Protecting health care professionals who act based on their conscience

by Child of the Ocean

I recently came across an interesting article titled “Conscientious Objection Gone Awry — Restoring Selfless Professionalism in Medicine” by Julie D. Cantor, M.D., J.D., in the New England Journal of Medicine.

This article argues against a rule, the Provider Refusal Rule, from the United States Department of Health and Human Services (DHHS) that legally protects health care professionals who act based on their conscience when treating patients.  For example, if a doctor is morally opposed to euthanasia then, according to the rule, he or she can legally refuse to perform that procedure.  This is undoubtedly a delicate issue, however, the argument presented by Dr. Cantor does not convince me entirely.

The article attempts to make the case that, if health care professionals were allowed to act on their conscience then “everyone connected to health care may opt out of a wide range of activities, from discussions about birth control to referrals for vaccinations … Taken to its logical extreme, the rule could cause health care to grind to a halt.”

Meaning of conscience

Firstly, the article exhibits a misunderstanding of the concept of conscience.  It suggests that “[w]hen broadly defined, conscience is a poor touchstone; it can result in a rule that knows no bounds”.  This conveys the idea that conscience is a matter of personal whim and inherently baseless.  However, conscience does not exist meaningfully without an absolute moral reality underpinning it.  In other words, meaningful conscience is not about whimsically deciding that something is right or wrong.  Instead it is a way of being in touch with the knowledge of what is factually right or wrong.  Knowledge of this moral reality is revealed by the Supreme Lord, and mere opinion does not change this reality.  For example, a person’s opinion of whether fire burns or not does not alter what would happen if that person were to put their hand in fire – they would get burned regardless of their opinion on the matter.  In this case, that fire burns is a factual reality.

Role of conscience in society and specifically health care

Secondly, the author does not seem to understand the magnitude of the positive impact that conscience has had in human societies and in health care.  It is conscience that keeps people from committing murders, not the laws criminalizing the act.  When the recent tragedy in Haiti struck, the many thousands who helped the recovery efforts did so because of their conscience.  When Gandhi urged millions to choose non-violent methods in their struggle for freedom against only a few thousand oppressors it was because of his conscience.  Even Einstein once said, “Never do anything against conscience, even if the state demands it.”

Regarding the health care professions, it cannot be denied that many are drawn to these professions because of their fundamental belief that helping those in need is a good thing; that is their conscience speaking.  The innumerable doctors who have made immense sacrifices to help others did so because of their conscience – this is real “selfless professionalism”.  At this point it must be acknowledged that there have been many atrocities that have been committed by people who kill purportedly because of their conscience.  In such cases, their so-called conscience is not in line with the absolute moral reality, and they will be punished by that same absolute moral reality; just like the person thinking that it is good to put their hand in fire is inevitably burned despite their opinion.

(On a side note, vilifying medical professionals that act on their conscience as possibly having “religious beliefs [that] demand suffering at the end of life” seems unprofessional of the author at best.)

A fundamental right

Finally, being able to think, speak, and act freely according to your conscience (but not criminally) is a fundamental human right.  It is a basic expectation in a free society.  And health care professionals are rightful members of society.  So when an individual who is both a doctor and a lawyer advocates for the suppression of health care professionals’ basic right to exercise their conscience it makes for a rather worrying contradiction.

“Child of the Ocean” is a medical student who blogs at the self-titled site, Child of the Ocean.

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  • http://www.chrisjohnsonmd.com Chris Johnson

    “. . . meaningful conscience is . . . a way of being in touch with the knowledge of what is factually right or wrong. Knowledge of this moral reality is revealed by the Supreme Lord, and mere opinion does not change this reality.”

    Putting it nicely, this is a highly problematical viewpoint for a future medical professional. Less nicely, it’s arrogant. You’re injecting your personal religious beliefs where they don’t belong.

    As a practical matter, this issue most commonly arises over reproductive matters — contraception, abortion, and the like. If you are personally opposed to something that is accepted (and legal) medical practice, your professional responsibility is to refer — respectfully — the patient to another physician. If you have an ethical concern over a hospitalized patient’s care, there are mechanisms for handling that as well. If you are asked to provide something that is possibly (or clearly) illegal, there are ways of dealing with that, too. What you cannot do is impose you notions of right and wrong on someone else. If your conscience is troubled by this, you are in the wrong profession.

    • http://wp.me/pMBQz-2e Child of the Ocean

      @ Chris Johnson

      “You’re injecting your personal religious beliefs where they don’t belong.”
      +
      “What you cannot do is impose you notions of right and wrong on someone else” (sic)
      +
      “Less nicely, it’s arrogant.”

      With all due respect, you are contradicting yourself.

      • http://www.chrisjohnsonmd.com Chris Johnson

        How so? You’re not my patient.

  • Marc Gorayeb, MD

    The piece was published in the NEJM? What brought it to this lowly state? To have published such drivel? I thank this post’s author for bringing it to our attention; it should serve as a good example of the impotent sophism that passes as scholarly work in today’s universities, and legal argumentation in today’s courts.
    The piece is riddled with straw man fallacies, and turns Western philosophical thought on its head. What is moral becomes unethical; what is conscientious becomes self-interested; doing the state’s bidding becomes “selfless professionalism.” The piece argues that we must suspend our shining guideposts – our moral lives – unless the guideposts are sanctioned by the state. Pathetically, the irony of all this is completely lost on the author.
    I began to refute the logic of the piece; but because virtually every paragraph is so factually and logically flawed, it would take too long to do so. Rather, I encourage everyone to read it for themselves (or not). It’s available on the web.
    If this work is the touchstone for rescinding the provider conscience rule, then this nation’s intellectual stock is in deep trouble.

    • Brian

      Long on bluster, short on substance, that.

      What is moral becomes unethical;

      Yes, absolutely, if the subjective moral standard invoked by the provider results in substandard care for the patient.

      what is conscientious becomes self-interested;

      Again, yes! Providers are free to choose their specialties, and I wonder why you seem to believe conscience ought not be at play at that time. If a provider decides to invoke conscience, and in so doing provides substandard or incomplete care to a patient, then you bet it’s self-interested and unprofessional.

      Let us assume, for the moment, that a given procedure would be legal, appropriate, effective, and desirable for a given patient, but the physician fails to even present information about that procedure based upon a philosophical objection thereto. It it right for a physician to artificially narrow a patient’s choices based upon subjective moral consideration? Who is a health care provider to determine for a patient what is or is not morally acceptable?

      doing the state’s bidding becomes “selfless professionalism.”

      Wait, what? This doesn’t even make sense. It’s not about doing the state’s bidding. It’s about not letting your individual feelings get in the way of providing care to a standard that is informed by the best evidence available.

      The piece argues that we must suspend our shining guideposts – our moral lives – unless the guideposts are sanctioned by the state. Pathetically, the irony of all this is completely lost on the author.

      All sound and fury, signifying nothing.

      • http://wp.me/pMBQz-2e Child of the Ocean

        @ Brian

        “Yes, absolutely, if the subjective moral standard invoked by the provider results in substandard care for the patient”
        +
        “…substandard or incomplete care to a patient”

        So Dr. Gorayeb’s view is “subjective” but you claiming that, say for example, refusing abortion is “substandard or incomplete care to the patient” isn’t subjective? What about the millions who think that abortion is nothing short of murder in the womb? So refusing to murder an unborn child or to refer the patient to someone else to commit that murder for them is now “substandard and incomplete care” because you so proclaimed? Or were you just being “subjective”?

        “Long on bluster, short on substance, that.” :)

        • http://www.chrisjohnsonmd.com Chris Johnson

          From the start I assumed this post was about abortion. Internet arguments about abortion never turn out well, although I will say this: abortion, within various limits, is legal. You believe abortion to be murder. That does not make it so; murder is a legal definition. Other religious traditions besides your own do not consider it murder. (See, for example, Dr. Dredd’s comment below.)

          Broadening the discussion from that hot-button issue, I practice pediatric critical care medicine and often deal with end-of-life decisions. I have cared for patients from different cultural and religious traditions, and have been, on occasion, asked to do something that I considered unethical. My professional responsibility in such situations is either to come to a compromise with the family that both of us can accept, or to find another physician for the child if that is not possible. The latter scenario has happened once in thirty years.

          Reality is messy.

          • pcp

            Exactly. This post is not about conscientious objections in any general sense, but specifically about abortion and abortion alone. It would have been more honest for the poster to declare that from the start.

    • http://wp.me/pMBQz-2e Child of the Ocean

      Thank you so much Dr. Goyareb. It’s nice to know there ARE doctors out there who have a conscience, can exercise it, AND perform logical reasoning – all at the same time.

      “What is moral becomes unethical; what is conscientious becomes self-interested; doing the state’s bidding becomes “selfless professionalism.””
      +
      “impotent sophism that passes as scholarly work in today’s universities, and legal argumentation in today’s courts.”

      Agree

      • http://www.chrisjohnsonmd.com Chris Johnson

        “Thank you so much Dr. Goyareb. It’s nice to know there ARE doctors out there who have a conscience, can exercise it, AND perform logical reasoning – all at the same time.”

        Of course there are. And more than a few disagree with your position vehemently.

  • pcp

    Why does “conscientious objection” apply only to those in medicine? Why shouldn’t Burger King be prevented from firing Hindus who refuse to sell meat products at the drive-through?

  • Marc Gorayeb, MD

    Physicians are not slaves to performing procedures just because the procedures can be done. An individual is free to find a physician with compatible moral views. The exceptions that prevent this from happening are really quite rare, notwithstanding the arguments that suggest these exceptions should drive the rule.
    Deciding what constitutes “substandard care” is not a simple matter. I am embarassed to have to state the obvious: the ethical practice of medicine is not prejudiced by adherence to a set of moral principles, particularly if those principles are well-established in our Western traditions.

    • Dr. Dredd

      The ethical practice of medicine is prejudiced by adherence if the patient does not also share a physician’s beliefs. That patient may not be in a position to find someone with “compatible moral views.” Ocean Child gets around this point by claiming that a “Supreme Lord” is the one who determines moral reality (and therefore everyone should have the same moral views), but just saying that doesn’t make it true.

      Furthermore, even if one does accept that a deity determines moral reality, not everyone worships in the same way. I am a Reform Jew; we believe life begins at viability. Why is that any less valid than the belief that life begins at conception?

      • http://wp.me/pMBQz-2e Child of the Ocean

        “That patient may not be in a position to find someone with “compatible moral views.” ”

        I see your point, but please bear in mind that I’m not advocating willy-nilly callous behavior by health-care providers in the name of conscience. I’m talking about the most exceptional of circumstances (such as abortion). I understand this is a difficult topic because it tugs on some very fundamental principles and doctors tend to have strong principles whatever they are.

    • Brian

      Physicians are not slaves to performing procedures just because the procedures can be done.

      No, they’re not. But neither do they have the right to effectively make decisions for patients through omission of information or refusal to provide or refer service.

      An individual is free to find a physician with compatible moral views. The exceptions that prevent this from happening are really quite rare, notwithstanding the arguments that suggest these exceptions should drive the rule.

      It should be noted that a physician is free to choose a specialty that jibes with his/her moral view, as well. In any event, to what extent should a patient be forced to weigh a doctor’s moral positions (which aren’t always easy to discover), and also to consider how that might impact his/her care?

      Deciding what constitutes “substandard care” is not a simple matter. I am embarassed to have to state the obvious: the ethical practice of medicine is not prejudiced by adherence to a set of moral principles, particularly if those principles are well-established in our Western traditions.

      Hmmm. That reads pretty close to you making the claim that our “Western traditions” are rooted in Christianity. And it’s not all that obvious, either. The ethical practice of medicine is prejudiced by adherence to said moral principles if those principles interfere with a patient’s right to informed consent and practice consistent with standard of care.

  • Marc Gorayeb, MD

    I took great pains not to co-mingle religious belief with morality. One can be completely independent of the other. And in the vast majority of situations, the affected patient has the knowledge or resources to find alternative services, if they so choose.
    Getting back to the original post, to use a hypothetical case or rare event as a predicate to mandate a general rule of behavior is weak and unconvincing. In our system, that approach should be reserved for the protection of fundamental constitutional rights of individuals against the government. That is the crux of the matter: the government forcing physicians to speak and behave according to its rules rather than those decided by concensus within the medical profession.

  • http://www.consciencelaws.org Sean Murphy

    “Resisting Ethical Aggression in Medicine,” A response to Cantor’s journal article from the perspective of freedom of conscience, is available at http://www.consciencelaws.org/issues-ethical/ethical079.htm

  • Brian

    This is just the sort of beast that conscience clauses invite.

    http://www.idahopress.com/news/article_528847ac-1e9f-11e0-8247-001cc4c03286.html

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