In a world where moral relativism has firmly taken root, doctors and medical practitioners struggle to remain true to themselves while at the same time meeting the needs of their patients and hospital administration boards. But recent victories, such as the one in Illinois for nursing student Anne Marie Dust, is a step forward in the effort to gain conscience protection for doctors in both Canada and the US.
Now a practicing nurse, Ms. Dust assists expectant mothers who have been put on bed-rest at an antepartum unit. At one time she thought that she may never be able to enter her chosen profession. Before she had even begun her program, the application form for the Nurse Residency Program at Vanderbilt University in Nashville, Tennessee required students to declare in writing that they would agree to participate in abortions.
Rather than acquiesce, she went to the Alliance Defense Fund (ADF) who helped her file a federal complaint to the Department of Health and Human Services. She lodged the complaint in early January 2011. According to a LifeSiteNews.com article (Sept. 9, 2011), “The complaint objected to the university’s 'illegal discrimination' in forcing students who are serious about their pro-life beliefs to violate their 'federal rights of conscience' by agreeing to assist in abortions.” The article reported that within a period of 26 hours following receipt of the complaint, the university rescinded its policy.
Cases similar to this one have been fought and won within Canada, advancing conscience protection each time, yet there remains a strong climate of concern among many medical practitioners. In a piece written on behalf of Nurses for Life, Mary-Lynn McPherson listed several cases in Canada where discrimination, subtle coercion and ill-will towards pro-life nurses resulted in them either quitting their jobs or performing abortions in violation of their consciences. The Markham Stouffville Hospital case in Ontario is worth noting. Eight nurses appealed to the Human Rights Commission (the College of Nurses would not intervene on their behalf) because they were being forced by a new hospital policy to participate in abortions. McPherson writes that “during the five long years before the case was settled these nurses suffered acute and bitter harassment and discrimination. Some left to find jobs elsewhere.” In May of 1999, the Hospital did finally agree to allow nurses to opt out of assisting with abortions.
Another well known case involved a Manitoba medical student who, in 2004, was refused graduation because he would neither participate in abortions nor affirm that he would refer women to such doctors. He had exhausted all avenues of appeal within the University hierarchy, when suddenly the University reversed its decisions and allowed the student to graduate. Writing on the subject, journalist Terry O'Neill noted that, “It is not clear why University authorities decided to accommodate the student, having previously been unwilling to accept his position.”
Pharmacists have their share of “ethical stress” in the work place too. Maria Bizecki of the Co-op Pharmacy in Calgary became the subject of an internal review by the Alberta College of Pharmacists in 2003 for her refusal to dispense the “morning-after” pill. After a year of not being able to work, she was vindicated.
Finally Cristina Alarcon, a BC Pharmacist who has challenged her College on matters of conscience, told students at a conference in 2006 that she fears being blacklisted. The latest “Code of Ethics” issued in July of 2011 for BC Pharmacists demands that prescriptions be filled even if doing so would violate the pharmacists conscience: “... should the system developed to ensure the timely delivery of the product or service fail, the [pharmacist], not withstanding their conscientious objection, has a duty to the patient to provide the product or service requested.” “This,” writes Ms. Alarcon, “could be very problematic were euthanasia legalized, don't you think?”
Ethical dilemmas in medicine continue to become more frequent and complex. In Unraveling the Ethical Physician, Dr. Stephen Genuis, a well-known author and researcher, board-certified in both Obstetrics and Gynecology as well as Environmental Medicine and published in diverse international medical journals including the Lancet, British Medical Journal, Canadian Medical Association Journal, Public Health and the American Board of Family Practice, discusses the stress felt by physicians. They are often having to balance the dictates of their own consciences with the demands of both their patients and the medical administrative bodies who are imposing policies on ethics. But whose ethics? When there is no moral consensus on these important issues, should not hospital boards and ethics committees be giving physicians more autonomy, not less? Dr. Genius writes, “with no universal ethic, however, it would be a non sequitur to conclude that good judgment or ultimate discretion automatically lies with any person or committee.”
The ethical physician desires to act in the best interests of his or her patient, but the guiding principles of ethics committees and even patients themselves are no longer the Hippocratic oath and the universal principle of “first, do no harm.” Instead, they have become the subjective values of non-paternalism, tolerance, and personal autonomy.
Should the patient or the ethic's board disagree with a physician's decision about a certain course of action, they can claim paternalism or intolerance, and immediately stifle honest inquiry and debate about important ethical issues. Dr. Genuis points out, “Criticizing or disciplining MDs for resolutely acting in a fashion they believe to be medically optimal for patients is intrinsically paternalistic toward those physicians.”
To skirt the problem of forcing physicians to act against their better judgment, these committees have been demanding that the physicians refer their patients to other doctors who do not have the same reservations about a given medical procedure. In January 2011, the College of Physicians and Surgeons of Saskatchewan released their final draft of the new Guidelines on Pregnancy requiring doctors to arrange for a “necessary referral” in the event they did not want to be involved with “termination of a pregnancy.”
“Ethical physicians,” writes Dr. Genuis, “refer to consultants who they determine will undertake interventions likely to be of assistance to the well being of the patient or society. From the vantage point of primary doctors, to knowingly carry out a consultation to another practitioner who they anticipate will proceed in a way the primary doctors feel is damaging, is to be complicit in harm.”
Commenting on the 2004 University of Manitoba case, lawyer Iain Benson wrote, “Without getting into the controversial question of how pregnancy could ever be a disease, it is clear that no proper protection of conscience could force a person who believes abortion is murder to refer a person to another murderer. Sorry that this is put rather bluntly but that is how those who are opposed to abortion see things.”
In other words, patients do not have a “trump right” to medical services over a physicians conscience, nor are physicians obligated to offer every and all medical services possible.
Some have suggested forcing the physician to leave his personal beliefs at the door. ‘‘In becoming a professional, you accept certain limits to your rights and freedoms, and anyone who doesn’t like it should choose another way of earning a living.’’ However, as Dr. Genius continues, “the folly of supplanting individual reason and values with expert advice and authoritarian dictates has been evident throughout history.” The Nuremberg Trials present plenty of evidence in this regard.
So what is the happy solution to handling patient, physician and hospital administration conflict? Forcing doctors to submit their wills to administrators threatens to harm doctor morale. Many already feel that they are being used as “mere technicians” rather than intelligent professionals who have the training and competence to step up to the challenges and joys of practicing medicine.
According to Dr. Genuis, “there are differing levels of doing ethics, including individual,
institutional, societal, and global... From the clinician’s vantage point, he or she has
a primary obligation of personal care to each patient, while institutions enjoy the unenviable task of considering the most efficient way to use limited healthcare resources to serve the greatest good...” He believes that on an individual level, physicians should make their ethical stance known at the outset. “It is prudent to explicitly inform prospective patients at the initial encounter about the practitioner’s approach to medical care and any specific limitations that may arise.”
In reference to the Manitoba case, Iain Benson councils the same thing: “[I]n a free and democratic society, [the physician] can only be required to tell a patient the following: 'I am conscientiously opposed to abortion and will neither perform one nor refer you to another physician who will. If that is what you seek you must go elsewhere.'”
Dr. Will Johnston of Canadain Physician's for Life takes it a step further. He believes that not only should the moral stance of the physician be made clear, but it should be done in order to fully inform the patient of the risks and realities of abortion, or any other medical procedure that is under discussion. “Pro-life physicians,” he says, “should declare their personal views to a pregnant patient considering an abortion in order to place the subsequent discussion in context. The doctor then has every right, indeed, a responsibility, to outline the potential mental and physical risks of abortion just as he or she would before prescribing a drug or weighing the merits of surgery.”
The philosophical construct that calls for tolerance and personal autonomy necessitates that all people have a right to not participate in what they perceive to be wrong, and as Dr. Genuis points out, “fundamental human rights and freedom of conscience incorporate self determination for the physician as well.” Rather than forcing doctors to comply to 'industry standards' in areas of grave moral concern, the onus should be on the patient to choose the manner of care they want. And medical practitioners like Anne Marie Dust must continue to bravely challenge those dictates that compromise physicians' integrity and freedom of conscience.
1 MDs, pharmacists should follow conscience, by Laureen McMahon, BC Catholic, 25 June, 2001