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Posted on June 6, 2017 at 8:08 AM

Guest post by Cheyn Onarecker, MD

Today, I am continuing my comments on the recent editorial against conscientious objections from the New England Journal of Medicine (subscription required). My previous objections to the elimination of protections for conscientious objections included: 1) the importance of maintaining the traditional balance that has always existed between the needs of the patient and the physician, and 2) the fact that medical societies make decisions on the acceptability of certain procedures that are influenced by society and do not represent the views of a large percentage of its members. I will now add a couple more reasons.

Third, it is impractical and unreasonable to demand that persons considering a career in medicine should be prepared to violate their moral convictions. When the Church Amendment was passed in 1973, allowing physicians to be exempt from performing abortions, there was no outcry from the AMA or any other medical society denouncing the law or declaring that rights of conscience were unethical. Since then, the number of laws and provisions to protect conscience rights have increased, not decreased. Philosopher Mark Wicclair explains that modern medicine, in general, has accepted the right of conscientious objection, and no young person entering medicine today believes that their moral and religious convictions are incompatible with a career in medicine. In fact, the AMA issued a directive to medical schools to excuse students from performing activities that violate their ethical beliefs. Not only that, but how would physicians be able to predict that someday their chosen specialty would develop a controversial treatment? Stahl and Emanuel assume that a medical student could choose radiology, but what does the future of radiology hold? Many physicians have stated that they would rather leave practice than to be forced to do procedures or make referrals against their conscience. With widespread physician shortages already affecting the care of our citizens, what sense does it make to eliminate large numbers of talented young people from a career in medicine because they want to practice medicine conscientiously?

Fourth, by rejecting physicians who practice medicine according to their conscience, we exclude the very professionals we need to prevent medicine from drifting from its ethical moorings. The history of medicine is full of ethical catastrophes, and Stahl and Emanuel cite eugenics and the classification of homosexuality as a disease as recent examples. But, according to the authors, medicine returns to its ethical path through a self-correcting process of “reflective equilibrium,” as if by some magical force, the profession spontaneously changes course and begins to right the wrongs that had been committed. But no magical force or automatic process stopped the forced sterilization of women in the early 20th century. Men and women, guided by their conscience, fought for decades to change the hearts and minds of citizens and the medical profession. Where would we be if they had passively complied with the accepted practice of the day? If we remove such men and women from our profession, who will be the agents of reform when medicine deviates from its proper direction in the future?

A recent Annals of Internal Medicine article about teaching medical ethics under Nazism concludes that the lack of “eternal values” in medical ethics allowed them to be coopted by the politics of the day. Those who expressed any conscientious objection to the prevailing thoughts were systematically removed from medical leadership, resulting in practices that are universally condemned today. Dr. Joe Gibes critiques this study in his April 21st article for the TIU Bioethics Blog. He appropriately concludes, “It is precisely because society, government, and politics are so fickle, that it is vitally important that the practitioners of this art cling tenaciously to the universal values stated so simply and starkly in the Hippocratic Oath: I will not kill, whether in the womb or out of it.”

Finally, since they suggest that healthcare professionals should ignore their conscience and follow the dictates of their professional organizations, Stahl and Emanuel appear to be defeating their own arguments. Following their logic, because most of the professional societies oppose their views and accept physician’s conscience rights, the authors should simply keep quiet. Their article, however, implies that they believe there are times when physicians should take a stand against the status quo. Even by their own standards, conscience must have more than just a limited role in medicine. To eliminate the right of conscience would be to jeopardize the ethical foundations of the profession. Instead, we ought to look for ways that we can accommodate those rights in order to provide excellent care to our patients.

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