Dr. Andy

Reflections on medicine and biology among other things

Wednesday, March 15, 2006

Ethics of conscientious objection

In the February 4th British Medical Journal, one Julian Savulescu, director of the Oxford Uehiro Centre for Practical Ethics argues that there is little if any room for autonomy by physicians in deciding not to provide certian kinds of care
A doctors' conscience has little place in the delivery of modern medical care. What should be provided to patients is defined by the law and consideration of the just distribution of finite medical resources, which requires a reasonable conception of the patient's good and the patient's informed desires. 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. Doctors should not offer partial medical services or partially discharge their obligations to care for their patients.
Certainly once can't accuse Savulescu of pulling punches.

I see a number of problems with this sort of reasoning, not least that the pool of potential physicians might be signficantly limitied if every medical school applicant had to be prepared to offer any medical service that was currently legal or might be legal in the future. I don't think breast augmentation should be illegal, but I don't see any problem with not doing them myself.

Now, in a letter responding to the original article, Vaughan Smith, powerfully points out the flaws in Sauvescu's "public servants must act in the public interest, not their own" line of reasoning:
Since visiting Auschwitz, I have grappled with the question of how I 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.

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.
which puts it more eloquently than I ever could. And points our the obvious problem that what is "legal" can vary immensely from time to time and society to society. One can of course object that conscientious objection by physicians hasn't been very effective, but that is an entirely different issue. I suspect that Savulescu wouldn't be impressed with US physicians who participated in mistreatment and torture of prisoners at Abu Ghraib and Guantanomo because it was "legal."

Note that I'm pro-choice, although not necessarily pro-abortion. I don't currently face the issue commonly, but would refer any pregnant patient who desired an elective abortion to a qualified provider. So it's Savulescu's reasoning I object too.

11 Comments:

At 10:49 AM, Blogger Flea said...

I agree with you Andy.

See my post on a related topic here.

Here's another way to look at it: even a whore wont do anything you ask her to do.

Why should we?

best,

Flea

 
At 4:14 AM, Blogger Barbados Butterfly said...

I'm in full agreement, although the benevolent institution that governs my training is not.

A few years ago I raised conscientious objections to participating in a live animal laboratory as part of a required surgical training course. I wrote letters explaining that I did not see the value of practising chest tube insertion and other practical procedures on an anaesthetised dog given that I had previously done the same on human cadavers. I did not feel that the death of an animal was justified for this and did not want to participate.

I was told in no uncertain terms that I had to participate, irrespective of previous experience or knowledge. Ultimately I had to participate, despite my strong objections.

I'm still dirty about it. But as the years go by I'm getting better at asserting my rights and beliefs.

For the record, I believe that all doctors should be pro-choice. Not pro-abortion, but definitely pro-choice.

 
At 2:25 PM, Anonymous mchebert said...

If there is no place for conscience in medicine, then there is no such thing as medical ethics, is there? Aristotle established 2500 years ago the basic premise of ethics: a person cannot be held responsible for an act he or she did not commit freely.

To say doctors must do what the law says is tanamount to saying that they may not exercise free will in their medical care. So we are all to be zombies of the law. The question then becomes not that people who object to the law should not become doctors; the question is why should anyone who believes in ethics at all become one if by doing so we agree to mindlessly submit to whatever the law may be?

The argument for the law as the absolute guide is a relativist argument, and it raises all the usual relativist problems. For example, if I practice medicine in South Dakota, where abortion is banned, and a patient comes to me asking questions about an abortion, I am supposed to tell her she can't have one. Meanwhile, a doctor 10 miles away in Minnisota must tell the same patient the opposite. And we are both doing the "right thing." Obviously this is absurd. Medicine is an international community, not a national one and we can't settle for such rank stupidity.

In addition, as to B. Butterfly's comments, I would like say one thing. In saying that all doctors must be pro-choice, she is mandating morality for doctors also. I disagree. I think a doctor can be anti-abortion, and I am. If a patient asks me about an abortion, I will refer her to someone who will give her information. I have a duty to do that. But I do not feel I have a responsibility to help, or in any way to assist her efforts. This is not being obstructionist. It is simply refusing to participate, which we all should have a right to do.

 
At 2:01 AM, Blogger janinsanfran said...

Andy and other commenters here, I'd be curious how you'd respond to pharmacists' assertions of conscientious objection. Do you see the same need for professional ethical discernment that is over and above local social dictates? Or not? In practical terms, I think the case can be very difficult either way, particularly in rural areas.

 
At 6:36 AM, Blogger Flea said...

Janinsanfran,

Let me turn the question back on you. I don't know what you do for a living, but it doesn't matter for the sake of this thought experiment.

Suppose you lived in a rural area in the antebellum South. Would you see the same need for professional ethical discernment that is over and above local social dictates (i.e., chattel slavery)?

best,

Flea

 
At 1:28 AM, Blogger Barbados Butterfly said...

Dr Hebert, I have no beef with your position. If a patient comes to you seeking an abortion and you refer her to someone who will give her the information she desires that is all I ask and all that anyone should ask of you.

I disagree with doctors who tell patients that abortion is immoral and try to impose their beliefs on the lives of others. But I do not think doctors should be forced to participate in activities against their will. I don't think I (or any woman) should be forced to bear a child against my will. I feel uneasy about abortion but it is legal in my society and I can imagine circumstances under which I would seek it. If I were to visit a doctor seeking a termination I would not expect that doctor to perform the termination against their personal beliefs. I would expect them to refer me to someone who could provide the information I was seeking and to do so without prejudice.

Being a tad idealistic I would like to see all doctors treat their patients the way I would expect to be treated.

I'm a vegetarian but I don't tell my patients that they should be vegetarians. If they asked where the local butcher was I'd have to say "Sorry, no idea... but maybe someone at Reception might be able to help you. Or perhaps I could look it up in the local directory for you?"

 
At 5:27 PM, Anonymous Anonymous said...

As a nursing student with the ultimate goal of working in L&D and the mother of a beautiful son with Trisomy 21, I could never participate in terminations for for that diagnosis, which routinely occur at the edge of viability, right up until 24 weeks. I could provide compassionate care for the patient after the procedure was completed. My understanding is that this sort of situation is usually handled among the nursing staff without issues. Similarly, many nurses will not participate in circumcisions. Should nurses (or other medical professionals) with strong beliefs seek other fields? Should I only seek employment in a Catholic hospital? Just thinking out loud...and FWIW I am reluctantly pro-choice.

 
At 10:03 PM, Anonymous jb said...

It's interesting that nobody has yet brought up the issue of medical folks participating in executions. The AMA says that it is unethical for an MD to participate, yet it is certainly legal in most states. If you posit that every MD would be required to do an abortion (apparently what Julian Savulescu would support) or every pharmacist must sell Plan B (a lot of folks in the USA believe that), why not require docs to oversee the occasional execution (analagous to doing jury duty)?

I didn't think so.

One of the reasons that I do not belong to the AMA is their nanny-like attitude that decides what's best for me to believe.

I don't think anyone should be requires to do an abortion. I have no problem telling a pregnant woman who is seeking an abortion, "Hey, you know, there's a baby in there!"

 
At 8:59 PM, Blogger wiffofanesthesia said...

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.
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.” That begs the question: what should one do if the law is unjust?
Recently a U.S. federal judge held that the execution of an inmate in California should be attended by two anesthesiologists. The execution was cancelled after the two doctors backed out, citing ethical concerns. According to Salvulescu’s thesis, the doctors' withdrawl halted a lawful procedure, one ordered by a court. Should they be stripped of their medical licences for their exercise of conscience. I am an anesthesiologist who lives only a short distance from the site of the proposed execution. Should I be stripped of my license since I failed to step foreward?
Perhaps he should quote King Richard a little further along in the same speech:
March on, join bravely, let us to't pell-mell;
If not to heaven, then hand in hand to hell.
If that wasn't enough blather, I have even more in my blog at http://www.etherfollies.blogspot.com.

 
At 1:43 AM, Anonymous vicodin 5 500 mg dosage said...

abortion is the same as kiling.. period...


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