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Friday, June 1, 2018

Essay 9: Intolerance of conscience threatens diversity in medicine


Editor's Note: This is the ninth essay in a series on conscience in healthcare, by Freedom2Care Director Jonathan Imbody. For the other essays, click "ConscienceEssay" on Topics at left.
In their commentary published in the New England Journal of Medicine,[i] Dr. Ezekiel Emanuel and Professor Ronit Stahl argue for discontinuing the historic policy of tolerating a diversity of ethical convictions among health professionals. Emanuel and Stahl urge dismissing conscience legal protections for health professionals, maligning such protections as merely "legislative tools that are used to insulate professionals from performing tasks that they personally deem objectionable."[ii]
In their view, conscience protections essentially function as an instrument of class warfare, a bourgeois oppression of the proletariat. A tool by which wealthy, selfish physicians dominate their poor, powerless patients.
Emanuel and Stahl decree that upon
entering the profession, physicians
sacrifice conscience and
individual medical judgement.

Emanuel and Stahl demand that physicians cast aside their self-centered concerns and bend to the will of the patient (especially when the patient demands a morally controversial procedure or prescription).
Since conscience objections in healthcare most commonly arise over pro-life issues, of course, the goal appears to be coercing into conformity all physicians who resist the authors' ideological tilt.
Emanuel and Stahl decree that upon entering the profession, physicians sacrifice conscience and individual medical judgement and "become obligated to provide, perform, and refer patients for interventions according to the standards of the profession (emphasis added)."

Abortion advocates prefer coercion to conscience accommodation

But apparently only those professional standards that comport with Emanuel and Stahl's intolerance of conscience—like abortion edicts issued by professional Ob-Gyn organizations[iii], [iv]--will qualify. The authors insist that "professional associations should resist sanctioning conscientious objection as an acceptable practice."
They condemn as "internally inconsistent," for example, the American Medical Association's statements on conscience and duty to patients. The AMA holds that “physicians’ ethical responsibility [is] to place patients’ welfare above the physician’s own self-interest” and declines to compel physicians to participate in procedures "'incompatible with the physician’s deeply held personal, religious, or moral beliefs."
Yet the AMA is simply advocating for selflessly caring for patients and also applying ethical standards to patient care; the two are compatible. The authors similarly condemn as "ambivalent" the American Pharmacists Association and the American Nurses Association, for advocating for patients' best interest alongside conscience freedoms for professionals.[v]

Conscience and faith can help advance patients' health

So focused on compelling physicians to perform abortions on demand in cases of controversy, it does not seem to occur to Emanuel and Stahl that a physician's personal, religious, or moral stance actually could advance a patient's best interest.
To disqualify faith-based health
practices and convictions simply
because they are faith-based
is hardly an evidence-based
approach to patient care.
A growing body of research reinforces that assumption, quantifying many benefits that faith can have on a person's health. To disqualify faith-based health practices and convictions simply because they are faith-based is hardly an evidence-based approach to patient care.
No evidence suggests, for example, that the medical community needs to challenge orthodox Jewish patients to start eating bacon or faithful Catholics to engage in premarital sex or evangelical Christians to stop praying for healing, simply because such behaviors are based on faith and conscience. On the contrary, the evidence suggests that finding a physician who practices medicine in concert with faith principles could actually help patients, and especially those who are engaged in practices harmful to their health.

Sometimes we need our doctors to challenge us

Ah, but challenging a patient's harmful health behavior might involve a physician saying something the patient does not want to hear. That sounds "judgmental" and "authoritarian." It might make the patient feel "unsafe" or "unaccepted."
The truth is that sometimes we need our physicians, who often are among the few people with whom we can share personal information under the protection of privacy, to inform and even challenge our health choices. The physician who truly merits our trust is not the one who does whatever we ask regardless of outcome or ethics but the courageous one who puts evidence, ethics and truth above cowardly accommodation for the sake of cultural acceptability.
Physicians who study both the design and Designer of our bodies may well be able, given the freedom to do so, to offer counsel that benefits patients regarding health practices consistent with religious belief. They also might be able to draw on those religious beliefs to counsel patients away from health harms.
But not if they have to check their religion at the door.



[i] "Physicians, Not Conscripts — Conscientious Objection in Health Care," Ronit Y. Stahl, Ph.D. and Ezekiel J. Emanuel, M.D., Ph.D., New England Journal of Medicine 376;14, April 6, 2017.
[ii]Stahl and Emanuel, p. 1380.
[iii] "The Limits of Conscientious Refusal in Reproductive Medicine, "ACOG Committee Opinion Number 385, Nov. 2017, stated, "Physicians and other health care providers have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. … Providers with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place."
[iv] The American Board of Obstetrics and Gynecology (ABOG) in 2007 published written guidance (Bulletin for 2007 Maintenance of Certification) that linked its physician certification procedures with the ethics positions of the American College of Obstetricians and Gynecologists (ACOG). The bulletin on page 26 outlined penalties if "the physician shall have violated any of 'The Ethical Considerations in the Practice of Obstetrics and Gynecology' currently published by The American College of Obstetricians and Gynecologists and adhered to by the Board." Those ACOG positions include a controversial official position issued in November (ACOG Committee Opinion Number 385) that called upon conscience-objecting obstetricians to refer patients for abortions—an act which many such physicians consider unethical.
[v] Stahl and Emanuel, p. 1382.

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