You’re a surgeon. A patient wants to look like a lizard. What do you do?

As medical treatments advance, the need to accommodate conscientious objection in healthcare is more pressing

The Guardian
Reproduced with permission

David S. Oderberg*

Imagine that you are a cosmetic surgeon and a patient asks you to make them look like a lizard. Would you have ethical qualms? Or perhaps you are a neurosurgeon approached by someone wanting a brain implant – not to cure a disability but to make them smarter via cognitive enhancement. Would this go against your code of professional ethics? With the rapid advance of medical technology, problems of conscience threaten to become commonplace. Perhaps explicit legal protection for conscientious objection in healthcare is the solution.

There is limited statutory protection for those performing abortion, and there is some shelter for IVF practitioners. Passive euthanasia (withdrawal of life support with intent to hasten death) is also part of the debate over doctors’ conscience rights. That’s about it as far as UK law is concerned – though freedom of conscience is enshrined in numerous conventions and treaties to which we are party. Abortion, artificial reproductive technologies (involving embryo research and storage) and passive euthanasia are the flashpoints of current and historic controversy in medical ethics. The debate over freedom of conscience in healthcare goes to the heart of what it means to be a medical practitioner.

Curing, healing, not harming: these are the guiding principles of the medical and nursing professions. But what if there is reasonable and persistent disagreement over whether a treatment is in the patient’s best interests? What if a practitioner believes that treating their patient in a particular way is not good for them? What if carrying out the treatment would be a violation of the healthcare worker’s ethical and/or religious beliefs? Should they be coerced into acting contrary to their conscience?

Such coercion, whether it involve threats of dismissal, denial of job opportunities or of promotion, or shaming for not being a team player, is a real issue. Yet in what is supposed to be a liberal, pluralistic and tolerant society, compelling people to violate their deeply held ethical beliefs – making them do what they think is wrong – should strike one as objectionable.

Freedom of conscience is not only about performing an act but about assisting with it. There are some people who ask doctors to amputate healthy limbs. If you were a surgeon, my guess is that you would refuse. But what about being asked to help out? Would you hand over the instruments to a willing surgeon? Or supervise a trainee surgeon to make sure they did the amputation correctly? If conscientious objection is to have any substance in law, it must also cover these acts of assistance.

This country has a long and honourable tradition of accommodating conscientious objectors in wartime – those who decline to fight or to assist or facilitate the fighting by, say, making munitions. They can be assigned to other duties that may support the war effort yet are so remote a form of cooperation as not to trouble their consciences. In any war, the objectors are a tiny fraction of the combat-eligible population. Yet when it comes to one’s rights, do numbers matter? Has their existence ever prevented a war from being carried out to the utmost? I fail to see, then, why we are tolerant enough to make adjustments for conscientious objectors in the midst of a national emergency, yet in peacetime would be reluctant to afford similar adjustments to members of one of the most esteemed professions.

Do we think medical practitioners should be no more than state functionaries, dispensing whatever is legal no matter how much it is in conflict with personal conscience and professional integrity – lest they be hounded out of the profession? Some academics think expulsion is not good enough. Or should healthcare workers be valets, providing whatever service their patients demand? Perhaps when practitioners find themselves faced with demands for the sorts of treatment I’ve mentioned – or perhaps gene editing treatments or compulsory sterilisation, society will act. Or maybe by then it will be too little, too late.

David S Oderberg is professor of philosophy at the University of Reading, and author of Declaration in support of conscientious protection in medicine

 

 

There is no defence for ‘Conscientious objection’ in reproductive health care

Abstract

A widespread assumption has taken hold in the field of medicine that we must allow health care professionals the right to refuse treatment under the guise of ‘conscientious objection’ (CO), in particular for women seeking abortions. At the same time, it is widely recognized that the refusal to treat creates harm and barriers for patients receiving reproductive health care. In response, many recommendations have been put forward as solutions to limit those harms. Further, some researchers make a distinction between true CO and ‘obstructionist CO’, based on the motivations or actions of various objectors. This paper argues that ‘CO’ in reproductive health care should not be considered a right, but an unethical refusal to treat. Supporters of CO have no real defence of their stance, other than the mistaken assumption that CO in reproductive health care is the same as CO in the military, when the two have nothing in common (for example, objecting doctors are rarely disciplined, while the patient pays the price). Refusals to treat are based on non-verifiable personal beliefs, usually religious beliefs, but introducing religion into medicine undermines best practices that depend on scientific evidence and medical ethics. CO therefore represents an abandonment of professional obligations to patients. Countries should strive to reduce the number of objectors in reproductive health care as much as possible until CO can feasibly be prohibited. Several Scandinavian countries already have a successful ban on CO.

Fiala C, Arthur JH. Eur J Obstet Gynecol Reprod Biol. 2017 Jul 23. pii: S0301-2115(17)30357-3. doi: 10.1016/j.ejogrb.2017.07.023. [Epub ahead of print]

 

Health indignity: A Carmichael hospital denied a trans man his hysterectomy. Now he’s suing.

Dignity Health moves patient’s surgery to another hospital over Catholic directives

newsreview.com

Dave Kempa

Two days before Evan Minton’s scheduled hysterectomy last September at Dignity Health Mercy San Juan Medical Center, a nurse called to discuss pre- and post-operation care. Toward the end of the call, Minton had a request.

“‘I just want to let you know that I’m transgender and my pronouns mean a great deal to me,'” he recalled saying.

According to Minton, the nurse was affirming. He hung up with a positive feeling. But the next day his doctor called with bad news. The hospital had canceled the procedure. He was terrified that the cancellation would add months or years to his physical transition.

Now, seven months later, the 35-year-old is teaming up with the American Civil Liberties Union to sue Dignity Health for denying care to a transgender patient. . . [Full text]

 

Illinois controversy about legislative overreach

 Catholic bishops withdraw opposition, others remain opposed

Confrontation centres on complicity

Sean Murphy*

 Introduction

Among American states, Illinois has the most comprehensive protection of conscience legislation, the Health Care Right of Conscience Act (HCRCA). In 2009 an attempt was made to nullify the Act with respect to abortion, contraception and related procedures by introducing HB 2354 (Reproductive Health and Access Act), but the bill died in committee two years later.1 Now it appears that the HRCA may be changed by Senate Bill 1564. Critics say the bill tramples upon physician freedom of conscience,2 while the bill’s supporters, like the American Civil Liberties Union (ACLU), claim that the bill is “about making sure no one is withholding information from the patient.”3

SB 1564 was actually drafted by the ACLU,3 but it was introduced by Illinois Senator Daniel Biss. He said that the amendments were partly in response to the case of a woman who was miscarrying over several weeks, but who was refused “diagnosis or options” in the hospital where she had sought treatment.4  Senator Bliss was apparently referring to the story of Mindy Swank, who testified before a Senate legislative panel about her experience.  The Illinois Times reported that she suffered “a dangerous, weeks-long miscarriage” because of the refusal of Catholic hospitals to provide abortions.5

Unfortunately, the Illinois Senate Judiciary Committee does not record or transcribe its hearings, and conflicting news reports make it difficult to determine exactly what happened at some critical points in her story.  Moreover, it appears that the Committee did not hear from the hospitals and physicians who were involved with Ms. Swank, so we are left with a one-sided account of what took place.6

Nonetheless, as a first step in considering the particulars of the bill and the controversy it has engendered, it is appropriate to review the evidence offered to support it.  We will begin with Mindy Swank’s testimony, even if some details are lacking, and then examine the experience of Angela Valavanis, a second case put forward by the ACLU to justify SB 1564.7  [Full Text]

Alabama House Bill 491 (2015)

Health Care Rights of Conscience Act

A BILL TO BE ENTITLED AN ACT

Relating to health care, to allow health care providers to decline to perform any health care service that violates their conscience and provide remedies for persons who exercise that right and suffer consequences as a result. [Full text]

Virginia’s compulsory vasectomy

Bioedge

Michael Cook

A Virginia petty criminal has been sentenced to 20 months in prison, three years supervised probation and two years unsupervised probation – and a vasectomy. Twenty-seven-year-old Jessie Lee Herald pleaded guilty to child endangerment, hit and run driving and driving on a suspended license. But it was for none of these that assistant prosecutor Ilona L. White imposed the condition of a vasectomy as part of the plea bargain.

“It was primarily due to the fact he had seven or eight children, all by different women, and we felt it might be in the commonwealth’s interest for that to be part of the plea agreement,” she explained.

He has also agreed not to reverse the vasectomy – which is difficult, in any case – as long as he is on probation.

The quirky conditions of Herald’s sentence, which went viral on the internet, provoked much commentary. It was called “temporary negative eugenics” at Jezebel and at Slate “reproductive coercion“.

Perhaps Ms. White lacks a sense of history, or she would have sensed the irony of compulsory sterilization in Virginia. In 2002, the 75th anniversary of a notorious Supreme Court decision, Buck v. Bell, Virginia Governor Mark Warner publicly apologized for the state’s past involvement in eugenics. He said, “The eugenics movement was a shameful effort in which state government never should have been involved.”

Carrie Buck was a young woman whom the commonwealth of Virginia wanted to sterilise because she came from bad stock. The case went all the way to the US Supreme Court, which ruled, in an 8-1 decision, against Ms. Buck. The majority ruling was written in 1927 by the legendary Oliver Wendell Holmes Jr., whose imperishable argument was:

It is better for all the world, if instead of waiting to execute degenerate offspring for crime, or to let them starve for their imbecility, society can prevent those who are manifestly unfit from continuing their kind. The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Three generations of imbeciles are enough.

After nearly a century, perhaps the commonwealth of Virginia has come full circle in its attitude toward eugenics. Except that now, two generations seem to be enough.


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Doctors reluctant to give young women permanent birth control

Chicago Tribune

Julie Deardorff

When Lori Witt began pursuing a tubal ligation at age 27, she said physicians refused to even discuss it with her, telling her she was too young and might change her mind about having children.

For more than a year, Witt tried to get sterilized. Finally she went with her 28-year-old husband to a military medical clinic overseas, where Witt said he was given a vasectomy with few questions asked.

Decades after sterilization became broadly available to women in the U.S., some still have trouble obtaining one of the safest and most effective forms of birth control.

The American College of Obstetricians and Gynecologists says nobody who seeks sterilization should be denied. But some women say the reality can be much different, especially for younger women and those without children. . . [Full text]

Alabama protection of conscience bill passes State House of Representatives

By a vote of 71-24, the Alabama House of Representatives has passed the  Health Care Right of Conscience Act in the state legislature.  The bill is intended to protect all health care providers from being compelled to participate, directly or indirectly, in abortion, human cloning, human embryonic stem cell research, and sterilization if they object to the procedures for reasons of conscience.  [Gadsden Times]

German Medical Association apologizes for physician complicty in Nazi atrocities

The German Medical Association has acknowledged and apologized for the participation of German physicians in Nazi programs of forced sterilization, euthanasia, and human experimentation.  The statement also acknowledged that “leading members of the medical community” were involved. [Washington Post]

California refuses reparation to victims of forced sterilization

The government and state politicians in California admit that the forced sterilization of about 20,000 citizens between 1909 and 1963 should not have happened.  The sterilizations were part of a state eugenics programme designed to prevent those identified as “feeble minded” or “defective” from having children.  However, they are unwilling to authorize compensation or reparation for the victims. [CNN]