Defining Doctors Down

There was a day in the not-too-distant past when physicians were respected, even revered, as learned professionals. We understood that doctors followed a “higher calling.” Indeed, physicians were expected to adhere to a code of conduct—epitomized by the Hippocratic Oath’s venerable injunction, “do no harm.”

Times have changed. The old hierarchies eroded and professional standards evolved accordingly. Some of this has obviously been for the better. For example, where doctors once made life-and-death treatment decisions, patients now may refuse care, e.g., no more tethering to medical machinery when one simply wants to die naturally at home.

But many of the changes have been for the worse. The doctor’s role is increasingly that of a highly trained “service provider,” whose job is to provide the patient with data to make informed choices and then perform all requested procedures. In this deprofessionalized milieu, many within the medical and bioethics intelligentsia argue that a doctor’s moral judgment—”medical conscience,” as it is sometimes known—has no place at the bedside.

Since the legalization of abortion (and in some places assisted suicide), most conscience debates have focused on whether doctors can be forced to take human life. This contest is being waged in Canada, where the Supreme Court conjured a positive right to euthanasia—enacted into law by Parliament last year. In the wake of legalization, most provincial medical associations published ethics opinions requiring doctors to provide lethal interventions for every legally qualified patient upon request or, if morally opposed, refer the patient to a doctor they know to be willing. Whether that duty will be embedded into the law is currently being debated.

Here in the United States, a 2007 ethics opinion of the American College of Obstetricians and Gynecologists (ACOG)—reaffirmed in 2016—invokes the term conscience while seeming not to know what it means:

Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious and moral beliefs on patients. … Physicians and other healthcare 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.

If ACOG’s view were ever mandated legally, every obstetrician and gynecologist in America would be required to be complicit in terminating pregnancies. Victoria, Australia, has already imposed a legal duty to abort-or-refer on all of its licensed doctors. Meanwhile, the American Civil Liberties Union has launched a campaign of litigation against Catholic hospitals that adhere to the church’s moral teachings, shopping for that one judge willing to shatter the religious freedom of church-affiliated health care institutions.

A push is also on to restrict conscience in less contentious fields of practice. The internationally influential Journal of Medical Ethics has published bioethicist Francesca Minerva pushing the logic of doctors-as-order-takers to its conclusion. Using examples of people who had horns surgically implanted in foreheads and feminists who wanted their bodies “uglified” as an ideological statement, Minerva makes the absolutist claim that a doctor’s job requires doing precisely what the patient wants:

If doctors make a conscientious objection to perform cosmetic surgery for artistic, whimsical, or political reasons on the sole ground that such interventions do not match the traditional goals of cosmetic surgery, they impose their own idea of what medicine is supposed to achieve. … Doctors have at least a prima facie obligation to perform treatments their patients request, even when they do not agree with the goals of the patients, their lifestyle, their idea of what is in their best interest and their values.

Think what this could mean. Doctors could be forced to participate in body mutilations that have nothing to do with treating disease or promoting wellness, such as the radical modifications undertaken by the late “Stalking Cat,” who had whiskers implanted to look feline (before committing suicide), or the “Dragon Lady,” a transgendered woman who has had her ears and nose cut off to look reptilian.

More ominously, doctors could be required to perform female genital mutilation. Minerva seeks to avoid this obvious consequence by blithely noting the practice is often outlawed. But that’s a dodge. FGM isn’t universally prohibited. Moreover, if patient desires are truly paramount—if “patient rights” are always to prevail over a doctor’s moral judgments—and the woman seeking the procedure believes it is a religious duty, on what logical basis could society outlaw FGM for consenting adults or doctors refuse to fulfill such requests?

If doctors are to be just technocratic service providers, they could similarly be required to participate in treatments for gender dysphoria, including sex change surgeries, regardless of their moral or religious views, forced to cooperate with self-cutters in harming themselves (that has been proposed seriously as a proper clinical response to the condition), and perhaps even compelled to wound as a means of protecting the patient from infection or more serious self-inflicted injuries.

And what about those unfortunate people who suffer from body integrity identity disorder, also known as body dysphoria, in which the patient identifies as disabled and wants to have a healthy limb amputated or spinal cord severed to become paralyzed? Don’t think that couldn’t happen. Browse the bioethics literature and you will find arguments that acceding to such intense patient desires should be deemed an appropriate treatment for the condition. Should a physician’s refusal to amputate come to be seen as a moral judgment rather than being strictly medical, what basis would there be for refusing to lop off healthy arms on request?

Time to hit the brakes. Allowing conscientious refusal to provide procedures not required to maintain life both protects doctors from authoritarian impositions and shields patients from harm. Honoring medical conscience also furthers social cohesion and promotes the general welfare by defending against destructive behaviors while maintaining the role of the doctor as healer rather than killer or enabler of dysfunction.

Beyond that, depriving doctors of moral agency would be harmful to the health care system as a whole. Not only would coercing doctors to provide elective procedures with which they disagree drive some of our best physicians into early retirement, such a policy would surely dissuade many talented students from entering the medical field in the first place.

This much is sure: We are all better off with doctors empowered to exercise moral judgment as professionals rather than being reduced to technicians obliged to perform any legal procedure a patient can afford.