Conscientious Objection and What Makes a Medic

Francesca Minerva has drawn my attention to this paper by Sophie Strickland, currently available as a pre-publication download via the JME homepage, concerning conscientious objection among UK medical students.

Students were invited to respond to a set of questions in an online poll to determine whether there were procedures to which they’d object, and in which they’d refuse to participate, and what they were.  They were also asked to identify their religious affiliation.

Respondents were asked to note if their objections to the […] 11 medical practices [mentioned] were for religious reasons, non-religious reasons or both religious and non-religious reasons.  Of all the objections raised in the study, 19.7% were for religious reasons, 44.1% were for non-religious reasons, and 36.2% were for both religious reasons and non-religious reasons.  Muslim students were more likely to report religious objections (28.4%), followed by Protestant students (27.0%) and then Roman Catholic students (23.01%).  Jewish students were the least likely to report religious objections (15.8%).  The proportion of non-religious objections ranged from 96.7% in atheist students to 21.0% in Protestant students.  The Sikh and Eastern Orthodox students have again been excluded because of their low numbers.

There’s a number of problems with online polls, of course – they’re vulnerable to impersonation and trolling, even if steps are taken to ensure that people can only respond once.  (Strickland doesn’t indicate how she dealt with these problems.)  Still: I’ll take her results at face value.

Unsurprisingly, there’s a fairly high number of people who’d object to performing abortions.  As someone who doesn’t really have a problem with abortions, I suspect that those students’ positions are ill-informed or ill-thought-out – but they do make a kind of sense, and I can see where the objections arise.  Abortion does involve the deliberate killing of something that is alive and, in a sense, human (though I’d deny that that implies ending a human life); and even if it’s false to say that the foetus has a high value, refusing to terminate a pregnancy is at least coherent and consonant with a claim that doctors ought to preserve life rather than end it.

There are some troublesome indicators, though.  A number of students would object to, or would refuse participation in, learning about the moral arguments concerning abortion.  There’s not many, but that there’s any at all strikes me as being very worrying.  I can’t get my head around the idea that getting a greater insight into a given position can itself be objectionable.  There’re certain walls of dogmatism that I can’t climb.

More worrying is the number of students – again, not high, but that it’s more than zero is what matters – that self-reported as objecting to learning about the clinical impact of alcohol.  Given any medic is likely to come across people who are drunk and people whose lives have been affected by booze, an objection to learning about alcohol seems to me to amount to an objection to competence.

It gets worse.  Much higher numbers would object to treating people intoxicated by alcohol or other drugs.  On the assumption that this is a genuine moral objection to treating such people, rather than a worry about the wisdom of doing potentially painful things to a potentially violent drunk, there seems to be a significant number of students who would refuse to do what medics are supposed to do on the grounds that they disapprove of some characteristic of the patient.  One might expect a high moral standard from doctors… but this is not morality.  It’s moralism.  Worse, it’s moralism that could potentially threaten someone’s life or welfare.

I’ve saved the scariest for last.  Once again, it’s not many, but there are some students who would object to an intimate examination of a member of the opposite sex, and some who’d refuse outright.  I’d like to know more about this: it’s not clear how the sexes balance out on this, which’d be interesting to know.  But notwithstanding that, are students scared that their own virtue might be corrupted?  That the patient will ravish them?  That they’ll be unable to stop themselves* ravishing the patient?  Do medical students – hell, does anybody – honestly believe this?  And, again, is such a batty belief sufficient to warrant the potential sacrifice of patient welfare?

As Minerva points out, correctly,

[s]tudies like this one show it is urgent to think of some counter-measures to solve the issue of conscientious objectors in medicine.  We need to know, for instance, if the Muslim future doctors who refuse to visit patients of opposite sex would leave aside their religious concerns when the life of the patient is at risk, or when it would take too much time and/or trouble to find a willing colleague.  And would conscientious objectors agree to find a willing doctor performing what they refuse to perform, or they would leave the burden of the research to their patients?

These are urgent questions; the points she raises next are perhaps even more urgent:

But we especially need to understand if it is really worth it to train in medicine people who will never perform all the beneficial, legal and safe treatments our hospital offer to the patients.  What is the point of investing public money and resources to provide a degree in medicine for people who put their moral or religious concerns before the wellbeing of the people they are supposed to cure?  Are we sure we want to put at risk our right to be cured just because we want to safeguard doctors’ right to conscientious objection?  Maybe we should stop hiring doctors who make conscientious objections in favour of the ones who are able to leave aside their moral concerns.  And maybe we should discourage students to pursuit a career in medicine if they cannot put their patients before their own moral or religious beliefs.

Strickland suggests that

[t]his project also raises the question of whether medical students have a right to act according to their consciences while at medical school, as opposed to merely holding conscientious objections.

I’m not sure it does: we don’t need an empirical study to raise these questions, or to answer them.  And Minerva’s point seems important here: it is not obviously impermissible simply to deny that students have any right not to learn certain things, and to deny that medics have the moral right not to treat people.

If a doctor, having qualified and done a minimally decent amount of work in the public sector, decides to go private and only do procedures that are compatible with his moral beliefs, howsoever strange they might be, then I suppose that’s fine.  But the idea that he has a right to object to learning about things, or to performing them while earning public money… well, that’s a different matter entirely.

*Yeah, it’s a cheap shot.

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