Why not make clinically indicated procedures the benchmark?
Over the last few years there has been a vigorous and fascinating debate about the use of conscientious objection (CO) in healthcare. CO is when doctors (and other healthcare professionals) opt-out of providing a medical service because they have serious moral objections—abortion is a widely cited example.
If enough doctors object to abortions, there is a legitimate concern that some patients will have difficulty accessing them—for example in Italy 70% of obstetricians refuse to participate in abortions, even though this isn’t the intention of CO. Some ethicists have argued there is no place for CO at all in healthcare, in the strongest of terms.
Curiously, though—and this is what aroused our interest—these same ethicists usually recognise that there are still some instances when doctors should be permitted to object and withhold their services. But how can they allow some objections and not others? One way is by claiming these objections aren’t really cases of CO, which seems a bit arbitrary. A better approach is to propose sensible criteria for allowing certain objections and disallowing others, and this is where the CO debate is at the moment.
Part of this debate involves critiquing certain features of common COs such as abortion, and our recent paper in the Journal of Medical Ethics examines two major criticisms.
The first is that CO may deny patients a beneficial medical procedure, and this is a bad outcome. However, we examined the research, and concluded that abortion is of dubious medical benefit—a somewhat controversial judgment given it is so widely used. Most abortions are requested for social reasons, not medical reasons, and so we believe this criticism isn’t valid.
The second criticism we tackle is that CO is based on personal beliefs, and these are untestable.
Yes, we agree that most moral beliefs are untestable, whether they are religiously based or not. Science can provide us with empirical evidence to inform our moral beliefs, but it can’t tell us whether abortion is right or wrong. The problem for critics of CO is that personal beliefs aren’t easy to replace with some other criteria if you still want to allow some objections. For example, if you instead use the ‘values of the profession’, it turns out that these are still partly predicated on personal beliefs regarding what’s good and what’s harmful for patients—and the more controversial the case, the less useful professional values turn out to be.
A suggested alternative is the ‘scope of professional practice’. Surely this takes personal beliefs out of the picture!
But there’s still a problem—sooner or later there will be something that is legal and within the scope of practice that doctors believe is harmful to patients in some way. One example is the practice of nontherapeutic infant male circumcision. Some ethicists claim doctors should just comply anyway—but we would prefer doctors who believe a treatment to be harmful and/or of no clear benefit to say so, and refuse to provide it!
After disarming these criticisms, we make our own proposal of a standard for what COs should be permitted that we think is worth considering: doctors should be able to object to providing any treatment or procedure that is not clinically indicated. A clinically indicated procedure is one that will clearly benefit a patient’s health and is appropriate for the condition being treated. We don’t think it fair that doctors should have to sacrifice their moral integrity for procedures that are not clinically indicated, even if they are part of their scope of practice.
Our suggestion is unlikely to cover all cases that we think doctors should be able to CO to, but it seems to be a reasonable starting point. There are certainly no easy answers when it comes to how CO should be implemented, but we hope our paper has clarified some issues and moved the conversation forward.
Bruce Philip Blackshaw is a doctoral research in philosophy at the University of Birmingham. Daniel Rodger is a Lecturer in Perioperative Practice at London South Bank University. This article has been republished from the blog of the Journal of Medical Ethics under a CC-BY-NC licence.
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