When I invited Dr. Wes Ely – the coauthor of a recent article regarding physician-assisted suicide – to write a Critical Care Commentary on said topic, an interesting thing happened: he declined and suggested that I invite a group of students from medical schools across the country to write the piece instead. The idea was brilliant, and the resulting piece was so insightful that the CHEST® journal editorial leadership suggested submission to the journal, and the accepted article will appear in the September issue. Out of that effort, the idea for the present piece was born. The result is an opportunity to hear the students’ voices, not only to stimulate discussion on conscientious objection in medicine but also to remind the ICU community that our learners have their own opinions and that through dialogues such as this, we might all learn from one another.
Lee Morrow, MD, FCCP
“No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.” – Thomas Jefferson
(Washington HA. The Writings of Thomas Jefferson. New York: Biker, Thorne, & Co. 1854,; Vol 3:147.)
What is the proper role of conscience in medicine? A recent article in the New England Journal of Medicine (Stahl & Emmanuel. N Engl J Med. 2017; 376(14):1380) is the latest to address this question. It is often argued that physicians who cite conscience in refusing to perform requested procedures or treatments necessarily infringe upon patients’ rights. However, we feel that these concerns stem from a fundamental misunderstanding of what conscience is, why it ought to be respected as an indispensable part of medical judgment (Genuis & Lipp . Int J Family Med. 2013; Epub 2013 Dec 12), and how conscience is oriented toward the end goal of health, which we pursue in medicine.
By failing to define “conscience,” the crux of the argument against conscience rights is built on the basis of an implied diminution of conscience from an imperative moral judgment down to mere personal preference. If conscience represents only personal preference – if it is limited to a set of choices of the same moral equivalent as the selection of an ice cream flavor, with no need for technical expertise—then it would follow that a physician ought to simply comply with the patient’s decisions in any given medical situation. However, we know intuitively that this line of reasoning cannot hold, if followed to its conclusion. For example, if a patient presenting with symptoms of clear rhinorrhea and dry cough in December asks for an antibiotic, through this patient-sovereignty model, the physician surely ought to provide the prescription to honor the patient’s request. The patient would have every right to insist on the antibiotic, and the physician would be obliged to prescribe accordingly. We, as students, are trained, however, that it would be morally and professionally fitting, even obligatory, for the physician to refuse this request, precisely through exercise of his/her professional conscience.
If conscience, then, is not simply a subject of one’s personal preferences, how are we to properly understand it? Conscience is “a person’s moral sense of right and wrong, viewed as acting as a guide to one’s behavior” (Conscience. Oxford Dictionary. Oxford, Oxford University Press. 2017). It exhibits the commitment to engage in a “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Sulmasy. Theor Med Bioeth. 2008; 29(3):135). Whether or not a person intentionally seeks to form his/her conscience, it continues to be molded through the regular actions of daily life. The actions we perform – and those we omit – constantly shape our individual consciences. One’s conscience can indeed err due to emotional imbalance or faulty reasoning, but, even in these instances, it is essential to invest in the proper shaping of conscience in accordance with truth and goodness, rather than to reject the place of conscience altogether.
By attributing appropriate value to an individual’s conscience, we thereby recognize the centrality of conscience to identity and personal integrity. Consequently, we see that forcing an individual to impinge on his/her conscience through coercive means incidentally violates that person’s autonomy and dignity as a human being capable of moral decision-making.
In the practice of medicine, the free exercise of conscience is especially relevant. When patients and physicians meet to act in the pursuit of the patient’s health, they begin the process of conscience-mediated shared decision-making, rife with the potential for disagreement. Throughout this process, a physician should not violate a patient’s conscience rights by forcing medical treatment where it is unwanted, but neither should a patient violate a physician’s conscience rights by demanding a procedure or treatment that the physician cannot perform in good conscience. Moreover, to insert an external arbiter (eg, a professional society) to resolve the situation by means of contradiction of conscience would have the same violating effect on one or both parties.
One common debate as to the application of conscience in the setting of critical care focuses on the issue of physician-assisted suicide and euthanasia (PAS/E) (Rhee J, et al. Chest. 2017;152[3]. Accepted for Sept 2017 publication). Those who would deny physicians the right to conscientiously object to PAS/E depict this as merely an issue of the physician’s personal preference. Given the distinction between preference and conscience, however, we recognize that much more is at play. For students and practitioners who hold that health signifies the “well-working of the organism as a whole,” (Kass L. Public Interest. 1975; 40(summer):11-42) and feel that the killing of a patient is an action that goes directly against the health of the patient, the obligation to participate in PAS/E represents not only a violation of our decision-making dignity, but also subverts the critical component of clinical judgment inherent to our profession. The conscientiously practicing doctor who follows what they believe to be their professional obligations, acting in accordance with the health of the patient, may reasonably conclude that PAS/E directly contradicts their obligations to pursue the best health interests of the patient. As such, their refusal to participate can hardly be deemed a simple personal preference, as the refusal is both reasoned and reasonable. Indeed, experts have concluded that regardless of the legality of PAS/E, physicians must be allowed to conscientiously object to participate (Goligher et al. Crit Care Med. 2017; 45(2):149).
As medical students who have recently gone through the arduous medical school application process, we are particularly concerned with the claim that if one sees fit to exercise conscientious objection as a practitioner, they should leave medicine, or choose a field in medicine with few ethical dilemmas. To crassly exclude students from the pursuit of medicine on the basis of the shape of their conscience would be to unjustly discriminate by assigning different values to genuinely held beliefs. A direct consequence of this exclusion would be to decrease the diversity of thought, which is central to medical innovation and medical progress. History has taught us that the frontiers of medical advancement are most ardently pursued by those who think deeply and then dare to act creatively, seeking to bring to fruition what others deemed impossible. Without conscience rights, physicians are not free to think for themselves. We find it hard to believe that many physicians would feel comfortable jettisoning conscience in all instances where it may go against the wishes of their patients or the consensus opinion of the profession.
Furthermore, as medical students, we are acutely aware of the importance of conscientious objection due to the extant hierarchical nature of medical training. Evaluations are often performed by residents and physicians in places of authority, so students will readily subjugate everything from bodily needs to conscience in order to appease their attending physicians. Evidence indicates that medical students will even fail to object when they recognize medical errors performed by their superiors (Madigosky WS, et al. Acad Med. 2006; 81(1):94).
It is, therefore, crucial to the proper formation of medical students that our exercise of conscience be safeguarded during our training. A student who is free to exercise conscience is a student who is learning to think independently, as well as to shoulder the responsibility that comes as a consequence of free choices.
Ultimately, we must ask ourselves: how is the role of the physician altered if we choose to minimize the role of conscience in medicine? And do patients truly want physicians who forfeit their consciences even in matters of life and death? If we take the demands of those who dismiss conscience to their end – that only those willing to put their conscience aside should enter medicine – we would be left with practitioners whose group think training would stifle discussion between physicians and patients, and whose role would be reduced to simply acquiescing to any and all demands of the patient, even to their own detriment. Such a group of people, in our view, would fail to be physicians.
Author Affiliations: Geisel School of Medicine at Dartmouth, Hanover, NH (Dr. Dumitru); University of North Carolina School of Medicine, Chapel Hill, NC (Mr. Frush); Ohio University Heritage College of Osteopathic Medicine, Athens, OH (Mr. Radlicz); Columbia University College of Physicians and Surgeons, New York, NY (Mr. Allen); Thomas Jefferson School of Medicine, Philadelphia, PA (Mr. Brown); Faculty of Medicine & Dentistry, University of Alberta School, Edmonton, AB, Canada (Mr. Bannon); Icahn School of Medicine at Mount Sinai, New York, NY (Mr. Rhee).