Medicine, Professionalism & Conscience: Is Pluralism 'One Size Fits All'?
(Watch the conference presentation on video: Medicine, Professionalism & Conscience: Is Pluralism 'One Size Fits All'?)
I don't think that anyone would deny that we live in a world that is permeated by a clash of worldviews1, in a society that preaches a complete separation of church and State; a society that feels threatened by a symbiotic cooperation between the latter, a relationship that is mutually enriching, as the divine exists within the secular. This is a reality that has been well illustrated to modern man by Tolkien's masterpiece The Lord of the Rings. What does it mean to be a healthcare professional in Canada today? Are we losing sight of the intrinsic goodness of the art and science of healing? And finally, is there room for differing views and philosophical ways of thinking, or is pluralism "one size fits all"? In this paper, I will explore the false dichotomy and growing lack of tolerance towards religious belief that permeates the medical profession in Western society.
In the field of Healthcare, there are medical professionals today who desire to care for the sick without violating their own deeply held religious, moral, and ethical principles. For the most part, they are not seeking to impose their morality on others, but simply need to be able to live and work without compromising their deeply held beliefs. Sadly, there are those who seek to impose their views on others; those too who believe that a religious faith-informed conscience should be kept at home—has no place in professional life, but not so with non-religiously formed faiths. This indoctrination begins at the university level, where students are taught that their own principles should be subjugated to meet the desires of patients who must now be referred to as "clients". Indoctrination then continues as promulgated by ethics committees set up by Medical Governing Bodies. Highly influenced by public opinion, such codes of conduct promote one predetermined set of principles only, a "one-size-fits-all" idea of what it means to be a medical professional; that there is only one way to work, one model, one set of beliefs that must be revered and followed by all healthcare professionals.
On certain issues of the day there are strongly contested viewpoints that are perfectly legal to hold. In a free and democratic society it is not the case that we are required to believe the same things. But what of the duty to serve? Ah, as Shakespeare said: "there's the rub".
Some who hold to one side of a contested viewpoint seek not only to promote these views, but they also believe that they are the only valid views, and that everyone else should abide by them. In particular, healthcare professionals should lay aside all other norms of conduct, especially if these have any religious foundation, in order to accept the utilitarian, pragmatic worldview that others may hold as the only valid code of conduct. Thus, some healthcare workers may feel coerced to participate in procedures they find morally abhorrent.2
A recent article in the BMJ3 exemplifies just this. Alas, I am not the only one who likes to quote Shakespeare. Quoting the villain in Richard the III, a king who was known for his ruthless dishonesty, widely published Oxford ethicist Julian Savulescu writes, "Conscience is but a word cowards use, devised at first to keep the strong in awe". Conscience, he says, can be an excuse for vice or invoked to avoid doing one's duty. Furthermore "conscientious objection is wrong and immoral when the duty is a true duty"—and, may I ask, whose definition of true duty shall we use? Richard the III's ? Hitler's ? Savulescu's ? Both the Nuremberg4 trials and the horrific Rwandan massacres5, where physicians of one tribe felt obliged to kill their patients from another, tell the tales of the horrific consequences of blind obedience grave duty [to serve], Savulescu continues, objection should be illegal. He believes in fact, that a doctor's conscience has little place in the delivery of modern medical care, an anachronistic belief in my view, as never before in the history of mankind has there been greater need for a critical appraisal of modern medical technologies and for a clearer understanding of what it means to be human. Savulescu goes on to say that what should be provided to patients is defined by the law and by the patient's desires, and states bluntly that if people are not prepared to offer legally permitted care to a patient because it conflicts with their principles or beliefs, they should not be doctors.6 Furthermore, he believes that conscientious objectors must be punished through removal of license to practice and other legal mechanisms. He insists, as most politicians do, that principles and conscience have different roles in public and private life, thus advocating what I would call the "split personality syndrome". Finally, Savulescu believes (for he too is a believer, as is every conscious human being), in a neutral [value-free] practice of medicine, or so he thinks. Value-driven medicine, he says, is a door to a Pandora's Box of idiosyncratic, bigoted, discriminatory medicine. And so, the irony is that we must all follow his own bigoted ideology, a purely technocratic, legalistic approach to the practice of medicine. He himself has unwittingly opened up the Pandora's Box of which he warns his readers. There is no room in his world for the divine within the secular; no room, in fact, for a moral critique of medicine itself; his is an invitation to amoral medicine. He has forgotten that medicine is both a science and an art, the beautiful art of healing which has a long historical Hippocratic tradition behind it. His ethics does not even mention that which is at the core of medical practice, namely, the "doctor-patient healing-caring relationship".7 Among the many responses received by BMJ to Savulescu's article, one by Trevor Stammers, Senior Tutor in General Practice stands out8: ". . .if values have no place in determining medical care, on what basis does Savulescu attempt to impose his own moral values on conscientious objectors? The paternalism he so despises is only matched by Savulescu's own and his ideal of "statute-driven medicine" seems to me more â€idiosyncratic, bigoted and discriminatory' than the moral values he is so intolerant of." Scottish psychiatrist Everett Julyan also wrote to the BMJ9: "Extending the logic of Savulescu's argument suggests that if, for example, physician-assisted suicide was legalized, then all doctors would have a duty to help their patients kill themselves. Only those individuals who agree (or acquiesce) should be allowed to practice medicine. Extrapolating this, the medical profession would be made up of individuals without a conscience whose collective morality is markedly different from that of the patients they serve." The intolerant views of Savulescu, he says, hardly reflect the diverse views on a wide range of ethical issues in our society. Doctor Julyan speaks from first hand experience, as in 2000 he was turned down for a job by North Glasgow Universities for revealing in an interview that he would have nothing to do with training that would involve abortions.10
Another illustration of the growing mentality that "one size should fit all", is an article by Bioethics Professor R. Alta Charo in the prestigious New England Journal of Medicine of June 2005 entitled "The Celestial Fire of Conscience—Refusing to Deliver Medical Care"11. Here the author assumes that there is only one acceptable "professional standard"—her own! This ethicist concludes that those who do not abide by the rules of her own ideological views should be willing to pay a price for their convictions. She writes: "What differentiates the latest round of battles about conscience clauses from those fought by Gandhi and King is the claim of entitlement to . . .. . . conscience without consequence". Professor Charo fails to give proper place to accommodation and would go for a "one size fits all" for all citizens. In my case, as a pharmacist unwilling to offer certain "services" for moral and professional reasons, this amounts to suggesting that I should be willing to lose my license or my freedom for not complying with her own set of moral standards. Charo believes that the medical professions should accept a "collective obligation" to provide that which is legal. This, she says, does not mean that all members of the profession are forced to violate their own consciences, but does necessitate ensuring that a system of referral is in place, so that every patient can act according to his or her own conscience just as readily as the professional can. What Charo does not realize, is that individual patients are not being forced to act against their own conscience when a service is denied them by an objecting provider. They are merely forced to visit a different provider, which may at most cause a little inconvenience. She also does not seem to realize that referral for a service that I cannot myself provide would be morally equivalent to providing it myself. Charo goes on to applaud the governor of Illinois who has forced all pharmacies, though, she says, not all pharmacists, to ensure access to services for all patients. What she does not mention, or perhaps realize, is that some pharmacists have been harassed and forced to quit their jobs because of this ruling. Finally, Charo believes that conscience is "a tricky business", with which statement I would agree; and she concludes by quoting C.S. Lewis (out of context, no doubt) to justify her own assumptions about the dangers of using ones conscience as a guide to universal truth.
And so as you can see, my own profession of pharmacy is also bathing, if not immersed in an ocean of intolerance toward anyone who does not share the viewpoints upheld by the establishment as the only valid viewpoints. Professional pharmacy journals have painted dissenting pharmacists as being unethical for not providing services that go against their deeply held moral, ethical, and religious beliefs that life is sacred from the moment of conception until natural death. Interestingly, one person's ensuring that a client knows the risks of a particular medication can be portrayed by another as evidence of intolerance and bigotry. In a recent ironic twist of events, even pharmacists who do wish to provide the Morning after Pill have been portrayed as being unethical for asking women too many embarrassing questions. Citing the need for absolute editorial freedom, there have been worldwide protests sparked by the firing of the editors of the CMAJ responsible for publishing the article which is so critical towards pharmacists. Yet no one is incensed by the lack of objectivity and the oftentimes malicious slander that is printed in the name of journalistic freedom about pharmacists and other healthcare providers who wish to follow their consciences.
For example, in May of 2000, the Canadian Pharmacists Journal published an article by an ethical advisor to the BC College of Pharmacists entitled: "Emergency Contraception and Professional Ethics".12 In this article, directed to disputes about the Morning after Pill, the author implies that there is no right to conscientious objection, and he insists that pharmacists must provide or refer patients for "recognized pharmacy services" despite moral objections. He not only claims that conscientious objection is not a right, but also that it is usually punished. Of course, this stems from his premise that because there are murderers, rapists, and thieves who do wrong by following an obviously erroneous conscience, then no one should have a right to freedom of conscience.13 Several people have written in response to Mr. Archer's piece- one of them is the chair of this conference, lawyer Iain Benson, Archer.14 The journal refused to print the rebuttal, and so to correct the errors, and for those who have not been given the rebuttal that has been distributed by concerned pharmacists at various conferences, it appears as though the ethical advisor's statements, which are driven by his own personal beliefs about the sanctity of life, should trump those of people who disagree with him on what is not, according to his own argument, a strictly scientific determination.
In October 2004, the editor of the above Canadian national journal15, went so far as to say that pharmacists who cannot accept the dispensing of the Morning after Pill should practice other careers "that do not put them in conflict with patients' rights and the public trust". This editorial elicited a response from numerous pharmacists across the country and at least one lawyer.16
The editor began by stating that tolerance is a bedrock value of our democracy and that it goes both ways; yet in the next paragraph she contradicts herself by stating that the onus is on the healthcare professional to respect the religious beliefs of the patient, and not the other way around. There is often a complete failure to consider the duty of accommodation that all employers have in all settings. Many articles are written as if the only beliefs and autonomy that exist are those of patients or clients. This is obviously erroneous. At least the Canadian Medical Association does not make the same error, merely requiring the physician to inform the patient when his own morality would influence his recommendations. This Code should be the model for all health care settings.
One Calgary pharmacist wrote:
The editorial written in October's issue was an excellent demonstration of the discriminatory harassment to which conscientious objectors are subjected. It is clear that Ms. Thompson and people like her feel their morality is superior and are prepared to impose it on anyone disagreeing with them . . .
In April 2000, an article entitled Ethics in Practice appeared in the official bulletin of the BC College of Pharmacists.17 It states that the College acknowledges that some pharmacists may have moral objections to providing recognized pharmacy services. Further on, it lists some of these future services as preparation of drugs to assist in voluntary or involuntary suicide, cloning, genetic manipulation, or even execution. As a compromise, the bulletin goes on, these pharmacists must refer patients to colleagues who will provide such services, and in the end deliver these services themselves if it is impractical or impossible for patients to otherwise receive them. Such statements as these show little or no knowledge of causality and the philosophical and theological basis for the refusal to refer—"No Mrs Jones, I cannot kill you, but Johnnie's pharmacy down the street will". The author of the article in the Bulletin then goes on to accuse conscientious objectors of lying to the public about existing services and of wanting to promote their own moral viewpoint. The moral position of an individual pharmacist, he writes, if it differs from the ethics of the profession, cannot take precedence over that of the profession as a whole. Who in this case, is imposing a morality on whom? These statements are a perfect recipe for the promotion of intolerance within the profession. The College not only refused to retract the derogatory statements, which suggested certain pharmacists "lie", but also refused to publish any other viewpoint, citing that the purpose of the Bulletin is to reflect official College policy.
Let us examine for one moment the following notion: Who or what is determining what the ethics of the profession as a whole should be? According to Dublin-based ethicist Teresa Iglesias, traditional [Hippocratic] medical ethics and medical practice have been changed by the continuous chain of judicial rulings and court cases in the US, Europe, and Australia. Having once retained guardianship to the science and art governance, while "society" and "the law" are taking full control of the medico-ethical domain. This disintegration of self-governed medicine, has resulted in two strands of medicine: a conscience-governed medicine, and a law-governed medicine. Thus, she says, moral wisdom is in danger of being "legalistically" destroyed.
And so just as the Medical Governing bodies have succumbed to endorsing "one size fits all" and over-riding what should be a plurality of views needing accommodation in a free and democratic society, the power of the association is invoked, unjustly, against the beliefs of practitioners.
Because today's society values the set of views on medical ethics which hold that abortion is fine, the morning after pill is fine, and increasingly that euthanasia is fine, etc., this set of views seeks to guide the once independent medical establishment. The establishment in turn has set itself up as supreme moral authority, and all this without any regard for an individual professional's freedom of philosophical understanding of life, and freedom of conscience and religion.18 Seeing itself as the guardian of the public interest, the establishment thus seeks to protect society against any dissenting healthcare provider. Religiously informed conduct is increasingly viewed by medical governing bodies and associations as a threat to the public trust. There is a generalized atmosphere that "one size fits all" is superior to models of accommodation. Thus we see increasingly, arguments about the need to have and to use more-widely, conscience clauses by dissenting professionals. While admitting influence from other societal factions, the rejection of any sort of influence that carries a religious faith-based perspective is denying the medical establishment any wealth of input from its members if these views conflict with the organization's own worldview. It so happens that the Catholic Church, for example, has a long tradition of theological and philosophical teachings on the right conduct of medical professionals. Although the Church's teachings on the defense of human life they express the consequences of our nature: who we are as persons, what our boundaries or limitations are as human beings. Furthermore, christian morality is not about a set of dos and don'ts, but about a person. It is a way of life. Contrary to popular fear, I am not advocating for a Theocratic approach to medical ethics, where healthcare professionals would be preaching God and sin to patients. This would not be an appropriate application of cooperation between church and State. Rather, I am asking for recognition of the reality that the divine necessarily exists within the secular and is not foreign to it, and that religiously informed conduct is not just a private affair but has public dimensions.
Whereas past pharmacy Codes of Ethics emphasized excellence in the performance of ones daily duties, today's Codes are increasingly concerned with patient autonomy, as though this were the highest good to strive for. Thus, irrespective of nationality, culture or beliefs, a pharmacist is told to conform to the new Codes of Ethics to ensure that the patient's interests are protected, or else to leave the profession. It is assumed that a pharmacist does not act in his patient's best interests when he refuses to provide a woman with a drug he deems harmful to herself and to her offspring in the case of refusal to dispense the Morning after Pill. No attention is paid to the fact that the client has all the freedom in the world to deal with the health professional of her choice.
Although there is more and more pressure for a physician to do so, there is still no obligation to refer for abortions in Canada, but merely a requirement to inform the patient when the physician's own personal morality would influence his recommendations.19 He is neither forced to perform abortions, nor to refer for this procedure. On the contrary, the BC Pharmacy Code allows pharmacists to object to the provision of pharmacy services that violate their conscience only so long as they willing to do so.20
To date the British Columbia, Saskatchewan,21 and Ontario Colleges22 of Pharmacists require referral by the objecting pharmacist. The PEI Board of Pharmacists requires the individual pharmacist to pre-arrange access to an alternate source, while not conveying objections to the patient directly, but to the manager. On the other hand, Alberta, Manitoba and Nova Scotia require that the objecting pharmacist participate in a system designed to respect the patient's right to receive the service they want. Although referral is not an explicit requirement, these provinces do require that management prearranges it so that the customers get what they want in an alternate fashion. The Newfoundland Board of Pharmacy merely states that objections should be conveyed to the manager, and not to the patient. But what if the manager is the one who is the conscientious objector, as is my case? I think we need to be a little more creative as to how accommodation is worked out in order to give maximal not grudging accommodation to conscientious objectors.
What most people do not realize is that referral for a service that I cannot myself provide, would be morally equivalent to providing it myself. In my particular case, I believe that giving a woman a Morning After Pill makes me a direct accomplice in the destruction of a human life should fertilization have taken place. Referral would also make me an accomplice. Contrary to popular belief, I am not seeking to block access to a product; I simply cannot be involved in its provision and the client is free to consult the professional of her choice.
What is behind this patient-wishes as "trumps" approach? Is it not simply attempting to win ideological battles through the back door?
One would be hard pressed to name another profession where this "service-seeker trumps" principle holds true. If a house owner tells the builder that he must construct the roof in such and such a way, and the builder in his opinion deems it unsafe, the principle of placing house owner autonomy above everything else could result in a disaster.
I would like you to consider these thoughts: Our country was not built upon the principle of unbridled autonomy of the individual, but on that of solidarity and a sense of community that upheld the freedom of conscience and religion of each citizen. Autonomy is necessarily limited. A baby is less autonomous than an adult, but no less human, a paraplegic less so than a fully healthy person, but is not any less human because of his limitations.
As ethicist Teresa Iglesias puts it, within the current liberal perspective, the idea of individual freedom is the external ethical principle which makes the "neutral" [valueÂfree] use of medicine something medically "good". Medicine today, she says, has become a "service" governed by market forces, which gives the patient—now called a "client"—what he or she wants. The doctor is there to serve the autonomy of the patient. When this autonomy cannot be exercised, the doctor must carry out what is the most "benevolent" thing to do in the best interests of the patient, and this could include "mercy killing".
The pressure is on full-blast for individuals, be they Theists or believers in the goodness of mankind, microcosms of the world in which they live, to separate their deeply held beliefs from the rest of their daily occupations: the result is a type of split personality, an individual living a sort of a disembodied faith that has no impact on what he does from day to day. History has shown that the erosion of personal conscience eventually leads to the erosion of professional conscience as well. We cannot have it both ways.
Finally, there are differing conceptions of the human person at issue. In the one, certain kinds of moral beliefs are to the fore, such as that the primary issue is whether the person seeking health care is getting what they want. In the other, this demand is not asserted in isolation, but within a society made up of believers of various sorts. Accommodation or cooperation requires this second idea of the person and beliefs, and stands opposed to the "one size fits all" approach that seems to be battling for control of the health care professions. In conclusion, I would like to quote John Paul II whose recognition of human life as lived in an integrated manner comports with the idea of the freedom of religion as having a public dimension as well as a private one. We should ponder what John Paul II meant when he wrote:
There cannot be two parallel lives in our existence: on the one hand, the so-called spiritual life, with its values and demands; and on the other, the so-called secular life, that is life in a family, at work, in social relationships, in the responsibilities of public life, and in culture. The branch, engrafted to the vine that is Christ, bears fruit in every sphere of existence and activity. In fact, every area of our lives, as different as they are, enters into the plan of God, who desires that these very areas be the places in time where the love of Christ is revealed and realized for both the glory of the Father and service of others.23
1 And there is an excellent article by lawyer Nikolas T.Nikas, entitled "Law and Public Policy to Protect Health-Care Rights of Conscience" that explains this very well. For those who are interested, it was published in the Spring 2004 issue of the National Catholic Bioethics Quarterly.
2 Please see www.consciencelaws.org
3 Savulescu, J. Conscientious Objection in Medicine. BMJ, Feb 2006; 332: 294-297 http://bmj.bmjjournals.com/cgi/content/full/332/7536/294
4 Wunder, M. Medicine and Conscience: The Debate on Medical Ethics and Research in Germany 50 Years After Nuremberg. Perspect Biol Med, 2000 Spring; 43 (3): 373-81 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10893726&dopt=Abstract
5 Gourevitch, Philip. We Wish to Inform you that Tomorrow we will be Killed with our Families: Stories from Rwanda. Picador publisher, New York 1998. http://globetrotter.berkeley.edu/people/Gourevitch/gourevitch-con0.html
6 It is not my intention to give a detailed analysis or critique here of Savulescu's paper. This has been more than well done by the 58 letters to the editor of BMJ that the article elicited, mostly from outraged medical professionals, medical students, ethicists, lawyers, philosophers, and patients.
7 Iglesias, Teresa. Medicine's Intrinsic Good. The Centre for Bioethics and Human Dignity. Quoted with permission. http://www.cbhd.org/resources/bioethics/iglesias_2003-09-09.htm
11 Charo, A.R. The Celestial Fire of Conscience—Refusing to Deliver Medical Care. N Eng J Med 352: 2471Â2473; 24, June 16, 2005. http://content.nejm.org/cgi/content/full/352/24/2471
12 CPJ, May 2000, Vol.133, No.4, p.22-26. cannot be viewed online.
13 Letters to the editor of CPJ/RPJ. Feb 2000."Standards of Practice" by Frank Archer.
14 See www.consciencelaws.org for these articles: In Defense of the New Heretics: A Response to Frank Archer by Sean Murphy; "Autonomy", "Justice" and the Legal Requirement to Accommodate the Conscience and Religious Beliefs of Professionals in Health Care, by Iain Benson.
15 CPJ/RPJ Oct.2004, Vol 137, No.8. Can be viewed at http://www.pharmacists.ca/content/cpjpdfs/oct04/Editorial-October04.pdf or by going to http://www.pharmacists.ca/content/hcp/resource_centre/cpj/index.cfm and clicking of CPJ and then on CPJ issues.
16 These letters can be accessed at www.pharmacists.ca.
17 Bulletin of BC College of Pharmacists. Ethics in Practice. March/April 2000. page 5. http://www.bcpharmacists.org/resources/cpbc/pdf/marchapril2000.pdf
18 See NAPRA's model statement at http://www.napra.org/docs/0/95/157/165/179.asp
19 College of Physicians and Surgeons of British Columbia endorses the Canadian Medical Association's Code of Ethics in refusal to treat: CMA Code of Ethics (updated 2004) policy no. 12. Inform your patient when your personal values would influence the recommendation or practice of any medical procedure that the patient needs or wants. http://www.cma.ca/multimedia/staticcontent/HTML/N0/l2/where_we_stand/CodeofEthics04.pdf
20 See Value VIII of Code of Ethics of Pharmacists of British Columbia at http://www.bcpharmacists.org/standards/ethicslong/
21 Statement Regarding Pharmacists' Refusal to Provide Products or Services for Moral or Religious Reasons. Approved by Council June 23, 2000. Saskatchewan College of Pharmacists emphasizes that it would be improper and unethical conduct if the pharmacist used the opportunity to promote his/her moral or religious convictions. http://www.napra.org/pdfs/provinces/sk/skreference_manual/Pharmacists%20Refusal%20to%20Provide%20Products%20for%20Moral%20Reaons.pdf
22 See all the Provincial Pharmacy Licensing Bodies at: http://www.napra.org
23 John Paul II. Edited by Joseph Durepos. Go in Peace: a Gift of Enduring Love. Loyola Press April 2003, p.190 http://www.ecatholicism.org/page.cfm?Web_ID=1378