Doctors should not be forced to refer patients for controversial procedures

By David Albert Jones.

Should doctors have a right not to provide legal but morally controversial procedures such as assisted suicide or abortion?  And, if a doctor declines to provide some procedure, should the doctor be required to refer the patient to another doctor who will provide it?

Where abortion or assisted suicide are legal, the law often provides a right not to participate.  However, some countries have no conscience protections and others give only limited protection.  In the United Kingdom, the Doogan case showed that the Abortion Act 1967 does not protect healthcare professionals from having to organise for abortions to take place.  In Australia, in relation to “voluntary assisted dying” there are strong protections in law, but research shows that it is hard for junior doctors to exercise their legal rights when senior colleagues hold a different view.

Respect for conscience is a matter not only of law but also of professional ethics.  The World Medical Association is currently revising its International Code of Medical Ethics.  The version that was shared publicly in 2021 included conscientious objection but required doctors with an objection to ensure “effective and timely referral to another qualified physician.”

In response, an open letter signed by over 300 academics and doctors argues that doctors should not be required to refer patients for procedures that the doctor sincerely and reasonably believes to be unethical.  Patients and the medical profession need doctors who are committed to acting ethically and who will not be bullied into doing what they judge to be seriously unethical.

There was a meeting about revision of the Code in Washington earlier this month.  It is reported that the WMA has pulled back from the uncompromising language in the consultation.  However, the Code still needs to be considered by the WMA Council and, if approved, be adopted at the WMA General Assemble in Berlin in October.  The outcome is not yet certain.

Some bioethicists have argued that doctors “have no moral claim in liberal democratic societies to the accommodation of their individual conscientious objections.”   The idea here seems to be that it is for democratic processes to decide what is legal and doctors should then be compelled to provide whatever is legal.  However, what is legal is not always ethical and there is diversity of view both in society and in the medical profession about what is ethical.  The majority is not always right and each person must take responsibility for his or her own actions.

Consider the example of assisted suicide in Australia.  It was illegal but is now legal.  Was it also unethical before?  Is it also ethical now?  It is permitted in Australia but is prohibited in most countries.  Many doctors in Australia consider assisted suicide to be ethical and are happy to provide it.  Others continue to think it unethical.  The dissenting doctors are not only expressing private opinions.  They are expressing the shared understanding of many healthcare professionals in Australia based on reasonable ethical concerns and in agreement with the current position of the World Medical Association.

People draw the line in different places but everyone draws a line somewhere.  In Belgium it is legal to provide euthanasia or assisted suicide on the basis of “constant and unbearable physical or mental suffering that can not be alleviated, resulting from a serious and incurable disorder.” This includes psychiatric conditions such as gender dysphoria.  Should a doctor in Belgium be required to refer someone who is trans and is suicidal to a doctor who is known to be willing to assist suicide for this reason?  Or, if a doctor objects to making a referral in this case should their objection be respected?

Doctors are increasingly under pressure from many directions.  There are allocation constraints, whether mediated by insurance companies or by government, there are targets whether set by healthcare managers, trusts or politicians.  Patients also come with confused ideas or unrealistic expectations shaped by the internet and social media.  Many have noted how healthcare workers have suffered both psychologically and morally during the pandemic.  A failure to respect conscience will result in further “moral injury” to conscientious clinicians.

Some say that doctors who object to medical practices that are legal could leave medicine and get another job.  However, forcing conscientious doctors out of medicine, and excluding people from some moral communities from taking up medicine, will have profound consequences for the profession and for society.  Failure to respect conscience could impact not only the make up of the profession but also undermine the morale of doctors and exacerbate problems of recruitment to some specialisms.

Furthermore, it is regarded as a truism that there is a positive duty to recruit a diversity of people into medicine.  Effectively excluding people from the profession on the basis of reasonable and widely shared moral, political or religious beliefs is flagrant discrimination.  It stands in direct contradiction to the aim of increasing inclusion and diversity within the medical profession.


Author: David Albert Jones

Affiliations: Director, Anscombe Bioethics Centre, Professor of Bioethics; St Mary’s University, Twickenham; Fellow, Blackfriars Hall, University of Oxford

Competing interests: The author drafted the open letter referred to in this post.

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