Conscientious objection
Charles Williams considers whether doctors have a right to stand by their moral convictions
In October 2007 a small number of UK Muslim medical students made the headlines for missing lectures about sexually transmitted
diseases and alcohol on moral grounds.w1 In November a general practitioner, Tammie Downes, was investigated by the General Medical Council after disclosing in a
newspaper interview her success in dissuading several women from having abortions.w2
These stories highlight a conflict between morality and medicine. What are we to make of doctors whose morals compel them
to opt out of certain tasks? Judgmental moralisers? Work shy cowards? Or courageous individuals who risk career progression
for higher ideals?
Debating abortion
One flash point in the morals-medicine minefield is abortion. Before 1967 abortion was illegal in the United Kingdom but was
widely practised, unsafely, in unhygienic backstreet “clinics.” The Abortion Act 1967 decriminalised abortion in certain circumstances.
The act also includes a clause that states that “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.”
Very few people actively call for this clause to be repealed, but some think that doctors who have a problem with taking part
in abortion should reassess their commitment to medicine or at least stay away from specialties such as obstetrics and gynaecology.
More and more abortions are taking place,w2 but fewer doctors are willing to perform them. The Royal College of Obstetricians and Gynaecologists is worried at the fall
in the number of young doctors willing to perform abortions,w3 and the British Pregnancy Advisory Service, which carries out a quarter of terminations in England, has said that in five
years’ time women’s access to abortion may be “severely restricted.”w3 This coincides with a more widespread recruitment crisis: according to the Royal College the number of trainees entering
the specialty needs to treble.w4 One opinion is that doctors who opt out because of conscientious objection are putting their colleagues in an unfair position.
I have been urged to “think about the poor gynaecologist being forced to do all the abortions because her colleagues refuse.” Some people believe that doctors in obstetrics and gynaecology should forgo their right to conscientious objection. Is abortion
a duty of the gynaecologist so that you should opt for a different specialty if you have a conscientious objection to abortion?
In fact, the job of the obstetrician and gynaecologist is varied, and there are many opportunities for subspecialisation.
It does not seem at all self evident that a conscientious objection to abortion should rule out a career in the specialty.
Legality and justness
Abortion is legal, and doctors exist to serve patients. So should a doctor be required to provide a service if women are legally
entitled to it? The ethicist Julian Savulescu equates the legality of an act with its justness in a passionate article against
conscientious objection.w5 History, however, tells us that such an argument does not stand. Doctors in Nazi Germany took part in the sterilisation of
patients with epilepsy and schizophrenia and in the murder of old, disabled, and other burdensome patients, doing their duty
under laws that sanctioned active euthanasia. Any praise we give to medics in that regime rightly belongs to the conscientious
objectors.
Many of our present day counterparts around the world are placed in situations with which we might be profoundly uncomfortable.
These include the death penalty and torture. If the law says that death is the appropriate penalty for certain crimes, should
a state registered doctor be able to opt out of his duty to give the lethal injection? If torture is considered a reasonable
way to extract information from a criminal, as it seems to be in Guantanamo Bay, should the medic treat a prisoner, patching
him up enough for further interrogation? Most of us hope for the courage to conscientiously object in these situations.
Statutory law and moral law are not synonymous in content because statutory law can change with time. The Declaration of Geneva
used to affirm the “utmost respect of human life from the time of its conception.” Since 1984 “from the time of its conception”
has been absent. In 1983 the doctor who is against abortion is in agreement with the codified morals of his profession, but
in 1984 it is a grey area. Morality is surely not so fickle?
When it comes to abortion, following the law is no simple thing either. The wording of the UK abortion law is ambiguous. It
does not provide details about the circumstances in which abortion is permitted or not, but it requires doctors to weigh up
the risks. But how do we compare the risk to a woman’s mental health of continuing a pregnancy with terminating it? Some research
shows that abortion has harmful psychological sequelae,w6 w7 although the Royal College of Psychiatrists believes the evidence base is inconclusive.w8 How great a risk is “substantial”? How bad must a physical or mental abnormality be to constitute a serious handicap? Even
a doctor willing to be involved in legal abortions may have to face questions of conscience.
Patients’ rights and doctors’ rights
Patient autonomy is paramount, but physician autonomy is also enshrined in law. The United Nations Universal Declaration of
Human Rights declares the universal right to freedom of conscience. The Human Rights Act affirms the right to “freedom of
thought, conscience, and religion.” The BMA also acknowledges this right, accepting that it must be held in balance with patients’
rights.w9
Evan Harris, a doctor and Liberal Democrat member of parliament, believes that doctors conscientiously opposed to abortion
cannot provide balanced counsel to patients seeking an abortion and should therefore ‘refer them to another doctor immediately
for that consultation.’ He criticised Tammie Downes, introduced at the beginning of this article, for trying to persuade patients
to go in one direction only and boasting of her “success” in a national newspaper.
Downes responded, “I don’t try to persuade anybody. I give them the facts and allow them space to think through the decision
that they are making.” She says that whether or not to have an abortion “has to be the mother’s choice. I have no right to
make that choice for them.” But she believes that it is her “duty as a doctor to help a woman make that choice.”w10
What makes a valid claim?
There will always be disagreement about what constitutes reasonable grounds to opt out of providing a service. People’s different
world views lead them to profoundly different takes on morality. It is not immediately obvious what constitutes a legitimate
claim for conscientious objection in practice.
All doctors agree to sacrifice some of their personal autonomy when embarking on a career in medicine because the duties of
the doctor state that we must make care of our patient our first concern, and we must treat our patients with respect, whatever
our life choices and beliefs. A legitimate claim for conscientious objection should be based on a deeply held objection to
what the patient is asking the doctor to do, not what the patient has done or how the patient lives.
Conclusion
The GMC acknowledges the central role of personal, cultural, and religious values and beliefs in the lives of doctors and
patients in its latest guidance on this issue.w11 It reiterates the core message of Good Medical Practice,w12 that doctors must show respect for human life and that doctors must not discriminate against patients. Doctors should inform
patients of any potential conscientious objection to a treatment and ensure that patients have sufficient information about
how to see another doctor if they wish to do so. So the GMC affirms the right to conscientious objection.
Conscientious objection in medicine is rarely an easy way out. It may add to paper work, complicate relationships with colleagues,
and leave the doctor feeling vulnerable and isolated. However, history shows that rapid changes of law is reason enough to
uphold the doctor’s right to raise conscientious objection. We may never all agree on what is the right thing to do in difficult
clinical and moral situations. But we need more doctors, not fewer, who are willing to defend what they think is right.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
Charles Williams fifth year medical student Trinity College, Oxford University
charles.williams@medschool.ox.ac.uk
Student BMJ 2008;16:235 | 18
- Foggo and Tahir. Muslim students get picky. Sunday Times October 7, 2007
- Department of Health Abortion Statistics, England and Wales: 2006. [Online]. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_075697 [Accessed: 12 February 2008]
- The Mail on Sunday. GP who made eight women think again. [Online]. Available from: http://www.mailonsunday.co.uk/pages/live/articles/news/news.html?in_article_id=452319&in_page_id=1770the [Accessed: 12 February 2008]
- Laurance, J. Abortion crisis as doctors refuse to perform surgery. The Independent 16 April 2007
- BMJ. UK trainee doctors spurn obstetrics and gynaecology. [Online]. Available from: http://www.bmj.com/cgi/content/full/332/7537/323-c/DC1 [Accessed: 12 February 2008]
- Savulescu, J. Conscientious objection in medicine. BMJ 2006;332:294-297
- BMA. Impact of Human Rights Act 1998 on medical decision making. [Online]. Available from: http://www.bma.org.uk/ap.nsf/Content/HumanRightsAct~relevant~article9 [Accessed: 12 February 2008]
- Reardon et al. Psychiatric admissions of low-income women following abortion and childbirth. CMAJ. 2003; 168(10):1253-6
- Fergusson DM, Horwood LJ, Ridder EM. Abortion in young women and subsequent mental health. J Child Psychol Psychiatry 2006; 47:16-24
- GMC. Personal Belief and Medical Practice (2008) [Online]. Available from: http://www.gmc-uk.org/guidance/ethical_guidance/personal_beliefs/personal_beliefs.asp [Accessed: 1 April 2008]
- GMC. Good Medical Practice (2006) [Online]. Available from: http://www.gmc-uk.org/guidance/good_medical_practice/duties_of_a_doctor.asp [Accessed: 20 March 2008]
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LIFE
Conscientious objection
(Charles Williams, July 2008)
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Dr. Shashi Sigdel
(June 26th, 2008)
Intern, Institute of Medicine, Kathmandu, sashi.silverline@gmail.com
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The above article gives a clear picture of a medical professional who is in swings to judge the morality and the practicality in the day to day practice. I extend my deep gratitude for respected writers for such wonderful information. In Nepal, the legalization of the abortion on September 26, 2002 A.D, was a break-through in the orthodox society that existed for centuries. Even at those times, there used to be abortions by the shamnism and the craftery practices. Before 2002A.D. the news of illegal abortion used to be on the limelight only when the mother was gifted with the fatal complications of the illegal abortion. However, even at present, only half of the woman know that abortion is legalized in Nepal(1).Nepal has one of the highest maternal deaths (539 per 100,00 live births) among SAARC countries. It is estimated that over half of the maternal deaths are due to unsafe abortions(4). In developing countries, about one in six married women faces an "unmet need" for family planning;they would rather not become pregnant, but are not using any form of contraception; Reducing unmet need can help reduce unintended pregnancies, which lead to abortions and unwanted births(2). An estimated 68,000 girls and women die each year from unsafe abortions and millions more suffer complications that need medical attention(2).Every 6 minutes a woman dies needlessly as a result of an unsafe illegal abortion(5). 20 million of the 46 million abortions performed annually are illegal and unsafe(2). Nepal has been trying its best to take the services to every nook and corners but a bunch of strategies yet need to be strengthened. For instance, One woman who went to her district hospital for an abortion did not have the money to pay the fee (which averages 1,000 rupees - 13.61 U.S. dollars û in government hospitals versus 1,350 rupees in NGO clinics.) She returned home and months later reported that her baby had been stillborn(1).Today, 59,000 Nepali women have had safe abortions, performed by 260 trained doctors at 133 !
approved centres, and if plans hold, trained nurses will soon be providing the service(1).despite all these, there is good glimmer of hope that a day a lady can acknowledge with pride that she had a legal, safe abortion after being counselled well for she was aware of the morbidity of the unsafe abortion and that she loved her life equally.
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LIFE
Conscientious objection
(Charles Williams, July 2008)
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Tarek Arab
(July 22nd, 2008)
4th year resident, Obstetrics and Gynaecology, University of Manitoba, Winnipeg, Canada, captflashheart@yahoo.com
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Medical students wishing to miss lectures on " ethical " or " religious " grounds should appraise whether or not they indeed belong in the medical profession. If they are not willing to do so, then perhaps the Dean of the concerned medical schools should do so on their behalf.
As a muslim, it DISGUSTS me to hear that muslim medical students have used the above as an excuse to shirk education that they will need one day, especially as prominent muslim doctors have written treatisies on the subjects that they find so abhorrent.
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LIFE
Conscientious objection
(Charles Williams, July 2008)
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Iain Benson
(July 22nd, 2008)
Barrister & Solicitor, France, iainbenson2@gmail.com
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The article nicely comments upon the need to respect the conscience and beliefs of physicians. This respect is currently under attack in various jurisdictions such as in Ontario, Canada where the Human Rights Commission and the College of Physicians and Surgeons of Ontario are suggesting there there should be a duty of referral for physicians.
On the other hand, the Canadian Medical Association, in its policy on procured abortion does not require referral, merely that the objecting physician inform the patient so that the patient (not the physician) may make alternative arrangements. Too often there is a tendency to view the physicians rights and freedoms as entirely subordinated to the wishes of patients. This is a serious error.
Mr. William's useful article goes some way to show why if we want ethical and conscientious physicians in an ethical health care system we must protect the conscience of physicians whether or not we may disgree with their views on certain matters. Such diversity and tolerance are parts of the necessary modus vivendi that should obtain in free and democratic societies.
One final point, the Muslim student example with which Mr. Williams begins his paper is not the same sort of issue as absenting oneself, once qualified, from, say performing or referring for abortions. Those who absent themselves from basic education that all physicians need are indicating that they do not wish to develop the knowledge base necessary to be good physicians. This is quite a different matter from knowing the area then saying "I don't do x, y or z" please go elsewhere."
Finally, if medical bodies are concerned that physicians or pharmacists are withdrawing from certain areas of morally contentious medical practices they may wish to re-evaluate the ethics of those practices. If concerns about access are at issue then the bodies themselves can provide central phone numbers and so on so that patients who wish certain procedures but cannot find a physician to do them, may get assistance from the centralized bodies thus not compromising the physicians who have a personal objection.
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