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The purpose of this blog is to stimulate thought and discussion about important issues in healthcare. Opinions expressed are those of the author and do not necessarily express the views of CMDA. We encourage you to join the conversation on our website and share your experience, insight and expertise. CMDA has a rigorous and representative process in formulating official positions, which are largely limited to bioethical areas.

Rights of Conscience, Moral Complicity and Free Speech

February 8, 2018

by Robert E. Cranston, MD, MA (Ethics)

CMDA’s Vice President of Government Relations Jonathan Imbody has posted a series of four essays on rights of conscience in healthcare on The Point. These are in response to “Physicians, Not Conscripts—Conscientious Objection in Health Care” by Ronit Y. Stahl, PhD, and Ezekiel J. Emanuel, MD, PhD.

The title of the article might lead a reader to believe the authors support a physician’s right of conscience, but they do just the opposite. They strongly assert the will of the patient over the conscience of the physician. They write, “Making the patient paramount means offering and providing accepted medical interventions in accordance with patients’ reasoned decision,” and “Health care professionals who are unwilling to accept these limits [putting aside their own conscience to support patient autonomy] 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 areas, leave the profession.” While this quote would seem to apply to a broad variety of issues, in the context of the article the authors are referring to abortion.

In 2004, CMDA’s Ethics Committee drafted an ethics statement on healthcare rights of conscience, which stands today as a continuing evidence of CMDA’s position on this critical area. It covers several points that are currently under fire.

  1. It notes, “all healthcare professionals have a right to refuse to participate in situations they believe to be morally wrong,” but notes that in such situations, “the healthcare professionals have an obligation to ensure that the patient’s records are transferred to the healthcare professional of the patient’s choice.”
  2. Similarly, it upholds this right as applicable to healthcare institutions, and states that these institutions “should not lose public funding as a result of exercising their right of conscience.”
  3. It further states, “No organization or governing body should mandate participate in policies or procedures that violate conscience.”

Stahl and Emanuel assert several highly questionable points. The first is that in medical decision-making, patient wishes should be the paramount consideration, and the second, which is connected but distinct, is that the “patients’ reasoned decisions” are to go unquestioned, so long as the patients consider them to be legitimate.

Tackling the first point: when Beauchamp and Childress published their positions on principles of ethical decision-making, they listed four guidelines to employ in decision-making: autonomy, non-maleficence (not doing harm), beneficence (doing good) and justice. Justice is ambiguous in that it could apply to a general sense of fairness or equitable distribution of finite resources. (If we were to employ this fourth standard, we would be shipping an equal share of healthcare professionals, supplies and money to most other countries in the world, something we are not doing.) Over the years, in many Western settings autonomy has become the de facto supreme standard, as assumed by Stahl and Emanuel in a circularly illogical fashion, to dictate actions. With little effort, we see that this unproven assertion makes no sense. Some patients demand actions that are unethical, illogical or harmful. We have no obligation to amputate limbs from patients with Body Image Dysphoria Syndrome, and we have no right, much less an obligation, to destroy a human being who is currently residing within another human being, simply because the person housing the child in question demands this.

The second point that a patient’s “reasoned decision” should dictate an action is absurd. As healthcare professionals, we engage our patients in dialogue, but we do not check our own brains or consciences at the door. When a patient demands treatments or evaluations that make no logical or ethical sense, the healthcare professional is not required to acquiesce.

With Stahl and Emanuel, we see the coming tsunami—conscience rights that we have considered bedrock for millennia are being done away with by a new agenda. Before long, patients will be able to demand and receive any legal procedure, treatment or investigation, or non-complying healthcare professionals will be sanctioned. Healthcare professionals whose consciences would not permit them to assist in the proposed actions (in this case primarily abortion) are being given the choice between leaving healthcare or becoming complicit in aiding or participating in actions they deem immoral.

What constitutes moral complicity? Complicity is “the state of being an accomplice; partnership or involvement in wrongdoing: complicity in a crime.” CMDA’s ethics statement supports transfer of records if requested, but does not require specific referral to a different consenting healthcare professional. For many Christian healthcare professionals, records should be transferred, since they essentially belong to the patient, but referral would represent complicity.

The U.S. Supreme Court has agreed to hear an appeal case regarding the 2015 California Reproductive Fact Act which would require all public programs including “anti-abortion” centers to notify all clients in their facilities that the state of California “has public programs that provide immediate free or low-cost access to comprehensive family planning services, prenatal care, and abortion, for eligible women.” It gives the state authority to impose large civil penalties against facilities that fail to comply. Brad Dacus of the Pacific Justice Institute likens this to forcing Alcoholics Anonymous groups to advertise places to obtain free alcohol or forcing Jewish synagogues to notify worshipers where they “can go to pray to receive Jesus.”

National Institute of Family and Life Advocates immediately filed legal challenge to the new law and were soon joined by several other pro-life entities in opposing this law. It has now passed quickly up to the U.S. Supreme Court.

Interestingly, this lawsuit is framed entirely around the issue of free speech—can California force clinics to say things that assault their moral standards?—because this is the constitutional question. Hopefully this narrow focus will serve to undo the Reproductive Fact Act. But make no mistake—this is another shot across the bow for people of conscience—comply with the progressive agenda, become complicit with anything legal no matter how immoral, or get out of healthcare.

Pray, and stay tuned.

Robert E. Cranston, MD, MA (Ethics)

Robert E. Cranston, MD, MA (Ethics)

Robert E. Cranston, MD, MA (Ethics), MSHA, FAAN, CPE, is a board certified neurologist, with additional training and experience in palliative medicine, executive coaching and medical leadership. He is completing his 30th year serving at Carle Health, (formerly Carle Foundation Hospital) in Urbana, Illinois, as an attending neurologist, and (Past Chair—14 years) of the Carle Ethics Committee. He is a clinical professor of medicine (neurology) at Carle Illinois College of Medicine in Urbana-Champaign and is on the clinical faculty of University of Illinois, Urbana-Champaign. He is a member of the CMDA Ethics Committee. He and his wife Tammy are grateful for their five grown children, their daughters- and sons-in-law and their 11 grandchildren.