Friday, 23 March 2007

Medicine and morality

The New England Journal of Medicine recently published a paper titled Religion, Conscience, and Controversial Clinical Practices. It was the results of a survey asking physicians about their views on providing treatments that they object to on moral grounds. In their introduction they state:
On the one hand, most people believe that health professionals should not have to engage in medical practices about which they have moral qualms. On the other hand, most people also believe that patients should have access to legal treatments, even in situations in which their physicians are troubled about the moral implications of those treatments. Such situations raise a number of questions about the balance of rights and obligations within the doctor–patient relationship. Is it ethical for physicians to describe their objections to patients? Should physicians have the right to refuse to discuss, provide, or refer patients for medical interventions to which they have moral objections?

The medical profession appears to be divided on this issue. Historically, doctors and nurses have not been required to participate in abortions or assist patients in suicide, even where those interventions are legally sanctioned. In recent years, several states have passed laws that shield physicians and other health care providers from adverse consequences for refusing to participate in medical services that would violate their consciences. For example, the Illinois Health Care Right of Conscience Act protects a health care provider from all liability or discrimination that might result as a consequence of "his or her refusal to perform, assist, counsel, suggest, recommend, refer or participate in any way in any particular form of health care service which is contrary to the conscience of such physician or health care personnel." In the wake of recent controversies over emergency contraception, editorials in leading clinical journals have criticized these "conscience clauses" and challenged the idea that physicians may deny legally and medically permitted medical interventions, particularly if their objections are personal and religious. Charo, for example, suggests that the conflict about conscience clauses "represents the latest struggle with regard to religion in America," and she criticizes those medical professionals who would claim "an unfettered right to personal autonomy while holding monopolistic control over a public good." Savulescu takes a stronger stance, arguing that "a doctor's conscience has little place in the delivery of modern medical care" and that "if people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors.
Savulescu's article that is referenced concludes:
Values are important parts of our lives. But values and conscience have different roles in public and private life. They should influence discussion on what kind of health system to deliver. But they should not influence the care an individual doctor offers to his or her patient. The door to "value-driven medicine" is a door to a Pandora's box of idiosyncratic, bigoted, discriminatory medicine. Public servants must act in the public interest, not their own.
The New England Journal of Medicine article, while weighing in on this problem, is actually a survey of 1144 physicians and analysis of only a few of the comments. The survey, while comprehensive, is slightly simplistic in how it approaches ethical questions. They find that
  • 63% of physicians believe that it is ethically permissible for doctors to explain their moral objections to patients
  • 86% believe that physicians are obligated to present all options
  • 71% believe physicians are to refer the patient to another clinician who does not object to the requested procedure
They also found that those that did not think they needed to disclose information about alternative procedures or needed to refer patients for medical procedures to which they objected on moral grounds were more likely to be men, those who were religious, and those who had personal objections to morally controversial clinical practices.

In their conclusion they make the astute observation:
Thus, those physicians who are most likely to be asked to act against their consciences are the ones who are most likely to say that physicians should not have to do so.
And this is the point isn't it. It is pointless to ask persons about objecting to behaviour they do not find morally repugnant. Issues discussed included contraception, abortion, assisted reproduction, euthanasia. It is not uncommon for persons to find these behaviours acceptable. It is all very fine for those that accept these activities to condemn those who don't for being unwilling to do them or even being unwilling to refer patients elsewhere. But many people find it difficult to understand others point of views. What they need to do is ask physicians about other objectionable practices; practices that pro-abortionists may not find acceptable. 2 examples would be administering a lethal injection to a criminal or handing over homosexual offenders (in a Muslim country say) to the authorities for imprisonment or execution.

The predictable response to this suggestion will be that these actions are immoral and therefore the issue is irrelevant. It however is very relevant and perfectly illustrates the point. They claim it is immoral to think abortion is wrong, it is immoral to tell a patient your anti-abortion views, it is immoral not to perform the procedure (especially if you base your opinion on "religious" reasons), if you refuse to perform the procedure it is immoral not to refer the patient. But place them in the same position with regard to something they morally object to and they will say they are not bound to behave in this way because it is wrong. But what is "wrong" in this sentence but a moral judgment?

Trevor G Stammers in the rapid responses to Savulescu's article says:
...if values have no place in determining medical care, on what basis does Savulescu attempt to impose his own moral values on conscientious objectors? The paternalism he so despises is only matched by Savulescu’s own and his ideal of “statute-driven medicine” seems to me more ‘idiosyncratic, bigoted and discriminatory’ than the moral values he is so intolerant of.
The objectors claim moral neutrality but they are far from it. If placed in a situation they find morally obscene they would think similarly, how could one not. To ask someone to restrict moral behaviour to his private life results in cognitive dissonance. To ask someone to behave contrary to his morals is morally repugnant. And to act according to one's morals is far more moral than to act against them.

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