguments. Suffice it to say that when Louis Pasteur read on the door of a scientific institution that science has neither country nor religion, he said that this may be true for science, but scientists have both a country and a religion. And a personal moral conscience, I would add. Competing interests: None declared |
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Michael Jarmulowicz, Associate Medical Director Bostwick Laboratories. W1T 5HE
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Julian Savulescu argues that doctors should not be allowed the right of conscientious objection1. However, he shows very muddled and illogical thinking in presenting his views. The conscience is that internal voice that tells us what is right and what is wrong. Is a notion of right and wrong no longer valid? Is Savulescu the sole arbiter of right and wrong? He argues that it was medical paternalism when doctors decided a patient's medical treatment, and that this has now been superseded by patient autonomy. But what about a doctor's autonomy? If we are not permitted to impose our views on our patients, on what logical basis has a patient the right to impose their views on the doctor? He argues that the doctor must be required to perform any activity which is legal. In the article he uses an example of an abortion on the grounds that the woman wants it for career reasons. Later in the article he uses the term "social termination" (his quotation marks). The abortion act allows abortion on purely medical grounds. Since when does a social abortion for career reasons qualify as medical grounds? The reality is that most abortions are performed for reasons that are certainly outside the strict definition of the wording of the act, and, strictly speaking, are therefore done illegally. I find it surprising that someone claiming to be a professional ethicist seems to lack any sound logic basis in their arguments. 1.Savulescu J Conscientious objection in medicine BMJ 2006 332 294-7 Competing interests: None declared |
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rb jones, retired consultant paediatrician I am retired and therefore have no place of work
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Professor Savelescu states that doctors have no right to object, on the grounds of conscience,to providing legally required services. In some States of the USA, execution by the administration of a lethal injection, by doctors, is a legally required service. Presumably he would claim that no doctor has the right to refuse to perform this service on the grounds of conscience Competing interests: None declared |
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John. H Scotson, Retired GP None. Retired
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What is conscience but that which recognises the distinction between good and evil with the will to do the one and avoid the other. The norms of society or Parliamentary decrees cannot change what is intrinsically evil into something which is good yet the author of the article seems more concerned with what is regarded as legal than what is right. Medical intervention should never be undertaken if it is in itself immoral. So many medical disasters from history can be cited when doctors have done what was legal but morally wrong It is indeed the duty of every doctor to have a well formed conscience and act according to the dictates of that conscience. For instance if the conscience of the doctor prohibits him or her to kill either before or after birth then the conscience should be obeyed without regard to legality or current medical practice What is ethics for if we discard the value of a good conscience. I found the article by Julian Savulescu very disturbing Competing interests: None declared |
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Charles A. Foster, Barrister Outer Temple Chambers, 222 Strand, London WC2R 1BA, Dr. Mary McCullins
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The world of Professor Savulescu (Conscientious objection in medicine: BMJ 2006; 332:294-7) is a bleak one. Doctors, for him, are mere technical functionaries. Their ethics are decreed, presumably, at some political level. Doctors exist to follow the protocols handed down from on high, and if they feel morally queasy about any of it, they are in the wrong profession. It is ironic that Professor Savulescu, one of the high priests of patient autonomy, is so dismissive of doctors' autonomy. The law does not have such a reductionist view of medical professionalism. It allows doctors to have principles. Article 9 of the European Convention on Human Rights provides 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." On the face of it, many of the conscientious objections so offensive to Professor Savalescu fall within the ambit of Article 9. Yes, Article 9 rights sometimes have to be sidelined in the name of the national good. But we are not talking about national security here. The NHS would not fall apart if real rights to conscientious objection were recognised. Competing interests: None declared |
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Andrew F West, Consultant Child and Adolescent Psychiatrist Wokingham CAMHS, Wokingham Hospital, Barkham Rd, Wokingham, Berkshire, RG41 2RE
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Julian Savulescu’s piece on conscientious objection demands, and will no doubt receive, critical discussion. My initial reaction was to respond ironically, presuming that he wrote the piece tongue-in-cheek. However, I am not practised at irony. Saying one thing and meaning another has always seemed too much like lying, and my conscience (sic) has tended to prevent me from being ironic with the conviction that is needed to bring it off. The other problem, which a colleague raised, was that Savulescu may have been writing with sincerity, and that to respond with irony might be disrespectful. I have therefore decided to respond as though he meant what he said. He is right that individual values can get in the way of ethical health care. He is catastrophically wrong in jumping to the conclusion that doctors should eliminate their own values from their practice. He might just as well argue that, as there can sometimes be problems with policies, we should ignore them all. It was this startling lack of philosophical and ethical sophistication in his writing that caused me to presume that he was being ironic. The paper opens with a quote from Shakespeare’s Richard III. Savulescu chooses to cite the values of a king who was known for his ruthless dishonesty (arguably almost devoid of conscience) , who put the Princes in the Tower, and whose subjects were ultimately too ashamed to fight for him at the Battle of Bosworth. In doing so, Savulescu has inadvertently put the case for the importance of conscience as an essential element of respectful and trusting relationships. He attributes the words to Shakespeare rather than his character, thus giving them greater weight. The Bard was probably himself writing ironically. Conscience, for Shakespeare’s Richard III was, after all, mostly guilt in the shape of the ghosts of his past victims. He could not go to war with a good conscience, so he had to ignore it. Finally, Savulescu, in what may be a Freudian slip, directs us in error to Scene iv, in which Richard, the “bloody dog” , gets the gruesome end that he deserves. This is an admonition and warning to those who would eschew the importance of conscience. Savulescu appears to take it as the opposite. Next we are introduced to the concept of conscience invoked to avoid duty. I would call this idea oxymoronic: One cannot knowingly, by definition, use conscience for an ulterior end, although one could pretend to, in which case avoidance of duty is the value to which one’s conscience is urging adherence. I hope that Savulescu is not suggesting that avoidance of duty is an important value for doctors. It is impossible to be impressed with the moral or philosophical weight of Savulescu’s argument when he uses absolutes ( “always” appears in two consecutive sentences) and value-laden phrases ( “Their values crept in...”, and "..has been squarely overturned...”) with reckless abandon. He refers to duty without saying to whom the duty is owed, and introduces “true” and “grave” duties without definition. He speaks of action in the public interest without alluding to the inevitable conflict between individual and public interest that pervades any debate about state provision of health services. Even his use of the word “paternalism” implies that it is a negative, when in ethical discourse it is a value of central importance to be weighed against autonomy - each having their role to play in differing proportions. He reduces complexity to a series of right / wrong dichotomies, and claims that a position that is morally defensible when adopted by a few becomes indefensible when adopted by by a larger number. He conflates distinct concepts (for example conscience with values with religious belief with adherence to a school of religious thought). He seems to believe that acting according to one’s conscience is the same as “making moral decisions on behalf of patients”. This is not a good example of reasoned argument! By his exclusive use of the termination of pregnancy as the medical paradigm, he exposes his starting point, but he doesn’t begin to discuss even this narrow area with balance. I would agree that a doctor who objects to abortion might choose to work in another area of medicine, but he fails to acknowledge that a woman who has a conscientious objection to abortion may have a right to treatment by a gynaecologist who does not perform the operation. He totally ignores other branches of medicine, such as general practice, geriatrics, psychiatry. Savulescu suggests that doctors should simply carry out instructions and that the full range of a doctor’s duties can be set out at medical school for the student to take or leave. I can only infer that he left clinical medicine at a relatively junior stage. Medicine must, by its nature, be an evolving profession, responding to an evolving world The doctor’s commitment must therefore be constantly renewed. It seems that, in Savulescu’s utopian vision of the world, medicine is neither an art, nor has it anything to do with a relationship between individuals; our scientific and moral knowledge is comprehensive and incontrovertible; last year’s scientific theories were held in good faith but were wrong, whilst this year’s are correct, and so faith doesn’t come into the equation. He seems to be advocating blind adherence to the current dominant values and he does not consider the risk of institutionalised abuse of medicine. He implies that though this happened in Hitler’s Germany and in the USSR, we have learned that lesson once and for all. He seems to have forgotten that the values of individual clinicians may be the only real safeguard against that horror. There is a place for the maverick and the iconoclast in ethical discourse and I welcome the provocation of this debate, but Savulescu has given us no clue, other than the outrageous nature of his argument, that he may be acting as “devil’s advocate”. He appears. therefore, to bring the weight of philosophy, Oxford University, and medical ethics with him. What worries me more than Savulescu’s views, therefore, is the fact that the BMJ has published them without qualification, disclaimer, or balancing argument. The danger of publishing this extreme view on its own and provoking uncontrolled debate is that the (hopefully) inevitable howl of protest may be read by some as the squealing of doctors as we are brought further to heel. I must conclude, therefore, by readily accepting that individual values can result in unethical practice. The risk, though, is best minimised by teamwork, continuous professional development, appraisal, and supervision. Personal integrity underpins the doctor-patient relationship. The values of the individual doctor are our safeguard against the institutionalised abuse of medicine. Competing interests: None declared |
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Tom Van der Linden, Patient KT19 9TA
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Dear Sir, Savulesco states: “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”. As I understand him, Savulesco is intolerant of doctors who hold values opposed to those that though they may be legal, are not acceptable to “religious” doctors, who accept the traditional view: first do no harm, and who do not wish to kill. Patients come from a variety of backgrounds and beliefs. They may have a problem with doctors who do not wish to support them when, for instance, they wish to continue a challenging pregnancy. I hear of patients who do not want the destructive treatment offered by doctors, but who, on declining such care, find themselves unsupported and pressured. They value a doctor who practices accordance to conscience, feeling that they receive better care, more suited to their needs. Conversely, they fear doctors who do not exercise their conscience. It would appear that doctors without religious beliefs impose their values too; perhaps even more extremely than those with religious views. Savulesco certainly seems willing to move towards extreme intolerance of those who hold views different from his own. I grew up in wartime Holland, occupied by Nazis. A desire to ensure that all doctors are willing to kill sends shivers up my spine. At my age, I am certain to become infirm – I deeply hope that I will be cared for by doctors willing to follow their conscience. Tom van der Linden Competing interests: None declared |
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David Lewis, General Practitioner The Tudor Surgery, Watford WD24 7PH
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Julian Savulescu has written a challenging opinion piece [ref 1] which will no doubt raise hackles in many quarters. I take issue with the casual dismissal of centuries of ethical thought by religious ethicists. Jewish ethics is couched in religious terms that may jar with secular thinking and some non-Jews. But central to Jewish practice and thought is the concept of free choice. A recent essay by the Chief Rabbi, Sir Jonathan Sacks last month [ref 2] alludes to this concept when discussing Pharaoh's 'hardening of his heart' to Moses' demand to let the Israelites leave Egypt - the Exodus. In particular, if Pharaoh had no free will in this matter, it was unjust to punish him (and the Egyptan nation)with the plagues. However, Pharaoh (and his people)are described has initially being obstinant - they chose not to let the Israelites leave. Pharaoh had a conscientious objection to letting the Israelite workforce leave. Within this story, Rabbi Sacks finds some important points which I believe contradict Savalescu's view concerning a doctor's duty to her patients. Rabbi Sacks writes: "Evil has two faces. The first - turned to the outside world - is what it does to its victim. The second - turned within - is what it does to its perpetrator. Evil traps the evildoer in its mesh. Slowly but surely he or she loses freedom and becomes not evil's master but its slave." From this, in my opinion, it follows that unless doctor's (and other public servants) actively object to morally objectionable instructions, the public servant will inevitably become evil. Rather than lambasting 'conscientious objectors' Savelescu may be wiser to turn his attention to the instructions from health service managers which doctors are encouraged to implement every day. I certainly believe it is evil to withold effective treatment from some people on grounds of cost when it is known the treatment is effective. I believe it is evil to deny healthcare to patients in the community because the worried well are encouraged to trot to the doctor within 48 hours. In Professor Savulescu model I have a duty to meet the wants of all my patients. This is wrong! However, I have a duty to meet the needs of all my patients and am struggling to do this because of the additional bureaucracy, for example 'Choose & Book' [ref 3]. He calls this paternalism but I call this common sense. Doctors who practice without a conscience would be dangerous - the infamous Harold Shipman may be such an (extreme) example. It is therefore imperative that doctors' professional bodies encourage 'concientious objection' when necessary for the sake of our patients. ReferencesCompeting interests: As a full time doctor I am faced with moral choices every day |
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Stuart J Fergusson, Medical Student (5th year) University of Glasgow. G12 8QQ.
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EDITOR – It is with breath-taking intemperance and a good deal of confused thinking that Savulescu sets out his opinions on conscientious objection: “to treat religious values differently from secular moral values is to discriminate unfairly against the secular.” [1] In essence, his argument is that ‘religion’ has no right to challenge the authority of ‘secular moral values.’ The case is made on the basis that a religious value is qualitatively distinct from a secular moral value and as such belongs merely in the personal domain. He seems oblivious to the reality that this assumption is merely an outworking of his own philosophical/religious framework. Surely secularism itself is an essentially religious phenomenon? The view that moral truths are primarily defined by the consensus of society is not a scientific deduction, but a philosophical opinion. Savulescu decisively fails to establish why his exclusively secular approach should have the right to determine a “reasonable conception of the patient's good.” In the absence of a compelling reason to bow to the conglomerate morals of secularism, medicine should continue to be practiced with an autonomous regard for personal conscience. [1] Savulescu J. Conscientious objection in medicine. BMJ 2006; 332: 294. Competing interests: None declared |
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James D Stevenson, Medical Officer/Instructor RAF Centre of Aviation Medicine
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The ethical logic discussed in Julian Savulescu’s article on “Conscientious objection in medicine” is flawed in important ways. Firstly, the contention that one should be aware of the commitments of the profession and “be prepared to undertake these or not become doctors” is stated as a fact, whereas it is Savulescu’s personal opinion. I became a doctor in 1973. There is no way in which I could be expected to anticipate the massive social and medical changes which have taken place since this time. Are we to expect that doctors are obligated to change their moral judgement to follow any path or eddy current societies or the governments may choose? I think not. I’m sorry, but I do not have to live with patients, or their relatives, or the courts, or the government; I have to live with myself. Nothing in the professional oath I took in 1973 bound me to follow every change and current in government policy or social whim over the last 30 years. Savulescu seems to want to have us believe that governments’ laws and social policy have the force of moral conviction. Regarding this point, Savulescu’s logic leads to the following: Military service in the defence of one’s country is an honourable form of public service. Those who take up the profession should likewise be aware that they should subjugate their personal moral judgement and do anything which the government and/or their commanders tell them to do. Regarding social, medical and moral policy, which government has got it right? Which country’s social and medical policies are we to follow? Those of Russia? Of South Africa? Of the United States? Or perhaps, those of the United Kingdom? Does this by chance suppose that the UK has exclusive rights regarding the proper judgement of medical and moral issues? This article seems to suggest so. On such opinions were the British Empire built. Competing interests: None declared |
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Peter KK Au-Yeung, Specialist Anaesthetist Hong Kong
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Savulescu placed Law first in his list of "Determinants of medical care" and argues that all doctors act as their Society tells them to via the laws it makes. This seem to be at variance with Principle IV of the Nuremberg Tribunal which stated that "The fact that a person acted pursuant to order of his Government or of a superior does not relieve him from responsibility under international law". That principle also recognized the importance of a person's moral choice. It thus seems that local laws are not the sole arbiter of what should happen in any one place, especially if such laws are unjust. His argument relating to abortion law is also contentious. Both the Abortion Act 1967 and the section of the Human Fertilisation and Embryology Act 1990 amending the former, which he quoted, seem to decriminalize abortion rather than legalize it. Section 1 of the Abortion Act 1967 stated that "a person shall not be guilty of an offence under the law relating to abortion ..." and Section 37(4) of the Human Fertilisation and Embryology Act 1990 likewise uses the words "No offence under the Infant Life (Preservation) Act 1929 shall be committed...". Perhaps some kindly lawyer reading these pages can enlighten me what difference, if any, exists between decriminalization and legalization. I am supposing there is a difference, otherwise why do the Laws not simply state something similar to "It shall be legal (or lawful)..." rather than using terms such as "not guilty" or "not committing offences". Competing interests: None declared |
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Edmund J Dunstan, Consultant Geriatrician Selly Oak Hospital B29 6JD
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Savalescu's rejection of conscientious objection is linked to a failure to understand it. He compares it with self-interest or views on policy, rather than anything higher, and seems to assume it is solely religious in origin - haven't atheists and humanists consciences too? To a doctor with, say, a conscientious objection to abortion or euthanasia, such acts are not in patients' interest, and therefore unethical. Conversely, the legalization of assisted suicide or, say, female foeticide, would not change ethics overnight. Imposing his determinants would undermine doctors as individually morally responsible agents. This could be a danger to our collective ethical sense in time, if our duties are seen as imposed from outside. He concludes that as public servants, doctors should act in the public interest: I always thought their first duty was to their patients. Competing interests: I am a Quaker |
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Adrian Blaj, SpR Psychiatry London
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I must confess I read Savulescu's interlude in disbelief, not once, not twice, but several times, from the beginning to the end, and viceversa. Firstly I thought he has an Oedipus complex vis-a-vis paternalism (read doctors). Then I thought he may share Eastern European roots and, perhaps, reads to much from Franz Kafka. Afterwards my thoughts jumped towards extrapolating his extraordinary theory to events which occurred during Ceausescu's regime when gynaecologists put their livelihoods (and own lives) at stake performing abortions (in desperate cases) according to their conscience, in clear defiance to the norms and legislation imposed by the communist system. And again, I thought: if the theory is correct, it should remain valid across cultures, countries, past, present and future...and I thought of USSR, China, Saddam... Then, I read the rapid responses and found a vociferous crowd of people pointing their fingers to the theorist. And again, I thought: this cannot be right, am I missing something here? I felt perturbed all day today until it just occurred to me that Savulescu is, after all, right: he talks about a *just and legal delivery of health services*, *true duty*, grave duty*, *legally permitted care*, in effect a very strong disclaimer which puts the whole issue in the form of the logical statement *x will happen if conditions y and z are fulfiled*. Or, as it is nearly impossible to define the concepts highlighted above, Savulescu absolves himself of any improper thinking as he places himself in the land of utopia... Sorry, I am not going to waste my time defending the Santa Claus concept. Competing interests: None declared |
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Paul D Kelly, GP principal Highfield Surgery, Blackpool FY4 2LD
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In seeking to suggest that in a publicly funded health service medical practitioners should disassociate values formed in their conscience from influencing their practice Savulescu seems to be suggesting that medical practice must be confined to a less than fully human engagement. Holding values, however formed, is integral to being human. Human medicine is all about making and enacting decisions in partnership with our patients. Almost always there is an ethical dimension to those decisions. I find it inconceivable that a doctor or his patient would find it acceptable to base decisions about what is the right thing to do on an ethical system that is totally utilitarian, state determined, devoid of personal values - values that in every other sphere of human life are integral to decision making. To act thus is less than fully human, a denial of who we are. Amongst the many other concerns prompted by this article is one about scientific rigour. It is published in the section of the journal entitled “analysis”, yet what is presented as fact (e.g. Summary Point: “Conscientious objectors who compromise the care of their patients must be disciplined”) is no more than opinion. The issues raised are indeed important ones to explore, but it is surely fallacious in a scientific journal to reach dogmatic conclusions that show little sign of arising from a reproducible and appropriate range of ethical analysis. With what scientific method has evidence been included or excluded? What really is the evidence that justifies the statement that values and conscience should not influence the care an individual doctor offers to his patient? Perhaps the real final analysis should be if Dr Savulescu were to find himself a victim of an avian flu epidemic. Would he honestly rather be tended by a doctor whose utilitarian law-driven ethics may mean it was better he did not risk his own life, or by one who’s values of self- sacrifice override the utilitarian ethic and who might just therefore be willing to risk all in order to care for one man? It could be part of that doctor’s wholesomeness that he may in conscience also be unable to undertake all care that is legal, but I know which kind of doctor I want to be able to choose when the chips are down for me. Competing interests: None declared |
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Frank H Bloomfield, Senior Lecturer in Neonatology Liggins Institute, University of Auckland, Private Bag 92019, Auckland, New Zealand
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Sir, Professor Savulescu seems confused about who moral judgements are made on behalf of when a doctor, in conscience, cannot provide a treatment permitted by law. 1 In declining to be involved in certain treatments because of moral beliefs, the doctor is making a moral judgement for him / herself, not the patient. Professor Savulescu’s constraints to increase equity in health care provision would preclude large groups of society from becoming doctors. They would also lead to a homogenous mass of spineless, morally turpitudinous automatons at the beck and call of their political masters, precisely the opposite of what was valued by the House of Lords Select Committee on Medical Ethics, which stated that “health care professionals are by no means a homogeneous group: they bring to their practice a variety of philosophical and religious views which make it unlikely that any single ethos is likely to dominate accepted practice in a way which might prejudice the interests of an individual patient”.2 Not long after Shakespeare wrote Richard III, George Chapman was attributed with writing “I am ashamed the law is such as ass” (Revenge for Honour, III, ii). Augustine of Hippo was a little more philosophical, but said essentially the same thing when he stated that “a law that is not just, seems to be no law at all” (de libero arbitrio, i, 5). Professor Savulescu would have all doctors unquestioningly following their duty to provide medical treatments allowed by law, however unjust that law may be. On the contrary, the duty to a firmly held moral belief is higher than the duty to the law. References 1. Savulescu J. Conscientous objection in medicine. British Medical Journal 2006;332:294-297. 2. Report of the House of Lords Select Committee on Medical Ethics. London: Her Majesty's Stationary Office, 1994. Competing interests: None declared |
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John B Zachary, Consultant Radiologist Barnsley Hospital, Barnsley, S75 2EP
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Editor - Julian Savulescu’s comment at the end of his article, ‘Conscientious objection in medicine’, that ‘value-driven medicine’ leads to ‘idiosyncratic, bigoted, discriminatory medicine’ suggests that he is intolerant with people whose opinion he does not share. He is, of course, welcome to ‘propose’ his opinion, as are we all. But then he goes on to suggest that his opinion be ‘imposed’, when he talks about ‘certain constraints [on doctors with a different opinion] are necessary…’ and gives a list of five. He appears to equate ‘morality’ with ‘legality’. But a law is only a just law when it is moral. Morality is based on the values derived from the nature of the human person. There is much muddled thinking about ‘conscience’, ‘freedom of conscience’ and ‘autonomy’. The ‘respect’ for another’s conscience should never require the abandoning of one’s own. Conscientious objection to the taking of human life, rooted in a rational understanding of the nature of the human person, may not be sacrificed to the mistaken consciences of those who would unjustly take life. Competing interests: None declared |
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Surendra I Deo, Medical Advisor St Ann's Hospital N15
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If Savalescus aim was to be provocative he has succeeded by writing an aricle that is flawed in its reasoning. Most would agree that the importance of respect for patient autonomy is a cornerstone principle in medical ethics. However autonomy is never absolute and depends on other factors. For instance one would not pursue ones own goals at the expense of harming others. Doctors are not mere technicians and medicine is not a technological science. The very nature of medical decision making involves subjective judgements. These may be rightly coloured by the doctor's own moral view - after all if respect for autonomy is important it should be applied equally. A better argument would be that doctors should have no leeway in ensuring that the patient is properly informed and so can consider all options and come to a best interests decision. It might be that the doctor would not personally comply with all requests e.g. for abortion or certain forms of contraception but the doctor would have to guide the patient to another doctor or facility that would accede to the patients request. Competing interests: None declared |
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David J Shepherd, GP Saffron Group Practice LE2 6UL
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Savulescu’s argument that conscientious objection should be outlawed in medicine is deeply flawed. It reveals a lack of understanding of such objection, its function in society and the motives of those who express it. He states that ‘doctors cannot make moral judgements on behalf of patients’. The fact is that they can, they do and both patients and society expect it and always have done. The key problem comes in his statement that conscientious objection is wrong in the context of what he calls a ‘true’ duty. He assumes that what is legal entirely constitutes a ‘true’ duty. No one else really believes this identification is valid. Religious or secular, no one really accepts that the law fully embodies all that which is right and proper. The point of conscientious objection is that it facilitates legitimate democratic questioning of the law and is one of the mechanisms society uses to protect itself against bad law. Suppressing it is dangerous. The history of the twentieth century should have taught us that. He constructs a series of fallacious arguments against it. He demonstrates inconsistency between different doctors in their response to a controversial termination request. This is hardly surprising when the law explicitly asks doctors to make a value judgement about the relative benefits to mother and child. It is unclear what he means by ‘facilitate’ the abortion. If he means ‘make a referral for assessment of the decision’ then the doctors who declined were clearly in breach of current guidelines and were not legitimately exercising a conscientious objection. If he means ‘sign a form legally allowing the procedure to go ahead’, then those doctors were acting according to the law as it stands by acting according to their judgement. The problem is not conscientious objection per se but the way the law is enacted. An immediate right to abortion does not exist in the UK and if it depends on judgements of individual doctors variation is hardly surprising. He then creates a series of straw men to knock down by implying that those in favour of conscientious objection would want its free and unfettered reign. The law recognises that this is inappropriate by making provision for conscientious objection in certain situations but not others. No one is arguing for the right not to treat over 70 year olds or people with bird flu on conscientious grounds. Not many would argue that it is appropriate to allow conscientious objection to internal examination, given that it is an essential part of many doctors’ jobs. His real anti-religious stance then leaks out in the incoherent claim that we should not allow ‘moral values... to corrupt the delivery of the just... delivery of health services’. My understanding was that moral values underpin justice! Values are values; you can’t split them artificially into secular and religious in any rigorous way. Conscientious objection seeks to inform the debate about which values should underlie medical practice. No one is arguing that religious grounds for conscientious objection should be treated differently from secular. There are plenty of doctors who object to abortion who don’t have any particular religious conviction. ‘When conscientious objection compromises… the equitable delivery of a service’, that is precisely the point to ask the question whether that service should be legal or really is in the interests of patients. He misunderstands conscientious objectors who act not merely out of self- interest to avoid moral taint but out of a heartfelt concern that the thing they object to is harming the patient and society as a whole. In allowing conscientious objection society recognises this potential positive contribution of its citizens. Savulescu creates a false spilt between the function of values and conscience in the public & private spheres. It is precisely because the delivery of the health service and creation of health policy cannot be separated that they have to be active in both areas. Momentary consideration of the debate about Herceptin shows that the two are inextricably entwined. The place of conscientious objection should be enshrined in law where it is recognised that there is a widely accepted debate about what people believe should be legal. Competing interests: None declared |
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Anne M Williams, GP 140 Thurston Rd G52 2AZ
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It is not only those with a religion who are against abortion. As a medical student I was invited, by the consultant to see the products extracted from an abortion. The little macerated rib cage remains imprinted on my memory. Multi-culturism and freedom does not mean searching for uniformity, but toleration of differing views. The author seems to want to deprive doctors of any freedom and autonomy as if they were not also a citizens with human rights. The main reason for a clinical decision, in favour of an intervention, is that it is of proven clinical benefit. As far as the mother is concerned, this is very much in question, esp. in the light of recent reports. As far as the other patient, i.e., the younger one in the womb, which only some clinicians seem capable of considering, death is of no benefit and a denial of a whole life-time of choices! He rather shoots his argument in the foot by stating that ‘termination of pregnancy should be available for a normal 13 week pregnancy if the woman wants it for career reasons.’ His argument about the law is flawed, abortion is still against the law in the UK, the Abortion Act only decriminalised it in certain situations. There is however, contrary to his implication, no provision for terminations to allow for career choices. If a woman’s mental health were to suffer so much, as to allow for a termination, one would question as to whether the woman would be fit to carry on with her career. One also wonders about her future mental health, when she has achieved her career aspirations and she will be put on the IVF waiting list. Competing interests: None declared |
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shimon M. Glick, professor emeritus Ben Gurion University ,Beer Sheva ,Israel, 84105
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Several brief questions for Professor Savulescu- 1.How should the physician deal with laws that change dramatically overnight? I remember that until June 30, 1970 abortion was illegal in New York City. One week later our hospital was investigated because we had not met our quota for abortions for that week! Laws change very quickly, as happened in the Northern Province of Australia with active euthanasia. Is the physician to blow with every passing wind and every legislative whim? 2.In the great State of Texas, where capital punishment is quite common shall every physician be required to offer his/her services?Here the objections have not necessarily come from the fundamentalist religious physicians,who may support capital punishment, but more likely from the liberal and often atheistic group-to say nothing about the World Medical Association. 3. What is one to do in countries where torture is legal and physicans are asked to participate as loyal citizens? Again are we to leave our consciences behind? 4. What are physicians who took seriously some form of the physician's oath to do if they are asked to perform a "legal" act which violates not only their conscience but also the oath they took? I do not think, as suggested, that an opposing viewpoint by another spokesman should necessarily be published. Rather I call upon Prof.Savulescu to reconsider and retract his provocative, and, I believe, unfortunate position which has great potential for harm to young medical students and physicians, who may take him too seriously. Competing interests: None declared |
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Alasdair H B Fyfe, Consultant Paediatric Surgeon The Royal Hospital for Sick Children,Yorkhill, Glasgow G3 8SJ
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Dear Sir, Julian Savulescu states emphatically that "values are important parts of our lives....but they should not influence the care an individual doctor offers to his or her patient," and "when the duty is a true duty, conscientious objection is wrong and immoral." These statements, on a superficial reading, seem sensible and fair. However, at closer examination of his article I would wholeheartedly disagree with its message, which I believe is a very dangerous one. As examples of possible dilemmas we are given two radically different ones: 1. Termination of pregnancy for serious handicap or for social reasons; and 2. An infectious disease specialist refusing to treat patients with bird flu because "she valued her own life more than her duty to treat her patients." One cannot place these two dilemmas in the same category, for the principles and morals concerned are totally different. Savulescu says "the primary goal of a health service is to protect the health of its recipients." Is this really so for the foetus who is the "recipient" of this termination of its life? An obstetrician who values the care of his patients more than his chances of promotion, reputation, or popularity-may well come to the conclusion that the best care he can give his patient is to preserve life, not destroy it. Surely, to "compell" that obstetrician to act against his conscience in this way, is dangerous and immoral. It may not be too long before assisted suicide and euthanasia are on our statute books; are we going to force doctors to comply with what goes totally against their ethical and moral code? This is surely not acceptable. As for the infectious diseases consultant who refuses to treat her patients because of fear for her own life. Of course, it is expected that doctors will act in the patients' interests whenever possible, and even at great cost...and that should be every doctor's stance. However, we from our detatched theoretical position may find it easy to criticise and condemn her "lack of care." But...which one of us carries the right to tell another that they must be ready to face any risk to themselves, for the sake of another. Every doctor has a "duty to care" and should fulfil his obligations to improve the health of his patients. These issues are crisp and clear in many illnesses and situations. For me to neglect a child who has acute appendicitis because it is late at night and I am tired, is clearly a breach of contract and negligence. But we cannot extrapolate that argument to the many grey areas which Savulescu highlights in his article. We must protect the individual freedom and rights of doctors who wish to refrain from procedures and practices which are not necessarily preserving health and life. It is a dangerous thing for society to remove the freedom to act in accordance with an individual's conscience. I do fervently hope that Savulescu's message is rejected by the overwhelming majority of doctors. Competing interests: None declared |
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Stephen Bamber, GP Principal Tharston, Norfolk NR15 2QU
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Savulescu's belief that a doctor's conscience has little place in the delivery of modern medical care has stimulated a lively collection of responses. The words and phraseology used throughout his essay have the authentic ring of totalitarian regimes, and reflect a somewhat chilling rigidity which is alien to the majority of physicians past and present. His experience of medical work must differ markedly from that of most doctors and most humans. For him the system is always more important than the individual, whether patient or doctor. This seems the antithesis of the view of doctors. He seems unaware that what can be done in any circumstance is not necessarily what should be done, either because it is legal, or is what the patient (or doctor) wants. Individual choice is not a luxury confined to patients but forms an essential part of the human condition. It is not confined to democracies, although its exercise in harsher societies can bring a heavy price for patient or doctor. Conscience and morality too are the essence of being human and of humanity. The mission of Savulescu's institution is stated as "research, teaching and contributing to public debate on the most important ethical issues of today". If learning is added to its agenda it will find that his analysis is unlikely to be shared widely. Competing interests: None declared |
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Ian McD Jessiman, Retired GP 17 Grange Drive, Chislehurst,BR7 5ES
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‘Conscientious objection in medicine’ EDITOR- I find it hard to follow Julian Savulescu’s argument (BMJ 2006; 332: 294-7). The basic issue from an ethical point of view would seem to lie in a ‘clash of autonomies’. Where two people’s rights of self-determination or ‘autonomies’ conflict, then neither one can have the right of precedence over the other. It is a question of how most ethically, most fairly, a balance is to be achieved. For anyone to exercise autonomy (or free will) they must, clearly, be completely free to make up their own minds. But most people also have an awareness of mutual obligation to others, which founds an obligation to respect the law – whether human or (for believers) divine. It is this aspect of our individuality (or autonomy) which leads us to obey the law. It is what is commonly known as conscience. If this is to be undermined by society, or by the law, or by an alleged appeal to the autonomy of others the whole voluntary basis for a united harmonious society is undermined. Law and order become meaningless and unmaintainable. The case of a doctor refusing to withdraw or withhold painful or futile treatment (his quotation on page 295) is another example of a clash of autonomies. Here the right (of the individual, the patient) to self determination, allows the ethical refusal of interventions or treatments to himself. This in no way infringes the self-determination or autonomy of others. The doctor has no right (by virtue of his/her autonomy) to inflict treatment on the patient. However, the exercise of autonomy does not go further and entitle the patient to demand that something (positive) should be done to him or her by another (though if that other is freely willing they may choose to do so). Put another way, a patient cannot demand that treatment should be given which is either contrary to the doctor’s clinical judgment or his/her conscience. Logically Mr Savulescu’s argument would mean that if a government were to decide that the death penalty should be restored and that it was ‘kinder’ to do this by lethal injection, then all doctors would be required to adopt this obligation and could be required to provide an execution service. What would the profession, or indeed the public, think of that? Certainly, Mr Savulescu, I did not become a doctor in order to end life. Ian Jessiman Retired GP. Chislehurst, Kent BR7 5ES Competing interests: None declared |
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Elizabeth Murray, GP and DH Career Scientist in Primary Care Department of Primary Care and Population Sciences, University College London, N19 5LW, Paquita de Zulueta
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The Editor We question Savulescu's statement that a specialist valuing her own life more than her duty to her patients during a bird flu epidemic would be demonstrating values “incompatible with being a doctor”1. In our practice, we have been considering the complex ethical problems and conflicting duties that will arise in the event of a pandemic and would welcome a wider debate on this subject. By February 6 2006, the World Health Organisation had received reports of 165 confirmed cases of avian influenza in humans, of which 88 have died (mortality rate 53%) (www.who.int/csr/disease/avian_influenza, accessed 7.2.06). The UK DH influenza pandemic contingency plan estimates an attack rate of 25%, and a case fatality rate of 0.37%2. Health care staff are likely to be particularly at risk with estimated sickness absence rates double the rate of the general population2. But if the DH estimates are seriously over-optimistic, and the case fatality rate remains high, at 25 – 50%, treating infected patients arguably would represent 'a grave risk to a doctor's physical welfare' 3. Furthermore, a substantial mortality rate amongst trained health care professionals would remove a vital resource for treating those in need, and damage the future viability of the health service. Horton makes a strong case for clinicians adopting a virtue based framework and retaining professionalism in their practice3. But the exercise of virtue requires integrating Aristotle's phronesis - practical wisdom or prudence - with compassion and altruism as endorsed by the Royal College of Physicians4. In this context, to recklessly treat a highly contagious individual without taking adequate precautions would be imprudent and irresponsible. Equity and fairness requires a professional to judiciously balance the needs of one patient with the needs of others, including those of his or her own family. (1)Savulescu J. Conscientious objection in medicine. BMJ 2006; 332:294-297. (2)Department of Health. UK Health Departments' Influenza Pandemic Contingency Plan (October 2005 Editition). 1-174. 2005. London, Department of Health. (3)Horton R. Medicine: the prosperity of virtue. Lancet 2005; 366(9502):1985-1987. (4)Royal College of Physicians Working Party. Doctors in society. Medical professionalism in a changing world. 1-51. 2005. London, Royal College of Physicians. Elizabeth Murray GP Principal and DH Career Scientist in Primary Care, UCL. elizabeth.murray@pcps.ucl.ac.uk Paquita de Zulueta. GP and Honorary Senior Clinical Lecturer, Imperial College. Competing interests: None declared |
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Amitava Banerjee, Senior House Officer, General Medicine John Radcliffe Hospital, Oxford OX3 9DY
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Like fellow responders, I read Savulescu’s article with utter disbelief. Thankfully, the rapid responses have covered many of the issues which Savulescu’s superficial, oversimplified and inadequate analysis of ethical issues failed to tackle. “The door to "value-driven medicine" is a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine.” I would ask Savulescu to accept that “value-driven” medicine (a nonsensical term in itself) is much more preferable than current scenarios of “target-driven medicine” or “politically-driven medicine”. Here, doctors are to treat patients based on artificial, rigid goals such “A&E department 4-hour waiting times” or “operating waiting list priorities” rather than clinical priority and individual patient needs (or desires). The one thing we agree upon is: “The primary goal of a health service is to protect the health of its recipients.” However, are such targets or political priorities really primarily to protect the health of those recipients? “Public servants must act in the public interest, not their own.” I fully agree but doctors are not the only people affecting the public health interests. Other health professionals, hospital managers, ethicists and politicians have the same responsibilities as public servants. The irony is that these other players do not seem to have the same accountability as doctors and yet want to dictate the modus operandum. Many aspects of this article are symptomatic of the way in which UK clinical practice is being increasingly influenced by people who clearly have little concept of what being a doctor and seeing patients entails in real life. The discussions of bird flu epidemics, and treatment of patients based on age show a lack of understanding of the clinical decision-making process. Ethicists, economists, politicians, all with their own ideas of how a healthcare system should be run, are trying to gradually turn clinical medicine into a set of rigid protocols and flow diagrams which can be universally automaton-driven. It seems that the only profession not contributing to the debate enough is the medical profession. Anybody who is at medical school or has looked at public health in any capacity knows that doctor-patient interactions are not that kind of science. The fact is that individual human beings differ in many crucial characteristics, both patients and doctors. Patients may differ in their capabilities, their values, their desires and their needs to name a few. Doctors vary in their speciality, their individual interaction with patients and their intrinsic values. This means that although doctor- patient encounters and decisions may be similar, they will never be exactly the same. For example, a doctor might refuse to give treatment for the benefit of the patient: if a patient is personally known to the doctor, he/she may choose to allow a colleague to take over the care to avoid embarrassment for the patient. Some patients want and need the doctor to make a decision because they lack the capability or cannot face the decision. This is not a generalisable “a+b=c” situation. Moreover, there is no shame in people sometimes wanting a “paternalistic” opinion from the doctor. “Doctors have always given a special place to their own values in the delivery of health care. They have always had greater knowledge of the effects of medical treatment, and this fostered a belief that they should decide which treatments are appropriate for patients— that is, paternalism. Their values crept into clinical decisions.” When a woman goes to a consultant gynaecologist, she is seeking the help of a specialist who has an expert knowledge in a particular field. We seek expert advice in many spheres of our lives where our own knowledge is lacking. Is my financial advisor being “paternalistic” when he advises me on the right course of action financially for me? “These examples show that people have to take on certain duties in order to become a doctor.” No they do not. These examples show that Savelescu wants to take away the right of medical students and doctors to question. When this right to question is removed, the standard of health care will be compromised as doctors become programmed machines unable to “think outside the box”. “Private elective medicine is different from public medicine. Doctors have more liberty to offer the service of their choice, based on their values.” A doctor’s duties do not change just because a patient is paying for the operation or treatment. In health care ethics, Savelscu should know that with “duties” come “rights” and “responsibilities”, for both patients and doctors. As a doctor, I have many “duties” towards my patients, but I have a “responsibility” to question my practice every day and to act as my conscience allows. Competing interests: None declared |
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Laurence B McCullough, Professor of Medicine and Medical Ethics Baylor College of Medicine, Center for Medical Ethics and Health Policy, One Baylor Plaza, Houston,, Frank A Chervenak
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To the Editor: Julian Savulescu’s account of conscientious objection in medicine1 is a bold statement that requires all obstetricians to perform abortions, regardless of any moral convictions that they may have to contrary. Unfortunately, he violates the standards of argument-based ethics.2,3 Savulescu claims that professional commitments, “what should be provided to patients,” are based on law and the just management of resources. To say the least, this is a contentious claim in contemporary medical ethics and therefore must to be argued. Having claimed law and responsible resource management as the ethically authoritative sources of doctor’s professional obligations, Savulescu is methodologically obligated4 to provide an account of relevant law and an ethical justification for why and how it should guide doctors’ clinical judgment, decision making, and behavior. He is also methodologically obligated3 to provide a rigorous ethical analysis of the very slippery concept of “inefficiency” in the management of resources to show why it is always, as he puts it, an “inequity” that is “unjustifiable.” He does neither. In all cases of conflict with the principles of individual conscience of “would-be conscientious objectors,” the professional commitments of doctors, Savulescu concludes, should control clinical judgment, decision making, and behavior. The intellectual and moral authority of this sweeping conclusion is a function of the argument given to explain and justify the “commitments of the profession.” No such argument is provided.. Savulescu’s failure to meet the standards of argument-based ethics means that the five “constraints” that are “necessary to ensure the legal, equitable, and efficient delivery of health care” spring fully armored from the head of Savulescu. Readers timorous enough to expect argument should, instead, genuflect and accept these constraints, simply on Savulescu’s unargued, albeit vigorous and witty, assertion of them. After all, initium sapientiae timor domini. Thus is medical ethics reduced to saying it is so. Frank A. Chervenak, M.D.
Laurence B. McCullough, Ph.D.
References 1. Savulescu J. Conscientious objection in medicine. BMJ 2006;332:294-7. 2. McCullough LB, Coverdale JH, Chervenak FA. Argument-based medical ethics: a formal tool for critically appraising the normative medical ethics literature. Am J Obstet Gynecol 2004;191:1097-102. 3. DeGrazia D, Beauchamp TL. Philosophy. In Sugarman J, Sulmasy DP, eds. The Methods of Medical Ethics. Washington, DC: Georgetown University Press, 2001:31-46. 4. Hodge JG, Jr., Gostin LO. Legal methods. In Sugarman J, Sulmasy DP, eds. The Methods of Medical Ethics. Washington, DC: Georgetown University Press, 2001:88-103. Competing interests: None declared |
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Ronald J Clearkin, Consultant Physician Kettering General Hospital, NN16 8UZ
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Dear Sir Savulescu's respect for the law appears to know no bounds. While in no way denying the respect rightly accorded to the law, it is naive at best to believe as Stavulescu proposes, that every law is necessarily good and beneficent. Nevertheless he uses this argument to override and absolutely deny any moral autonomy to a doctor. That Stavulescu can maintain such a viewpoint in the face of all rational and historical testimony to the contrary, requires either an extraordinary innocence of the real world, or more likely, an intense personal faith in a utopian future. While this is ironic given Stavulescu's clear antipathy to religion, it is also deeply disturbing, entailing as it does a total disregard for the calamitous 20th century experience of medicine practiced under similarly utopian, totalitarian regimes. To support his argument to abolish a doctor's moral autonomy, Stavulescu turns to Shakespeare in an attempt to smear those who might exercise a principled or conscientious objection as cowards. Additionally he would also strip them of their right to medical employment. However, in quoting Shakespeare (the quote is in fact from Richard III V vi 39)in order to abuse conscience, Stavulescu appears to overlook the fact that Richard is not only a murderer, but "subtle false and treacherous" (Richard III I i 37). An interesting choice of medical role model. Yours faithfully Ronald Clearkin 1. Savulescu J. Conscientious objection in medicine. BMJ 2006; 332:294-297. Competing interests: None declared |
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Adrian K Midgley, GP Exeter, EX1 2QS
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I'm surprised as many as 40% were inclined to "facilitate" an illegal act. To draw a conclusion from that, based n it being a poor show that so few would act for a patient's rights is an incorrect analysis emitting a grinding as of an axe. The law is set by the people, and circumscribes most of our actions. The people set this law in this case, and may reset it in due course, and career grounds do not fulfill the requirements of that particular Act. Laws permit us to do things, they sometimes compel, but a situation where everything that is not forbidden is compulsory is morally bankrupt State, and likely to be bankrupt in other ways soon afterward. Competing interests: I'm a doctor |
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Vaughan P Smith, General Practitioner Taunton, Somerset TA2 7SZ
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Dear Editor Since visiting Auschwitz, I have grappled with the question of how I, personally, would have behaved as a doctor in Nazi Germany or Stalinist Russia. I hope I would have had the moral courage to refuse to participate in the various perversions of Medicine that these regimes demanded - for example , respectively, eugenic "research" and psychiatric "treatment" of dissidents (see Ref.1). I hope, but not being a very courageous person, I'm not at all sure. My chances of behaving honourably would have been greatest if I had felt part of an independent medical profession with allegiance to something higher and more enduring than the regime of the day. They would have been least if Savulescu's opinions had prevailed (which, I suppose, they did). The most charitable interpretation of Savulescu's article was that he wanted to criticise doctors who obstructed women's requests for abortion. If so, he could have made an interesting case on ethical grounds. But by widening his argument, first to the usual suspects of Christians and Americans, and then to anyone who dissents from the current State ideology, he destroyed it. A happy but unintended consequence. Savulescu is entitled to his opinions, but they shouldn't have been presented as "received wisdom". Presumably you printed his piece because it is radical and challenging. That's OK, but there are at least 100,000 practising doctors in this country and although we are generally intelligent caring and skilful, many of us are surprisingly sensitive. We need to be supported as well as challenged. Perhaps you could print some encouraging articles from time to time? After 30 years of reading the BMJ, Savalescu's article was the first one to make me feel physically sick. Yours faithfully Dr Vaughan Smith (Reference: Nyiszli, M: "I was Doctor Mengele's Assistant", Frap- Books, Krakow, 2001. ISBN 83-906992-7-3.) Competing interests: None declared |
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Rosamond Rhodes, Professor, Medical Education Mount Sinai School of Medicine (New York 10471)
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To understand the social role of medicine and its ethics, it is important to recognize that the medical profession is a social artifact created by giving control over a set of knowledge, skills, powers and privileges exclusively to a select few who are entrusted to provide their services in response to the community’s needs and to use their distinctive tools for the good of patients and society. Although a good deal of medicine involves preventing or healing disease and or restoring function, defining medicine narrowly in those terms leaves out numerous medical roles. For example, we call upon medicine for the provision of prenatal care and birth control, even when no one is ill. We call upon medicine to ameliorate a dying patient’s suffering, even when the disease cannot be healed nor function restored. Medicine is very much like other professions in this respect. Consider that firemen are called to rescue cats and children from tall trees and policemen are called to subdue escaped tigers even when no fire or law enforcement issues are involved. They have the wherewithal, so they get the job. Similarly, the special knowledge, powers and privileges of medicine explain why assisted reproduction as well as birth control, pain management, and cosmetic surgery are included within the domain of medicine. This account of the ethics of medicine brings a frequently overlooked issue to the floor, namely the place of personal morality or individual conscience in the practice of medicine. Again, the problem is not unique to the medical profession. In the military, soldiers owe obedience to the chain of command. Those in the military are not free to make their own judgements about which military actions are justified and how much force is appropriate. Instead, unless an order clearly violates military policy, soldiers are obliged to follow the orders of higher ranking officers, who, in turn, must follow the direction of their political authorities. Similarly, lawyers and judges are not free to make decisions based on their own values and private conscience. They are committed to following the rule of law even when their personal values dictate a different conclusion. Whereas the fact that professional responsibility overrides personal values is well accepted in other fields, those who write about the ethics of medicine typically ignore this element in their discussions or champion personal conscience over professional responsibility without explaining how they reach such a conclusion. (E.g., Pellegrino 1987) Any account of the ethics of medicine based on fiduciary responsibility and trust, leads, however, to the opposite conclusion, one that is consistent with Julian Savulescu’s stand in his paper “Concientious objection in medicine.” Doctors are primarily trusted by patients because of their role. Patients and society expect doctors to act in accordance with the “Standard of Care” which includes both adherence to the technical requirements dictated by evidence and clinical experience and the long standing ethical precepts of the profession, such as the duty to provide care, confidentiality, and non-judgmental regard. Patients and society rely upon physicians to meet that shared standard in all that they do. In other words, a patient who arrives in an Emergency Department does not expect Catholic medicine from a Catholic physician, Jehovah’s Witness medicine from a Jehovah’s Witness physician, self-centered medicine from an egoist physician, or the laying on of hands from a physician who happens to believe in their power. Patients reasonably expect good medicine that meets the patient’s need in accordance with the “Standard of Care” from every physician. This means that medical practice is not a matter of private judgment. Rather, medical decisions should be the ones that any competent physician facing a comparable clinical situation would endorse as a matter of professional judgment. This means that any physician who took the commitments of the profession seriously should be willing to provide the same treatment for the patient. Just as disagreements over treatment decisions have to be resolved by turning to the available evidence and the “Standard of Care,” conflicts between principles of medical ethics that arise in individual cases have to be resolved in terms of principle-related reasons that other medical professionals would also find compelling. Deviations from the ethical “Standard of Care" have to be justified to peers in terms of principles of medical ethics or by special considerations about the physician’s skills, the patient’s values, or the patient’s anatomy that colleagues from the profession would endorse as relevant reasons for a departure given the particular circumstances. In other words, we expect physicians to consult the clinical and the ethical “Standards of Care,” rather than their own heart of hearts in making medical decisions. Although this conclusion seems obvious when the focus is on the technical features of medicine, the point needs to be made explicit, as Savulescu does, with respect to the ethical features of medical care. Individual physicians are not entitled to make individual, personal judgments about the dangerousness of treating HIV positive patients or responding to a disaster. When it comes to providing treatment for patients who are HIV positive, each individual physician must provide treatment because, according to the judgment of the profession, the means for protection are effective and the risk of infection is not significant enough to defeat the professional duty to provide treatment. During a disaster, unless expert medical judgment determines that a situation is too dangerous for anyone to approach, physicians are required to assume the risk and provide needed medical attention. In other words, personal priorities and personal assessment of risk have no place in the response of the medical professional. Individuals who have committed themselves to uphold the professional responsibilities of medicine, have, in essence, endorsed the ethical “Standard of Care,” rather than personal conscience as their principles for making medical decisions. Consider some additional instances in which an individual might want to refuse to provide medical care is a matter of personal judgment. Is it ethically acceptable for a doctor to refuse to provide life preserving surgery to a Jehovah’s Witness who refuses to accept blood transfusion because of the desire to avoid the personal pain of losing a patient who could have been saved? Is it morally acceptable to pass on the job to some willing but less experienced surgeon who is more likely to lose the patient during the course of the procedure? Is personal conscience a sufficient justification for refusing to provide pain medication to a suffering patient? Does personal discomfort or discretion justify refusing to disconnect the ventilator of a competent dying patient who has decided that he wants it no more? When a physician chooses to act on his own values instead of honoring his patient’s, the physician puts his own interest in ease of conscience above the fiduciary responsibility that is the defining feature of the ethics of medicine. The doctor who chooses to avoid personal psychic distress, declares his willingness to impose burdens of time, inconvenience, financial costs, and rebuke on his patients so that he might feel pure. Someone who places his own interests above his patients’ departs from medicine’s standard of promoting the patient’s good and violates a crucial tenet of medical ethics that every physician is duty bound to observe. I understand Julian Savulescu to hold that becoming a doctor is at the same time granting professional judgment authority over personal preference. Someone who is not prepared to make that commitment should choose another livelihood in which such conflicts will not arise. We recognize that those who would love to wear a uniform adorned with medals, drive a tank, and march in parades, cannot be soldiers if they also want to abide by conscience and their conscience tells them that killing is wrong. Similarly, conscientious objectors who take seriously both personal values and the obligations of medicine should be willing to pay the price of their commitments rather than asking other colleagues and patients to bear the weight of their convictions. REFERENCES Pellegrino, E.A. Toward a Reconstruction of Medical Morality. The Journal of Medical Humanities 1987, 8(1). Rhodes R. The Ethical Standard of Care. American Journal of Bioethics, 2006 (In Press). Savulescu, J. Conscientious objection in medicine. BMJ 332: 294-297. Competing interests: None declared |
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Alexander C. Tsai, Medical student Case Western Reserve University School of Medicine, Cleveland, Ohio USA 44106-2459
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Editor -- One would expect a commentary on an issue of much contentiousness to be carefully considered. However, Savulescu's analysis and comment on conscientious objection in medicine (1) fails to meet this standard. First, Savulescu's essay would benefit from a more carefully drawn distinction between conscientious objectors in the public vs. private sector. He motivates his essay by discussing situations involving certain aspects of conscientious objection that have arisen in U.S. private sector medicine in recent years (p.295). However, Savulescu's central argument against conscientious objection in medicine has to do with deteriorations in "quality, efficiency or equitable delivery" (p.296) of care that may or may not occur when conscientious objectors are agents of "public medicine" (p.295, emphasis mine). To begin such an essay by appealing to developments in the U.S. private sector would seem to be extraneous to his central argument. At the very least, one might presume that the legal uncertainties as well as degree of preoccupation with quality, efficiency, and equity might be different for a physician in the UK who works for the NHS vs. a physician in the U.S. who is a partner in a private group practice (or, for that matter, a pharmacist in the U.S. who works in a private retail pharmacy). Indeed, towards the end of his essay (p.296), Savulescu slips in a three-sentence paragraph on the differences between private and public medicine. This distinction seems to be crucial for Savulescu, as he concludes, "Public servants must act in the public interest, not their own" (p.297). However, by the time he makes the public-private distinction clear -- at the end of the essay -- the borders between the two have already been muddled. Given that this caveat is relevant to the clarification of his central argument against conscientious objection in medicine, one would have expected Savulescu to identify the distinction earlier and to treat it with more precision. Second, Savulescu's argument about professional ethics appears to hinge on empirical estimates. He writes, "When a doctor's values can be accommodated without compromising the quality and efficiency of public medicine they should, of course, be accommodated. If many doctors are prepared to perform a procedure and known to be so, there is an argument for allowing a few to object out" (p.296). Given that Savulescu is attempting to construct an ethical argument against conscientious objection in medicine, his reasoning seems suspect. On the one hand, given the current balance of supply and demand for certain services (e.g., abortion), he states that conscientious objection "should not be tolerated" (p.296). On the other hand, were the balance of supply and demand to shift, he suggests that an ethicist might reasonably condone conscientious objection. As I read it, Savulescu is actually suggesting that what should or should not be tolerated as ethical very simply depends on the situation -- not, as it were, on the basis of principle. Such argumentation flies in the face of conventional reasoning on professional ethics. Third, if the central argument against conscientious objection in medicine hinges on the degree to which it introduces inefficiency and inequity (given a certain balance of supply and demand), it would be reasonable to expect Savulescu to muster robust empirical evidence in support of his claims. Yet he provides none, save for a small convenience sample of clinical geneticists and obstetricians attending conferences in Australia that leaves numerous empirical questions unanswered, to wit: If an expectant mother has the misfortune of presenting to an obstetrician who is an employee of the NHS and who is unwilling to terminate her baby's life, how many days or weeks would elapse until she could locate an obstetrician who would be willing to do so? Is a poor or otherwise disadvantaged mother less able than a wealthier mother to locate, in a timely manner, an obstetrician who is willing to terminate her baby? What medical consequences would occur, or what additional direct and indirect costs would be incurred, as a direct result of any delays? Do the answers to these questions change -- and therefore the ethical course of action -- if one considers a situation of medical emergency vs. medical urgency? If one considers a rural vs. urban setting? Certainly the empirical burden is high. This is understandably so -- if, as Savulescu suggests, the ethical course of action for public sector physicians depends upon empirical estimates rather than on professional principles. Beauchamp and Childress have argued that we "bear a very heavy burden of proof in arguing that coercion of conscience is necessary" (2). Savulescu has not met that standard, and his arguments therefore fail to persuade. I would welcome his clarification on these matters.
Competing interests: None declared |
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Peter Gooderham, Tutor Cardiff Law School, Cardiff University
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It is remarkable that Savulescu [1] uses a quote from Shakespeare’s Richard III, one of the greatest villains of fiction, to support his argument, but perhaps a multiple murderer is an appropriate authority for one seeking to override conscience. I can quite understand why colleagues wonder if this is tongue-in-cheek. I agree with Savulescu that the law on abortion needs clarifying. Section 1(1)(d) of the Abortion Act 1967 reads, as amended, ”(1) Subject to the provisions of this section, a person shall not be guilty of an offence under the law relating to abortion when a pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith … (d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.” The meaning of “substantial risk” and “seriously handicapped” are not defined. Little wonder, perhaps, that some practitioners may choose to rely on the provisions of section 4 of the same Act: “(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.” Savulescu speaks of what is “legally permitted” and states that “the place for expression and consideration of different values is at the level of policy relating to public medicine.” Conscientious objection is legally permitted by the Abortion Act, and expression and consideration of different values did indeed take place when the Act was passed, when it was amended, and on other occasions. Ultimately, society has expressed itself through Parliament, and if Savulescu does not like the outcome, there are better ways for him to address this than viciously attacking doctors’ consciences. Finally, I note Savulescu’s comment that “practitioners have a legitimate right to refuse to provide a service which they believe to be illegal. However, they should make this reason clear to patients and also the fact that the law is unclear. They should also inform patients of the availability of other practitioners who take a different view of the law.” In other words, he seems to argue that they should assist or encourage activity which they believe is – or may be- unlawful. A better course of action would be to seek appropriate advice. This might be from a defence body or trust solicitors, who in turn might choose the safer course of seeking a declaration from a court of law. [1]BMJ 2006;332:294-297 (4 February) Competing interests: 1) Retired medical practitioner 2) Member of the Richard III Society, which recognises Shakespeare's fictional character as a misrepresentation of a medieval king whose conscience may well have been well-developed for a man of his times |
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Steve Kelly, Addiction Specialist and Surgical Assistant Gosford Australia 2250
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Every response but one condemns Savulescu's article. That one compares doctors to frontline uniformed forces, who are marshalled at the command of senior officers, to do the bidding of those officers, at the risk of personal, or at least professional punishment if they do any less. Not to mention possible harm if they do follow orders!! Doctors are not like firemen, nor policemen, nor soldiers. If at all, they may be compared to the senior officers of those groups, who take into account the 'big picture' and direct the course of the action taken by the unit. Hopefully they will do so with conscience, and consideration of the complexities before them, rather than merely applying laws which were not made for the particulars of the situation arising 'today'. Not like the humble infantryman, who may be taught to clean his rifle as shown by semi- naked pretty girls in a comic book, to ensure he pays some attention to what is instructed. If we were taught like that, to follow orders in that manner, maybe we should face a martial court if we do not wish to 'fight' and do the job .... But what are the editors of a once fine journal of medical knowledge doing, to let such an opinion piece be published? Like the recent bible re -writing of Kutz (BMJ, Dec 2005), it does not fit in that part of the BMJ. If it were merely a letter expressing an opinion, we would all think that Savulescu (like Kutz) is entitled to think as he may, but pay it little regard if we disagree. And they are entitled to their opinions, for better or worse. Instead, published in the place where we should expect better than reasonable academic thought (and review), we find an article which must succumb to the weight of the criticism it has recieved in many fine writings above. All but one (so far) demonstrate that the quality of Savulescu's argument does not reach the level of the schoolyard let alone the professorial podium from which he speaks. Not only the editors of the BMJ, but the caretakers of the Oxford Uehiro Centre for Practical Ethics, and of the University of Oxford itself, might well stand back in awe at the level of writing we now see in black and white. Do the editors need to drag authors with useful contributions in off the street? There are plainly many respondents to this article who would provide a better platform for a professional discussion of ethical matters than Savulescu's article has managed. As others have requested, I am now looking forward to a possible rebuttal of the many learned critiques he has received. Are they all mistaken? Will we see a better rendition of Shakepeare's intended meaning than we have in the above responses? Will anyone, supporting Savulescu, render a better understanding of European and UK laws than we have seen above? Will the learned professor show us that he is right when he argues "it is wrong to believe that something is wrong – a self-refuting argument"(quoting Julyan, above)? De Murtinho-Braga has taken an extreme step in response. If the BMJ continues in the pattern set by Kutz and Savulescu, the editors may well see many joining him! Competing interests: I choose to continue practicing Medicine with a conscience, and daresay many patients are glad that we do. |
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benjamin dean, sho australia
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The frenzy of opinion in reaction to Professor Savulescu's article demonstrates that generalising is of very limited use when the quagmire of ethics is approached. His concluding remarks are indeed conclusive and leave no room for the conscientious objector under any circumstance. This is not an easy argument to defend. Ethics can understood by diluting the subject down into several distinct areas ( autonomy, justice blah de blah ) as many ethicists have tried to do. This is useful for teaching the basics to the ethically uneducated, however this system encounters serious problems if used when trying to justify complicated ethical judgements. The beauty of ethics is its greyness and the fact that there are no absolute rights or wrongs. The rule based systems provide no easy solutions, and help propagate the pretence that ethics can be broken down into simple chunks of black and white. Interestingly the law is often incorporated into rule based ethical systems. The law is far from ethical on occasion and arguably ethical decisions can be made irrespective of the law. We may go to prison for breaking the law, however this does not mean that our actions were unethical or 'wrong'. For example would doctors that refused to cooperate with the Nazi regime be ethically wrong simply becuase their decisions ignored the corrupt law of the time? quite clearly not in my opinion. The argument can go on and on, but one thing never appears to change as regards ethics- there are no absolutes. Each decision or action must be seen in full context of the situation, and even then it is very rare to get an absolute concensus of opinion. This is the beauty of the subject. Competing interests: None declared |
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John P Heptonstall, Director of the Morley Acupuncture Clinic and Complementary Therapy Centre Leeds LS27 8EG
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Sir I have a number of friends who are physicians who would agree with the statement they are now expected to accept being "marshalled at the command of senior officers, to do the bidding of those officers, at the risk of personal, or at least professional punishment if they do any less"; one resigned from GP service for reasons like those, after more than 10 years being no longer prepared to subjugate self-determination of patient care, based on an excellent medical education, to government and health department dictation. Regards John H Competing interests: None declared |
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Christopher J Harrison, GP Brooklands Medical Practice M23 9JH
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Editor While sharing the distress and distaste felt by many other correspondents, the views expressed by Savulescu [1] are perhaps not so surprising. He has previously advocated positions which many in the medical mainstream would find disturbing, including the commercial sale of body parts and the legalisation of performance-enhancing drugs in sport [2,3]. I agree with him that paternalism can cause problems. However, he appears to consider consumerism to be the only alternative. This ignores a huge body of literature on the patient-centred method [4, 5]. The patient- centred approach explicitly allows the doctor’s views and judgements to be considered. If Savulescu really thinks that autonomy has few limits, I would not wish to be on the same plane as him when he decides to exercise his autonomous right to tell the pilot how to fly the plane. As other correspondents have pointed out, a doctor’s values can strongly enhance patient care. Removing all values would return us to the worst, most narrow-minded biomedical approach to patient care. Perhaps the most serious flaw in what I consider to be a disappointing article is his apparent display of double standards. In one of his better articles, he points out how apparently well-meaning individuals can cause deep offence through their choice of words[6]. He is particularly critical of those who give advice to people they do not know well. As he says, “When it has no chance of being received well, advice such as this cannot be defended”[6]. I do not feel Savulescu has made much effort to understand those of us in medicine (the vast majority) who are influenced by our values. Why did Savulescu choose to write the article in such an offensive way? Why, when he could see the distress that he has caused, has he not sent a rapid response to apologise to those of us working hard at the coalface trying to deliver a patient-centred health service? As he says elsewhere, “We should choose carefully what we say”[6]. In at least this aspect I can agree with Savulescu. [1] Savulescu J. Conscientious objection in medicine. BMJ 2006; 332: 294-297. [2] Savulescu J. Death, us and our bodies: personal reflections. J Med Ethics 2003; 29: 127-130. [3] Savulescu J, Foddy B, Clayton M. Why we should allow performance enhancing drugs in sport. Br J Sports Med 2004; 38: 666-670. [4] Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Social Science and Medicine 2000; 51: 1087-1110. [5] Stewart M. Towards a global definition of patient-centred care. BMJ 2001; 322: 444-445. [6] Savulescu J, Foddy, B, Rogers, J. What should we say? J Med Ethics 2006; 32: 7-12. Competing interests: None declared |
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Andrew Ashworth, GP Davidsons mains Medical Centre, EDINBURGH EH4 5BP
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Isn't Savulescu's unstated argument here not about "ethics", but about "authority"? In a real example, a group of Consultants agreed not to prescribe a new product licensed for those between 16 and 18. An individual doctor objected to their voluntary ban, preferring to continue to use an older product that was unlicensed in that age group. All acted in good faith within the bounds of their individual consciences. The group chose to ignore the authority of the licence, the individual the authority of the group. If, as Salvulescu argues, authority is the arbiter of ethics, all acted unethically. Centralising Governments push towards proscribed prescription through the media of protocols, guidelines and targets: those of us who object to such undermining of our professionalism need to be watch that our views are not described as "unethical" by those Governments. Despite the lack of a declaration of competing interest, it seems likely that Savulescu has a salaried dependency on Government "authorities" since, in England, Universities are state sponsored - perhaps the author could be invited to examine his conscience in objecting to conscientious objectors. Competing interests: I was the Individual |
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Giles N Cattermole, SpR Emergency Unit, University Hospital of Wales, Cardiff CF14 4XW
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Sir, Savulescu paints a terrifying portrait of his utopian future for medicine. A future in which medical practitioners are mere tools in the service of the state. A state which will dictate their actions regardless of their consciences. Conscience itself will be relegated to the realm of superstitious religion, unfit for the enlightened and obedient. Whether the state commands abortion, capital punishment, euthanasia or compulsory sterilisation of the mentally or racial unfit, the doctor- technician must comply or face punishment. Presumably this denial of an individual's right to object to the dictats of the state will apply to all in public life. To lawyers, journalists, ministers of religion, nurses, teachers... after all, it's been done before, and not beyond living memory. Human freedom becomes irrelevant and illegal in the face of the power of the state. One would have hoped that the lessons would have been learned, but history unlearned is destined to repeat itself. To paraphrase Orwell, if you want to understand Savulescu's picture of the future, imagine a boot stamping on a human face - for ever. Competing interests: I do not believe that the State is always right |
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Kelly A Markham, SHO Norwich
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I was horrified by Savulescu's article. According to him I should not be allowed to be a doctor because I have and act on my religous beliefs, I refuse to be a puppet of either the law or the state and I think for myself! Fortunately my patients and my collegues respect my right to act in accordance with my beliefs as I respect their rights to act within their own moral code and within the law. I am very grateful for the doctors, patients and others who have so eloquently exposed Savulescu's "conclusions" as shallow and illogical. I would also like to voice my concern that this opinionated article was publised without any substantial published debate. Was this a failure of the editors to adequately review the article and understand the issues it attempted to address? Competing interests: None declared |
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John P. Watson, Consultant Physician Leeds General Infirmary, Gt. George St, Leeds LS1 3EX
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Savulescu demands, on pain of being struck off the medical register, that we should offer "legally permitted, efficient, and beneficial care" to a patient without being influenced by our personal values [1]. But a decision that a course of action is "beneficial" is in itself a value judgment. While we might all share values that support prescribing a life saving course of antibiotics for a young, otherwise healthy person with severe pneumonia as beneficial, the question of whether the same course of antibiotics is beneficial for an elderly, terminally ill patient will be influenced, whether we like it or not, by our personal values. It is impossible for anyone to practice medicine without being influenced by some personal values - whether or not they stem from a religious belief. But perhaps Savalescu should consider the consequences if his position were adopted. If all conscientious objectors to abortion on demand - whether Secular, Catholic, Evangelical, Muslim, Orthodox Jewish, etc. - were to resign from the medical profession tomorrow (or even just those in posts where the issue arises - Obstetrics, General Practice, Genetics, Radiology, Anaesthetics, etc), where would that leave the provision of the equitable and efficient health service he desires? 1. Savulescu J Conscientious objection in medicine BMJ 2006; 332: 294 -7 Competing interests: I was once turned down for a post in Obstetrics after being asked about my religious beliefs in the interview. |
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Stephen Hayes, GP, GPwSI dermatology Bitterne walk in centre, Southampton UK
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Stammers wonders if the requirement on onstetricians/gynaecologists to deliver abortion services has had an effect on obstetric recruitment. It is not unbelievable. I developed a deep cerebral and visceral horror of abortion since I first discovered what it was at about the age of 14. Applying for an obstetric SHO post as part of my GP training in the 1980s, I was informed in the job description that 'the unit carries out approximately 1,000 terminations a year and the SHO will be expected to participate'. I didn't apply, and never did an Obs/gynae job, which affected my career. No doubt I could have found an O/G SHO post somewhere, even overseas, but rightly or wrongly I didn't, due to the real or perceived pressure to be involved in abortions. Later, at one GP job interview I was pointedly asked for my opinion on abortion and having stated it, it was made quite clear to me that I need not apply for the job. I saw many job adverts asking for the applicant's views on the 1967 abortion act. How well I have served my fellow humans as a doctor is not for me to judge, but I could not have served at all if deprived of the ability to say 'no' to a command I sincerely believed was wrong for both the patient and myself. During 2 decades as a GP, I have referred many women, over 100, to the local facility on request, and they all got their abortions apart from the one or two who changed their own minds, but I would rather have my right hand cut off, or indeed suffer death myself than sign an abortion certificate. If Savulescu's views prevailed, I do not believe that I would be the only one excluded from medical practice. By all means legislate to end the hypocricy that pretends that abortion is not available on request as a 'fall back' method of birth control in the UK, if that is what the people want then let it be on request in name as well as in fact and do away with the need for 2 doctors signatures. It is hard to see that the numbers could increase as a result. But let it be separated from medicine and be carried out by abortionists in premises away from where the sick are treated by doctors who remain true to Hippocrates' (peace be upon him) traditions. Competing interests: as stated above |
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Eldad J Ben-Eliezer, GP Robertsbridge, East Sussex, UK
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Editor: Stammers and others have given excellent responses to this one-sided and inflammatory article, but I would like to add one further point. I find it ironic that Savalescu suggests doctors would use their conscience as an excuse to avoid their duties during a pandemic such as influenza. In fact I believe the opposite is true. During the the pandemics that ravaged the Roman world of the first centuries AD, the very real fear of fatal infection caused most people to leave even their families and friends to die alone. It is hard for us to imagine the horror of those plagues, where whole towns were literally wiped out. But it is well documented that the Christians at the time risked their lives to care for the sick, many of them paying for this with their own lives. Conscientious objection is not cowardice - history is full of stories of very courageous men and women who stood up for what they believed and paid for it with imprisonment or death. I was very disappointed that the BMJ published this piece. Certainly, there is a place for debate. I accept that many people do not share my views that all of human life is sacred. I am ready to debate and defend the motives of those who feel that their conscience will not allow them to participate in an action which they feel is wrong. But for an author to suggest that doctors who hold different values from his own should be punished and removed from practice is highly offensive and a step too far. Competing interests: None declared |
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Piers M W Benn, Lecturer in Medical Ethics Imperial College London W6 8RP
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Whilst I do not agree with Julian Savulescu's strong stance against allowing conscientious objection in medicine, I am surprised by the violent feelings evoked in so many respondents, often based on missing Savulescu's main point. I doubt if many respondents would agree that doctors should be allowed conscientiously to refuse participation in treatment on just any ground whatsoever. For example, if a fundamentalist gynaecologist refused to administer pain relief during labour, on the grounds that labour pains are a punishment for Eve's sin in the Garden of Eden (see Genesis), I don't think he or she would get much sympathy. Such a doctor should have to choose between the profession and following his/her convictions. On the other hand, other stances - e.g. against abortion - are more problematic. Clearly if one is against abortion, one is likely to support the right of refusal. Even if one isn't, one may think the anti-abortion stance has enough in common with the accepted values of medicine for conscientious refusal to be legitimate. The difficulty is in getting all parties to controversial issues to agree on when refusal should be allowed, regardless of whether the stances in question are right or not. Perhaps some progress can be made here, but it seems unlikely consensus will ever be reached. Piers Benn Competing interests: None declared |
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Hugo van Woerden, SpR CF10 3NW
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The fundamental flaw in Savulescu’s1 recent BMJ paper is the assumption that the law of a country is always morally impeccable and should, therefore, automatically be enforced. If Nazi law stated that Jews were to be euthanized, was that law consequently “right” and no doctor should have been free to conscientiously object to enforcing it? Were doctors “right” to conscientiously object to being ordered to give psychotropic medication to political and religious prisoners in the former Soviet Republic of Russia? Savulescu fails to acknowledge that the Hippocratic oath opposed abortion for over 2000 years, and that as recently as 1948, the Declaration of Geneva reaffirmed, “respect for Human Life … from the time of conception”2. No piece of legislation that Savulescu refers to, and that is morally or ethically controversial in medicine, was ever passed by 100% of the members of the legislative body of a country. Existing morally and ethically controversial legislation has always been opposed by a minority of legislative representatives. The possibility that this minority in society may be morally and ethically “in the right” is the fundamental basis for allowing conscientious objection. Savulescu does not address the right of patients who, for example, hold abortion to be murder, not to be treated by a gynaecologist whom they regard as a mass murderer. Thinking even more widely, do patients have the right to be treated by a doctor who holds their values? If, as a patient, I am treated by a doctor who fundamentally rejects my set of values, how can I have confidence that the doctor will genuinely act in my best interests? I have observed doctors, who believe that children with Down’s syndrome would have been better off being aborted, shun contact with patients who disagree with them, and show indifference in treating the child after birth. Savulescu suggests conscientious objectors should be disciplined. Should such doctors be “disciplined” for the effect their values have had on the care they have provided? Should they have had to pass the patient on to a pro-life doctor who did not hold their biased position and who consequently would not provide such a poor quality of interpersonal care? The belief that “moral judgements” can be avoided in making “clinical decisions” is an illusion. The very existence of medicine is founded on the premise that it is “morally good” and therefore worthwhile to treat patients. Medicine assumes that to care for and heal people is morally good, and that not to care or heal, when it is in one’s power to do so, is morally wrong. Human beings are vested with moral worth, which makes it morally right and proper to care for them. This is fundamentally a religious concept. The alternative utilitarian answer is that people are only to be treated if this results in a return to being economically “useful” and leads to the conclusion that the weak and the old should be disposed of. Prospective medical students who have strong moral beliefs should be welcomed into medicine, not refused entry as Savulescu suggests. To turn the concept on its head, perhaps totalitarian, utilitarian secularists who want to remove religious and spiritual care from medicine should be banned from entry instead? References 1. Savulescu J. Conscientious objection in medicine. BMJ 2006;332:295 -7. 2.World Medical Association. Declaration of Geneva – physician's oath. Geneva: World Medical Association, 1948. Competing interests: None declared |
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Tom G Heyes, GP Clinical Director Leeds West PCT LS12 6QD
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I agree with the readers above in their well expressed and cogent criticisms of Prof Savulescu's piece, which aroused strong feelings of indignation for me also. On reflection, the debate started here is a very important one for those of us who are fortunate enough not to live under the sort of totalitarian regime he seems to advocate. How do we reconcile individual values, however these are formed, with our duties as citizens and as employees, whether of a private or a public enterprise? While we refuse the imposition of state-approved values on everyone, neither do we allow the unfettered exercise of everyone's personal freedom, where it conflicts with the rights of others - hence the debates recently over the religious hatred law and the trials of the BNP members and Abu Hamza. What we should be discussing is the extent to which personal freedom and conscience should be constrained by the requirements of law, cultural values and of employers including the NHS. This is an important topic that deserves to be debated more fully. Competing interests: I am a doctor working in Britain |
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Tom R C Boyde, private practice 10 Harley St W1G 9PF
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Savulescu’s article [1] came like a blast of fresh air to a fuggy room so it was disturbing to find him attacked on spurious grounds of violating “the standards of argument based ethics” [2], attacking the “usual suspects of Christians and Americans” [3], and misunderstanding the ethical dilemma of a doctor facing infectious disease [4]. Whatever may be said against him or for these critics, there is no doubt that Savulescu is perfectly correct on one point, that it is and should be contrary to law for a doctor to withhold information from patients in such manner as to prevent competent individuals from taking fully informed decisions about their future medical treatment. A criminal offence for an individual doctor to decline to do any given procedure? - surely not - but to obstruct legally permissible treatment or conceal knowledge against the known or knowable wishes of the individual patient - clearly wrong. Murray and de Zulueta [4] condemn Savulescu for saying what he did not say, a common enough debating tactic. It is of course ethically permitted, indeed required, for any doctor dealing with infection to preserve his or her own health as far as possible, for the greater good, just as the diving buddy must first make sure that his own oxygen supply is maintained (more familiar perhaps over emergency oxygen in passenger airplanes). Smith [3] is wrong if he thinks that only Christians and Americans oppose and obstruct abortion, though they may be the only ones in recent times to murder abortionists. Savulescu doesn’t use either word. Also, there is no justification to compare someone who proceeds in accordance with a patient’s wishes (over say euthanasia or abortion) to another person altogether who participates in state-directed murder or human experimentation. They are opposites: the first is a liberal, the second a fascist. Chervenak and McCullough [2] ask for a different kind of argument to those Savulescu has provided: that doesn’t make his conclusions wrong. Self-evidently it is true that some doctors, a very few, ought to disqualify themselves from practice or certain kinds of practice by reason of disability arising from religious or quasi-religious belief. Nearly all doctors, mercifully, including nearly all Catholic doctors of my acquaintance, do exactly as Savulescu wishes them to. When they cannot or will not carry through some procedure themselves, they facilitate their patient’s access to another practitioner. They are all too likely to sacrifice their own lives in caring for sick people (that includes my own students), and are deeply reluctant to cause death merely by inaction. They certainly don’t spend time worrying about theoretical ethics when it is a matter of acting quickly to preserve a life or a family. So the only thing he got wrong is in thinking that his ethic need be externally determined and imposed by some kind of busybody or other, if not Church then the State. In reality it already is at the core of our profession. Professor T.R.C. Boyde, 10 Harley St, London W1G 9PF 1] Savulescu, J. Conscientious objection in medicine. BMJ 2006:332:294-7 (4 February) 2] Chervenak, F.A., McCullough, L.B. Author did not meet standards of argument based ethics. BMJ 2006:332:425 (18 February) 3] Smith, V.P. Doctors’ freedom of conscience. BMJ 2006:332:425 (18 February) 4] Murray, E., de Zulueta, P. The ethics of responding to bird flu. BMJ 2006:332;425 (18 February) Competing interests: None declared |
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Peter KK Au-Yeung, Specialist Anaesthetist Hong Kong
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Dr Stephen Hayes' personal experiences regarding abortion makes interesting reading and may shed a little light on the report in the current issue of the BMJ about a recruitment crisis in Obstetrics and gynaecology (1). Certainly, long hours and the potential for litigation with compensation sums of astronomical figures are two undeniably big deterrents to recruitment, but the requirement to do abortions could also turn otherwise willing recruits away. I must say that I failed to be convinced that it is impossible to be a good obstetrician or gynaecologist if one does not do abortions. Certainly no anaesthetist would maintain that those who cannot anaesthetise a patient for open heart surgery could never be a good anaesthetist (provided the doctor concerned does not pass himself off as a cardiac anaesthetist). (1) UK trainee doctors spurn obstetrics and gynaecology Brettingham BMJ.2006; 332: 323 Competing interests: None declared |
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David Jones, Academic Director St Mary's College, Twickenham
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The reasonableness of consciencious objection is to some extent relative to the issue under consideration. This is certainly true. However, Piers Benn does not illuminate matters by given an example that is essentially a caricarture unrelated to the past or present practice of Christian physicians: the supposed injunction of Genesis regarding the pain of child birth. What is in question here is not a fanciful practice unknown in history but a practice known from the earliest times and known from the first to be an issue of great ethical importance. Hounding out of the profession those with any objection to any abortion so long as it is requested by the patient would exclude not only Hippocrates but a fair percentage of the present medical profession. A principled objection to killing a foetus (in general or in one particular case), like a principled objection to killing in war (in general or in one particular case), is the kind of appeal to conscience that is understood and respected in all but the most totalitarian regimes. This seems to be acknowledged in enshrining in law a conscientious objection to participate in abortion. I submit that the reason that Julian Savulescu's piece evokes such a reaction is precisely that it fails to show any respect for the reasonable autonomy of the physician in his or her practice of ethical medicine. Competing interests: None declared |
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Philip G. Ney, Psychiatrist Victoria, BC V9B 2W7
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Maybe Shakespeare believed that conscience was for cowards, however, psychiatrists learned long ago that those without a conscience were psychopaths. It is also clear that those who are afraid to use their conscience give themselves away as cowardly. Call it whatever you may, everyone has a conscience. You may believe that conscience arose from religion or philosophy or history, but it is more likely that it is embedded in the instincts for group and individual survival. We now know there are three, not four fundamental forces in the universe. Scientists are excited by the possibility of discovering the one force that unifies everything. Thus we must conclude that truth is unitary. Eventually conscience and science must agree. Most doctors know of many cases such as this one. A teenager was brought to emergency by her mother, a nurse, who is convinced the child is deathly ill with septicemia. The good doctor orders the correct, reliable lab tests, which show nothing amiss. So she is sent home. Shortly thereafter, the distraught mother brings her back and insists she be hospitalized. She is, but dies within six hours, of septicemia. We older doctors were taught not to rely upon lab tests, but on clinical observation, experience, wisdom, instinct that can tell us something is drastically wrong even when the science of radiology, biochemistry, etc. show nothing abnormal. You may call this inner awareness prescience, or conscience, but it was every good physician’s and every wise man’s guide long before science and law became so important. After all, which came first? “The law,” said Eichman, “I only did what was ‘legally permitted,’” before he was executed for transgressing a higher moral law. “Science,” said Darwin, and everyone bowed so low, they set aside their critical faculties. How is it possible “eminent scientists” didn’t realize that after the discovery of the second law of thermodynamics, evolution was impossible, if not ridiculous? Long before science was able to show the destructiveness of cigarette smoking, Christians forbade their children from indulging on the basis of conscience. If you were to be guided by good science, you would realize that 99.5% of abortions are not indicated for health reasons and have no proven therapeutic value, but rather, accumulating evidence shows their harmful effects. If only doctors had listened to their conscience more closely, millions of women would not now be suffering. Do you know of any long-term study of families that have contributed to the euthanasia of someone near and dear? I can assert from many clinical cases that husbands, wives, children, guardians who have requested or agreed to ‘pulling the plug’, or removing the intravenous or nasogastric feeding tube, have instinctually driven guilt which complicates their grieving. Grief thus complicated often becomes pathological, and frequently that results in difficult to treat depression. The best evidence to date shows that the more sex education, the more sexual activity. The earlier the sex education, the earlier the sexual activity, and therefore the increased demand for contraceptives which, against their conscience, doctors are increasingly pressured into prescribing, even while there is growing evidence of adverse long term effects both from estrogens and the implicit permission to be sexually active. Therefore, being a pragmatist, I will carefully listen to my conscience. Practically speaking, I will be guided by my conscience, and then the best science available, and then possibly the law. Conscience will probably keep me out of trouble with everyone but those who don’t have one, or don’t think the conscience needs to be listened to. Competing interests: None declared |
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Sylvia M Watkins, Honorary Consultant Physician retired
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Sevalescu makes the basic error of confusing what is legal with what is ethical. A legal course of action may well be unethical and no individual should be forced to undertake such an action against his conscience. It will be a sad day for all of us if doctors are forced to choose between acting unethically and losing their licence to practise. Competing interests: None declared |
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Brian J Bane, Chief of Anesthesia San Rafael, CA 94903
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It is well that Julian Savulescu quotes Richard III in his editorial against conscience in medicine. Dr. Salvulescu not only selects one of Shakespeare's greatest villains, but also agrees with him: he maintains that conscience can be an excuse for vice. He argues that a doctor's conscience should be excluded from medical care. 1 Unfortunately, when you cast off one standard of behavior, you must assume another. Since conscience cannot properly be your guide, Dr. Salvulescu proposes that doctors should follow "the law." 2 That begs the question: what should one do if the law is unjust? Dr. Mengele worked within the laws of Nazi Germany. He was not held back by conscience. Should any doctor be? Recently a U.S. federal judge held that the execution of an inmate in California should be attended by two anesthesiologists, to ascertain that the inmate was unconscious before receiving the lethal medications. The execution was cancelled after the two doctors backed out, citing ethical concerns. According to Salvulescu's thesis, these doctors interfered with a lawful procedure, one ordered by a court. Should they be stripped of their medical licences for their exercise of conscience. I live only a short distance from the place of execution. Should I be stripped of my license since I failed to step foreward and offer my services? Dr. Salvulescu's arguments are inconsistent. He writes that "conscientious objection is wrong and immoral." 3 Yet later in the same article he implies that we cannot allow "moral values or self interest to corrupt the delivery of the just and legal delivery (sic) of health." 4 Is it logical for Dr. Salvulescu to describe conscience as immoral, or is he corrupting his own message with moral values? Perhaps he should have quoted King Richard a little further along in the same speech: March on, join bravely, let us to't pell-mell;
1. Savulescu J. Conscientious objection in medicine. BMJ 2006;332: 294-7. (4 February.) 2. IBID p. 294 3. IBID p. 294 4. IBID p. 296 Competing interests: None declared |
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Marta Munzarova, Head of the Institute of Medical Ethics Medical Faculty, Masaryk University, Komenskeho nam. 2,CZ-60200, Brno, Czech Republic
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Sir, I am extremely grateful to all respondents to Savulescu ‘s article /1/. They almost unanimously proved the quite clear knowledge what medical ethics is all about and also the fact that it is not possible to let it destroy by those without conscience. I, as medical doctor with long experience at the bedsides of severely ill patients as well as in medical research in oncology, devote myself during the last decade to the first aim – teaching medical ethics within the frame of future physicians’ education. Coming from the totalitarian regime I highly appreciate the freedom of thought and speech - but on the other hand - I am aware, probably even more sensitively than others, of the great risk coming from completely another side: ideas always have consequences. And ideas proclaimed by those who educate future generations of medical doctors in bio”ethics” might be disastrous not only for them but for their patients as well. There are other ideas, coming as well from bioethicists in English - speaking world, which are also very dangerous. Some of them support morality tolerating everything. A morality without any attempt to find out the distinction between right - good, and wrong – evil, without even a remote admission that something like “moral truth” might exist which is common to the good of /and for/ man and to the good of /and for/ humanity. They deny even the right to life of somebody, who “has ceased to be a person and…. can either be killed or allowed to die or preserved alive as we choose”. /Exact quotations of those and other ideas which outrage my conscience - see 2./ Several responders remembered Nazi doctors. It this context it is very appropriate to quote Elie Wiesel’s article “Without conscience”/3/ and his foreward to “The Nazi Doctors and the Nuremberg Code”/4/: “ The areas of scholarship, learning, education and culture must also be reexamined in the light of what happened.” “Why did their education not shield them from evil?” “What, then, is the role and goal of teaching?….What can happen to culture, to education?” Are nowadays medical students educated in good ethics? And is Elie Wiesel not “naive in believing that medicine is still a noble profession, upholding the highest ethical principles?”/3/ 1. Savulescu, J. Conscientious objection in medicine. BMJ 2006; 322:264-297. 2. Munzarova, M. Towards the abolition of man: the voice of disabled persons cannot be ignored. Bull. Med. Eth. /London/ 174; January 2002, 13 -21. 3. Wiesel, E. Without conscience. N Engl J Med 352; April 14, 2005, 1511- 1513. 4. Wiesel, E. The Nazi Doctors and the Nuremberg Code. Human Rights in Human Experimentation. In: George J. Annas and Michael A. Grodin, eds. Oxford University Press, 1992, vii-ix. Yours faithfully Marta Munzarova Competing interests: None declared |
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John Stone, none London N22
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I returned to this extraordinary article today. These are the words of Richard III in Shakespeare's play as he goes out to fight his last battle: "Let not our babbling dreams affright our souls, For conscience is a word that cowards use, Devised at first to keep the strong in awe." Richard has just been visited in his sleep by the ghosts of those he has murdered on the route to power and in remaining there: Henry VI, the Duke of Clarence (his brother), Lord Rivers, Lord Grey, Lord Hastings, the Princes in the tower, his wife Anne, and the Duke of Buckingham. Juxtaposed with conscience is naked power. I have a few questions. How could an Oxford philosopher claim authority from a line ripped out of context in this way, as no undergraduate literature student would do? How can we justify any authority except through continuing open moral debate? Do we really live in an age in which we can confidently defer to the state and its servants? And how is the Uehiro Foundation funded - a subject upon which I can find no information? Competing interests: None declared |
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Paula R Boddington, Senior Research Fellow in Ethics and Genetics Ethox Centre, Division of Public Health and Primary Health Care, Oxford University, OX3 7LF
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I read Savulescu’s article when it appeared in 2006 but did not read the rapid responses; returning to the topic recently, I read the plethora of responses with admiration at the range of the incisive and often poignantly expressed critiques of his impoverished position, but also with a growing unease and disquiet concerning the original article, if taken as a representative offering of those working in what might be variously called "medical ethics" or "bioethics". Several of the responses referred to Savulescu's position and institutional affiliation. Since then, I have taken up a post as researcher in ethics and genetics, also at Oxford University albeit not within Savulescu's centre. I would like to reassure those concerned that, just as within the medical profession, freedom of conscience is alive and well amongst those academics who research, teach, and additionally hopefully learn about, ethics. Savulescu's views on many matters are hotly contested by many other philosophers and ethicists. An individual's conscience is an indispensable well-spring of morality, indeed of humanity; although like anything of human origin, it can lead us astray, without it all is lost. It is an essential part of any attempt at democracy and openness and time and again has proven an effective and often sole weapon against inhumanity and evil. The conscience of an individual needs to operate alongside the views and experiences of others, the lessons from history, from other cultures and worldviews, from the endeavours of groups to produce rules, regulations, and guidance; but it is a sine qua non of our humanity, and to suggest that it be eradicated in an entire profession is, as almost all the rapid responses testified, errant nonsense. The huge surprise was that the extreme views of one individual, ironically arguing against individual freedom of opinion, were published in the BMJ without a fuller exploration of the issues. Thank goodness for the rapid responses! To the suggestion that conscience is not allowed in other professions, for example, in the armed services, so too has no place in medicine I say this: the denial of freedom of conscience to rank and file members of the armed services is precisely because they are trained to execute orders that may go against every instinct of humanity. Even if this may be a necessity in a few extreme circumstances, that is, even if some wars are indeed just, there are still occasions when it is right that individual soldiers should risk court martial and disobey orders. If this is so even for those trained to be agents of destruction, when it comes to the medical profession ... words fail me. The practice of medicine "as of life in general" essentially requires individual as well as group judgement about the proper treatment of cases and the relevance of general rules. Without conscience, it would become more than inhuman and unethical, it would actually become impossible. No rules, regulations, or scientific generalisations can possibly tell anyone exactly what to do on every occasion in the intricate nuances of real life and practice. Paula Boddington Senior Researcher in Ethics and Genetics, Division of Public Health and Primary Care, University of Oxford Competing interests: I am a philosopher working at Oxford University. My current post is funded by the EU under the Procardis programme, project number 037273. |
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