Medical Defence

Hail,

And here is an interesting article in a recent student BMJ about conscientious objection among doctors - specifically whether doctors are within their rights to refuse to carry out procedures they find unethical. The author is Charles Williams, a medical student, and he writes passionately and articulately and reasonably - but I feel utterly, utterly wrongly - about a subject he has obviously considered at some length. His whole passage gave me a feeling of deep unease, and I'll try to explain what I felt, and why, and why I am less convinced of the rightness of his position after reading his argument than I was before.

(As an aside, as I understand the current Australian legal position, no-one is compelled to carry out an abortion or to provide contraception. In that it's like any other medical procedure. However, duty of care still exists - if you don't provide contraception, you have to make sure that you patient can get access to it somewhere close and cheap and convenient. Otherwise you're not doing your job, and you're liable, which is as it should be).

Anyway. In summary, as I understand him, Mr Williams writes that an inalienable right to conscientious objection exists, and that, as part of that inalienable right, doctors can refuse to participate in terminations. Rather than being penalised or pilloried, they should be praised. He closes by arguing we need more, rather than fewer doctors with the conviction to defend what they believe is right.

This does not convince me, on a number of levels. Lately I have become suspicious when I hear the term "conscientious objection". It strikes me that it is often used as a cheap debating trick - a sneaky appeal to a dubious higher authority. The term "conscientious" evokes a conscience, and by doing so suggests that some final arbiter has been consulted, that the speaker has visited some higher moral plain and returned with something somehow superior to our petty concerns and prejudices. Once something is named as a matter of conscience, it becomes somehow impolite to question or challenge it. There is just a respectful nod and the conversation moves on.

This is a fairly bizarre argument, once you look at it. From what I can work out, it asks the listener to believe that within each of us (or within the speaker, at any rate) there resides an inerrant moral-o-meter, something that enables the speaker to accurately and precisely determine at a glance the moral rightliness or wronglitude of an action, phrase or belief, something whose pronouncements should be taken on faith. I see no evidence of such an organ.

What I do see is a human tendency to rebadge and relabel things to our own advantage, to lie to ourselves and to others in order to maintain our accustomed levels of comfort. It is more comforting - and this isn't the nicest explanation - to attribute thoughts and words and deeds to our conscience rather than to our prejudices, or our laziness, or lack of imagination, or our desire not to think too hard.

Now, that may sound harsh. It is. But if it were true, it would explain how so many of these acts of conscience people talk about somehow end up replicating the same old patterns, making things worse for the marginalized, kicking not only those who are down, but those whom we knocked down in the first place. It would explain how people who draw their inspiration from the Bible and the Judeo-Christian code of ethics, for example, can be at ease with the whole rich man and eye of the needle thing, be udderly unconcerned when a calf is seethed in the milk of its mother, but will be struck with righteous rage when it comes to homosexuals or women. All of a sudden, when it comes inconveniencing others rather than ourselves, the weak rather than the powerful, God is not mocked.

These are ugly ideas. But otherwise we have to say it's an unfortunate co-incidence that Mr William's ideas, if acted upon, would kill vast numbers of women. It's sheer bad luck that Mr Williams' actions would result in sepsis, in fistulae, in suicide and infanticide. It's a terribly unfortunate but totally unforeseeable thing that the prayer-book is followed by the coat-hanger, and the coat-hanger by the coffin*.

Maybe it's not some mythical conscience, Mr Williams. Maybe it's something else, something women have heard from doctors before, something internalised and unconscious but pretty much there all the time.

In simpler terms, maybe it's not God. Maybe it's you.

Anyway. The history of conscientious objection, of people who followed their own moral code rather than that of society or "normal" medical practice, is no cleaner or dirtier than that of any other field of endeavour. One of us is no wiser nor more stupid than all of us.

Sincere, intelligent, diligent men and women have examined their conscience and then sterilized miscegenating women, or electrocuted homosexuals to cure them, or experimented on Jews. In the end, maybe you will get lucky, maybe you won't. If you are a conscientious objector, maybe you will end up lauded as a good person, as a saver of lives, an advancer of knowledge. Maybe you will end up as a footnote, a grainy photograph, a name in an article about Buchenwald or Sakhalin or Tuskeegee.

Either way, you will have done what you believe to be right. But His eye is on the sparrow, mate.

Anyway, I have said too much and left too much of what I wanted to say unsaid. there is a sense in which I don't have a right of reply here, in which the right of reply belongs to those who have seen the cost of the conscientious objectors piety, who have to bury the bodies they created to appease their conscience. That response has been given by Dr Shashi Sigdel, whose response gives less of the air of deliberation of Mr Williams, but more one of desperation and hope, and has the added benefit of being written by the bedside rather than by someone yet to practice.

But I am preaching to the already saved.

In the end, there are only two choices. The alternative to doing what a doctor should do, to doing your job, to healing the sick, to easing suffering, is to selectively doing your job, healing only the sick whom you choose to heal, easing suffering for those who meet your specific criteria. That may be the path Mr Williams has set out upon, and I wish him well with it, but I cannot agree that medicine needs more like him at all.

Thanks for listening,
John

*If only there had been a robust collection of data about the possible consequences of denying access to abortion, a body of evidence similar to the one that Mr Williams regretfully concedes does not exist about the terrible consequences of allowing abortion. Rather than relying on people's consciences as a guide, we could base this data on, say, scientific evidence, derived from clinical trials and the like. We could call it, I don't know, evidence based medicine.

Stop me when I get too crazy.