Principled conscientious objection (CO) for health care workers is under threat from laws in several jurisdictions around the world. A number of prominent bioethicists have attacked the idea of refusing to participate in euthanasia or abortion as unethical.
“A doctors’ conscience has little place in the delivery of modern medical care,” Oxford’s Julian Savulescu has argued in an influential article. The World Health Organization has declared that conscientious objection to abortion may be “indefensible”. The European Parliament has criticized CO in strong terms.
At the same time, many doctors and nurses feel that CO is an integral part of their practice of medicine.
In the middle of this heated controversy, the World Medical Association (WMA) is in the middle of developing its policy on conscientious objection. The WMA is an international confederation representing 115 national medical associations.
WMA experts met in Washington DC last week to finalise changes in the International Code of Medical Ethics (ICoME). The most contentious proposal was mandatory referral — obliging doctors who object to euthanasia and other controversial procedures to refer to a willing doctor.
There was strong opposition to this move, as an open letter organised by the UK’s Anscombe Bioethics Centre demonstrated. It was signed by over 100 doctors and medical ethicists. At the moment the WMA’s policies stipulate that “No physician should be forced to participate in euthanasia or assisted suicide, nor should any physician be obliged to make referral decisions to this end.”
A compromise agreement was reached and a revised draft will be considered at the WMA General Assembly in Berlin in October.
The compromise will require that patients should be immediately informed if their doctor has a conscientious objection and should be told about their right to consult another qualified physician. It will also provide that patients be given sufficient information to initiate such a consultation. Patients are not to be harmed or discriminated against, nor their health endangered.
Importantly, the compromise did not mandate mandatory referral.
Supporters of CO are relieved. “If these proposals had been approved, the impact on the ethical practice of medicine would have been profound,” said Dr Tim Millea, of the Catholic Medical Association. “Physicians would be required to provide or directly refer patients for physician-assisted suicide, abortion, transgender surgery, and other unethical measures.”
The Anscombe Bioethics Centre gives some background to the opposition position on mandatory referral:
There are wider implications of making effective referral compulsory in the context of conscientious objection. For example, if a physician who objects in conscience to a legally-sanctioned medical procedure is obliged to identify and make effective referral to another physician who does not object, then in some jurisdictions a physician who objected to participation in “enhanced interrogation”, or to capital punishment, or to force feeding of a prisoner who is on hunger strike, or to “conversion therapy”, could be forced to facilitate these procedures by effective referral. However, to require a conscientious objector to facilitate delivery of a procedure to which they have a serious ethical objection is a direct attack on their conscience and moral integrity.
A principled conscientious objection is always to a procedure and not to a person. Physicians must not refuse to treat a particular patient or group of patients because of beliefs about them unconnected with the medical propriety of the procedure. In particular, physicians must not refuse to treat criminals or enemy combatants or refuse to treat the health consequences of the patient’s way of life, choices, or beliefs.
Debate on CO has been going within the WMA since 2018. The process of revising the ICoME was led by working group members and observers from more than 20 countries. It was discussed in four regional conferences, a dedicated conference on physician conscientious objection, and a consultation of WMA members.
This article has also been posted on BioEdge, an online newsletter on bioethics.