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

Conscience is our safeguard

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

Competing interests: No competing interests

06 February 2006
Andrew F West
Consultant Child and Adolescent Psychiatrist
Wokingham CAMHS, Wokingham Hospital, Barkham Rd, Wokingham, Berkshire, RG41 2RE