{"id":3275,"date":"2018-01-29T14:17:43","date_gmt":"2018-01-29T13:17:43","guid":{"rendered":"https:\/\/blogs.bmj.com\/medical-ethics\/?p=3275"},"modified":"2018-02-19T01:41:28","modified_gmt":"2018-02-19T00:41:28","slug":"conscientious-objection-a-quickish-answer","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/01\/29\/conscientious-objection-a-quickish-answer\/","title":{"rendered":"Conscientious Objection: A Quick(ish) Answer"},"content":{"rendered":"

Guest post by Mary Neal, Law School, University of Strathclyde<\/em><\/strong><\/p>\n

The Conscientious Objection (Medical Activities) [HL] Bill<\/a>, introduced by the crossbench peer Baroness O\u2019Loan, received its second reading in the House of Lords on Friday 26th<\/sup> January and successfully proceeded to the committee stage.\u00a0 In a post on this blog<\/a> the following day, Iain posed a very reasonable question about clause 1(1)(a) of the Bill.\u00a0 That clause would allow health professionals to refuse to be involved in \u201cthe withdrawal of life-sustaining treatment\u201d, and Iain asks how this can be compatible with existing civil and criminal law, under which it is unlawful to fail<\/em> to withdraw treatment (including life-sustaining treatment) from a competent patient who no longer consents to it, or from a patient who lacks capacity if treatment is no longer in her best interests.<\/p>\n

Before responding, I should declare an interest: I\u2019m a spokesperson for the Free Conscience campaign<\/a>, which supports the Bill.\u00a0 <\/a> I endorse the Bill\u2019s premise that healthcare professionals should, in key areas of practice, benefit from statutory conscience rights that are both meaningful and effective.\u00a0 This is not currently the case: some professionals who require protection, and are likely to require it even more in future (general practitioners and pharmacists, for example: see my post here<\/a>) have no statutory<\/em> protection at all, while others have \u2018protection\u2019 that is so narrowly-drawn as to be unfit for purpose.\u00a0 (This was exposed recently by the UK Supreme Court\u2019s judgment in Greater Glasgow Health Board v Doogan <\/em><\/a>[2014] UKSC 68, about which I’ve written here<\/a>.)\u00a0 The O\u2019Loan Bill would redress both of these deficiencies in the current law.<\/p>\n

Iain\u2019s question, however, is specifically about the sub-clause dealing with conscientious objection (CO) to withdrawing life-sustaining treatment, and whether it is compatible with the law relating to unlawful treatment.\u00a0 (He sets out the relevant law in his post, so I won\u2019t duplicate it here.)\u00a0 At least two main points can be made in response to the question he raises.<\/p>\n

(i) Existing GMC guidance permits CO to withdrawal of life-sustaining treatment<\/em><\/p>\n

The first point is that doctors, at least, are already<\/em> subject to guidance that tells them they can opt out of involvement in the withdrawal of life-sustaining treatment.\u00a0 The General Medical Council (GMC) guidance Treatment and care towards the end of life: good practice in decision making <\/em>(2014) advises doctors, at paragraph 79, that<\/a><\/p>\n

You can withdraw from providing care if your religious, moral or other personal beliefs about providing life-prolonging treatment lead you to object to complying with:<\/p>\n

(a) a patient\u2019s decision to refuse such treatment, or<\/p>\n

(b) a decision that providing such treatment is not of overall benefit to a patient who lacks capacity to decide.\u201d<\/p>\n

However, you must not do so without first ensuring that arrangements have been made for another doctor to take over your role. It is not acceptable to withdraw from a patient\u2019s care if this would leave the patient or colleagues with nowhere to turn.<\/p><\/blockquote>\n

Paragraphs 80 and 47-48 set out the procedure to be followed in case of a dispute, and paragraph 127 confirms that the guidance also permits CO, on the same terms as above, to \u201cwithdrawing, or not providing, clinically-assisted nutrition and hydration\u201d.<\/p>\n

The British Medical Association (BMA) favours a narrower right of CO.\u00a0 On its website, it states that<\/a>, in addition to the contexts of abortion and fertility treatment (where statutory rights of conscience already exist), it countenances CO \u201cto withdrawing life-prolonging treatment from patients who lack capacity, where other doctors are in a position to take over the care.\u201d\u00a0 But whereas the BMA supports CO only where the patient lacks <\/em>capacity, the GMC countenances CO to the withdrawal of life-sustaining treatment from patients with or<\/em> without capacity.\u00a0 Thus, doctors already<\/em> practice under guidance that recognises the kind of entitlement that Clause 1(1)(a) would enshrine in statute.<\/p>\n

Iain reflects on the various possible forms that a right to opt out of treatment withdrawal might take in practice; some he acknowledges as far-fetched, while others are more plausible.\u00a0 Given the existing GMC guidance, however, we can ask not \u201cwhat might<\/em> this mean in practice?\u201d but \u201cwhat does <\/em>this mean in practice?\u201d\u00a0 In other words, we can enquire into how doctors currently<\/em> rely on the existing GMC guidance, asking what form(s) CO takes, how widespread it is, whether it creates significant practical problems, and so on.<\/p>\n

Clause 1(1)(a) would put the GMC guidance on a statutory footing and extend it to other relevant health professions (nurses and midwives, for example, are currently able to exercise CO<\/a> in the two contexts covered by statute: abortion and fertility treatment).\u00a0 Rightly so: why should only doctors<\/em> be permitted to practice healthcare in accordance with their consciences?<\/p>\n

The desirability of the change brought about by Clause 1(1)(a) is one thing, however, and whether it would be compatible with existing law another. The fact that it would largely replicate existing guidance does not necessarily mean there would be no incompatibility.<\/p>\n

(ii) Compatibility with the law on unlawful treatment<\/em><\/p>\n

When a competent patient indicates that she no longer consents to life-sustaining treatment, or when a decision is taken that continued treatment is no longer in the best interests of a patient without capacity, continued treatment is unlawful.\u00a0 In both types of case, the Trust treating the patient has an obligation to ensure that treatment is discontinued urgently.\u00a0 But this obligation belongs to the Trust.\u00a0 (For example, in paragraph 99 of her judgment in Ms B v An NHS Hospital Trust <\/em>[2002] EWHC 429 (Fam), Dame Elizabeth Butler-Sloss, P. explicitly distinguishes between the duties of individual healthcare professionals and the duties of the Trust, and finds that Ms B has been treated unlawfully \u2018by the NHS Hospital Trust\u2019.)\u00a0 If an individual professional notifies her employer that she has a belief that forbids her from performing the act of withdrawal (switching off a life support machine, or disconnecting a feeding tube, for example), it is incumbent upon those with management responsibility to assign the task to someone else who has no such objection.<\/p>\n

What, other than direct acts of switching off or disconnecting, might be covered by clause 1(1)(a)?\u00a0 For the record, I agree with Iain that palliative care obviously does not fall within the rubric of \u2018withdrawal of treatment\u2019, so would not be something to which a professional could object (in the highly unlikely event that any professional would wish to).\u00a0 Otherwise, as noted already, I don\u2019t think there is a need to speculate \u2013 we can enquire into current practice under the GMC guidance.\u00a0 Crucially, in terms of Iain\u2019s question, it is difficult to imagine how an individual professional could personally commit a battery (or anything else) while exercising a right under clause 1(1)(a).\u00a0 The only circumstances I can conceive of in which an individual professional who objected to treatment withdrawal might end up committing battery would be if she attempted to reinstate<\/em> treatment after it had been discontinued.\u00a0 But this seems very far-fetched, and would involve a positive act, whereas the Bill seeks to confer the right not <\/em>to do something.<\/p>\n

How could an individual professional treat a patient unlawfully by not <\/em>acting?\u00a0 A Trust certainly could, by failing to arrange for the removal of treatment that is no longer consensual, or no longer in a patient\u2019s best interests.\u00a0 Once again, however, this is not an obligation which rests with individual professionals, and this would be even more clearly the case if such individuals had a statutory right to conscientiously object<\/em>.\u00a0 For all of these reasons, in my view, the existing law relating to battery and unlawful treatment presents no obstacle for this Bill.<\/p>\n

Mary Neal<\/em><\/strong> is\u00a0a senior lecturer in law at the University of Strathclyde in Glasgow, researching and teaching medical law and ethics with a particular focus on beginning and end of life issues and rights of conscientious objection. She is a current member of the BMA Medical Ethics Committee and a spokesperson <\/em>for the Free Conscience Campaign, which supports the Conscientious Objection (Medical Activities) [HL] Bill.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Guest post by Mary Neal, Law School, University of Strathclyde The Conscientious Objection (Medical Activities) [HL] Bill, introduced by the crossbench peer Baroness O\u2019Loan, received its second reading in the House of Lords on Friday 26th January and successfully proceeded to the committee stage.\u00a0 In a post on this blog the following day, Iain posed […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1240,968,2153,443,2148,591,2745,7988,577,1544],"tags":[],"class_list":["post-3275","post","type-post","status-publish","format-standard","hentry","category-blogosphere","category-clinical-ethics","category-guest-post","category-jme","category-law","category-life-and-death","category-professionalism","category-regulation-and-regulators","category-resource","category-the-nhs"],"yoast_head":"\nConscientious Objection: A Quick(ish) Answer - Journal of Medical Ethics blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/medical-ethics\/2018\/01\/29\/conscientious-objection-a-quickish-answer\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Conscientious Objection: A Quick(ish) Answer - 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