Physician Conscience and Patient Autonomy: Are They Competing Interests?

FAQ (2012): Many people, including professional societies, argue that physicians should ignore their moral convictions in deference to the autonomy and rights of patients. Please offer a concise response to this matter.

What Is Conscience?

Moral convictions are the manifestation of an individual’s conscience. Dr. Daniel Sulmasy has provided a thorough definition of conscience as composed of two interrelated parts: “(1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating would violate that commitment” (Sulmasy 2008). Dr. Sulmasy further distinguishes between retrospective conscience and prospective conscience. The retrospective conscience is disturbed when an individual has done something or failed to do something. It is considered the judgmental conscience because it is only upon retrospective evaluation that the individual realizes something was wrongly decided and resolves not to do that something again. Furthermore, Sulmasy states that when a conscience is said to judge right and wrong, it is no different than employing faculties of reason, emotion, and will. Therefore, conscience arises from the commitment to engage in the “self-conscience activity, integrating reason, emotion, and will, in self-committed decisions about right and wrong, good and evil” (Callahan 1991). In short, conscience is not mere “preference,” nor is it simply “the little voice inside one’s head,” untethered to truth or the transcendent reality that objectively exists outside of one’s own assessment. Conscience is an integral part of the human person, and thus, the violation of it (in pressuring doctors to accede to a patient’s demands) becomes a serious assault on the human person herself.

The Physician and Patient Are Both Persons

Since conscience derives from the nature of the person (rather than one’s role or occupation), physicians should not abandon their moral convictions in the practice of medicine nor in any aspect of their lives. Physicians and patients are both persons, who come together in a doctor–patient relationship built upon mutual trust within the context of illness and vulnerability (Pellegrino 1994). Interpersonal ethics depend on the recognition of the other as intrinsically equal, possessing the same worth. When physicians don the emblematic white coat, they do not give up their personhood and place their conscience on the back burner. The vocation of medicine should be one that fulfills the physician’s personhood and conscience in a pursuit of health for the patient, not a compromise of fundamental values and human rights. Truly caring for a patient’s well-being requires the provider to fully integrate their personhood as practitioner—to include their moral convictions.

The aim of the physician must be one that works toward an end goal of “health” for the patient rather than presenting a laundry list of choices with the aim of fulfilling patient (or “client”) “desires.” Calling for a deference to patients in medical decisions without regard to physician expertise and conscience reduces moral convictions to mere preferences. A patient’s autonomy must be recognized and supported, but patient autonomy is not an absolute. If it were, then a physician is a cipher and the patient will take the lead on their medical care. The physician, in that view, would only be present as a technician, providing whatever the patient decides. Patient autonomy must be in balance with the professional input of the physician, who has the obligation to speak his or her mind regarding what is in the best interest of the patient rather than acting as a cipher for patient desires.

Some “Thought Experiments”

Imagine a patient demands a month’s supply of opioids for musculoskeletal pain that the physician thinks could be treated more conservatively. Should the physician prescribe the opioids against his conscience simply because the patient demands it? If such decisions were simply about autonomy, then the doctor in his “technician role” ought to. If instead, a conscientious objection is both a medical and moral objection, the physician has a right to redirect the patient toward treatment that heals the whole person.

Now imagine this second thought experiment. Ask a patient (or a doctor) this straightforward question: “Would a patient even want a physician who gives her what she desires, instead of what the physician thinks is medically and morally best for her as a whole person?” It seems that a scenario where the physician may inconvenience the patient by sharing their moral preferences would actually be preferable to a patient. This physician first and foremost commits the vision of the “well-working” of the patient, and the patient is free to pursue options with this in mind (Kass 1975).

What Is Truly Good Transcends “the Desired” and “the Permissible”

Opponents of conscientious objection have the tendency to paint situations as the physician against a patient who is simply struggling to assert their legal right to a treatment or procedure of their choice. This transactional view of the physician–patient relationship does not comport with reality. There should be no necessary connection between the legality of a procedure and the right of a physician to conscientiously object to it. Dr. Julian Savulescu’s (2006) opinion that “if people are not prepared to offer legally permitted, efficient, and beneficial care to a patient because it conflicts with their values, they should not be doctors” is unfounded. Conscientious objectors object precisely because it is their genuinely held moral conviction that the procedure requested is not “beneficial.” A procedure is not beneficial just because the patients want it. Furthermore, the fact that a procedure is legal is also totally irrelevant—what matters is whether or not it is good: morally good and good for the patient. Morally abhorrent practices have been legal throughout history. One need not look further than the Buck v. Bell decision allowing for state-sponsored sterilization of certain “mental defectives” (Fernandes 2002) or the medical communities’ embrace of the prefrontal lobotomy—once-legal procedures and practices now nearly universally condemned.

Medicine Is a Covenant, Not a Contract

Medical training is naturally hierarchical and inherently tends to encourage a culture of subordination. During training, there are incentives not to speak up, even when there is explicit evidence of wrongdoing. Since residents and attending physicians often complete evaluations in places of authority, students will readily subjugate everything from bodily needs to their conscience in order to appease their attending physicians. Evidence indicates that medical students often fail to object when they recognize medical errors performed by their superiors (Madigosky et al. 2006). This is simply unacceptable but shows the crucial nature of conscience in forming how we practice—even outside controversial issues in bioethics. The weakness of conscience leads to a chipping away of one’s moral compass, which changes the person herself. Inaction can occur when there is worry about repercussions from conscience expression. For the physicians and students who try to do right, this may lead to a deep resentment or apathy, which may prompt an exit of the medical field of the those we need the most, certainly to the patients’ detriment. So, while opponents of conscientious objection define the problem as a simple one—get rid of the “problematic, religious physician” and the problem is solved—in fact doing so weakens the moral nature of the profession as a whole, by removing those very persons who are most committed to integrity. Both physicians and patients must be respected as autonomous individuals and recognize that the physician–patient relationship is more than a mere transactional agreement—it is a covenant of mutual respect for one another’s conscience with the unified mission of treating the patient as a whole.

Biographical Note

Christopher M. Radlicz, MS, MPH, is a second-year medical student at Heritage College of Osteopathic Medicine, Ohio University.

Ashley K. Fernandes, MD, PhD, is an associate director of the Center for Bioethics and Medical Humanities at The Ohio State University College of Medicine and an associate professor of pediatrics at Nationwide Children’s Hospital.