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Posted by on Nov 4, 2016 | 1 comment

Do Doctors Need Consciences?

dr-noShould medical professionals have consciences? A recent statement by a group of bioethicists suggests we might be better off if they didn’t. In their words, “The status quo regarding conscientious objection in healthcare in the UK and several other modern Western countries is indefensible.”[1] Instead, the bioethicists recommend 10 ethical guidelines for conscientious objection, including the following:

  1. Healthcare practitioners’ primary obligations are towards their patients, not towards their own personal conscience. When the patient’s wellbeing (or best interest, or health) is at stake, healthcare practitioners’ professional obligations should normally take priority over their personal moral or religious views.
  2. In the event of a conflict between practitioners’ conscience and a patient’s desire for a legal, professionally sanctioned medical service, healthcare practitioners should always ensure that patients receive timely medical care. … In emergency situations, when referral is not possible, or when it poses too great a burden on patients or on the healthcare system, health practitioners should perform the treatment themselves.

Although it is short and underdeveloped, the statement contains several claims that deserve examination. In this blog post I am interested only in the authors’ concept of the conscience, which they define as the moral and religious views of healthcare practitioners that prevent them from providing services like abortion or medical assistance in dying to their patients. On that basis, the authors then argue that conscientious objection in healthcare is at best a nuisance, and at worst a threat to the interests of patients and society. Indeed, from the statement alone it is difficult to see any positive value for consciences in the healthcare system, or why societies might have any interest in accommodating conscientious objection by medical practitioners.

There are a variety of legal, ethical, and theological arguments that could be made against the positions in the statement, but in the remainder of this post my modest goal is simply to suggest that consciences do have a role in healthcare, and we can see this in the controversies surrounding the practice of CPR and other life-sustaining treatments.

From television alone, CPR or cardio-pulmonary resuscitation may not seem like a complex or controversial treatment. But already in the 1980s, resuscitation in a hospital setting involved an impressive array of treatments, such as “placing tubes within the trachea for artificial respiration; electro-cardiac shock; introducing one or more intravenous lines; administering intravenous medication… and in rare circumstances, emergency placement of a temporary pacemaker.”[2] Since then, even more options have become available, including the amazing Extracorporeal Membrane Oxygenation Machine.[3]

The proliferation of life-saving and sustaining treatments presents doctors, patients, and everyone else involved in healthcare with difficult decisions about when to initiate, withdraw, and/or withhold such treatments. In response, medical associations in Australia, Canada, the United Kingdom and the United States have issued recent policy statements about decision making in end of life and intensive care. The Canadian Medical Association puts the issue quite plainly: “CPR is not clinically indicated in all cases … there are people who benefit from life-saving and -sustaining interventions, and others for whom there is no benefit and potentially significant harm … it may serve only to increase pain and suffering and prolong dying.”[4]

In other words, for every case the potential benefits and burdens of each treatment must be evaluated carefully, which means that for better or worse the personal conscience of the patient and their physician will be involved. [5] Why is the physician involved? Because while it’s the patient that will live, die, and suffer, very few patients have the medical education or experience to understand the range of possible treatments and make a well-informed judgment about the benefits and burdens of different options. In turn, the physician must have not only medical knowledge, but also a conscience, because they need both the compassion to understand the hope and suffering of their patients and the courage to challenge their desires and expectations of medicine, and in some cases, refuse to meet them.

Indeed, the relevance of the physician’s ethics is defended by a recent consensus statement of five critical and intensive care societies. The authors of this multi-society statement give several reasons why doctors should refuse to give futile interventions, first being that “administering ineffective interventions goes against the most basic ethical obligations of clinicians to benefit individual patients and to avoid harm.”[6] They also argue refusals are justified by an “obligation to steward medical resources responsibly, which preclude administering expensive interventions that cannot accomplish the desired physiological goals.” Finally, they suggest the integrity and trustworthiness of the medical profession “would be undermined if clinicians administered interventions that they knew could not benefit the patient.”

Yet even if doctors need ethics to make decisions about life-saving and sustaining treatments, how does that justify accommodating medical practitioners who give a blanket refusal to giving or administering lethal prescriptions to assist death? First, although the goal of one set of interventions is to save life, and the other is to end it, “all refusals of therapy are ultimately justified by the ethical belief that the goal of therapy is to provide benefit and avoid harm.”[7] Obviously, different people disagree on whether medical assistance in dying provides benefit or harm, but as we’ve seen, decisions around life-saving and sustaining treatments are just as controversial.

Second, for anyone – in medicine or outside – to merit description as courageous, compassionate, conscientious, honest, or prudent, they must be consistently so. Some who is courageous only when there is no pressure to compromise is not courageous at all; the same goes for any other display of conscience. Therefore, unless we want medical practitioners who will never refuse any request, not even for the most expensive, ineffective, and futile treatments, we must keep space for conscientious objection in healthcare.

[1] Savulescu et al, “Consensus Statement on Conscientious Objection in Healthcare,” 2016. Available at http://blog.practicalethics.ox.ac.uk/2016/08/consensus-statement-on-conscientious-objection-in-healthcare/.

[2] George J. Annas, “CPR: When the Beat Should Stop,” Hastings Center Report 12, 1982.

[3] For more details on ECMO, see http://emedicine.medscape.com/article/1818617-overview.

[4] Canadian Medical Association, “CMA Statement on Life-Saving and -Sustaining Interventions,” 2013. Available at http://policybase.cma.ca/dbtw-wpd/Policypdf/PD14-01.pdf.

[5] Of course, in many situations involving life-support the patient is unconscious and a surrogate makes decisions for them, and furthermore physicians may have to consult with a committee or board regarding their treatment. For the sake of argument, however, I will refer to a scenario with a single patient and physician.

[6] Bosslet et al, “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units,” 2015. Available at https://www.thoracic.org/statements/resources/cc/inappropr-ther-st.pdf

[7] Goligher et al, “Why conscientious objection merits respect,” Canadian Medical Association Journal 188, 2016.

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Michael

Michael began his bachelor's degree in science at The King's University College, completed a master's degree in theology at Regent College, and is now a doctoral student in theology at Regis College. Aside from a certain similarity in names, all three schools inculcated an appreciation for philosophy, in which Michael continues to dabble while working towards a dissertation on the ethics of enhancement. When he's not studying, Michael enjoys biking in Toronto traffic, watching speculative television shows, and playing board games with his wife Irene.
  • Jisoo

    Thank you Michael for this post. When discussing professional “primary obligations toward the patient” versus “personal conscience”; I think it boils down a complex area of Medicine into a simple dichotomy. As a practicing paediatrician I feel that a lot of the time my “professional conscience” brings technicolour to my “personal conscience” as a Christian. It no longer becomes an ethical debate scoured over philosophy & religious text books where one is tallying the ‘pro-life’ ‘pro-choice’ arguments…. I am faced with people with a story to tell. I have been in “no hope” situations for children stuck on ventilators as a vegetable since birth and kept alive for over half a year because parents (often religious) are convinced that God’s miracle will happen – refusing to believe that what the medical team have told them is true. And having been thru cases like these, you kinda wonder whether “pro-life” is really “pro-life” at all… and perhaps we are actually trying to defy God when He is calling someone home.