In a recent “Sounding Board” article for the prestigious New England Journal of Medicine, Drs. Ronit Y. Stahl and Ezekiel J. Emanuel call for the elimination of medical providers’ conscience objection rights. Their suggestions, if reflected in legislation and medical licensure requirements, would lead to blatant discrimination against medical providers who hold sincere moral objections to certain medical interventions and would expose patients to significant risk of harm.
The authors contend that because medical providers freely choose their professions, they are “obligated to provide, perform, and refer patients for interventions according to the standards of the profession.” To support their claim, they appeal to differences between military and medical conscientious objection, to internal inconsistencies within the codes of ethics of various professional medical associations, and to the role of “professional role morality” in determining providers’ responsibilities to patients. The authors’ arguments, we will show, are uniformly weak.
In his prophetic work The Abolition of Man, C.S. Lewis wrote that through society’s embrace of moral relativism, “We make men without chests and expect of them virtue and enterprise. We laugh at honour and are shocked to find traitors in our midst.” Drs. Stahl and Emanuel want physicians without chests, physicians who are mere functionaries, carrying out whatever their professional associations suggest regardless of what their consciences say. The proposal is dangerous and inhumane. True consideration for patient well-being demands that providers make use of a fully integrated conscience.
Differences Between Military and Medical Conscientious Objection
The authors infer that the differences between military and medical conscientious objection justify the latter’s elimination; in essence they argue that conscientious objection in a non-military context is justifiable only when it perfectly parallels that in the military. However, it is fallacious to infer that B does not warrant C from the premises that A warrants C, and that B is in some respect unlike A. While relevant similarities to the military case would support an argument for conscience exemptions in the medical case, it is simply false that medical exemptions could only be defended on those grounds.
First, the authors incorrectly claim that military conscientious objectors generally object to state-mandated conscription, while medical objectors object to practices of their profession. In fact, military conscientious objectors object to performing the duties and practices specific to soldiers—participating in combat and harming others, for instance—and not to state-mandated conscription as such. The state could conscript people into the National Park Service if legislators thought doing so served a vital state interest, and some citizens might then raise a religious or moral objection to managing trout stock, back-country brush clearing, or rescuing stranded hikers. Such an objection would be to the practices of the profession in question, not to the principle of conscription. Military conscientious objectors, however, generally object to specific professional practices of soldiers, not to conscription itself. Objectors to military conscription are generally pacifists, not anarchists—they do not object to service of country outright, only those services that directly or indirectly support combat. This is made clear by the example of past conscientious objectors like Corporal Desmond Doss, who were not conscripted, but rather volunteered for military service.
The authors place extreme importance on the distinction between voluntary and conscripted service—in fact it forms the core of their argument, as they claim that if one enters a profession voluntarily, he is obligated to accept all “standard” practices of the profession, regardless of what his conscience says about those practices. Implicit in their claim is that the act of voluntarily entering a profession constrains the conscience’s ability to inform one’s decisions and actions within that profession. Their claim is self-evident in some instances: for example, it is a ridiculous notion that an executioner who voluntarily entered his profession could reasonably conscientiously object to performing executions—the very act which is essential to his professional practice as an executioner.
Medicine, however, is different. For the authors’ distinction between voluntary and conscripted service to stand and have moral relevance, they must show that all “standardized” interventions of a particular specialty are essential to the practice of that specialty—that performing elective abortions is essential to being an obstetrician, that performing gender reassignment surgery is essential to being a plastic surgeon, that enabling a patient’s suicide is essential to being a geriatrician—and that to object to performing such interventions is to object not simply to the intervention, but to the practice of that specialty in its entirety (as in the case of the executioner who objects to performing executions).
The authors make no such demonstration.
In fact, forceful arguments can be made that abortion is anathema to the practice of obstetrics, that destroying rather than restoring organs’ functions is anathema to surgery, and that causing death is anathema to medicine, period; to proceed further, one could argue that when physicians perform such interventions they are not practicing medicine, but a twisted perversion of it—no matter who deems their practice “standard.” Whether one volunteered is therefore not morally relevant to the question whether someone can conscientiously object to practices of his profession, especially so in the case of medicine. As such, the difference between voluntarily entered medical practice and conscripted military service cannot be used to justify elimination of conscience rights for medical practitioners.
A related difference the authors use to justify eliminating medical conscience exemptions is the claim that military objectors oppose an “unchosen combatant role,” while medical providers enter their profession voluntarily. We’ve already seen that this is incorrect, for military objectors may have chosen their role.
Furthermore, though, conscientious objection in medicine does oppose a “combatant” role. Pro-life physicians object to performing elective abortions because abortions end life and cause harm, as pacifists object to ending lives and causing harm in combat. It does not follow that because the pro-life physician objects to abortion he is therefore opposed to healing women or opposed to medicine in general, just as the pacifist is not necessarily opposed to serving his country in some non-combat capacity. If a provider is coerced under threat of loss of licensure or expulsion from his practice to perform interventions he considers harmful—which is precisely what the authors call for—he becomes conscripted into an “unchosen combatant role,” and like the military objector, by the authors’ principles he deserves an exemption.
The authors run into the same problem when they declare that military conscience objectors face serious penalties for resisting conscription while medical practitioners do not, and conclude therefore that medical conscience objections should be eliminated. On the one hand the authors claim that penalties for resisting military conscription justify conscience exemptions for conscripts; on the other hand they would remove medical conscience exemptions, and penalize providers who resist being conscripted into performing morally objectionable interventions by forcing them from medical practice. Through their perverse, circular logic, the authors in fact provide justification for, and indeed make necessary, the very conscience exemptions they would eliminate.
Professional Societies, Professional Standards, and Professional Role Morality
Continuing from their descriptions of differences between military and medical conscientious objections, the authors contend that professional medical societies should, based on notions of established professional standards and professional role morality, eliminate conscientious objection from their codes of ethics and practice guidelines.
The authors define healthcare providers’ primary interest: “to promote the well-being of patients.” There is no controversy about that claim, or the similar claim that providers should “regard the . . . patient as paramount,” or again that providers should practice the standard of care within their specialty.
The authors extend their argument beyond their claims, however, insisting that the only manner in which providers make the patient paramount is by following every standard practice, even those that providers find objectionable or inappropriate for their patient(s). The authors’ argument presumes that what is professionally “standard” trumps what is morally right, in essence making the designation of “professionally standard” sacrosanct. However, the history of medicine is rife with examples of interventions once considered “standard” but of a dubious moral (or medical) nature. Procedures such as forced sterilizations of mentally retarded individuals and lobotomies—both once standard, commonplace procedures—have caused considerable harm in the past.
The authors freely admit that professional societies “can make mistakes” in formulating such standards. They propose that those mistakes be corrected through application of political philosopher John Rawls’s method of “reflective equilibrium,” a process of gradually balancing diverse considered judgments to achieve a settled coherence among our principles. But reflective equilibrium presupposes that no party demands unconditional and unquestioning adherence to its own principles, so the authors’ suggestion for addressing the fallibility of professional societies is in manifest tension with their general thesis that all objection to professionally accepted medical interventions should be delegitimized and prohibited.
To further support their argument against medical conscientious objection, the authors claim the American Medical Association Code of Ethics permits blatant discrimination against classes of patients (those infected by HIV, LGBTQ patients, diabetics, etc.)—a puzzling position, as the AMA Code states no such thing. It in fact specifies the opposite, explicitly allowing physicians to forgo morally objectionable interventions and forbidding the refusal of treatment to protected classes of patients.
A second straw-man argument involves the authors’ example of a woman seeking care for a life-threatening ectopic pregnancy; they inject controversy into a scenario in which the question whether it is immoral to decline to treat such a patient is neither disputed nor contested. No reasonable provider, regardless of his or her beliefs on abortion, could consider refusing such a patient necessary, life-saving treatment to be ethical. The specific treatment the patient received might differ based on the moral beliefs of her attending physician—for example, a Catholic physician would probably forgo the use of the “professional standard” methotrexate in favor of a salpingectomy, in accordance with the principle of double effect—but the question whether to treat at all is uncontested.
Humane Physicians Need Freedom of Conscience
Drs. Stahl and Emanuel exhibit alarming disregard for conscience, which seems to stem from a fundamental misunderstanding of what, precisely, a conscience is. As Richard Gula argues, the freedom to exercise conscience is fundamental to a person’s humanity, and a person’s conscience is central to his or her identity, in that it shapes and supports the moral framework of a person’s life.
It is nonsensical to suggest that a person’s identity changes once he arrives at work, or that he can selectively access it in one locale but not another—as he would be required to do if, while professing moral opposition to abortion at home, he were obliged to perform abortions at work. What the authors describe is not a conscience, but an amoral preference for certain behaviors in certain situations. A profession without conscience is not human in any meaningful sense. Nor is such a profession humane.
Physicians are historically and rightly constrained against doing harm, but that does not mean there is only one way to practice medicine. The professionally “standard” intervention for a class of patients is not necessarily the right intervention for each individual patient. To argue otherwise diminishes both patient and provider autonomy. In a diverse and liberal society, there is no reason to make the practice of medicine monolithic. Such total and inflexible adherence to professional standards, in fact, may prevent the provider from focusing on the unique nature and circumstances of each individual patient, as a patient-centered approach to medicine, and ideally his conscience, calls him to do.
Many countries in Europe, our neighbors in Canada, and some states in the US have “standardized” physician-assisted suicide, and some have implemented policies similar to the authors’ own recommendations, with troubling results. Providers and patients should both take a lesson from the history of eugenics: widely popular in the early twentieth-century United States among policymakers, as well as biological and social scientists, the eugenics movement also once enjoyed a great deal of support from American physicians. Drs. Stahl and Emanuel would do well to note that the American medical profession's once favorable position on eugenics did not suddenly change because eugenicists experienced a change of heart overnight; it changed because the relatively few politicians, academics, and medical providers morally opposed to eugenics refused to participate in it and also—as Christine Rosen documents—spoke out against it. Not until the atrocities of World War II came to light were eugenics proponents essentially forced to disavow their position, over the movement’s close association with Nazism. Are we to await the next Holocaust before entertaining objections to morally questionable interventions?
Providers and patients must ensure that conscience protections remain enshrined in ethical codes and practice guidelines. Driving out conscience in favor of blind devotion to professional standards will create a class of providers who have neglected to cultivate virtue and have ceded their humanity. To paraphrase Lewis, in “removing the organ and demanding the function,” we should not be surprised if, when called upon to defend their patients’ humanity, these “physicians without chests” no longer know how.
Michael D. Stark, MD, and his wife, Grace E. Stark, MA, Bioethics & Health Policy, currently live in Guam with their newborn son, Gabriel.