Conscientious objection in medicine
Health care providers have a duty to provide care. However, their values can sometimes conflict with these duties. Is it acceptable to refuse care to a patient if it goes against the morals, ethics or religious beliefs of the provider? This is where conscientious objection comes in. Conscientious objection in medicine is the refusal to provide the requested treatment because of the moral beliefs of the provider.
“We live in a rapidly changing legal and policy landscape in terms of health care and health care ethics,” said Ronit Stahl, PhD, of the University of California, Berkeley, participating in a recent panel of health professionals and ethics. who have come together to advocate for or against conscientious objection in medicine.
The panel, hosted by the Biomedical Ethics Program at the Yale School of Medicine, included moderator Sarah C. Hull, MD, MBE, assistant professor of medicine (cardiology); Stahl, arguing against conscientious objection; and Mark David Siegel, MDProfessor of (Pulmonary) Medicine and Director of the Traditional Internal Medicine Residency Program, advocate for conscientious objection. The virtual discussion can be seen here.
Against conscientious objection
“I want to make it clear that the argument I’m making is about pluralism and power,” Stahl prefaced, speaking out against the right of providers to refuse care based on their individual beliefs.
Conscientious objection, she said, is tricky because there is no single notion of what constitutes religion or what defines patient-centered care. Regardless of religious belief, everyone struggles with values-based ethics. Moreover, these values may change over time. Stahl asserted that placing individual beliefs above professional standards is a rejection of the fundamental obligation of health care – the duty to ensure the well-being of patients in the way they choose to live.
“In that sense, I think we can consider this a conflict of interest – not financial, but a conflict of interest over beliefs,” she said. Stahl said that while not anti-religious, anti-moral or anti-ethical, the lack of external scrutiny of these objections is a problem. “You don’t have to prove anything about your objections or that you’ve held them for a long time or applied them evenly,” she said. “You just invoke it, and you’re protected. … The costs are all put on patients who cannot access care.
“The current system that exists, it allows, in my view, the perpetuation of inequality in these areas,” Stahl said, “…especially in a system where people don’t always have as many choices and where they try to navigate through a lot of complexity without complete information.
“I think it’s really important for justice,” Stahl said. “And so the problem with how consciousness has emerged as a health care system is that this power is unbalanced and asymmetrical. The law in this sense allows personal beliefs to be imposed on patients in the form of a refusal to provide care. She said it’s especially distressing at times when refusal surprises a patient.
“To deny patients care that is integral to the profession is in my view a problem and, in fact, for me, unethical,” said Stahl, who added that conscientious objection in medicine can lead to an erosion of the relationship between provider and patient, as well as trust in health care as a whole.
She also pointed to an imbalance of protection between providers. “It protects those who refuse to treat — who refuse care — but not those whose conscience compels them to provide medically accepted but politically contested care,” including in the areas of reproductive services and LGBTQ care.
For conscientious objection
If standard practices change and your moral beliefs do not change, are you obligated to change along with the expectations of your profession?
“Clinicians are moral beings too,” Siegel said, as he argued for conscientious objection. “Morality is intrinsic to our professional identity.”
He noted that the federal government protects conscience rights. In facilities receiving federal funds, health care providers who refuse to participate in services because of moral objections or religious beliefs are protected from discrimination and have formal avenues of redress if they believe this right is violated. violated.
Siegel asserted that if society wants clinicians to take moral and ethical obligations seriously, but if they cannot follow their own beliefs, how can we expect them to adhere to their professional responsibilities? He also suggested that talented people who could make a great contribution to the profession might choose not to pursue it if they could not object to certain aspects of it.
“If deeply held moral beliefs are seen as disposable, that would be problematic,” he said, adding that over the course of their careers, the world around practitioners can easily change. “We enter these professions at an early age, not necessarily knowing what we are okay with, nor recognizing that there is potentially a changing moral landscape.”
On one important point, Siegel agreed with Stahl. “Any support for conscientious objection must ensure that vulnerable patients receive the care to which they are entitled,” he said. “We need to recognize that clinicians have power over patients and we need to recognize patients’ rights. Siegel added: “There is potential for abuse, using moral objections as a smokescreen for discrimination. It might not really be a moral belief, but you just don’t want to care for someone from a vulnerable group. He agreed there was a lack of oversight to detect this potential abuse.
For advice, Siegel turned to the American College of Obstetricians and Gynecologists (ACOG), which has clear recommendations for conscientious denial — guidelines with parallels in other medical disciplines.
To highlight a few: The well-being of patients must be paramount; health care providers must provide accurate and unbiased information; clinicians must provide potential patients with accurate, prior notice of their personal moral commitments; clinicians have a duty to refer patients in a timely manner if they cannot provide the standard reproductive services requested by patients; in emergencies where referral is not possible or could adversely affect a patient’s mental health, providers have an obligation to provide medically indicated and requested care, regardless of the provider’s personal moral objections ; and in resource-poor areas, access to safe and legal reproductive services must be maintained.
Hull, the moderator, pointed out that both arguments agree on the importance of providing accurate information and not withholding information, regardless of moral beliefs. Moreover, emergency situations prevail over the right to refuse care based on moral convictions. “Rather than being an ad hoc individual basis, there should be institutional norms and standards to codify appropriate situations for the exercise of conscientious objection,” Hull said. In areas where there is no professional consensus on the morality of a certain action, different viewpoints should be allowed while allowing patients to receive care and respecting clinicians as moral agents.
An audience member asked Stahl, “What place do implicit racial or ethnic biases play in those who choose to oppose a patient’s care?”
“I think what’s so difficult with implicit bias is that people don’t stand up and say, ‘because I’m a racist. I won’t deal with this person,’ or ‘because that I’m homophobic, I’m not going to prescribe PrEP to prevent HIV,” Stahl said. choices people make and the outcomes that flow from them. That’s why I think we have to be very, very careful not to assume that any assertion that someone says moral is inherently moral, and because I think it has been and continues to be used in a discriminatory way .
The definition of care, or “do no harm”, also came into the discussion. For example, clinicians may view physician-assisted suicide or abortion as harm, a view contrary to common professional standards of care. “If causing death does not accord with an orientation to health, it is wrong to say that such practitioners refuse care,” said an audience member. “On the contrary, these practitioners refuse to participate in a procedure that does not lead to health. Again, this does not negate care.
“To me, that’s a really important distinction to make,” Hull said, “there’s maybe a lot of room for debate there.”
This 90-minute discussion could easily have lasted much longer – a conversation that is sure to continue in many healthcare settings.