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43 Physician conscientious objection in anesthesiology practice
The Case
An anesthesiologist learns of an assignment in an isolated, off-campus location on the day of the procedure, which is a transvaginal oocyte retrieval. During conversation with the patient in the preanesthesia area, he learns that she is having pre-implantation genetic diagnostic studies of any fertilized eggs, and that these results will determine future options, which include deciding to reject and discard any that would test positive for rare inheritable diseases such as cystic fibrosis. The anesthesiologist believes that this case should not have been assigned to him as he previously had stated to his department that he has a conscientious objection to participating in certain reproductive procedures. Time is of the essence as the infertility obstetrician indicates that the timing of the retrieval must take place within the next hour.
Perhaps the most fundamental political ideal in the US is that one should be free to pursue whatever conceptions of “the good” one desires (autonomy), but subject to the limitation of avoiding acts that are harmful to others (nonmaleficence). As such, there is general acceptance of rights-of-conscience, which in this chapter we shall refer to as conscientious objection – a refusal by a physician to act in a way that is not in accord with deeply valued personal beliefs. In the scenario above, however, insistence on withdrawal from providing care not only could result in harm to the patient, but will disrupt the efficiency of institutional operational functions (with attendant adverse economic consequences), potentially incurring the wrath of unsympathetic coworkers (including those of the anesthesiology department). The potential to create not only physiologic but also psychological harm to this patient is ethically preeminent.
In this case the infertility obstetrician already has “contracted” for services with the patient, and, per routine has “arranged” for anesthesia services. However, the “contract” between patient and anesthesiologist does not take hold until the agreement between them actually has occurred. It is reasonable for the patient to expect unimpeded care by a team of physicians led by her infertility obstetrician.
The anesthesiologist in this case has unwittingly been placed in the position of being expected to provide anesthesia for a procedure that could lead to events that are in violation of his deeply held moral convictions. Perhaps the most common example of conscientious objection for anesthesiologists in the US is that of anesthetizing a patient who is having an abortion. Indeed, the federal government has promulgated healthcare workers’ right-to-conscience protection laws, rules, and regulations. However, federal employment laws require the balancing of reasonable accommodation for employees who have religious, ethical, or moral objections to specific aspects of their jobs with the resultant hardships that would burden employers given their accommodations of the employees’ beliefs. The needed delay to rectify our anesthesiologist’s assignment, given the extremely tight window of opportunity for the success of this infertility process (retrieval of high quality oocytes) has the potential to violate the contract between the infertility obstetrician and the patient.
The following discussion is limited to requested medical services that have been deemed medically appropriate and to which there is legal entitlement. The focus will be on why conscientious objection (refusal) by physicians is generally considered ethical behavior; however, there are controversial caveats.
Validity of conscientious objection
In the US, citizens are permitted significant latitude in defining the personal beliefs and values they adopt for themselves. Furthermore, in developing a lifestyle that is congruent with their moral convictions, they need not be concerned with personal safety because their beliefs might be construed as those of a minority. When claiming conscientious objection, individuals endeavor to preserve a sense of self, their integrity or wholeness that enables their human spirit to flourish. Americans value the diversity of its citizenship and its attendant disparate convictions and lifestyles. Because respect for conscientious objection is based, at least in part on respect for personal integrity, some understanding of integrity is in order.
Personal integrity includes a set of coherent principles that have been expressed verbally (or in writing), and manifest conduct that is consistent with those stated principles. “One’s words and deeds generally [should] be true to a substantive, coherent and relatively stable set of values and principles to which one is genuinely and freely committed.”1 These core values are arrived at over time – and even may change over a lifetime – as each member of society decides how to live an individually satisfying life within the framework of common social goals. Yet, there may be tension among competing principles as problems can arise that are impossible to resolve by adherence to one principle without violation of another. For individuals to retain their integrity, their values and actions ought to be relatively constant over time.
Moral distress may occur when an individual is manipulated or coerced into performance of actions contrary to core values. A person’s conscience must assess whether or not such behavior is permissible within the context of those core values. If deemed impermissible, then it is reasonable to refuse to perform otherwise socially acceptable – or even expected – actions, particularly if that individual is willing to accept the consequences – even harm – of such refusal. Society has codified that an individual’s core values, should they fail to coincide with established societal core values, are, nonetheless, potentially socially permissible. Witness certain of the more common types of conscientious objection, such as refusal of vaccinations and military service. Indeed, for healthcare providers, there are legal precedents and protections afforded to those who conscientiously object to participation in services to which the patient is legally entitled, therein setting the stage for ethical debate.
Concerns with conscientious objection
There are concerns with the potential abuse of conscience clauses as they could involve the inappropriate application of personal beliefs to the physician–patient relationship. Indeed, invocation of a conscience clause could serve as a subterfuge for discrimination against patients based on characteristics of the patient such as race, gender, religion, sexual orientation and so forth.
Refusal by a physician to perform a service based on conscientious objection may constitute only part of what is entailed in an objection. The generally accepted obligation of a physician after refusal is to facilitate the referral and orderly transfer of the patient to another physician willing to perform the procedure. However, the objecting physician may strongly believe that even making such a referral constitutes complicity in the objectionable procedure. Others, however, construe such conscience-based refusal to refer as patient abandonment.
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Informed consent and the pediatric patient
The use of ethics consultation regarding consent and refusal
Revising the Uniform Anatomical Gift Act – the role of physicians in shaping legislation
Animal subjects research Part I: Do animals have rights?
Disclosure of medical errors in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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