Medical conscience for me, but not for thee

Promoting a one-way conscience right favouring the medical intelligentsia

National Review

Wesley J. Smith*

The New York Times has published an opinion column by cardiologist Sandeep Jauhar that decries the Trump administration’s increased enforcement of medical conscience. But he actually promotes a one-way conscience right that favors protecting the predominate ideological views of the medical intelligentsia, while forcing dissenters to sacrifice their own religious and moral beliefs. . . [Full text]

A Philosophical Defense of Conscientious Objection to Abortion

Medical Bag

Medical Bag Contributing Writer

In an article published in the Journal of Medical Ethics, Bruce Philip Blackshaw of the department of philosophy at the University of Birmingham, United Kingdom, and Daniel Rodger from the School of Health and Social Care, London South Bank University, United Kingdom, defended conscientious objection to abortion provision, claiming that the usual arguments critics make for disqualifying conscientious objection in healthcare do not apply in cases of abortion. . . [Full text]

Professionalism eliminates religion as a proper tool for doctors rendering advice to patients

Udo Schuklenk

Abstract

Journal of Medical Ethics

Religious considerations and language do not typically belong in the professional advice rendered by a doctor to a patient. Among the rationales mounted by Greenblum and Hubbard in support of that conclusion is that religious considerations and language are incompatible with the role of doctors as public officials.1 Much as I agree with their conclusion, I take issue with this particular aspect of their analysis. It seems based on a mischaracterisation of what societal role doctors fulfil, qua doctors. What obliges doctors to communicate by means of content that is expressed in public reason-based language is not that they are public officials. Doctors as doctors are not necessarily public officials. Rather, doctors have such obligations, because they are professionals. Unlike public officials doctors are part of a profession that is to a significant extent self-governing. This holds true for all professions. The …

Responding to religious patients: why physicians have no business doing theology. Jake Greenblum Ryan K Hubbard Journal of Medical Ethics 2019; – Published Online First: 20 Jun 2019. doi: 10.1136/medethics-2019-105452


Schuklenk U. Professionalism eliminates religion as a proper tool for doctors rendering advice to patients. J Medical Ethics. 2019 Sep 12. pii: medethics-2019-105703. doi: 10.1136/medethics-2019-105703. [Epub ahead of print]

Why not common morality?

Rosamond Rhodes

Abstract

Journal of Medical Ethics

This paper challenges the leading common morality accounts of medical ethics which hold that medical ethics is nothing but the ethics of everyday life applied to today’s high-tech medicine. Using illustrative examples, the paper shows that neither the Beauchamp and Childress four-principle account of medical ethics nor the Gert et al 10-rule version is an adequate and appropriate guide for physicians’ actions. By demonstrating that medical ethics is distinctly different from the ethics of everyday life and cannot be derived from it, the paper argues that medical professionals need a touchstone other than common morality for guiding their professional decisions. That conclusion implies that a new theory of medical ethics is needed to replace common morality as the standard for understanding how medical professionals should behave and what medical professionalism entails. En route to making this argument, the paper addresses fundamental issues that require clarification: what is a profession? how is a profession different from a role? how is medical ethics related to medical professionalism? The paper concludes with a preliminary sketch for a theory of medical ethics.


Rhodes R. Why not common morality? J Med Ethics 2019;0:1–8. Published Online First: 11 September 2019. doi: 10.1136/medethics-2019-105621

Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion

 Bruce Philip Blackshaw, Daniel Rodger

 Abstract

Journal of Medical Ethics

Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice.


Blackshaw BP, Rodger D. Questionable benefits and unavoidable personal beliefs: defending conscientious objection for abortion. J Medical Ethics 2019 Aug 31. pii: medethics-2019-105566. doi: 10.1136/medethics-2019-105566. [Epub ahead of print]

Conscientious objection: how much discretionary power should physicians have?

BioEdge

Xavier Symons

There has been significant debate about conscientious objection in healthcare in recent years. Some scholars have argued that conscience protections in law and professional codes of conduct may lead to negligence in medical care and may put patient wellbeing at risk. For example, Oxford bioethicist Julian Savulescu has argued that conscience protections open a “Pandora’s box of idiosyncratic, bigoted, discriminatory medicine”, and that “public servants must act in the public interest, not their own”. 

But should physicians have the right to exercise professional discretion with patients? 

Some scholars, such as Daniel Sulmasy, argue that physician discretion is an essential part of good medical practice, and that restrictions on conscientious objection would have a negative impact on medical care. In a 2017 article in the Cambridge Quarterly of Healthcare Ethics, Sulmasy argued that physicians should have the right to exercise their judgement about which treatments they will provide, provided that they are not practicing medicine in a manner that is discriminatory or harmful to patients. He wrote that “professional judgments are both technical and moral in all cases”  and that it is important to “respect and protect a wide discretionary space for physicians regarding ethically controversial interventions”. According to Sulmasy, 

“Conscientious refraining from actions when such restraint does not risk illness, injury, or death, would not seem to rise to the level of being sufficient grounds for compelling conscience”.

This argument, however, has been criticised. Doug McConnell, an ethicist at the University of Oxford, argues in the journal Bioethics (and in Oxford’s Practical Ethics blog) that too much physician discretion can lead to people being denied basic forms of medical care. While Sulmasy agrees that physicians should not practice discriminatory medicine, his framework still allows for objecting doctors to refuse patients treatment for “commonly accepted ailments, such as rashes, headaches, mild depression and anxiety”. 

McConnell also argues that Sulmasy’s framework undermines the fiduciary relationship that clinicians should have with their patients. Sulmasy appears to give equal weight to the interests of doctors and the interests of patients. Thus, a doctor can refuse a patient a treatment if the treatment conflicts with their ethical or religious convictions. But McConnell argues that this is incompatible with a fiduciary relationship: 

“within fiduciary relationships, the party with the fiduciary duty should place greater weight on the others’ interests and, so be prepared to go against his conscience”. 

Physicians, in other words, should be prepared to put patient interests ahead of their own moral or religious convictions. 

Yet McConnell may have misunderstood Sulmasy’s account of the fiduciary relationship between clinicians and patients. Sulmasy is a student of Edmund Pellegrino — a medical ethicist who wrote at length about the notion of “the patient’s good”, and argued that this should be at the centre of a doctor’s professional concerns. It is hard to believe that Sulmasy would downplay a physician’s duties to their patients. 

Perhaps the real distinction between McConnell and Sulmasy is not their concern for the good of the patient, but rather the way in which they conceptualise the patient’s good. For Sulmasy, the patient’s good is determined by a set of moral and technical considerations, whereas for McConnell, the patient’s good is more a matter of their individual preferences and interests.

This article is published by Xavier Symons and BioEdge under a Creative Commons licence. You may republish it or translate it free of charge with attribution for non-commercial purposes following these guidelines. If you teach at a university we ask that your department make a donation to BioEdge. Commercial media must contact BioEdge for permission and fees.

Conscientious Objection, Professional Discretionary Space, and Good Medicine

Practical Ethics

Doug McConnell

Some argue that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences (Sulmasy, 2017). Interestingly, those who are against conscientious objection in medicine make the exact opposite claim – giving physicians the freedom to act on their consciences will undermine good medicine. So who is right here? . . . [Full text]

Defending freedom of conscience on emergency contraception

CMF Blogs
Reproduced with permission

Philippa Taylor*

The UK’s biggest abortion provider, British Pregnancy Advisory Service (BPAS), has attacked pharmacists who do not sell the ‘morning-after pill’ for conscience reasons. 

After one incident when a pharmacist would not dispense emergency contraception to a woman for ‘personal’ reasons, BPAS condemned both the pharmacist and the conscience protections provided to pharmacists. A petition was set up to prevent pharmacists from claiming freedom of conscience rights. 

Under the current law, covered by guidance from the General Pharmaceutical Council (GPhC), pharmacists with a genuine conscientious objection to selling the pill may refer the customer to another pharmacist.

However, BPAS complained that it is ‘impossible to overstate the significance of even one pharmacist conscientiously objecting to selling the morning-after pill’. 

Fortunately, the General Pharmaceutical Council, in this case, upheld its guidelines and the consequent media coverage has now died down, temporarily at least.

This may seem like a one-off minor incident, but it is an illustration of increasing pressures on freedom of conscience protections. It is often assumed that the role of the conscience in medicine is relevant only to a few specialised and limited areas such as contraception or abortion, but in fact, the concept of the conscience goes right to the heart of what it means to act in a moral way, to act with integrity.

If we do not stand by those who are under pressure, the problems will only get worse and will spread. A well-known quote, often attibuted to Burke though it may have come originally from J S Mill, warns: ‘He should not be lulled to repose by the delusion that he does no harm who takes no part in public affairs. He should know that bad men need no better opportunity than when good men look on and do nothing.’

The Christian Medical Fellowship (CMF) has therefore written to the General Pharmaceutical Council to ensure they are aware of our concerns and to thank them for holding to their guidance. The text of our letter is as follows, with their response after it:

‘I am writing to you following the recent news coverage of a Lloyds pharmacy worker who, according to news reports, conscientiously objected to selling the morning-after pill and directed a customer to another pharmacy instead. I note that a petition has since been set up to prevent pharmacists from claiming conscientious objection rights.

‘The Christian Medical Fellowship is the UK’s largest faith-based group of health professionals and we contributed with both written and oral evidence to your review of your Guidance on Religion, Personal Values and Beliefs. We publicly welcomed the new Guidance and the statement accompanying it, in which the Chief Executive of the General Pharmaceutical Council highlighted the positive contribution that pharmacists’ faith can make in their provision of care. We also welcomed the clear statement that: “Pharmacy professionals have the right to practise in line with their religion, personal values or beliefs”.

‘We all aspire to person-centred care. In any care scenario, there are (at least) two parties – the carer and the one receiving care – each of whom has rights. The General Pharmaceutical Council guidance helpfully achieves a balance between the patient’s right to service access and the pharmacist’s right to freedom of conscience.

Respect for the sincerely held religious and moral beliefs of employees is essential and we are concerned that some of the demands being made, based on this one recent case, would marginalise the beliefs, values and religion of pharmacists disproportionately and unnecessarily, and trivialise their right to freedom of conscience under the law. Despite widespread coverage of this case, we have yet to see evidence of recurring complaints under the present provisions.

‘While we strongly support the right to freedom of conscience for pharmacists, we do also emphasise the importance of openness and sensitive communication with colleagues and employers; any refusal to supply should be made courteously and sensitively.

‘On behalf of CMF, I want to thank the Council for protecting the right of pharmacists to refuse to engage in certain procedures that violate their most profound moral convictions.

‘I also encourage the Council to continue to make it clear, publicly, that all pharmacy professionals have the right to practise in line with their religion, personal values or beliefs.

Yours faithfully

Dr Mark Pickering
Chief Executive, CMF

The General Pharmaceutical Council replied with the following two sentences:

‘Our existing guidance In practice: Guidance on religion, personal values and beliefs (to which you refer) remains in place. We have no current plans to review it. As you are aware, the guidance sits under our standards for pharmacy professionals and relates to standard 1, Pharmacy professionals must provide person-centred care.’

The point here is simple but vital: if we care about liberty and personal integrity, we must make a reasoned defence of it in the public square, from the smallest incident to the biggest.

Physician-Assisted Suicide and the Perils of Empirical Ethical Research

JAMA Netw Open. 2019;2(8):e198628. doi:10.1001/jamanetworkopen.2019.8628

Daniel P. Sulmasy

Al Rabadi et al1 compare statistics on physician-assisted suicide (PAS) available from public databases for the states of Washington and Oregon and find similar profiles and trends, which is unsurprising given the similarity of the laws and demographic characteristics of these states. Among the unanswered questions are what such a study can contribute to medical ethics (about PAS or any other ethical controversy) and what the limits are of such work.

Cautions

First, it should be noted that the medical literature is, in general, favorably disposed toward the empirical and the new. Although this predilection is often advantageous for scientific progress, it introduces a problematic bias when applied to ethical questions. The appeal of the study by Al Rabadi et al1 is that it is empirical, and by comparing data from 2 states for the first time, it can be considered novel. Because there are new reports each year and the practice of PAS is legal in only a few states, descriptive reports about PAS are published frequently. This means, however, that articles defending the ethical status quo (ie, against PAS) tend to be shut out of the medical literature because they are not reporting anything new and, therefore, cannot have any data. The result is an impression of growing acceptance of PAS, but it really represents an artifact of a scientific bias. . . . [Full text]