Gabriel M. Gurman, MD
In most cases the anaesthesiologist’s activity depends first of all on another physician’s decision. The indication for surgery, for an endoscopy or for an MRI examination of a child needing sedation is accepted a prioriby the anaesthesiologist and his/her job is to assure the best conditions for performing the procedure, taken into consideration, first of all, the patient’s safety. In some situations, the anaesthesiologist is supposed to advise the procedure performer about the need to first prepare the patient, to bring him/her to a medical condition which would assure the smooth course of anaesthesia and surgery.
All the above are very well known to every single anaesthesiologist and they are part of the daily practice in the operating room and outside it. But what would happen when the task of the anaesthesiologist is contradictory to their conscience and their own ethical principles? Fortunately, this kind of situation is very rare in our practice. Nevertheless, it could happen any day. Literature calls it conscientious objection (CO).
The term is an old one. It was used more than a century ago for the first time in the military, and it was defined as refusal on moral or religious grounds to serve or to bear arms in a military conflict. Later on, the concept’s significance was enlarged and its definition included a situation ofmaking known one’s objection to complying with a specific standard or practice.
The medical topics that could need the trial of CO might include, for instance, refusal to perform an abortion, mainly in an advanced stage of pregnancy, or opposition to offer reproductive advice to gay couples or severely mentally handicapped people. Another very suggestive example, which I found in my search for materials which would help better understand the concept, is that of the paediatricians who would refuse to propose to parents that their children be vaccinated against varicella, because this specific vaccine was developed by using tissues from aborted foetuses.
But one could question: What is the impact of this specific ethical concept on the anaesthesiologist’s daily activity? Surprisingly or not, our profession could offer us a rather significant list of clinical situations in which a specific anaesthesiologist might need to think twice before taking part in a procedure that might imply ethical aspects. Here are some examples.
Is the anaesthesiologist obliged to anesthetize a pregnant woman for an elective abortion if they are morally against this procedure, which for some is considered a crime? This opposition could be based on the principle that: “Intentionally ending a life violates the very core principles we have vowed to uphold in our profession.”1This situation is similar to another one, this time on the other edge of life. For instance, what about a patient treated in an intensive care unit and who developed brain death, but the family demands the continuation of life support measures? Is it permitted that the anaesthesiologist in charge of the patient continue ventilating the patient because doing so comes against their own principles regarding the futility of care?
But here is an argument against this attitude: “A doctor’s conscience should not be allowed to interfere with medical care.”2In other words, one does not take G-d’s place and does not actively interfere with the time of death, whatever the definition of death could be.
And what about a clear need for a blood transfusion during surgery, in a patient belonging to the Jehovah’s Witnesses group? This is a completely different situation, because in this case blood administration, which might save the patient’s life, would come in real contradiction with the patient’s beliefs and demands. How is this situation compatible with the sacred principle that it is forbidden, by any means, to compromise the care of the patient who is under your responsibility?
One last example is that of the electroconvulsive therapy (ECT) in psychiatry, a technique not accepted, from the moral point of view, by some practitioners. ECT is controversial, and there is a professional minority that tries to discredit ECT and its practitioners, considering that ECT is morally wrong and there is a good reason for it to be banned. But ECT is considered today the method of choice for treating depression, when the drug therapy did not improve patient’s condition.
What could be the position of that anaesthesiologist regarding this method of treatment, which could be contrary to his/her own moral principles? The reader could be assured that the CO concept represents a vivid subject of debate in the literature. It involves not only physicians, but also ethicists and bioethicists, philosophers and theologists. Some of them aired another concept, that of incompatibility between the concept of CO and the role of a health professional.
Primum non nocere, say those who are against justification of the right of a healthcare provider to refuse a treatment that is intended to help the patient’s medical condition or to interfere with the natural course of end of life. The opponents of the CO principle are totally against the situation in which a physician would deny a specific treatment (which is a part of the standard of care) because of their personal beliefs. It seems that also in this field nothing is white or black.
Some voices would claim that it is impossible to make, in every single case, the separation between the professional values and the personal beliefs. Others defend the principle of accommodating conscience,3implying that each situation must be discussed and decided upon by considering its specificity. For instance, how the principle of CO overlaps with clinical judgment in a specific situation and for a specific healthcare provider.
So, coming back to our specialty, it is obvious that things are not as simple as they seem to be. Each of us possesses their own moral and ethical principles and they are to be checked every time a problematic situation arises and needs to be solved. I do not think that there would be a place for a department policy concerning these very sensitive items. I am of an opinion that each of us has the rightto conscientiously object to providing care that conflicts with our own personal, moral, and religious beliefs. We have a responsibility for the patient’s care but also for our own personal and professional values. At the same time, we are supposed to avoid any decision that would compromise a patient’s wellbeing.
Fortunately, anaesthesiology is a specialty practiced in a team. We are not at all isolated from our peers. This is a real advantage and it might be used to find a solution in difficult cases that are the result of the possible conflict between our own beliefs and the patient’s needs. A solution could be rather easily found among the members of the same department. A task could be transferred to another physician and thus the patient’s care would not be jeopardized.
Sometimes a solution could be found when things are known and discussed in advance. For instance, the possible need for a blood transfusion to a member of the Jehovah’s Witnesses group could be presented to the patient and all the necessary explanations be offered to them with the hope that given the special situation, which could jeopardize life, the patient would accept the solution proposed by the anaesthesiologist.
We live in an era in which the personal rights and beliefs of each human being are to be respected. The anaesthesiologists do not make an exception from this rule. From time to time we find ourselves in a situation that implies a very serious judgment regarding our conscience and our duties. Morton and Kirkwood4specified that “Conscience is the mental process by which one can be accountable in their actions to their deliberations of what is right or the good thing to do in a given or future situation.”
The CO item is a too important one not to be included in the education program of each physician and of each department. Professional education implies open discussion on the most sensitive issues and CO is one of them. It is the duty of each of us to openly discuss the CO topic and its multiple facets and to try to understand the need to find a specific solution for each specific case, rather than trying to create a universal policy. Because in the case of CO there is no universal panacea.
- Messeli FH, Waters DD. N Engl J Med2017;377:1.
- Savulescu J. Brit Med J2006;332:294.
- Trigg R. J Med Ethics2015;41:174.
- Morton NT, Kirkwood K.HEC Forum2009;21:351.