Keeping a clear conscience

ALL doctors should know that their prime duty is to make the care of patients their first concern, regardless of any personal beliefs. But what if a doctor strongly objects to performing certain procedures because it conflicts with these beliefs? Should they be allowed to refuse to be involved?

That was the question put to a group of medical students in a recent survey for the Journal of Medical Ethics. As part of the survey, researchers also asked trainees if they had objections to carrying out intimate examinations of patients of the opposite sex or to learning about and managing alcoholrelated illness.

Nearly half of the 733 students surveyed felt that doctors had a right to object to performing any procedure that conflicted with their religious, moral or ethical beliefs. In some ways, the surprise is that this figure is not 100 per cent. Surely every doctor has a right to refuse to be involved in a procedure that he or she finds morally, ethically or religiously abhorrent? It would then become a matter for each individual to make a judgement as to where the bar is set. A doctor who was comfortable with performing a late termination of pregnancy, for example, might well have an objection to administering a lethal but legally sanctioned injection to a condemned prisoner on Death Row.

The Journal’s study does not go to such extremes as lethal injection but keeps largely to common clinical presentations. It groups possible reasons for “conscientious objection” or refusal to be involved in the management of a patient into two types.

The first relates to specific procedures or prescribing and can be defined broadly as objection to the task. The usual example here is termination of pregnancy but it could just as easily be provision of contraceptive advice to under 16s or sex determination of a foetus where there is no clinical reason to provide parents with this information.

Here the advice from the General Medical Council’s (GMC) guidance Personal beliefs and medical practice states: “Where, for personal, moral or religious reasons, you are not prepared to discuss or carry out a procedure that the patient requests and which is not illegal or against the best interests of the patient, you must be prepared to refer the patient to another practitioner who can manage the patient.”

This seems a workable and appropriate way of balancing the doctor’s overriding duty to make the care of the patient his or her first priority with the acceptance that doctors’ firmly held personal ethical frameworks may mean that some procedures are abhorrent. It builds in a clear safety net for the patient by requiring the doctor to refer the patient to another appropriate practitioner.

It is worth noting that in England, Wales and Scotland, the right to refuse to participate in terminations of pregnancy is protected under section 4(1) of the Abortion Act 1967 (the Act does not apply in Northern Ireland). It states that “no person shall be under any duty, whether by contract or by any statutory or other legal requirement, to participate in the treatment authorised in this Act to which he has a conscientious objection”. However, doctors have no legal or ethical right to refuse to provide care for patients pre- and posttermination of pregnancy.

The second type of conscientious objection relates to patients rather than procedures and can be defined as objection to the person and their background, beliefs and lifestyle choices. Refusal to see, treat or even learn about disease resulting from alcohol misuse is clearly in this category. It could be argued that objection to performing intimate examinations is refusal to carry out a procedure but the qualification, “… examining a person of the opposite sex”, clearly defines it as an objection to the person (based on their gender).

The GMC’s guidance Good Medical Practice has something to say on this subject and makes it pretty clear (in paragraph 7) that: “You must not unfairly discriminate against [your patients] by allowing your personal views to affect adversely your professional relationship with them or the treatment you provide or arrange.”

This is further underlined later in GMP where it states that: “All patients are entitled to care and treatment to meet their clinical needs” and goes on to emphasise that doctors have an obligation to treat a patient even where this might put the doctor’s own health at risk.

Worryingly, five per cent of students in the ethical study objected to intimate examination of patients of the opposite sex and 8.5 per cent would object to treating patients who are suffering from acute alcohol intoxication. (Smaller proportions would go further than objecting and would firmly refuse the intimate examination or to manage alcohol intoxication.)

Medicine will always need highly principled individuals but these medical students and doctors are not permitted by the GMC to pick and choose whom they will treat. There is also the question of how practical the stance actually is in the complex world of clinical medicine. The doctor cannot choose to treat only part of a male patient’s HIV complex where that patient is both a haemophiliac and bisexual. What if they were then required to manage the risk to this man’s (heterosexual) wife?

It is very worrying that there are medical students already well along the path of their medical studies whose personal ethical and religious framework means that they will not treat particular patients who have made lifestyle choices that those students find objectionable. Even with the most careful choice of jobs after qualification, it is impossible to be sure that the doctor will not have to manage such a patient, often in an on-call role where it may be very difficult to find someone else to take over.

Medical schools have a duty to consider applicants equally regardless of their moral or religious beliefs or of their lifestyle choices. Surely they also have a duty to remind applicants that the GMC may well sanction doctors who unfairly pick and choose which patients they will examine or treat? It should then be up to those applicants to decide for themselves if medicine is really the correct career choice. Perhaps a follow-up study could be arranged to ask the conscientious objectors if they were made aware, when they applied to study medicine, that they would inevitably face such difficult choices.

Mr Des Watson is a senior medical adviser with MDDUS

SCENARIO:

A 16-year-old patient, Miss B, presents at A&E on a Sunday morning seeking emergency contraception. She is seen by Dr E and tells him that she had unprotected sex the previous night following a drink and drugs binge. She reassures him that the sex was consensual but she is concerned she might be pregnant and is worried her parents will find out.

However, Dr E is a practising Catholic and disapproves of Miss B’s drinking and drug-taking. He also has a conscientious objection to prescribing contraception and explains to her that he is not prepared to treat her because of his personal beliefs. Miss B is unhappy and challenges the doctor’s refusal. He tells her another doctor will treat her but does not submit a request until later that morning, due to Miss B’s behaviour. Miss B is finally seen by another doctor three hours later.

The following week, she submits a complaint to the hospital about the way Dr E handled her case and this is eventually resolved by way of an apology from Dr E.

Key Points

• Never refuse or delay treatment because you believe a patient’s actions have contributed to their condition.

• If you have a conscientious objection to treating a patient, you must explain their right to see another doctor and ensure they have enough information to exercise that right.

• If the patient can’t make their own arrangements, you must ensure arrangements are made, without delay, for another doctor to take over their care.