What do we do when patients’ interests and doctors’ objections are in tension?
There is an apparently easy answer to that question. A near-universal maxim in modern Western medicine is that doctors should always prioritise patients’ interests:
Good doctors make the care of their patients their first concern.
(General Medical Council, 2013a, paragraph 1) Doctors may practise medicine in accordance with their beliefs, provided that they […] do not deny patients access to appropriate medical treatment or services.
(General Medical Council, 2013b, paragraph 4) A physician shall, while caring for a patient, regard responsibility to the patient as
paramount.
(American Medical Association, 2001) Where it is available and approved by NICE [the body that authorises individual
interventions for availability in the UK National Health Service], patients are entitled to timely, clinically-indicated care or treatment that is provided in a supportive, sensitive and non-judgmental manner. The legal right to such care and treatment is enshrined in the NHS
Constitution. Doctors seeking to exercise a conscientious objection must take care not to undermine this right.
(British Medical Association, 2013)
In the bioethics literature, too, failure to prioritise a patient’s interests over one’s own is frequently identified by critics as what goes wrong when doctors decide to act on their objections:
Someone who places his own interests above his patients’ departs from medicine’s standard of altruism and violates a crucial tenet of medical ethics that every physician is duty bound to observe.
(Rhodes, 2006, p.78)
The settled view of much of the medical profession appears to be that, whatever reasons we might have for granting moral weight to doctors’ personal objections (and I have argued that there are two good ones, namely risk of harm and considerations of tolerance), those reasons are outweighed by the obligation to prioritise patients’ interests.
Taken at face value, this seems to be a very strong principle. Although it doesn’t say that a doctor’s personal beliefs can never be respected, it does seem to limit the occasions when they can be respected to occasions only where they don’t conflict at all with patients’ interests. In every other situation, doctors’ personal beliefs must come second to the interests of patients. Indeed, the GMC’s assertion that “good doctors make the care of their patients their first concern” implies that those who put any other considerations —
including their own moral beliefs — above the interests of patients in any given situation are simply not good doctors. (This is essentially the consistent position of ethicists Udo
Schuklenk and Julian Savulescu, two of the most vigorous opponents of conscientious objection in recent years, whom I cite several times in this thesis.)
Intepreted this way, this rule makes patients’ interests a trump card and dismisses all other considerations as irrelevant. But I think there are two good reasons to suspect that such a unsubtle, absolutist interpretation is not quite the right way to think about things — and, indeed, not what’s intended by the authors of the guidance I quoted above.
The first reason is that it’s inconsistent with the law in many jurisdictions, and indeed with much of the rest of the guidance issued by regulatory authorities. If prioritising patients’ interests were a trump card, the GMC (for instance) could have stated this in a sentence and that would be the end of the matter. In fact, much of the detailed guidance in publications
such as ‘Personal Beliefs and Medical Practice’ (2013b) consists of specific instructions about how and when other considerations, such as the doctor’s own beliefs, can also affect decision-making: for instance, in the event that a doctor refuses to offer a particular controversial procedure to a patient, the GMC permits a degree of inconvenience to that patient so that other options or referral can be arranged. Such arrangements would be ruled out, and thus the detailed guidance would be superfluous, if the rule about prioritising patients’ interests was supposed to be interpreted in an absolute way.
The other reason for rejecting an absolutist interpretation is a logical one: we would not be tempted to apply the same interpretation to other areas of professional activity. The GMC’s rule about doctors making patient care their “first concern” is not just aimed at moral objections; it’s supposed to cover all areas of a doctor’s professional activity. Yet the GMC wouldn’t expect a doctor to put himself in mortal peril, or threaten the wellbeing of other people, or bankrupt himself, in order to maximise a patient’s interests. As Robert Veatch puts it:
In spite of the uniformity of commitment to this platitude, it is becoming increasingly clear that no one really believes literally that the physician should always act so as to do
everything that will benefit his or her patient. […] For example, quite a number of patients would have their interests served best if their personal physician stayed with them in their homes twenty-four hours a day, yet no one ever advocates that they do so.
(Veatch, 2000, p.702)
If the admonition to prioritise patients’ interests is not intended as an absolute rule in other areas of regulated professional practice, then why should we take it as an absolute rule in the context of moral objections either?
So while prioritising patients’ interests is clearly regarded as important by regulatory authorities, to be weighted heavily when considering what to do, it can’t be intended as an automatic trump card. In at least some situations, there is room for manoeuvre. This kind of manoeuvre could take one of two forms:
• One might try to square the circle by maintaining a commitment both to prioritising patients’ interests (in general) and to respecting doctors’ objections (in general). I consider how this could be done in a moment.
• A compromise could be found which allows the interests of both sides to be
respected to a degree, while still ensuring that patients’ interests are not impacted to too great a degree. I consider this option in detail in the next chapter, on referral.