Sick man in bed surrounded by physician, priest and attendants. Woodcut attributed to Albrecht Dürer in 1509. Image courtesy of Wellcome Library, London, via Creative Commons

Trampling on health care providers’ consciences

(RNS) Western culture wants to welcome and protect different perspectives. But that commitment to pluralism is butting up against another cherished value — the commitment to respect an individual's conscience — on an increasingly challenging front in the culture wars: controversial medical practices.

This is happening in many different countries, but in the United States we are seeing lawsuits attempting to protect physicians from being forced to counsel patients on assisted suicide and Catholic hospitals from being forced to perform abortions.

Bioethicists have been thinking for many decades about how to balance a commitment to pluralism with a commitment to justice when it comes to these kinds of controversial medical practices.

The most recent example of this came when the Brocher Foundation gathered an impressive international group of bioethicists in Geneva to put out a consensus statement on “contentious objection in health care.” Here is the opening paragraph to the statement, just released this week on Oxford’s Practical Ethics website:

"Healthcare practitioners’ primary obligations are towards their patients, not towards their own personal conscience. When the patient’s wellbeing (or best interest, or health) is at stake, healthcare practitioners’ professional obligations should normally take priority over their personal moral or religious views."

These claims provoke a number of questions. Here are just a few:

Who counts as a patient? Of what does a patient’s “wellbeing” consist? Rights being respected? Which rights? What happens when they conflict? How should one patient’s well-being be measured against the well-being of many others?

Let’s do some historical thought experiments to drive home the weight of these questions:

A. Imagine you are a Christian physician in late first-century, pagan Rome when a patient comes to you with his just-born child who, because she is a girl, he wants you to kill by giving her hemlock.

B. Imagine you are a Catholic physician living in Nazi Germany working in the psych ward of a Catholic hospital when a patient who initially asked you to admit his mentally ill daughter now asks you to kill her so she is no longer a drain on the Reich’s resources.

You cannot participate in either act, of course, without violating a fundamental part of who you are. But signatories of the Geneva statement would insist you either assist the patient in killing his child or refer your patient “to another practitioner who is willing” to help kill his child.

Furthermore, the signatories insist that if it is too burdensome for your patient to travel to the nearest physician willing to perform the medical service, you must perform it yourself.

We are told, after all, that “a patient’s desire for a legal, professionally sanctioned medical service” trumps “personal moral or religious views.”

These historical examples shed light on two “legal, professionally sanctioned medical services” in many contemporary Western cultures: abortion and physician-assisted killing. Signatories of the Geneva statement believe health care providers must be willing to participate in the kinds of killings that many consider morally similar to A and B above. The signatories even claim that providers should be forced to perform such killings as part of their training in medical school and that they may be discriminated against in employment because of their refusal to perform such killings in the future.

Another historical thought experiment challenges the signatories from a different perspective:

C. Imagine you are a pro-LGBT psychiatrist practicing in the 1950s United States. Suppose you are approached by a father with a daughter, 12, who identifies as a lesbian. Further suppose that this patient requests you to perform "restorative therapy" on his daughter in an attempt to, in his words, "turn her back into a heterosexual."

Such therapy was, at the time, a “professionally sanctioned” medical service. The signatories would be forced to conclude that this physician should either provide the therapy himself or refer the father and daughter to a physician who would do the therapy. And in an “emergency” situation — perhaps where the family cannot reasonably travel to the closest psychiatrist willing to provide the therapy -- the physician should be forced to provide it himself.

These historical thought experiments remind us that the moral confidence the signatories have in a medical practice simply because it is legal and currently accepted by medical professionals is completely unwarranted.

We’ve gotten things dramatically wrong when it comes to our medical practices in the past, and there is absolutely no reason to believe we aren’t getting them dramatically wrong today. One of many reasons to err on the side of protecting the consciences of health care providers is that we must provide them the freedom to resist the practices our broader culture has not yet recognized as unacceptable.

(Charles C. Camosy is associate professor of theological and social ethics at Fordham University in New York City. His most recent book is "Beyond the Abortion Wars: A Way Forward for a New Generation.")

Comments

  1. So professional medical ethics, medical necessity and informed consent of a patient must be subordinate in a healthcare provider to the arbitrary religious dogma of its owners?

    Give us all a break. A hospital isn’t a church. People looking to go to one do not usually have the luxury or choices to pick one in line with their personal views.

    The author in his typically obvious bias, believes that care of patients is always secondary in a hospital. This is morally disgusting. Like many self righteous types, the author believes he knows better than patients do and that having an opinion on a subject is the same as a right to decide for others in personal matters.

  2. What a incoherent article. While I understand the premise/idea and support that to a large extent, I must point out that the hypothetical examples are simply atrocious, historically in some, outlandish in others. In fact those examples are exactly why the article is incoherent.

    Example A, in the first century the parents would have either killed the girl themselves or have another do it for money. They would not seek out a physician. People are doing this same act today in parts of this world.

    Example B, it was not the doctors who decided that mentally challenged citizens were to die, it was in fact the Nazi’s who enacted this crime. Doctors either complied or in some cases did mercy killings so they would not be butchered by nazi henchmen who came for them.

    Example C, You failed to elaborate on what is restorative therapy and as we all know the difference in treatment for what was once termed a mental disorder varies drastically with the quality of care. Then doctor shopping as an option.

    What is also rather odd is the plain fact that there is someone a parent, caregiver, who is not even portrayed as such. It comes off as if “patient” of said doctor wants the doctor to do something to someone else without detail, relationship, it’s bizarre. Perhaps Mr Camosy needs to do a total rewrite because this article wouldn’t pass a 5th grade composition exercise. Maybe he was on a deadline and just could only get this off in time, but it really is poor work.

  3. “Like many self righteous types, the author believes he knows better than patients”

    I wouldn’t say that.

    I’d say the author DOESN’T believe he knows better than the doctors, which is why he wants to leave decision-making in the hands of individual doctors and not politicians, whereas I’d say YOU, like many self righteous types, believe you know better than the doctors, which is the only reason you’d advocate forcing a doctor to do something against their conscience.

    Personally, I believe doctors aren’t and shouldn’t be slaves, you can’t compel someone to perform labor without making them into slaves, and you do not know better than individual doctors.

  4. That is not what the article is about. He doesn’t want decision making in the hands of ”
    doctors at all, nor in line with tenets of professional medical conduct. He wants hospital administrators and clergy to determine how doctors are to proceed. The “conscience” of the healthcare provider meaning the religious dogma of a hospital’s owners.

    You should read the article more closely before you start casting aspersions on its critics.

    “I believe doctors aren’t and shouldn’t be slaves, you can’t compel someone to perform labor without making them into slaves”

    Yet the article is about doing that to them. Using religious dogma as an excuse to compel them from doing their licensed duty as doctors to the public and to their patients.

  5. Balloon, apparently you don’t know (1) what a historical thought experiment (as opposed to a historical event) is or (2) that parents with minors are consider co-patients in terms of decision-making.

    To help you with (1), you might check this out: https://en.wikipedia.org/wiki/Thought_experiment

  6. Your logic denies medical practitioners any autonomy at all. Conscience does not equate unilaterally with religion by any means despite your interpolation.

  7. What the author pretends is conscience, flies in the face of notions of professional medical ethics and informed consent. His examples were ill conceived, ignorant of background history and completely misinterpreted a doctor/patient relationship.

    A doctors duty is to provide the most effective care to a patient. All of their actions must fall in line with such concepts. It is the basis of their professional ethical duty to a patient. That is the source of their conscience in such situations.

    Typically religious “conscience” is invoked by hospital administrators against doctors. Keeping them from using their full professional judgment in treating a patient. Playing fast and loose with informed consent by refusing not only to provide certain treatments, but also information about them or referrals elsewhere.

  8. Though it doesn’t make a difference, since it is a thought experiment, but you are wrong on Example B. The Nazi’s sanctioned what the medical and juridical system had already started.

  9. No one should be forced to act against their conscience. However that does not mean that they can escape the consequences. They may lose their license, face arrest, pay fines or lose state/federal funding. The author relies on hyperbole as there are workarounds to many dilemmas. If religious beliefs are your reasons know that society cannot allow them to violate the constitutional and civil rights of other citizens.

  10. That is not even close to accurate. The Nazis campaigned rigorously for warehousing and then killing the mentally ill. At no point even at the heights of the popularity for eugenics was murder contemplated as an option, prior to the Nazis. Sterilization was the commonly accepted practice. Especially in the US.

    Camosy hides behind “thought experiment” to ask factually loaded questions and push a particularly ignorant view of professional medical ethics.

  11. It depends on what we mean by “Nazi’s.” The proposals started during the Weimar Republic and the psychiatric community started its program, admittedly during the Nazi era, but prior to getting official approval from Hitler.

  12. Actual killing patients wasn’t even on the table prior to Hitler.

  13. I agree with other commenters that this article is not well written. For instance, C is no more about religion than it is about medical ethics. If a doctor feels a treatment is harmful to the patient or medically inappropriate, she is ‘ethically’ bound not to do it.

    Another side of this is medical professionals who deliberately lie about medical information – abortion causes breast cancer, LBTG folks are more promiscuous than heterosexuals, etc.

  14. Precisely what representative sample of medical professionals have you surveyed to buttress your argument? I was citing conscience as a moral construct apart from the specificity of religion.

  15. You understand a doctor has a professional duty to render the best available care to patients, right?

    Do you understand that patients have a right to make informed decisions about healthcare options? That doctors have a duty to provide that information?

    This is the basics of professional medical ethics. Failure to do these things is the legal definition of malpractice.

    What the author pretends is conscience really amounts to compromising or attacking professional medical ethics in service of outside beliefs and/or prejudices.

  16. It was pretty obvious the author was looking to use poor analogy as a backdoor argument to excuse how Catholic medical providers play fast and loose with professional medical ethics and patient health in service of religious dogma.

  17. So what happens when a physician and his/her patient disagree about what constitutes the best available care? Then that patient has the freedom to seek care more attuned to their perspective elsewhere; it’s called the free market system. Normatively, the instances of such disagreement are few except when they fall into the highly charged areas of abortion or assisted suicide. I find it easy to understand that a physician might not view abortion as in the best health interest of the patient. Certain studies have indicated that the emotional and mental health of a woman often suffers subsequent to the termination of her pregnancy via abortion. That is a legitimate care consideration. Also, I can understand why a physician would hesitate to assist a suicide; potentially the desire to die does not arise from a state of mental or emotional health. As one who has often contemplated suicide as a function of severe depression and despair I am not without sympathy for the patient. For the terminally ill, palliative care is often available whereby pain is reduced and the ending stage of life becomes tolerable. Whether a physician’s views are religious or not does not qualify non medical professionals to question their theory of care.

  18. When one is introducing the doctor’s personal/religious beliefs into the situation, they aren’t dealing with what constitutes best available care. But the author wants to claim pretend interjecting such things is perfectly acceptable. Its why he is chafing against the definition of professional medical ethical duty quoted in the article.

    “So what happens when a physician and his/her patient disagree about what constitutes the best available care? ”

    One has to ask, “Has the patient been properly informed by the doctor of what are the best available medical options in the situation?”, “Is the patient referring to something which is even medically possible/viable/ethical?”. Informed consent of a patient is the key here. Not just the patient request. Asking such a question in a vacuum is inherently misleading.

    “Certain studies have indicated that the emotional and mental health of a woman often suffers subsequent to the termination of her pregnancy via abortion. ”

    Virtually none of which has passed muster in professional peer review. They are almost entirely ones funded by anti-abortion groups. Such concerns are not for a medical doctor but a psychiatrist. A doctor who performs abortions (or could) could not make such considerations on a professional basis

    “Also, I can understand why a physician would hesitate to assist a suicide; potentially the desire to die does not arise from a state of mental or emotional health.”

    Again not the purview of a medical doctor, but a psychiatrist.

    “For the terminally ill, palliative care is often available whereby pain is reduced and the ending stage of life becomes tolerable.”

    You can’t make such categorical statements on such situations. It always depends on the individual. It is best left up to the individual to make informed decisions as to their care regardless of such generalizations.

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