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ss nucleus - summer 2011,  conscientious objection

conscientious objection

Conscientious objection (CO) in healthcare is the right for practitioners not to participate in legal clinical procedures to which they hold a moral objection. The most widely understood application relates to termination of pregnancy, but there are many other procedures that are already or could become relevant, for example: circumcision for other than medical indications; prescription of the morning-after pill; and if it should become legal, euthanasia. But this right is under attack.

'Conscience is but a word that cowards use, devised at first to keep the strong in awe'
(Richard III, Act V, scene iii).

So began a polemical article in the BMJ by Julian Savulescu, a prominent Oxford medical ethicist.(1) He condemned CO by doctors as inefficient, unjust and inconsistent. Patients waste time 'shopping' for a doctor who will perform a procedure they are legally entitled to; doctors are employed to do things they refuse to do. CO is the refuge of the selfish and workshy. Such 'valuedriven medicine' is paternalistic, idiosyncratic, bigoted, discriminatory, often immoral and should be illegal. Instead, provision of services to patients should be defined by law, constrained only by consideration of just distribution of limited resources and chosen freely by fully informed patients. Public servants should be aware of their state-defined duties, and if they have moral objections to those duties they should not become doctors. Those doctors whose consciences compromise the delivery of patient care should be punished.

These sentiments were echoed recently in the Student BMJ. (2) CO is a 'crisis of faith', and 'if you firmly believe abortion or contraception are murder, or homosexuality and adultery are sinful; if you can't suppress a religious perspective that distorts your medical judgment: don't be a doctor'. Opposition to CO is not confined to academics and students; it's happening at a professional and parliamentary level. When the GMC published its recent guidance ( )on this, the BMA complained that the doctor's right of CO went beyond what was acceptable, and called for its limitation to a list of clearly defined procedures. (4) At the Parliamentary Assembly of the Council of Europe (PACE) in July last year, former MP Christine McCafferty proposed regulation and restriction of the right of CO by healthcare workers, especially regarding reproductive health services. (5)

The first assumption behind these objections is that personally held 'values' are subjective, internal and private. It is accepted that doctors might have values, and even have a right to express them, but not that these values should have any impact on the delivery of healthcare that is legal, available and freely chosen by the patient. The second is that what constitutes 'healthcare' is defined by the state, and its practitioners are technicians directed by the state.

Why so much opposition recently? Perhaps it is encouraged by well publicised examples of students refusing to attend lectures about sexually-transmitted diseases, or to attend to patients of the opposite sex. (6) Perhaps there is a growing secularist confidence that religion should be marginalised. Perhaps there is increasing demand for procedures and new technologies, supply of which will be limited by the current practice of CO. So what is our response?

Firstly, there's the legal position. The 1967 Abortion Act states: 'no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in any treatment authorised by this Act to which he has a conscientious objection.' (7) Similar protection was provided in the 1990 HFE Act. (8) There are still exceptions to the right to CO in the case of saving the life of or preventing 'grave permanent injury' to the pregnant woman, and there are no other UK statute laws guaranteeing CO. There is a case law example of a secretary who refused to type abortion referral letters, suggesting that CO is only legally valid for those 'actually taking part in treatment designed to terminate a pregnancy'. (9) This could mean that GPs would not, in law, have the right to object to signing such referrals. (10) More recently, Margo MacDonald's defeated assisted suicide bill in Scotland didn't make any provision for CO. However, in response to the McCafferty report, PACE affirmed the right and asked member states to guarantee it. (11) Resolutions by PACE are not binding on member states. In short, current UK legal protection of CO is actually quite limited.

Secondly, there's the professional position, which for doctors means GMC guidance especially as expressed in the document Good Medical Practice. The latest, 2006, edition was supplemented in 2008 by Personal Beliefs and Medical Practice. (3) This acknowledged that all doctors have personal beliefs which affect their practice, but must sometimes be prepared to set them aside. Regarding CO, the guidance is very clear: 'Patients may ask you to perform, advise on, or refer them for a treatment or procedure which is not prohibited by law… but to which you have a conscientious objection. In such cases you must tell patients of their right to see another doctor… and ensure they have sufficient information to exercise that right.' This is qualified by the requirement that the doctor may also have to arrange transfer of care if patients cannot do so themselves. Explicitly, it is not acceptable for doctors to withhold information about the existence of treatments to which they have a CO; nor to refuse other medical treatment to someone who is awaiting or has undergone such a treatment; nor to delay, restrict or opt out of treatment of patients because of their views about them, their lifestyle or the aetiology of their problem. This guidance is remarkably open: doctors do not need to prove a reason for their CO (as was required, for example, for Quaker pacifists in previous wars), and there is no limitation of CO to certain designated procedures.

Thirdly, there's an historical argument. What are the dangers without CO? There are notorious examples of the moral corruption of a medical profession which fails to oppose state-sanctioned abuses of patients: forced sterilisations in many countries in the 20th century; euthanasia and horrific experimentation in Nazi Germany and Japan; the Tuskegee syphilis experiments on black people in the USA which only stopped in 1972; organ transplants from prisoners in China. This argument can be made more personal - many of those who oppose CO for reproductive healthcare procedures are likely to support it for doctors to refuse to be involved in capital punishment, (12) or in assessing prisoners as fit for 'enhanced interrogation'. Closer to home, many would want the right to opt out of performing non-medically indicated circumcisions. Presumably those secularists who think people should only become doctors if they're prepared to perform any function that the state decrees, must draw the line somewhere?

Lastly and most importantly is the moral position, which for Christians begins with a biblical understanding of medicine and humanity. Healthcare is not mending machines, but 'restoring the masterpiece'. (13) People were made wonderfully in God's image, but the image is broken. Sin and suffering have been the human condition since the fall; but in Christ there is hope. He brings healing in all its fullness; restoration of relationship with God; growth in that relationship as we become more like the image we were made to reflect; and a sure promise of an end to all disease and death when we will have new bodies in a new creation. If we're at all unsure as to the value of human beings, remember Jesus lived and suffered as a real man; he died as a human and for humans. As he preached the coming Kingdom, there was an explosion of physical healing that demonstrated the presence of the King and his compassion and power, the need for forgiveness, and the future hope of a world without sickness. Christian medicine today is born from the intrinsic worth of and our love for individual people, and points towards that hope of perfect restoration. But it reminds us too of our underlying sin and our fundamental need for relationship with God through Jesus. Medicine cannot therefore be anything but 'value-driven'. It is shot through with the value of humanity and the value of Christ's atoning death!

And so our Christian conscience is vital; we must practise medicine according to God's revealed will. Everyone has a conscience (Romans 2:14-15), which both guides our future actions, and approves or rebukes us for acts committed. It would be wrong to perform an act that goes against one's conscience and it would be wrong to force someone to do so (Romans 14). John Wyatt has written that 'when a person is coerced by… the state to act in a way which transgresses these core ethical values then their internal moral integrity is damaged'. (14) It would be worth asking those who oppose CO, whether they would prefer to be treated by a doctor with integrity, or without?

But sin corrupts conscience (Titus 1:15, 1 Timothy 4:2); we can deliberately deny what we know to be truth (Romans 1:32), as Christians we know what we should do, but often don't do it (Romans 7:19). Conscience alone is unreliable; we need a conscience that is steeped in Scripture, shaped by God's Word in the power of his Spirit. Conscience is subjective, God's truth is objective (1 Corinthians 4:4). If CO were merely the pleading of a subjective conscience, then I could have sympathy with Savulescu. But for a Christian, CO is not based solely on my conscience. It's based on God's Word. It is not an internal objection that I think gives me the right to refuse the command of the state; it is the external truth of God. It is not a lower law that allows me to disobey the law of the land, it is a higher law. CO is not 'self-interest' or 'personal upset', but concern to be holy as God is holy (1 Peter 1:15-16).

And so although we are to submit to the authorities, who are placed there by God to commend good and punish wrong-doing (Romans 13, 1 Peter 2:13-17), sometimes Christians have to refuse to obey them. Daniel refused to stop praying to God (Daniel 6), his three friends refused to bow before the statue of the king (Daniel 3). Peter and John refused to stop speaking about Jesus (Acts 4:19-20, 5:29). God's law is higher than man's law. But in all those cases, and in countless examples through history, such refusal resulted in punishment. To submit to the state in those cases meant not to obey, but to face the consequences of standing for God's truth in a godless world.

And so it may be for Christians in medicine. Beware of arguments that appear to accept that CO is just about our 'personal values'; it isn't. Beware of relying on our fallen consciences rather than on God's Word. Beware of resorting to the safety of guidelines and laws which may be changed. By God's grace, we have the right to CO made explicit in our professional guidance, given concrete examples in the law, supported by a European assembly. We can argue from history or personal example in favour of it. But in the end, we need to be prepared to stand for Christ, and the experience of those before us suggests that this will be costly.

It was Shakespeare's Richard III himself, who spoke those words quoted so approvingly by Savulescu. In full, it reads:
'Let not our babbling dreams affright our souls: conscience is but a word that cowards use, devised at first to keep the strong in awe: our strong arms be our conscience, swords our law. March on, join bravely, let us to't pell-mell. If not to heaven, then hand in hand to hell.'

A murderer, a tyrant, a man who ridicules conscience, a man for whom there is no higher law than his own strength. Such a man leads his followers to hell. Let us not follow him, but Christ. It means the way of the cross, but its destination is glory.

References
  1. 1. Savulescu J. Conscientious objection in medicine. BMJ 2006;333:294-7
  2. 2. Riddington T. Religion and hypocrisy. Student BMJ 2011;19:d2502
  3. 3. General Medical Council. Personal Beliefs and Medical Practice. GMC 2008. London: GMC; 2008
  4. 4. Dyer C. GMC guidance on conscience goes too far, says BMA. BMJ 2007;335:68
  5. 5. Parliamentary Assembly of the Council of Europe. Women's access to lawful medical care: the problem of unregulated use of conscientious objection. 2010; Doc 12347.
  6. 6. Foggo D, Taher A. Muslim medical students get picky. Sunday Times 7 October 2007.
  7. 7. Abortion Act 1967, Section 4.
  8. 8. Human Fertilisation and Embryology Act 1990. Section 38.
  9. 9. Janaway v Salford Health Authority. All England Law Rep 1988 Dec 1;3:1079-84
  10. 10. Hill DJ. Abortion and conscientious objection. Ethics in Brief 2010;16(1).
  11. 11. Parliamentary Assembly of the Council of Europe. Resolution 1763, 2010
  12. 12. Arie S. Unwilling executioners? BMJ 2011;342:1286-7
  13. 13. Wyatt J. Matters of life and death (2nd edition). Nottingham, IVP; 2009
  14. 14. Wyatt J. The doctor's conscience. CMF Files 2009;39
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