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X.    PROJECT RECOMMENDATION

X.1    Conscience in the medical profession

X.1.1    Speaking in Jerusalem in 2016,  WMA Secretary General, Dr. Otmar Kloiber, drew attention to the expectation that conscience will guide physicians in the practice of medicine, drawing from that a lesson about the importance of freedom of conscience:

The Declaration of Geneva and the International Code of Medical Ethics demand the physician to exercise his or her profession with conscience. That, of course, is meaningless if a conscientious objection is impossible. No physician must be forced to carry out activities that are either deemed to be unethical altogether, like participation in capital or corporal punishment, the force feeding of prisoners or to perform services he morally cannot subscribe to.

In essence, physicians do not surrender their human rights when becoming a physician. Not be coerced to provide certain treatments is a matter of dignity and integrity for the physician as well.1

X.1.2    Consistent with Dr. Kloiber's remarks, Professor David Oderberg of Reading University expands upon the role of conscience in medicine in A Declaration in Support of Conscientious Objection in Health Care:

In health care, conscience plays an essential role in the professional judgment – often subtle and delicate – that practitioners must exercise in their daily work. If health care workers are not to be reduced to mere functionaries (of the state, of the patient, of the legal system), they must be free to exercise their professional judgment and to allow their consciences to inform that judgment. This freedom of professional judgment informed by conscience must translate into the freedom not to be involved in certain activities or practices to which there is a conscientious objection.2

X.2    A broad and principled approach

X.2.1    WMA policy documents occasionally refer briefly to judgements of conscience, but it does not appear that the Association has ever attempted to explain why conscience is central to medical practice, or to connect this idea clearly to the exercise of freedom of conscience. Further, all of the brief references to the subject have been made within the context of controversies associated with specific practices or issues.3,4,5,6

X.2.2    A significant shortcoming of procedure-specific policy-making and legislation is that it is inflexible.  A policy or law that prevents coercion with respect to abortion does not apply to artificial reproduction, eugenic practices or human experimentation.  Responding to ethical controversies spawned by the rapid advance of medical technology is especially challenging.   It is not practical for the WMA to spend one to three years developing a protection of conscience policy applicable to a single procedure, and repeat the process every time a new controversy arises.

X.2.3    Moreover, when policies are developed in the midst of controversies about specific procedures or problems, the policy response may be shaped by features unique to the circumstances and prove problematic when considered in other contexts.  A special problem arises in the case of morally contested procedures, when what ought to be judicious reflection on freedom of conscience becomes entangled in partisan debates about the acceptability of the procedures themselves. Opposing sides in such debates may well come to see such policies merely as strategic weapons to be turned to ideological advantage.

X.2.4    Conscience policies developed in relation to specific procedures tend to foster and entrench a morally partisan viewpoint, whether the viewpoint is that of a dominant majority or a powerful minority.  This leads to discrimination, either by allowing conscientious objection to some procedures, but not others, or by imposing arbitrary and discriminatory limits on the exercise of freedom of conscience: by, for example, allowing physicians to refuse to refer for euthanasia, but forcing them to refer for artificial reproduction.

X.2.5    For all of these reasons, it is preferable to take a broad and principled approach that keeps the focus on the nature and importance of freedom of conscience, avoiding entanglement in controversies about the acceptability of morally contested procedures.

X.3    Avoiding authoritarian "neutrality"

X.3.1    It is equally important to reject attempts to impose authoritarian solutions masked by a pretence of neutrality. For example, a theory of social contract professionalism that has attained dogmatic status may be applied by those in power to "resolve" moral issues by subordinating them to purportedly neutral "professional" obligations. This approach is exemplified by Udo Schuklenk and Julian Savulecu, who assert that "professionalism" precludes conscientious objection.7,8

X.3.2    To claim, for example, that physicians act ethically or with integrity only if they conform to professional expectations could be taken to mean that "professional expectations" override the moral agency and moral integrity of physicians. This is not a neutral claim.  Further, physicians may disagree profoundly about whether participation in a given morally contested procedure exemplifies adherence to or a violation of professional commitments: euthanasia is only the most recent and obvious example. Hence, an attempt to regulate the exercise of freedom of conscience by demanding conformity to a theory of professionalism that fails to respect the moral agency of physicians will generate unjust discrimination and exacerbate rather than resolve conflict within the profession.

X.4    A stand-alone general protection of conscience policy

X.4.1   Assuming one avoids entanglement in disputes about the acceptability of procedures/interventions, as well as authoritarian "neutrality," a serviceable policy for protection of conscience must be based on the understanding that recognition that respect and protection of freedom of conscience serves the fundamental good and dignity of the physician as a human person, not merely professional autonomy or independence. It must include a number of basic features:

a) protection of the moral agency and integrity of physicians by ensuring that they are not compelled to do what they believe to be wrong, including referral and other forms of close cooperation;

b) non-discrimination concerning physician judgements of conscience, both as to the acceptability of a procedure/intervention and decisions about participation or non-participation;

c) an expectation that physicians will provide patients with timely notice of deeply held beliefs that may influence their recommendation or provision of procedures/interventions the patient may request;

d) an expectation that physicians will provide information necessary to enable a patient to make informed decisions and exercise moral agency;

e) an expectation that physicians will provide information to allow patient access to other physicians, health care providers or the local, regional or provincial health care system;

f) insistence that objecting physicians cannot be expected and must not be made to assume responsibility for ensuring access to procedures to which they object; the state, other entities or non-objecting colleagues must assume that responsibility.

Notes

1.    Kloiber O.  Patients' Rights - A World View. The Patients' Rights Act 20 years on – Achievements and Challenges.  Presentation at Peres Center for Peace, Jaffa, Israel. 2016 Jan 18 [Internet]. Protection of Conscience Project [Cited 2018 Sep 30].

2.    Oderberg D.  Declaration in Support of Conscientious Objection in Health Care [Internet]. University of Reading; 2018 [Cited 2018 Sep 30]. Declaration, para. 2.

3.    World Medical Association.  Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects [Internet]. 2008 Oct [Cited 2018 Sep 30] para. 3.

4.    World Medical Association. Declaration of Malta on Hunger Strikers [Internet]. 2017 Oct [Cited 2018 Sep 30] para. 17.

5.    World Medical Association.  Declaration of Lisbon on the Rights of the Patient [Internet]. 2015 Apr [Cited 2018 Sep 30] Preamble.

6.    World Medical Association.  Declaration of Oslo on Therapeutic Abortion [Internet]. 2006 Oct [Cited 2018 Sep 30] para. 3.

7.  Schuklenk, U. Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. J Med Ethics 2017;43:234-240.

8.  Savulescu J, Schuklenk U. Doctors have no right to refuse medical assistance in dying, abortion or contraception.  Bioethics Bioethics [Internet] 2017 [Cited 2018 Sep 29] ;31(3):162-170.