Conscious Objection Defended

I wanted to relate the contents of an article that I’ve just read in the most recent Triple Helix (the journal of the Christian Medical Foundation, Winter 2018, not yet available as a free PDF, but soon…), because it really opened my eyes to the positive aspects of Conscious Objection (CO). So often we are fighting on the back foot, having to defend against the attacks – and that is really difficult when all that we are confronted with is negativity. Time spent on consideration of the positive arguments for the stance that we have on various subjects is bound to encourage us, and give more fuel for whenever we are hit with objections.

The article is by Trevor Stammers, who is the Reader in Bioethics and Director of the Centre for Bioethics and Emerging Technologies at St Mary’s University College, Twickenham [which sounds like the best job ever]. After dealing with a number of objections to CO, he puts forward a number of arguments in favour of CO:

  1. The safety of patients. Rather shockingly, he highlights the recently identified coming to light of a huge number of premature deaths in the War Memorial Hospital in Gosport, allegedly related to the working practices of a member of staff who appeared to be giving high dose opiates to patients who were not in imminent risk of dying. He looks to a potential state where doctors are not allowed to object to giving lethal injections to patients that request, on moral grounds, and asks what mechanisms there could be that would prevent abuses of this power? And he draws the surprising parallel between CO and whistleblowing – both actions of protest, borne out of objections seated in a person’s moral integrity – how would a whistleblower make a stand against these actions, when they are officially commanded by the state?
  2. Benefits to healthcare institutions. I like this. “Far from CO bringing society to its knees…  the moral integrity facilitated by accommodating it holds society to account. A world without conscientious objectors is like ‘salt that has lost its saltiness.'” He states that “professions which are of central importance to society depend on their practitioners having moral integrity” (emphasis mine). I love that term, moral integrity. His argument is that agents within a system who have moral integrity will be critical of poor working practices and poor systems, and as long as they have the freedom to criticise, the outcome is generally an improvement in the institution’s functioning and outcomes. We’re all for Quality Improvement in the NHS nowadays, but QI doesn’t have to be about making our numbers look better and our pieces of paper move faster – QI can be about rescuing humans from a dehumanising system. And I love this next statement: “The attempt to drive all expressions of moral or religious belief, practice, or conviction out of healthcare will also lead to a sharp decline in patient well-being. Patients too, have different moral or religious convictions to which we need to be sensitive.” As I see it, we can have a diverse patient group, served by a diverse group of doctors capable of compassion and acts of virtue. Alternatively, we can have diverse patient group served by agents of the State, medical automatons, undeviating from protocols, jobsworths, ‘professional’ carers in the worst sense of the word.  He ends this point with a great question – “How can the profession by sensitive to the moral and religious conviction of our patients if we drive out of the profession those of our own who have conscientious objections to some legal practices?”
  3. Promoting moral integrity and preventing moral distress. By objecting, we are not doing it out a desire to make other peoples’ lives complicated, but because the required action grates against our deeply held convictions. Doing something which goes against my convictions causes a certain amount of distress; being compelled to do something against my convictions “is a form of moral torture“.
  4. Beneficence and the goals of medicine. “If conscientious objection is outlawed, the whole purpose of medicine becomes distorted.” I go back to a previous point – as doctors we are not merely agents of the State, and Stammers argues that neither are we entirely at the whim of patients. He cites an article by Saad in the Journal of Medical Ethics written in response to an earlier article in the same journal rejecting the role CO in cosmetic surgery, putting forward a concept Saad calls Patient Preference Absolutism – whatever the patient says, goes. He gives an example of a patient with a gouty toe – it is the patient’s right to refuse to take medication for the toe, but it is not their right to compel a surgeon to amputate that toe to relieve pain. He draws a distinction between positive and negative patient autonomy – the right to refuse treatment, versus the right to demand treatment. He makes the startling and profound statement that allowing patients to be the ultimate arbiter of their treatment risks undermining one of the four key principles of medical ethics, that of beneficence – “If beneficence is reducible to acquiescence, it is hard to see how it can ever have any continuing significance in ethics”. Basically, if medical staff are ultimately just service providers for their patients, with non of their own autonomy, then it radically changes the nature of our work, the nature of healthcare, and the entire system of ethics that underpins how we consider every patient contact. That is the end of professionalism, and the end of the profession.

His conclusion sums up his arguments nicely, and I want to pick out one phrase from his last paragraph which hits home – “It is also a defence against moral distress in healthcare staff”. I certainly feel distressed at times when considering what is round the next corner for healthcare in NI and beyond, and I feel for my colleagues in the Republic of Ireland, and I can but look on at the protests on CO, hoping to learn lessons and prepare myself for when the debate inevitability hits us.  But reading this article has helped galvanise my  attitude to CO, and recognise it as a vital part of our profession. I hope that in writing this some will be encouraged also, and I look forward to reading more of Trevor Stammers’ work on the subject, glad that we have so able an apologist in our ranks.

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