Julian Sheather: What role for conscientious objection in medicine?

julian_sheatherWhat do we mean by conscience? What part, if any, should it play in medical practice? Should health professionals be free to object to providing lawful treatments on the grounds of conscience? If so, how far should the freedom extend?

These questions were the focus of a fascinating recent roundtable in Glasgow, organised by the Accommodating Conscience Research Network. (ACoRN)

Two distinct questions emerged. Firstly, what do we mean by conscience? Secondly, what respect is it due in a publicly-funded health service?

Like many well-worn concepts we think we know—roughly—what we mean by conscience. But on a second look it gets trickier. We can probably agree that conscience has several basic features. It is subjective: when we examine our conscience we turn our moral gaze inward. It refers to our own private morality, even though we may claim external support for it. Kant referred to it as an “inner court”. It is also a motivating force—it provides reasons for action or inaction.

Although a moral capacity—it is about right and wrong—it has no pre-ordained moral content. You may believe that participating in abortion is wrong, I may believe that women have a right to it. They can both be matters of conscience.

It is linked, slightly mysteriously, to identity. Some feel that if asked to go against their conscience they are harmed, though it is not easy to specify how. Whatever the nature of the harm, it is linked to the reasons why conscience is sometimes played as a moral trump. Claims grounded in conscience are often said to have particular force.

This is allied to another feature of conscience: it has cognitive content. It is plausible to think of conscience as a feeling that conveys thoughts. When I listen to my conscience I am being instructed or guided, I am being given knowledge. But of what? And this is where it gets really interesting. There was a great paper at the roundtable about two kinds of knowledge claimed for conscience: knowledge of truths and knowledge of reasons. And this is the slightly rickety bridge into a second question—the question of what respect is due to conscience in public health care.

One (worrying) claim made for conscience is that it enables direct access to moral truth. According to this view, if I listen closely enough I will hear the truth and therefore have my guide. Nothing else is needed. Introspection is enough. At least one huge problem with this is reliability. How do I know I am listening to my conscience and not buried prejudice? And if new information, or more persuasive arguments emerge, how should I respond?

A (to me) much more attractive view is that when we look inward we are reflecting upon our internalised values—that we are taking a core sample of our sedimented beliefs and experiences and working out how they fit the circumstances we find ourselves in. According to this view, although it has a personal aspect, our conscience also faces outward, to the public sphere. As such the pronouncements of our conscience are open to reasoning, revision and, where appropriate, accommodation.

Which brings us to the scope of conscientious objection in a publicly-funded health system like the NHS. What part should the private beliefs of health professionals play when delivering public services? This looks like a political question. How do we adjudicate between a claim to a lawful and publicly available procedure and a claim by a health professional that she doesn’t want to provide it? How far should private reasons intrude in the public sphere?

I like an argument put forward by bioethicists Peter West-Oram and Alena Buyx. To put their subtle argument crudely, whatever normative force supports a conscientious objection must support a claim to timely and appropriate treatment. The former cannot trump the latter. And this extends to the organisation of health services. No claim in conscience can logically lead to burdens for those seeking lawful treatment.

To this should be added some pragmatism. The sheer complexity of modern healthcare means that accommodating a wide range of conscience claims will likely lead to chaos—and to avoidable harms.

Currently the law supports a right to conscientious objection with regards to participating in abortion and certain procedures linked to fertility treatment. I can see no good reasons for extending it.

Julian Sheather is ethics manager, BMA. The views he expresses in his opinion pieces are entirely his own.