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Grounds for objection
Examining the ethics of conscientious objection in healthcare.
Doug McConnell interviewed by Dallas Bastian
To what extent should healthcare be left up to a clinician’ s discretion?
Dr Doug McConnell, from Charles Sturt University’ s School of Humanities and Social Sciences, unpacked this question at a recent conference in Sydney on the role of conscientious objection in healthcare.
McConnell delved into the issue of discretionary space and argued for it to be relatively narrow and limited by professional policies.
Co-hosted by CSU and Macquarie University, the conference saw international and Australian philosophers and bioethicists explore the ethical challenges posed by healthcare professionals who opt out of taking part in treatments or practices on the grounds of conscientious objection.
McConnell said conscientious objection by healthcare professionals is one of the most important issues in healthcare ethics.
“ Refusing to treat a patient or perform a medical procedure poses obvious problems for patients and limits their access to the care they are entitled to receive,” he explained.
“ This dilemma will only grow with medical advancements such as embryonic stem cell therapies, genetic selection, or human enhancement.”
Nursing Review spoke with McConnell about the complexities of conscientious objection.
NR: How does conscientious objection play out in the modern Australian context, and what are some examples patients or healthcare workers might come across? DM: In many ways it plays out the same as in other cultures around the world. We have a general problem that arises from the fact that we need a structure in public healthcare. We need some laws and some policies to guide our healthcare as providers. This will allow us to avoid rogue doctors providing clearly bad treatments, and it lets patients know what to expect from the healthcare system. You might say we’ re not going to allow terminations of pregnancies after, say, 24 weeks, and these laws and policies will prevent physicians from doing that if we’ ve decided that this is a bad thing to do. Then it also lets patients know what to expect, so it helps the system be efficient as well.
Then of course the problem arises that we disagree on exactly what those laws and policies should be, even though we might agree that we need some laws and policies. We get the situation where we’ ve settled on some, but we inevitably have a subset of people who disagree with exactly where we’ ve set the policy. Say we’ ve set 24 weeks for when you can terminate a fetus, some people are going to object to the fact they can’ t terminate fetuses later, and, of course, some are going to object to the fact that we’ re terminating fetuses at all.
Essentially, a problem that arises from having a set of laws and policies on how to provide public health is that we have a tension between those who are more in favour of a thoroughly secular public health system, which could make for less, if any, room for objections on religious grounds, and those who think that religious viewpoints should be more thoroughly integrated in public health decisions, or at least accommodated in some form.
In Australia, it’ s hard to get a grip on how frequently healthcare professionals are objecting to providing treatments, but we definitely see it coming out with pharmacists failing to provide emergency contraceptive medication on occasion, and
we also see doctors refusing to perform terminations of pregnancy.
At least the professional bodies, the doctors, the pharmacists, and some nurses in Australia make provision for conscientious objections, so these professionals have the right to object on conscientious grounds, but the guidelines are that you have to make sure, if you are an objector, that the patient receives the therapeutic response they’ re supposed to get, so that means referring them to someone who will do it, essentially. And if there is no one nearby in an emergency situation, you’ re still supposed to treat.
So, that’ s the situation in Australia. And of course, if we let euthanasia come up, it looks like we’ re not too far from having policies that are going to allow euthanasia, so that’ s also an issue where we would expect people to have conscientious objections.
You presented on discretionary space, and how wide that should be to ensure for the best healthcare. What are some of the key considerations? The reason we might want discretionary space, or that physicians or healthcare professionals should have some discretionary space, is that because of the complexity of clinical decisions, we can’ t have a set of rules that would guide every clinical decision. So, we’ re going to get idiosyncratic situations coming up, and sometimes it’ s going to be better to let the clinician make a judgement based on what they see in front of them, rather than trying to imagine a set of rules that would be able to guide the decision in all these cases. You just can’ t imagine what’ s going to come up. So, we can agree that some discretionary space is important for good medicine.
And as I’ ve mentioned, we would want to still limit this discretionary space in some ways, so if we think that fiduciary duty is an important aspect of good medicine, then we should think there should be some rules that ensure that professionals fulfil that duty to their patients.
I argue for the idea that discretionary space should be relatively narrow and limited by rules or professional policies that are appropriate for the profession. And I argue against Daniel Sulmasy, who argues for a wider discretionary space limited only by ideas of religious tolerance. So, he thinks we should allow physicians space to practise medicine in ways that won’ t be destructive to society. I think that’ s overly generous and will result in worse medicine than if we go for my narrower discretionary space. ■
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