Erasing Conscience
Controversies
over the conscience rights of health care workers are not limited to
state and federal governments. Professional medical associations have
recently constructed codes of ethical conduct concerning the right of
health care workers to refuse to participate in certain medical
procedures. One of the most influential is “The Limits of Conscientious
Refusal in Reproductive Medicine,” a statement by the Ethics Committee
of the American College of Obstetricians and Gynecologists. While it
claims to respect the value of conscientious objection, the statement
places such severe limits on the exercise of this objection that little
of conscience finally survives.
The A.C.O.G. declaration begins with praise
of personal conscience as having “a critical and useful place in the
practice of medicine. In many cases, it can foster thoughtful,
effective, and human care.” However, as the declaration attempts to
“balance” the claims of conscience against other considerations, the
scope for the exercise of conscience is progressively reduced.
One limitation on the right of conscience is
the danger of imposition. The A.C.O.G. statement underlines the value
of patient autonomy. “To respect a patient’s autonomy is to respect her
capacities and perspectives, including her right to hold certain views,
make certain choices, and take certain actions based on personal values
and beliefs.” The committee fears that conscientious medical objection
can constitute an “imposition of religious or moral beliefs on a patient
who may not share these beliefs,” thus assaulting patient autonomy. The
refusal to prescribe contraceptives is cited as an example of such an
assault. In this exaltation of patient autonomy, the health care
professional becomes a simple servant of patient desire, as long as the
desired treatment is legal. The traditional duty of the doctor to
promote the actual good rather than the subjective wishes of the patient
crumbles in such a consumerist indenture to the other’s will.
A second limitation stresses the health of
the patient, an indisputable medical good. But the A.C.O.G. code places
health into a consequentialist framework. The refusal, based on
religious convictions, to perform a sterilization could impinge on the
patient’s own conception of maximal health. “Religiously based refusals
to perform tubal sterilization at the time of caesarean delivery can
place a woman in harm’s way.” There is no consideration of the grave
assault on physical integrity represented by such an act of mutilation,
regardless of hypothetical future health benefits.
Despite the statement’s insistence that
health care professionals consider the broader social context of their
actions, it nowhere recognizes the grim history of coercion accompanying
such post-delivery tubal ligations, especially when performed upon poor
women dependent on state welfare.
Another limitation arises from the question
of social discrimination represented by acts of conscientious objection.
“The impact of conscientious refusals on the oppression of certain
groups of people should guide limits for claims of conscience.” Two
examples cited by the committee are the refusal to provide fertility
treatments to same-sex couples and the refusal to provide certain
“reproductive services to women.” The declaration condemns such refusals
on the ground that they constitute discrimination against homosexuals
and women as a class.
But the A.C.O.G.’s censure rests on a
dangerous confusion between the refusal to perform a certain act and the
refusal to serve a certain group. The refusal of a doctor to provide
the surgery and hormonal treatments to change the gender appearance of a
patient is not the same as refusing to provide cancer treatment to a
transgender patient. Many institutions refusing to perform abortions,
notably Catholic hospitals, have a distinguished record of serving a
disproportionately female group of clients.
If the A.C.O.G. code reduces conscience to a
minor concern, other contemporary voices would simply abolish
conscience altogether. The Oxford philosopher Julian Savulescu argues
that “a doctor’s conscience has little place in the delivery of modern
medical care.... If people are not prepared to offer legally permitted,
efficient, and beneficial care to a patient because it conflicts with
their values, they should not be doctors.” Benighted health care workers
still clinging to the Hippocratic Oath’s prohibition of abortion and
euthanasia need not apply.
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