Issue 42 / 7 November 2011

CONSCIENTIOUS objection by doctors, as is commonly practised, is discriminatory medicine. Only a fully justified and publicly accepted set of objective values results in ethical medicine as a proper public service with agreed and justified moral and legal standards to which doctors should be held.

Imagine that a doctor refused to examine a patient of the opposite sex on religious grounds. This is treating the patient unequally and unfairly on morally irrelevant grounds. It is sexism and therefore wrong, regardless of the doctor’s religious practice.

Australian society does not and should not tolerate sexism, even if it is institutionalised by other countries or religions, or is part of the doctor’s values. Similarly, if a doctor refuses to treat a patient because they are black, or Jewish, or gay, or drunk, it is discrimination, even if conscientious discrimination.

Yet some of the doctors of the future believe they are entitled to refuse to examine patients because they are of the opposite sex or drunk.

Respect for current conscientious objection is grounded in a dangerous moral relativism: that morality and moral rightness are culture-specific, or equate to individuals’ own values and desires. This is false.

Female infibulation is wrong, even in those countries and cultures that condone it. We must stand up for a non-relative morality and an objective account of interests.

People should be free to live according to mistaken values or religious values. But they should not have the liberty to coerce, directly or indirectly, other people to live according to their own values, even if they are medical professionals.

Freedom to practise religion does not imply freedom to impose religious values on others in a secular liberal society. The same applies to secular moral values.

The place to decide what kinds of values should govern public institutions and practices is in a public forum, not by the bedside. For instance, a secular doctor might believe that people with advanced dementia or brain damage, who no longer recognise themselves or others, are not persons. She might believe it is right to kill such non-persons.

However, this moral belief is not widely shared by the community at this point in time. Even though the doctor strongly believes it is morally justified, she should not kill or support the killing of specific individuals with advanced dementia but, instead, argue for legal reform in a public forum.

Conscientious objection is often justified by a person saying that they are acting in a patient’s best interests. However, deciding what a patient’s best interests are requires input of the patient’s values, but is not determined entirely by them.

It is partly, but importantly, an objective judgement. If a Jehovah’s Witness believes that a blood transfusion is not in his interests, it does not mean that a blood transfusion is against his interests. We should withhold blood transfusions from people who refuse them, to respect the objective principle of liberty, not because blood transfusion is against their personal interests.

Similarly, one can, on the objective principle of distributive justice, deny further care to patients who are wasting limited medical resources through non-compliance or recalcitrance, but not because the patient offends the treating doctor’s individual values.

The place of conscience is in dialogue with patients. Doctors argue for what they believe is right and engage patients in moral dialogue. This is what I call “rational non-interventional paternalism” or liberal rationalism. But in a liberal society that respects personal freedom, doctors should ultimately offer what are just, legal medical procedures.

Conscientious objection will become more common because of increasing societal pluralism and treatments becoming more morally contentious. Such objection may be justified.

For example, drugs developed by the use of slave labour or by the maltreatment of children in developing countries should not be used, even if licensed. Doctors should refuse to perform female genital mutilation.

What distinguishes these justified objections from current refusal to perform abortions or deliver contraception?

Justified conscientious objection is an objection to harming people. But harm and benefit are not in the eye of the beholder — they are grounded in a robust, morally justified concept of best interests and of moral status.

Doctors should conscientiously object to female circumcision for this reason. But current conscientious objection is not morally justified because it is not grounded in a justified and agreed conception of interests.

As a result, these forms of unjustified conscientious objection harm patients.

Professor Julian Savulescu is director of the Uehiro Centre for Practical Ethics, faculty of philosophy, University of Oxford, UK.

This ‘Opposing Views’ article appears in the MJA. It is reproduced with permission of the MJA. Please click here to read the opposing view by Dr Brian Conway.

Posted 7 November 2011

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11 thoughts on “Julian Savulescu: Beliefs can do harm

  1. James Jansson says:

    Interesting, although a little confused in getting to the point. I think he would have been better by outlining exact circumstances in which conscientious objection occurs and why it is desirable in some circumstances. For example, female genital mutilation is unnecessary, can cause harm and is often against the patient’s wishes. On the flip side, refusing to refer a woman to an abortion clinic is wrong because not having an abortion may cause the woman harm (this is the actual reason why abortion is allowed under Australian law) and the woman wishes to have an abortion.

    We live in a democracy where the people decide what is morally acceptable, not a handful of doctors. If a doctor takes it into their own hands to decide what is right and wrong they are overriding the democratic determination of society. In Australia, England and New Zealand (where doctors earn money under a nationalised system) doctors are essentially employed to give medical care to patients by the government, and hene the people. Failure to give treatment is a failure of duty, and should result in termination just like any other field.

  2. Michael King says:

    Prof Savulescu speaks of things, such as female genital mutilation, as “wrong”, but his morality by consensus can not provide an objective basis for calling anything wrong, as in that setting all values are decided by a vote and as such are not “right” or “wrong” but only what one can convince the majority is in their interest. This is similar to our legal system, which is not concerned with right or wrong, only with legal or illegal. It assumes axiomatically that the law to be applied is “right” but this can’t be proven in the absence of an absolute standard to determine what is right. One must remember that consensus is a poor method of determining truth; even the Nazis were elected by the people they ultimately enslaved.

  3. Sue Ieraci says:

    In relation to the medical student described above, I don’t think we need to let the “discrimination” spectre enter the discussion. It’s about standards. You either have achieved your learning objectives to practise medicine (across the whole spectrum) or you haven’t. I can’t see how a student who has never touched a male could possibly either pass medical school or fulfill an internship. We need to be very cautious that a misdirected sense of “justice” for the individual student doesn’t allow us to lower standards.

  4. Chunder Bose says:

    I was conducting a Med 2 clinical exam when a female Muslim student refused to examine a patient of the opposite sex. I brought this to the attention of the supervisor who took no action. Can’t imagine how this person will manage as a resident doctor if she only will attend to female patients, though these days I guess the hospital will put another resident on to cover her rather than say this is unacceptable behaviour.

  5. Paul Gatenby says:

    I have some sympathy with the views of the author, although I believe it is safer to be guided by the broader expectations of society. The example picked by critics of this are reasonable, they avoid harm, one of the profession’s obligations. It is however difficult to argue that refusing to prescribe the OCP yet there are large areas of rural US and increasing areas of rural Australia where the combination of religious fundamentalism and shortage of providers is leading to a conscience excused lack of services. Having recently encountered fundamentalist medical students for the first time in 35 years of teaching I am gradually moving towards Julian’s views.

  6. Adam says:

    I believe that it is wrong to believe in moral relativism. All my friends agree with me so I must be right.

  7. Simon says:

    This is a strange objection to moral relativism! Do you (Julian) not infer that ‘objective moral values’ are those “shared by the community at this point in time”? Is this not an argument FOR moral relativism – values that change along with those of the community?

    Are you suggesting an objective “justified and agreed conception of interests”? From where can this objectivity come? Have we not all been shaped by our backgrounds – religious or non-religious?

    As you do, I too believe in objective morality and I’m sure that many reading your article will also. However, readers will reach their positions in very different ways, from many different philosophical and religious perspectives.

    It seems you are suggesting that your ‘objective morality’ is THE ‘objective morality’. Does this not put you in the same position as those who argue for their ‘objective morality’ and attempt to impose it on others.

    Although moral relativism must be rightly rejected, it is undemocratic to chose a particular ‘morality’ and impose it on others. The laws by which our society – and profession – are governed must be a result of robust debate and some form of workable consensus. This consensus is not a concession to relativism but rather the only way we can work together despite different philosophical perspectives in what is a pluralistic society.

  8. Rob Loblay says:

    Not wrong Bruce. As doctors, our moral values & beliefs are often different from those of our patients. You should not be forced to do a procedure against your own strong moral objections, any more than your patients should be forced to forgo the procedure because of your unwillingness to do it. Referring elsewhere is the appropriate way of dealing with a clash of values.
    Julian often adopts a contrarian position on controversial issues and is always stimulating, but he sometimes carries his arguments to an illogical extreme. He needs to recognise that “morally justified concepts of best interests and moral status” are themselves subjective value judgments about which thoughtful people of good will can have different views. Seems that Julian believes he is the arbiter of what constitutes the most “robust” moral argument.

  9. Anon 2 says:

    Bruce, of course you have the right to refuse to DO the procedure. What you don’t have the right to do is to refuse the patient ACCESS to the procedure because of your personal beliefs. So what you are doing by providing a timely referral satisfies the needs of both you and the patient.

    Anonymous, the article is not suggesting doctors should be forced to do things against their moral beliefs. In fact, quite the opposite. Get off your high horse and have another read.

  10. Anonymous says:

    The idea that because somebody has the technical ability to do something they should be coerced to do it is ridiculous. It is at least as wrong to force a doctor to act against his or her own conscience as it is to force a patient to do so.
    Prof Suvalescu has some interesting ideas about morality, eg, that it is not relative but also that it seems to be adopted by consensus view. That’s certainly an interesting approach to ethics but it’s not the only one.
    On controversial issues that are legal, I believe doctors should have the right to simply tell patients that they do not do such procedures if they wish but that the patients are free to seek that sort of care elsewhere. We are employed by the healthcare system, not owned by it.
    The opposing view article put it best: “The patient is free to seek the refused treatment elsewhere but should not coerce the doctor’s cooperation in something they believe will be harmful for the patient.”

  11. Bruce says:

    I am a gynaecologist. I do medically indicated termination of pregnancy including for fetal anomaly. I have done social terminations but now, for personal reasons, no longer will. I am prepared to refer for same. Am I wrong to refuse?

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