Intended for healthcare professionals

Analysis And Comment Ethics

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

The Priority of Professional Ethics Over Personal Morality

 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

09 February 2006
Rosamond Rhodes
Professor, Medical Education
Mount Sinai School of Medicine (New York 10471)