The following is a commentary on last week’s post, Conscientious Objection in Medicine: A Moral Dilemma, written by Dr. Bradley.
Commentary by Antonella Surbone, MD PhD FACP, Ethics Editor
The piece by Dr. Bradley raises a highly controversial issue in today’s medicine, physicians’ conscientious objection. Dr. Bradley reviews recent legislature, as well as medical literature, including the underlying ethical argumentation. Unfortunately, the key issue of ethical and moral justification for conscientious objection in medicine is unlikely to be resolved through abstract debate and argumentation, no matter how cogent. In fact, when we talk of “patients’ wishes within reason” or of “appropriate treatment” , we inevitably stumble upon the real core issue at stake: by whom and how is it decided what a reasonable or an appropriate wish is. Morally speaking, who can claim to have the “true final saying” in the cases presented as examples? The woman who decides for an abortion because she was raped (or because she’s already a single mother of two who can’t afford to provide for a third child) or the religious physician whose religious faith tells him that abortion is killing a human life and cannot be performed under any circumstances? In the case of assisted suicide, isn’t it the same? Once we have established the patient’s competence and excluded the presence of untreated depression or pain, or of any external influence on his or her decision, can we then move on to say that the patient’s wishes to die are within reason? They may be legally valid, but their moral justification can still be questioned by a physician who opposes any form of killing, rather than healing, as part of his or her professional duties. (1)
Medically appropriate, legal, ethical and moral are not only different terms, but they do apply to different spheres of our life and reasoning. Yet, they are inextricably bound together in the daily reality of clinical medicine, and physicians have the obligation to reflect very seriously about their professional commitments, as well as the boundaries that they may or may not be allowed to impose once they have chosen medicine as a profession. (2) The Preamble to the AMA Declaration of Professional Responsibility states, on behalf of all physicians, that “humanity is our patient” and that we have the duty to treat the sick and injured with competence and compassion, and without prejudices, e racial, ethnic, and other forms of biases. (3) This involves respecting patient’s values and autonomy. In my medical oncology practices, have I seen, sometimes in the same day of clinics, young women diagnosed with breast cancer opting for an abortion and others determined to continue a risky pregnancy: I spoke at length with all of them, provided all available information and even expressed my own opinion, when I was directly asked for it. In the end, I respected their decisions, which they all had reached through a difficult process of pondering all pro and cons, in consideration of their individual circumstances and values.
In the end, today’s ethical debate centers around two opposed views: one assumes patient autonomy as central to today’s medical care, where patients and physicians are bound through a relationship of equal partnership and patients are often called “clients or consumers” of “physicians providing services”. The other considers the patient-doctor relationship as an asymmetric relation of help, based on the need that the patient has for the help of the physician, with knowledge and experience in a given field of medicine.
According to the first view, once a medical treatment is medically and legally approved, there is no place for conscientious opposition. By contrast, where more importance is given to the relational aspects of the patient-doctor relationship, there is more space for patients and doctors to debate the morality of patients’ choices or requests. As a consequence, the physician may express his or her different own moral or religious convictions and assume a position of conscientious objection, if another physician is available and willing to promptly assume the patient’s care and abide by the patient’s desires or requests.
This kind of referral must be done personally by the physician claiming a right to conscientious objection to a colleague, and always after having always provided the patient with full unbiased information. As Dr. Bradley reports, referral policies carry the potential risk to invalidate the informed consent process: an ethical mistake that no physician can commit any longer.
I wish to end my brief commentary by referring all interested readers to the extensive written and online debate that has followed the article by Dr. Savulescu in BMJ. (4) The many commentaries of some among the best known and most respected bioethicists will intensely stimulate reactions and thoughts: I highly recommend it to all physicians at any stage in their career, since we all have encountered situations where our beliefs of what was appropriate or reasonable for our patients’ were discordant with what they considered such, and younger doctors will find face similar situations too. Indeed, it is not solely the refusal of abortion or PAS that may raise moral issues of conscientious objection. On the contrary, pondering how we wish to reach a common meaning of “reasonable wish ” or “appropriate treatment” together with our patients, applies to many of our clinical decisions.
At the risk of falling into the easy solution of using casuistry instead of ethical argumentation and justification, however, I will conclude with my personal experience of a successful ethical patient’s referral. The patient was me, I had been hospitalized as an emergency at the end of my second month of pregnancy for a serious complication that could have threatened both my life and the developing one of my future child. I spent eight consecutive months at two major teaching hospitals in NYC, initially cared for by my OB-GYN, who came to make a diagnosis, but then concluded that the pregnancy was at too high risk for both me and the fetus. She spent a long time explaining all details to me, and I understood them fully. Yet, I had always dreamed of a child and I was 41 year old : I decided that I would not have an abortion, not even an amniocentesis, and I would accept God’s or nature’s decision. After a month, my OB-GYN came into my room one evening, accompanied by a trusted colleague of hers, and told me that she could no longer care for me, but he had accepted to do it. I was transferred to a different institution, cared for wonderfully by my new OB-GYN and visited occasionally by my prior one. All went well in the end, though it wasn’t an easy time of my life. Upon discharge from follow-up post-partum care, I resumed seeing my old OB-GYN for regular check-ups. I always considered what she had done, and how she had done it, highly moral.
Medicine involves abstract ethical and legal debate, but medicine is first a profession we undertake to help suffering human beings, with whom we connect. Being capable of doing so is the essence of being a doctor.
1. Pellegrino ED. Doctors must not kill. J Clin Ethics 1992; 3:95-102.
2. American Medical Association. AMA Code of Medical Ethics: current opinions with annotations 2008-2009.
3. American Medical Association. Declaration of Professional Responsibility. Available at www.AMA.org
4. British Medical Journal, online comments to Savulescu J. “Conscientious Objection in Medicine.” BMJ 2006;332:294-297.