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Conscientious objection by healthcare professionals a ‘cultural proxy war’

Refusing to administer certain treatments on grounds of conscientious objection by medical professionals has turned into “a kind of a cultural proxy war, driven by implicit ideological commitments”, writes Chris Bateman, quoting Stuart Rennie, an associate professor of Social Medicine at the University of North Carolina at Chapel Hill, during a collegial debate at the 16th annual international conference on Clinical Ethics and Consultation.

The event took place at the Asara Wine Estate in Stellenbosch from 30 November to 3 December last year. The hybrid conference, attended by some 70 delegates in person and about 250 registered online, went ahead after its postponement in April 2020 due to COVID-19. Physical attendance this time was curtailed by the November uncovering in South Africa of the Omicron variant and precautionary flight bans imposed by several countries, both before and after its subsequent emergence globally.

Rennie and his colleague, Udo Schuklenk, professor of Philosophy at Queen's University, Kingston, and Ontario Research Chair in Bioethics, were debating a motion that “doctors in hospitals have no moral justification for demanding conscientious objection accommodation as far as the delivery of professional services within their scope of practice to eligible patients who request those services”.

Among the more contentious areas where some doctors refuse to treat patients, (or refer them to colleagues), are abortion, euthanasia or assisted suicide, gender re-assignment surgery and/or surgery to lesbian, gay, bi-sexual or transexual people, or prescribing hormone-altering, emergency contraception or memory-enhancing drugs.

Rennie argued for compromise and a change to legal frameworks and policies in the many countries where conscientious refusal to treat by medical professionals is allowed, saying this was necessary to “create room” for conscientious objection by healthcare professionals. He “drew the line” at Schuklenk’s contention that eliminating conscientious objection from medicine altogether, mainly because of its clash with the central tenets of the Hippocratic Oath, was the only pragmatic way to go.

“I don’t think that’s going to work. I don’t think the United States is going to become Sweden (and several other Scandinavian countries where legal clauses allowing conscientious objection by healthcare professionals simply don’t exist), or something like that.

"The chances of that seem slim to me. While I agree there’s a lot of abuse taking place and a lot of conscience clauses that are more protective of healthcare professionals than patients, change is needed. The question is, what kind of changes? Reform? Or just eliminating conscientious objection altogether? If you ask me to be realistic, I’d say one should at least start with a better compromise position than the one we have,” he said.

Schuklenk argued that the “ethics” underlying the accommodation of what he termed “a conscientious refuser in modern medicine” were fundamentally flawed when it came to the very raison d’etre for a person entering the study and practice of medicine.

“The healthcare professional acknowledges he or she has a professional obligation to provide patient care, yet refuses to provide a service, not on grounds of professional judgment, but on grounds of individual conscience. The issue is not conscientious objection, but conscientious refusal, because a professional could object to a practice on grounds of his or her conscience, but provide the service anyway, being professionally obliged to do so,” he explained.

Underpinning this, he cited the World Medical Association’s (WMA), modern (2017), adaptation of the Hippocratic Oath, i.e.: “I solemnly pledge to dedicate my life to the service of humanity; the health and well-being of my patient will be my first consideration, and I will practice my profession with conscience and dignity and in accordance with good medical practice”. Schuklenk noted the Association’s emphasis on good medical practice: it must take priority over personal conscience issues.

He added, “It’s got so bad that in some states of the US healthcare professionals have a right to refuse healthcare even in life-threatening circumstances, and they will get away with it, scot-free! What’s happened here is that culture wars have finally landed in medicine. They’ve been there for some time outside, but now they’ve infiltrated medicine.”

‘Moral compromise’ comes with the job

He took “brutal exception” to one academic assertion, (Cowley et al) that “being forced to act against one’s conscience can result in a loss of integrity, and this in turn leads to strong feelings of guilt, remorse, and shame as well as a loss of self-respect”, and to people dropping out of the profession, or, “if they know their integrity will not be protected, not entering the profession in the first place”.

“My view here is brutal, straightforward and honest. Don’t volunteer to join a profession where the delivery of some of its core services threatens your integrity. Become a taxi driver or a painter rather, or a philosophy professor like me! Vulnerable patients are the weaker party here, their access to services takes priority over a professional’s integrity issues.”

Schuklenk questioned why “today, many of us mistakenly think that conscientious objectors are honourable people, real ethical people…the reason, I think, is historical”.

“In the year 295, Emperor Maximilianus refused to join the Roman army, so they murdered him; during the Nazi reign in Germany, they murdered Quakers; people are jailed in some countries for refusing to join military service.”

He said that today, international human rights documents protected such conscientious objectors, who were markedly different from medical professionals who volunteer to join the healthcare professions. “It’s not your conscience that drives your clinical judgment,” he stressed.

He quoted a former Roman Catholic priest and academic, Daniel Sulmasy, director of Georgetown University’s Kennedy Institute of Ethics: “Conscience is our conviction that we should act in accordance with our individual understanding of what morality demands of us, and on wilfully and voluntarily acting in accordance with what we consider to be morally good and right.”

Schuklenk agreed that these acts could be both retrospective and prospective. More importantly however, conscience had “no relevant epistemic property”.

“Instead, it’s a really a strong feeling you have. Nazis and Ku Klux clan members have conscience – but we can be really wrong, no matter what our conscience tells us.”

Incompatibility thesis

He and his colleagues had come up with what they called “the incompatibility thesis”.

This posits that unlike refusing treatment on professional, clinical grounds, the actions of “conscientious refusers” are motivated by judgments that are conscience-based.

“They know exactly what their obligations are and yet they decide not to do it, based on their idiosyncractic personal beliefs. Simply put, professional conduct and conscientious refuser accommodation are incompatible,” he added.

Rennie said the general aim of his contrary “compromise position” was to constrain conscientious objection, not eliminate it, “such as to strike a reasonable balance between healthcare professionals’ exercise of conscience and the interests/rights of patients”.
The position assumes that such objections can be based on values vitally important to the objector, and typically are part of a shared moral tradition, rather than an idiosyncratic subjective stance.

Whenever feasible, he said, objecting healthcare professionals should provide advance notification to patients/surrogates, administrators, supervisors and or employers. Their accommodation should not impede a patient’s or their surrogate’s timely access to information, counselling and referral, nor impede a patient’s timely access to healthcare that is legal and consistent with accepted medical standards of care. Such accommodation should also not impose excessive burdens on other healthcare professionals, administrators or organisations, nor enable discrimination.

“These guidelines I suggest are not defending the status quo – rather, they provide a critical perspective on existing ‘conscience clauses’,” he said.

Rennie said if access to abortion were a concern, it would be better to advocate for more abortion providers and clinics. Conscientious objection is generally not the major obstacle to abortion access for patients.

Citing the South African Choice on Termination of Pregnancy Act, (1996), he said it did not obligate healthcare workers to take active part in an abortion but rather obligated them to assist in saving the life of a patient, even if the emergency were related to an abortion.

“On a compromise view, some conscientious objections should be rejected, and objectors should bite the bullet,” he conceded. However, measures should be taken to “reduce the potential for these dilemma-causing situations”.

Rennie said conscientious objection was rooted in a long cultural history, which did not make such beliefs correct. However, much of modern debate had “a tendency to pretty much discredit conscientious objection to further assert an argument”.

“That’s no surprise. It’s a kind of a cultural proxy war.”

 

See more from MedicalBrief archives:

 

ICCEC 2021: International focus on the ethical dilemmas of COVID-19

 

Emotional debate anticipated over amendment to SA 'abortion' Bill

 

Are the Dutch euthanasia laws a 'slippery slope'?

 

The complex story of 'medical xenophobia' in SA

 

Mandatory vaccinations: 'Ethical and necessary’ in South Africa

 

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