As noted in previous essays, a New England Journal of Medicine opinion piece entitled, “Physicians, Not Conscripts — Conscientious Objection in Health Care,”[1] by Affordable Care Act architect Dr. Ezekiel Emanuel and University of Pennsylvania professor Ronit Stahl, advocates for limiting the exercise of conscience objections. The rare ethical issues for which they would countenance conscience freedom are only those issues for which the “healthcare community” has not yet developed a consensus:

“There is, however, a specific role for conscientious objection. It provides limited recourse in professionally contested interventions — that is, interventions about which the health care community is debating whether participation is appropriate or not. For example, physician-assisted suicide is currently legal in five states, and whether physicians should participate in it is at the center of a robust ethical debate among health care professionals. (Conversely, although abortion is politically and culturally contested, it is not medically controversial…).”[2]

If a Supreme Court decision were to unilaterally make assisted suicide on demand legal nationwide, as it did in 1973 with abortion on demand, presumably Emanuel and Stahl’s grudging conscience allowances regarding assisted suicide would evaporate.

Even closer to their point, if the American Medical Association (AMA) supported abortion on demand, or human cloning[3] or life-destroying embryo research,[4] objections become moot and all dissenters must submit to this “health care community consensus.” In fact, the AMA does support each of those controversial practices, and many health professionals consider the practices ethically repugnant.[5]

Eighth-grade ethics: “Popularity makes right.”

Emanuel and Stahl offer an ethic fit for the eighth grade. Just as young teens who don’t follow the popular elite face bullying and social conformity demands in the eighth grade, so too healthcare professionals with less popular views must submit to the medical elite or face ostracization and censure.

The majority rules and the minority lose. Wear the same clothes and listen to the same music like everyone else or eat lunch alone. Support abortion, human cloning and lethal embryo research or lose your healthcare career.

What happens when the consensus is dead wrong?

In a 1927 U.S. Supreme Court decision upholding eugenics legislation, Justice Oliver Wendell Holmes, Jr. cited the need to “call upon those who already sap the strength of the state” to sacrifice their progeny, since they are “manifestly unfit from continuing their kind.” Justice Holmes succinctly summarized the rationale for medical assaults on non-consenting adults, quipping, “Three generations of imbeciles are enough.”[6]

President Teddy Roosevelt expressed a widespread view when he asserted, “I wish very much that the wrong people could be prevented entirely from breeding.”[7]

The plan for physicians to cleanse the population of undesirables followed the consensus of the political, academic and cultural elites, including some in the medical community.

Enjoying legal and political sanction and participation by the medical profession, eugenics at the time could have been considered a guiding norm—the kind of norm that under the Emanuel-Stahl plan would have to be followed regardless of conscience objections. Non-eugenicists, physicians who conscientiously object to sterilizations, need not apply for medical positions.

“Choose, you lose.” You chose the medical profession; now you must follow the dictates of the medical profession’s elites.

The United States Holocaust Museum[8] notes that in early 20th century Germany, it was not Hitler and the Nazi party but rather the medical community that first provided the philosophical foundation and legitimization for ridding society of unwanted human beings. Apparently bereft of any moral authority higher than utilitarian pragmatism and nationalism, the German healthcare community elite had come to deem as standard medical practice the euthanasia of “useless eaters”:

“Eugenics advocates in Germany included physicians, public health officials, and academics in the biomedical fields, on the political left and right. Serving on government committees and conducting research on heredity, experts warned that if the nation did not produce more fit children, it was headed for extinction. A growing faction, linking eugenics to race, championed the long-headed, fair ‘Nordics’ as ‘eugenically advantageous’ and discussed ‘race mixing’ as a source of biological degeneration. Eugenic ideas were absorbed into the ideology and platform of the nascent Nazi Party during the 1920s.”[9]

The American eugenics movement outlasted the Nazi program, for seven decades carrying out approximately 60,000 sterilizations in 32 states, including 20,000 in California alone.[10] Adolph Hitler actually had highlighted the American program as a competitive example, urging his countrymen to surpass it.

Emanuel and Stahl’s autocratic proposal—to ban conscience objections when the medical community has established a consensus—would have eliminated from the medical profession any German physician who conscientiously objected to systematic euthanasia and ethnic cleansing. Under Emanuel’s and Stahl’s “popularity makes right” ethic, German physicians in the 1930s who dated object to racism and medicalized murder would be ejected from the profession. Only those who embrace the state’s doctrine of Aryan supremacy and the medical community’s embrace of euthanasia may practice medicine.

Hitler’s SS would not need to round up conscientious objector physicians; the medical community would do the job.

Likewise, Emanuel and Stahl’s anti-conscience proposal would have eliminated any objectors to America’s eugenics policies. The policy pronounces that health professionals gave up their conscience freedom upon choosing the medical profession. In doing so, they become bound to submit to the elite-driven consensus of the health profession. So objectors must submit to elites in the medical community intent on ridding the nation of “imbeciles” through eugenic forced sterilizations.

Tyrants can wear military uniforms or lab coats.

Whether through military force or professional edicts, the ultimate goal of tyrants political and professional is to secure and enforce their own power and purpose and to eliminate all opposition. The intolerant, authoritarian policies advocated by conscience freedom opponents such as Emmanuel and Stahl do precisely that.

The take-no-prisoners, conscience-intolerant approach they espouse establishes an unyielding, supreme authority that quashes dissent. A medical elite dictates that every health professional must perform any procedure and write any prescription that patients demand and the elite has determined is acceptable.

If the patient wants it, you give it, you do it. No exceptions.

That’s ideological tyranny, dressed up as patient autonomy. And it’s not coincidental that those who suffer and lose their careers under such tyranny are pro-life health professionals.

“Even if you like your doctor, you cannot keep your doctor.”

Authors Emanuel and Stahl leave no doubt about what they consider non-negotiable dogma, going so far as to assert that abortion “is not medically controversial.” That view, of course, is disputed by the thousands of pro-life and faith-based physicians who say they actually will leave the medical profession before compromising their conscience on ethical issues such as abortion.[11]

What happens to conscientious health professionals when medical associations or the government follow Emanuel and Stahl’s line of thinking and exclude such professionals from the practice of medicine?

For the authors, the consequences are stark:

“Health care professionals who are unwilling to accept these limits have two choices: select an area of medicine, such as radiology, that will not put them in situations that conflict with their personal morality or, if there is no such area, leave the profession.”

Leave the profession.

What happens, then, to patients who depended on those doctors? Emanuel and Stahl claim to be protecting patient choice by eliminating conscience laws from medicine.

Those patients lose access to the health professionals they had chosen.

Absent conscience protections in healthcare, patients lose access to the thousands of faith-based professionals, hospitals and clinics who currently minister to the poor, the marginalized and the uninsured. Pro-life women lose access to and the ability to choose pro-life obstetricians. The one-in-six patients currently served by Catholic health institutions[12] suddenly must look elsewhere. The already severe shortage of primary care physicians suddenly erupts into an unsolvable crisis, erasing healthcare access for millions of Americans.

“Even if you like your doctor, you cannot keep your doctor.”

Eliminating conscience freedom hardly protects patients.

How does disallowing conscientious objection on issues of abortion, transgender surgeries or embryo research protect patients?

• Half the patients who enter abortion facilities do not leave alive. Unborn babies are certainly not protected by eliminating conscience objections.
• Research shows that most children and teens conflicted with transgender issues—it’s called dysphoria for a reason—eventually change their minds as adults. [13] Yet a 2016 rule by the U.S. Department of Health and Human Services disallowed conscientious objections to transgender demands. Children and teen patients who will later regret a transgender change that a doctor could have counseled them about are not protected by disallowing conscience and professional judgment.
• Far from helping patients, embryo-destroying stem cell research has only diverted millions of research dollars away from proven-effective non-embryonic stem cell research—research that has already provided cures and therapies for patients with over 80 diseases. Patients awaiting non-embryonic stem cell therapies are not protected by disallowing conscience objections.

Protecting patients and protecting conscience freedoms go hand in hand.

Whistleblowers can turn the tide of an unethical consensus

No one needs conscience protections for views that accord with the establishment or popular opinion. We only need conscience protections when our views diverge from the dictates of the ruling elite or the pressures of the dominant culture.

Why is it worth allowing dissent? One practical consideration: Whistleblowers can save lives.

During the infamous “Tuskegee Study of Untreated Syphilis in the Negro Male,” the United States Public Health Service in a secret experiment purposely withheld effective syphilis treatments of penicillin from poor African American sharecroppers. The U.S. government’s health officials launched the unconscionable experiment in 1932. It took four decades until a courageous whistleblower, 28-year-old U.S. Public Health Service employee Peter Buxtun, exercised conscientious objection and exposed the horror of the experiment.

Buxtun knew all too well what happens when government and institutional medical elites dictate health policy. His family had escaped the Nazis in Czechoslovakia in 1939. Buxtun’s conscientious objection helped expose the Tuskegee experiment and its cost in human lives, eventually leading to the program’s shutdown in 1972.[14]

Conscientious physicians remain patients’ last line of defense

I highlighted the value of conscientious objectors in medicine, in a commentary published in USA Today entitled, “Personal conscience strengthens law:”

Citing revelations of substandard outpatient conditions at the Walter Reed Army Medical Center, a USA TODAY editorial promotes legal protections for whistle-blowers. But legal protections alone are insufficient to motivate an individual to buck an establishment that has gone AWOL ethically.

Whistle-blowing requires resolute character and a conscientious commitment to bedrock ethical standards.

The absence of such individual character and universal standards breeds ethical malpractice, such as the infamous Tuskegee experiment, which deliberately denied penicillin treatment for African-American syphilis patients.

Such lessons from history apparently have not given pause to the Obama administration, which proposes removing a conscience protection regulation that implements the right of health care professionals to follow life-affirming, patient-protecting standards such as the Hippocratic oath.

Based on three civil rights laws passed over the past 35 years with bipartisan support, the provider conscience regulation implemented by the U.S. Department of Health and Human Services simply ensures that participating in abortion and other controversial procedures remains a choice and not a mandate for health care professionals.

According to two recent national surveys, Americans support the conscience protection regulation by a 2-1 margin, and 92% of faith-based physicians surveyed warn that they will leave medicine before bowing to pressure to violate ethical standards and convictions. The administration can avert a crisis of health care access for poor patients and those in medically underserved areas by simply keeping regulatory and legal protections for health care professionals who remain anchored to ethical standards.

When the political or medical establishment loses its moorings, conscientious physicians remain patients’ last line of defense. [15]

History shows that the medical community too often tragically has failed to police itself, leading to the loss of lives and to grave, irreversible injustices. In such cases, it has taken courageous conscientious objectors to challenge the system and end the injustice. The historical evidence shows that conscientious objection provides a vital and sometimes lifesaving check on institutional power.

Absolute power corrupts, and when tyrants silence conscientious objectors, absolute power corrupts absolutely.

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[1] “Physicians, Not Conscripts — Conscientious Objection in Health Care,” Ronit Y. Stahl, Ph.D. and Ezekiel J. Emanuel, M.D., Ph.D., New England Journal of Medicine 376;14, April 6, 2017.

Stahl and Emanuel, p. 1384.

[2] Stahl and Emanuel, p. 1383.

[3] AMA Code of Medical Ethics Opinion 7.3.8: “Regardless whether they are obtained from embryos donated by individuals or couples undergoing in vitro fertilization, or from cloned embryos created by somatic cell nuclear transfer (SCNT), use of embryonic stem cells currently requires the destruction of the human embryo from which the stem cells derive. … Embryonic stem cell research does not violate the ethical standards of the profession. Every physician remains free to decide whether to participate in stem cell research or to use its products.” https://www.ama-assn.org/delivering-care/ethics/research-stem-cells, accessed March 1, 2019.

[4] Code of Medical Ethics Opinion 7.3.8″ “Physicians who conduct research using embryonic stem cells should be able to justify greater risks for subjects, and the greater respect due embryos than stem cells from other sources, based on expectations that the research offers substantial promise of contributing significantly to scientific or therapeutic knowledge.” https://www.ama-assn.org/delivering-care/ethics/research-stem-cells, accessed March 1, 2019.

[5] The AMA Code of Medical Ethics Opinion 4.2.7: “The Principles of Medical Ethics of the AMA do not prohibit a physician from performing an abortion in accordance with good medical practice and under circumstances that do not violate the law.” https://www.ama-assn.org/delivering-care/ethics/abortion, accessed March 1, 2019.

[6] Buck v. Bell, a 1927 Supreme court case upholding a Virginia law that authorized the state to surgically sterilize certain “mental defectives” without their consent.

[7] “When America believed in eugenics,” New Statesman, Dec. 10, 2010. https://www.newstatesman.com/society/2010/12/disabled-america-immigration accessed 9/27/17.

[8] Visit https://www.ushmm.org/information/exhibitions/online-exhibitions/special-focus/nazi-persecution-of-the-disabled. Accessed March 1, 2019.

[9] “Science as Salvation: Weimar Eugenics, 1919–1933,” U.S. Holocaust Museum website, https://www.ushmm.org/exhibition/deadly-medicine/narrative/index.php?content=science accessed March 1, 2019.

[10] “Unwanted Sterilization and Eugenics Programs in the United States,” PBS Independent Lens, Jan. 26, 2016, accessed online at http://www.pbs.org/independentlens/blog/unwanted-sterilization-and-eugenics-programs-in-the-united-states/ 9/27/17.

[11] Over nine of ten (91%) of faith-based physicians in a national survey agreed, “I would rather stop practicing medicine altogether than be forced to violate my conscience.” http://www.freedom2care.org/learn/page/polls-april-2009, accessed 9/19/17.

[12] Catholic Health Association, https://www.chausa.org/about/about/facts-statistics accessed 9/19/17.

[13] Research shows that there are significant risks with gender transition procedures in childhood. Along with physical impacts like heart conditions, increased cancer risk, and loss of bone density, the peer-reviewed longitudinal studies of children with gender dysphoria (that HHS accepted as valid) found that fewer than 1-in-4 children referred for gender dysphoria continued to experience that condition into adulthood.

[14] For more about Peter Buxtun and the Tuskegee study, see “Tuskegee Experiment: The Infamous Syphilis Study,” at the History channel’s website, https://www.history.com/news/the-infamous-40-year-tuskegee-study. Accessed March 1, 2019.

[15] Jonathan Imbody, “Personal conscience strengthens law.” Published in USA Today, May 8, 2009.