Conscientious objection in medicine
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7536.294 (Published 02 February 2006) Cite this as: BMJ 2006;332:294
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
- Savulescu J. Conscientious objection in medicine. BMJ 2006 Feb 4;332:294-297.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 3rd ed. Oxford: Oxford University Press, 1989: 390.
Competing interests:
None declared
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Is Savulescu displaying double standards?
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
Competing interests: No competing interests