Let me first set up the problem very simply. Here are two principles, each of which has strong appeal:
1. Respecting moral objections: Doctors’ moral objections to participating in a given
procedure have moral weight.
2. Acting in the patient’s interests: Doctors ought to provide appropriate medical
services in a way that furthers the patient’s interests (or ‘best interests’: I assume that the two terms are equivalent, and I prefer the shorter one).
I submit that we have pro tanto reason to assent to both these principles. The first is the conclusion which I hope has been established by the foregoing chapters; I’ll talk about the second in some detail in the remainder of this chapter. The problem, then, is what to do when the two are in tension — that is, when it’s impossible to fully satisfy both.
Obviously, such a tension is not always present. It only arises in situations where a doctor’s duty to act in the patient’s interests involve her performing some action which conflicts with her moral views. One would hope that few doctors find themselves in situations like this day in, day out, at least when practising public medicine voluntarily in peacetime in relatively liberal countries. But such situations can arise from time to time in medical practice, more or less frequently depending on the area of practice under consideration, and especially when a controversial new medical procedure is legalised (I mentioned many examples of such situations in chapter 1). In these situations, principle 1 pulls in the direction of respecting doctors’ moral objections and principle 2 pulls in the direction of not doing so. So we need a way to resolve the tension in order to determine what expectations we should place on doctors.
What do I mean by ‘interests’? Like Feinberg, whom I quoted on p.85 of this thesis, I am content to leave the answer to this question a little vague, and simply say that something is in my interests if it furthers my total wellbeing in some way.62 One clear component of
patients’ interests, for instance, is in receiving timely and effective treatment appropriate to their medical needs. But the phrase can also be interpreted more broadly to cover more
62 UK primary legislation is also content to leave the exact definition of ‘interests’ to the courts. Even the
Mental Capacity Act 2005, which depends on the concept of ‘best interests’ for nearly every one of its provisions, only offers very sketchy advice about what these mean or how to determine them if a person is unable to express them for himself: “consider, so far as is reasonably ascertainable, (a) the person’s past and present wishes and feelings, […] (b) the beliefs and values that would be likely to influence his decision if he had capacity, and (c) [most helpfully of all!] the other factors that he would be likely to consider if he were able to do so” (UK Government, 2005).
general and indirect interests of both individual patients and patient populations as a whole, examples of which include:
• Accommodating patients’ desires: Patients have an interest in having their desires about their own treatment taken into account and accommodated, when those desires are based on full information (Moulton & King, 2010).63
• Facilitating informed consent: Patients have an interest in being provided with the maximum available information about the benefits and drawbacks of all available treatments, so that they can make well-informed decisions about their own care (Manson & O’Neill, 2007).
• Avoiding unjustified discrimination: Patients have an interest in not suffering unjustified discrimination. Doctors should set aside their own views of a patient’s identity or lifestyle when providing care (Vicol & Gergely, 2011).
• Just distribution of resources: Patients have an interest in our ensuring, as far as possible, that appropriate healthcare resources are justly distributed among all entitled patients, based on each patient’s need (Culyer & Wagstaff, 1993). For the sake of argument, I assume that each of these examples is straightforward and widely accepted. In fact, each of my examples has a whole weight of philosophical literature behind it, and none is entirely uncontroversial; the single reference I’ve provided for each example above points to what I believe to be a good overview of the issue in question. But the complexity under the surface doesn’t concern me here. I only intend these to be
examples of the kinds of interests that might conflict with a pro tanto right of doctors to
have their moral objections recognised, over and above the obvious interests patients have in receiving timely, effective and appropriate treatment. No part of my argument in this chapter relies on the ultimate success of any one of them.
Again, hopefully none of these principles will always be in tension with the principle of respecting doctors’ moral objections. Sometimes — usually, one would hope — the doctor is able to discharge her day-to-day responsibilities without compromising either her moral
63 In an extended essay arguing against the principle of beneficence in medicine, Veatch (2000) maintains
that patients’ desires about their own treatment are not only a key component of their interests, but also the only reliable proxy available to doctors for determining the nature of most other components. I have a little more to say about this on p.171 of this thesis.
beliefs or any of the principles listed above. But each of them can give rise to tensions in at least some situations. For instance, the principle of ensuring just distribution of resources seems to conflict with the principle of respect for moral objections where a doctor’s refusal to participate in a controversial procedure will lead to uneven treatment of patients, either because some but not all doctors offer a particular treatment, or because a single doctor refuses to offer the treatment to all patients on an equal basis. And the principle of facilitating informed consent seems to conflict with the principle of respect for moral objections when a doctor is reluctant to make a patient aware of treatment options of which she (the doctor) disapproves, such as the availability of certain sexual health services to same-sex couples. The existence of these conflicts is, of course, the main source of the moral and practical difficulty which is my focus throughout this thesis.
Professional and moral obligations
One further principle that’s commonly cited to weigh against a doctor’s right to object — but that I didn’t mention in my list of examples above — is that of a perceived professional or moral obligation for the doctor to ignore his personal moral qualms (Meyers & Woods, 1996). We might say, ‘I recognise your objection to offering this procedure to this patient, but you have an overriding obligation to do it anyway’. Such an obligation might be attributed either to professional considerations — ‘the medical profession places an
obligation on you to offer this treatment to this patient, never mind your objection’ — or to
moral considerations — ‘it would be wrong of you not to offer this treatment to this patient,
never mind your objection’.
Perceived professional and moral obligations are important, and, as I say, commonly cited in cases where doctors object to particular procedures. So why didn’t I list them as a principle above? Because simply saying that a doctor has an obligation to act in a particular way is not yet, in itself, to give a reason for him to act in that way. It’s only an assertion that there is such a reason. If you ask me why you shouldn’t break a promise, what you want from me is some account of what the source and nature of the obligation is. If I respond, ‘Because you have an obligation not to break your promises’, this is really just the same as saying, ‘Because you shouldn’t break your promises’. It may be true, but it’s vacuous; it doesn’t yet say why you shouldn’t break your promises.
If you and I both acknowledge the obligation, then we may not need to go into detail about its source or nature. But if we disagree about it, simply asserting the obligation won’t help us to understand or resolve our disagreement. Indeed, professional or moral obligations are frequently cited in support of both sides of the disagreement. If we try to encourage a doctor to ignore his personal beliefs on the basis of his perceived obligation to do so, the doctor might perfectly well reply, ‘Actually, it seem to me that I have an obligation not to offer this treatment to this patient — that’s why I object to it in the first place’. (I discussed this at length in chapter 1.) This assertion also gets us nowhere.
So when I assert an obligation in the face of your disagreement, I owe you an account at least of what that obligation consists of. Ideally, I should also be able to give you an account of where it comes from, whether it stands up to close examination, whether it does indeed conflict with other obligations in the way it appears to, and (if so) whether and how those conflicts might be resolved. In the current context, what that means is that I can’t just say, ‘The reason you should ignore your personal objection to this procedure is that you have an obligation to do so’. Even if that’s true, it’s an empty assertion.