At its General Assembly in October, the World Medical Association adopted a new text for its International Code of Medical Ethics. Some doctors had urged that the Code impose on doctors who conscientiously object to abortion or assisted suicide a duty to refer to a colleague who would provide these interventions.
The WMA rejected this view and adopted compromise wording that gives doctors a duty “to minimise disruption to patient care” but does not require referral.
To understand the significance of this it is useful to go back to the origin of the International Code of Medical Ethics and to the origins of the WMA itself.
In the early part of the 20th century medical doctors were at the forefront of a movement to improve public health by eugenic means. In practice this entailed the incarceration, sterilisation, eugenic abortion or, ultimately, euthanasia of those regarded as unfit by reason of congenital disease, deformity, or feeble-mindedness. The ability to pursue this agenda varied from country to country but was given freest reign in Germany in the 1930s. The large-scale non-voluntary killing of those deemed to have “lives unworthy of life” began in hospitals in Germany and Austria. Doctors later played a key role in the concentration camps, determining who was unfit to work and who should be euthanised. Some also used prisoners for scientific research.
This happened not because doctors were coerced into acting in this way. For the most part they were volunteers putting into action ideas that they had held even before the Nazis came to power. When it came to eugenic euthanasia, they believed in that “the syringe belongs in the hand of the physician“.
The Nazi crimes against humanity were exposed after the war at the Nuremberg trials, which included a special trial of Nazi doctors.
It was in a determination that such actions never be repeated that the United Nations was founded in 1945 and the World Medical Association in 1947. Both organisations took as foundational the inherent dignity of the human person and hence, in 1948, the United Nations adopted the Universal Declaration on Human Rights and the WMA adopted the Declaration of Geneva – a modernised version of the Hippocratic Oath. The following year the WMA supplemented the Declaration with an International Code of Medical Ethics. The Code is expressive of the very identity of the WMA.
Neither the 1948 Declaration nor the Code included any reference to conscientious objection. However, the Declaration required doctors to act “with conscience” and to “maintain the utmost respect for human life from the time of its conception“. This clause reflected the prohibition of assisted suicide and abortion that was present in the ancient Hippocratic Oath.
The right to “conscientious objection” in healthcare emerged in the United Kingdom as a clause in the Abortion Act 1967. Parliament increased access to abortion but also recognised that abortion was ethically contested and that many healthcare professionals regarded it as unjust and contrary to the goals of medicine. The law therefore protected healthcare professionals from participating in abortion except in rare cases where the procedure was necessary to save the life or to prevent grave permanent injury to the physical or mental health of a pregnant woman. There was no duty on doctors to provide or facilitate abortion for unwanted pregnancy or for eugenic reasons.
Since 1967 increasing numbers of countries have legalised abortion and most have made clear that doctors are not obligated to participate. A similar right of refusal has been incorporated in some laws permitting euthanasia or assisted suicide. However, as abortion and euthanasia became normalised, the societal, professional and legal protections given to healthcare workers who object to these practices have been weakened. Opponents of conscientious objection have argued that doctors should always do as the patient requests and as the state makes provisions for.
Ironically it is philosophers who claim expertise in ethics who have been most prominent in disparaging respect for conscience.
At the same time, the reality is that in contemporary medicine doctors are constrained in what they can do for patients for many reasons. They are no longer independent professionals. They function within large bureaucratic systems of service provision, paid for by the state or by insurance companies, overseen by government and by professional and regulatory bodies.
These systems advertise themselves as offering choice to healthcare consumers, even though this is not necessarily the experience of patients. In this context it is not only politicians, healthcare managers, armchair philosophers and others outside the practice of medicine who have embraced the language of “patient autonomy”. Many doctors have come to think it wrong even to ask what would be good for the health of patients. Doctors should give a patient what the patient requests where it is legal and the healthcare system makes provision for it, even if the doctor thinks that this would be harmful, unjust or unethical in some other way. The customer is always right.
This is a caricature but it represents very powerful legal, institutional and cultural forces. It is not simply an abstract philosophical idea but is how many doctors experience healthcare and why many feel demoralised and leave the profession early. They have been reduced to functionaries.
The movement to uphold the conscientious practice of medicine is a struggle for the soul of the profession. It is a struggle to maintain that it has a soul and is a profession. Doctors who object often have sound professional reasons to do so, based on experience, evidence or concerns for the best care and safety of their patients. Healthcare is not just a machine within which one must “minimise disruption” and “maximise satisfaction” of healthcare consumers.
That many doctors and other healthcare professionals retain commitment to practice medicine as a vocation was shown by the hundreds of doctors and academics who signed the open letter to the WMA on conscientious objection that was organised by the Anscombe Bioethics Centre. This is still a vision that attracts professionals and is why they stay in medicine.
If doctors who object to some procedure as harmful, unjust or otherwise unethical had been required to refer to a less scrupulous colleagues who would provide it, the very idea of practicing medicine “with conscience” would have been undermined. Indeed, the Code would have come to contradict the original Declaration of Geneva, as it would have required physicians to refer patients for interventions that directly end life.
It is heartening to see that conscience has been upheld by the World Medical Association, a medical body representing doctors in so many countries. With increasing pressures on health and social care from many quarters, patients do not need the imposition of uncritical adherence to state or institutional control. They need professionals who will act consistently and conscientiously for the good of patients according to their knowledge and judgement.
Conscientious professionals are the last line of defence for ethical patient care.