Doctors and Conscience: Just Say No?

Hospital rota co-ordinators are a curious breed and most will rapidly earn the ire of junior doctors. Whilst some are wonderfully efficient they tend to be the exception to the rule and many a time I’ve been told off my night shift only a few days before I am to suffer it, or have turned up only to find the other doctors on the rota have long ago left medicine or emigrated. It is a tough job and I envy them not but it often leads to complicated situations. Gynecology units will often offer an abortion service in the operating theatre and when the doctor due to be assisting the consultant on the termination list has been simultaneously assigned to another part of the hospital the hunt is on to find another doctor whose conscience allows them to take part in terminations. Many doctors (including O&G trainees) [1] often have negative attitudes towards abortion and therefore when asked generally follows is an awkward shuffling of the feet and muffled refusal.

Something that has always struck me as curious is that if one feels that abortion is murder and that if you are aware that abortion is taking place in the operating theatre next door do you need to do more than conscientiously object. Surely if you knew one of the surgeons was butchering two year olds no one would feel it was simply adequate to say  “well I’m not taking part in that so it’s okay” but instead feel compelled to act. Is it enough, as Solzhenitsyn says that:

“… the simple step of a simple courageous man is not to partake in falsehood, not to support false actions! Let THAT enter the world, let it even reign in the world – but not with my help” ~ Alexander Solzhenitsyn, Nobel Prize Acceptance Speech (Nobel Prize, 1970)

During medical training we were all told that conscientious objection allowed us to decline some parts of the practice of medicine we found morally unacceptable. Some philosophers feel that “medical students and trainees be aware the commitments of the profession and be prepared to undertake these or not become doctors [2].” Yet such a stance seems rather extreme given the complicity of doctors in some of worst actions of Soviet (and indeed Nazi) regimes when medicine was often a tool used against dissidents.

Thus if we accept that conscientious objection has a place in medicine is there a line we can draw between it and civil disobedience? To return to the abortion example the doctor may not want to physically intervene in the operating theatre because they have pacifist tendencies. However are they morally obliged to employ civil disobedience to protest over what they see as wrong?

The question between civil disobedience and conscientious objection has troubled me throughout my medical practice and, as with most philosophy the deeper one examines the issue the murkier the waters become. For some writers such as Thoreau your conscience is inviolable:

“Must the citizen ever for a moment, or in the least degree, resigns his conscience to the legislator? Why has every man a conscience then? I think that we should be men first, and subjects afterward [3]”

Yet for others whether one can partake in civil disobedience has to be determined by the context. According to Lefkowitx if there is

“…a justifiable political authority….citizens…have a duty to obey the law that correlates to the state’s right to rule them …At a minimum civil disobedience involves disobeying the law for the purposes of political participation….but the right to political participation is already adequately recognised and protection by law in a [just state]…while in certain circumstances the citizen of a [just state] may act rightly when she commits an act of civil disobedience…it is never the case that she has a right to do so [4]”

Therefore though a doctor may be morally right to engage in civil disobedience they may not have a moral right to be civilly disobedient as they have other means of enacting change via the political process (we could argue that we live in a state that lacks justifiable political authority but that would be one kettle of fish too far to open for this post). Whilst I’ve used abortion as an example (as it is an easy fit for moral discussion) we could equally apply this to engaging with higher authorities when they put forward dictates that are not necessarily felt to be in a patients best interest.

References

[1] Gleeson R, Forde E,  Bates E,  Powell S,  Eadon-Jones E, DraperH (2008), Medical students’ attitudes towards abortion: a UK study, Journal of Medical Ethics 2008;34:783-787

[2] Savulescu J (2006), Consceintious objection in medicine, BMJ Volume 332, 4 Feb 2006

[3] Thoreau HD (1849), Walden and Civil Disobedience, Penguin Classics (1983)

[4] Lefkowitx D (2007), On a Moral Right to Civil Disobedience, Ethics (Jan 2007) 117: 202-224

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