Friday, 22 July 2011

Always Let Your Conscience Be Your Guide? Part 3

Should students be accepted for medical school if they have no intention of treating certain people or conditions?

A survey shows that a significant number of medical students think doctors should be able to refuse any procedure that contradicts their beliefs. The procedure that causes the most contention is, as always, abortion.

Not all of the respondents were religious; non-religious students thought opt-outs should be a right too - 35% thought there was a place for conscientious objection. The survey also found a prevelance among the religious to object to certain procedures and patients.

In general, support for a doctor's right to refuse any procedure that troubles their beliefs was highest among Muslim medical students at 76.2% while 54.5% of Jewish students thought the same, as did 51.2% of Protestants and 46.3% of Catholics.

More than double the number of Muslim students than non-believers would refuse an abortion when contraception failed. A higher percentage of Muslim students than others would object to prescribing contraception. Nearly eight percent of them also stated they would object to ‘intimately examining a person of the opposite sex’. The survey didn't ask how students would feel about examining LGBT people which, along with not exploring the reasons for objections in the non-religious, is a limitation.

Doctors opting out of treating certain patients is only part of the problem. Some students are refusing even to learn certain areas of medicine in the first place.

It was reported in the Sunday Times four years ago that some Muslim medical students were refusing to attend lectures or answer exam questions on alcohol-related or sexually transmitted diseases because they claimed it offended their religious beliefs. This was corroborated by both the BMA and the GMC. Professor Peter Rubin, chairman of the GMC’s education committee, said: “prejudicing treatment on the grounds of patients’ gender or their responsibility for their condition would run counter to the most basic principles of ethical medical practice”.

GMC guidelines recognise the right of freedom of expression for medical students but state that this 'cannot compromise the fundamental purpose of the medical course: to train doctors who have the core knowledge, skills, attitudes and behaviour that are necessary at graduation'.

The GMC also specifically states that a foundation level doctor cannot practise while refusing to examine patients on grounds of gender or those patients whose illness can be attributed to their lifestyle. Guidance drawn up by the GMC advises doctors to refer a patient to a colleague if they object to a certain procedure or treatment. They must also give patients enough information so they can seek treatment elsewhere within the NHS. In some situations, doctors' consciences can (and should) be accommodated but the foundation level doctor is often the first one to see acute patients and any delay in treatment could have serious implications.

The research paper on the survey concluded that ‘Once qualified as doctors, if all these respondents acted on their conscience and refused to perform certain procedures, it may become impossible for conscientious objectors to be accommodated in medicine’. It also states that ‘The views of large numbers of Muslim students are contrary to GMC guidelines, and thus the medical profession needs to think about how it will deal with the conflict’.

Although Muslim students are clearly a growing problem, Muslims are not the only ones to object to certain procedures. The Christian Medical Fellowship, which has 4000 members, is also strongly anti-abortion, for example. Almost a third of the students surveyed wouldn’t perform an abortion for a congenitally malformed foetus after 24 weeks, a quarter wouldn’t for failed contraception before 24 weeks and a fifth wouldn’t even perform an abortion on a minor who had been raped.

Some of the reporting of this survey has gone straight to worse-case scenario and ignored the finding that a lower percentage of students would refuse to carry out a procedure than actually objected to it. However, the percentages are still significant and the situation needs to be addressed while respondents are still students. If the number of medical students prepared to carry out a termination when they qualify is shrinking, then women will find it hard to access abortion safely and quickly in the future.The UK may be drifting towards the situation in Italy where nearly 70% of gynaecologists refuse to perform abortions and 50% of anaesthetists refuse to assist on moral grounds even though abortion is legal.

While the GMC is holding out against students' right to pick and choose what they learn, the question remains - why do people want to become doctors if they are only going to treat certain patients or conditions, and where do they think they will practice this limited form of medicine? It's not just women's needs that are taking second place to beliefs; the provision of universal healthcare is being challenged too. Perhaps medical students need to be triaged when they apply to colleges and clearer limits set on the conscience to make sure that patients' needs always come first.

I wrote a response to the GMC consultation on conscience opt-outs for the National Secular Society some time ago.

In Part 1 I looked at the affect on women of pharmacists being able to opt out of selling emergency contraception if it's against their beliefs. I also wrote a consultation response for the NSS on this subject. It's not just in the UK where conscience is becoming a problem. In Part 2 I looked at the debate in the Parliamentary Assembly of the Council of Europe on doctors' opt-outs.

Update 3 August 2011
In related news, a Christian midwife is refusing to wear trousers because Deuteronomy 22:5 says that it's wrong to wear the clothes of the opposite sex. Trousers are part of the uniform for hygiene purposes and the hospital is so far sticking to its guns saying that wearing them is 'proportionate'. Let's hope she never wears clothes of mixed fibres and doesn't have pierced ears.


  1. I understand that people need to abide by their morals and beliefs but medicine should be impartial and free from judgement religious or otherwise - why bother being in the profession otherwise?

  2. I agree with April. Medicine should impartial from religious or moral objections. Otherwise why take the oath? Doesn't make sense and totally unethical.

  3. How do idiots get enrolled to study medicine in the first place?

  4. Sounds about right. You shouldn't take a job in an abbatoir if you are a strict vegan with an ethical objection to meat, after all.

  5. To be fair, chances are that the number of procedures these religious doctors would refuse to perform are small, and I don't believe they include any first-response actions which would threaten life if referred to another doctor.

    Moreover, the Abrahamic religions explicitly encourage the breaking of their laws in order to save a life. Judaism is most famous for this, but a similar injunction exists in Islam (versions of taqiyya, etc.) and Catholicism.

    So I think it's easy to overstate the impact of these objections on actual everyday practice given the politically incendiary subject of abortion.

    That aside, I believe any students who refuse to learn aspects of medicine that are "offensive" ought to be summarily flunked out and advised to reread Avicenna's Canon of Medicine, wherein the great Muslim physician covers STDs without batting an eye.

  6. So, you seem to be suggesting that the Nuremberg principle should be ignored for doctors. That they should not listen to their comsciencd and do ad they are told.

    Or is it that only people who agree with you should be allowed to be doctors?

  7. Sorry, "as they are told"

  8. They ought to agree with the basic requirements of the GMC for a person to practise as a doctor.

    A worst case scenario, but one that happens occasionally: A minor is raped and falls pregnant: Who performs the abortion, after the minor and her parents are consulted and agreement is reached that an abortion is desirable? Presumably the doctor with a conscientious objection (CO) refuses to carry it out, but refers the case to a colleague who will. Whose God is served by the CO? The abortion is carried out, after a delay and some further emotional wrangling that the young girl could well do without. The CO feels that they have followed their code of moral conduct - but the abortion is still carried out. Hardly a conscientious objection if the procedure still happens, as they know it will. My point is that the CO is a hypocrit, because they are going through the motions of 'not allowing' an abortion. Is there really such thing as a Moral Loophole? Because that is what it is. If you object to something so much, then you ought not be involved in that profession at all. Find a different job, become a priest or an activist: Render unto Ceaser that which is Ceaser's. :-D

  9. ' seem to be suggesting that the Nuremberg principle should be ignored for doctors. That they should not listen to their comsciencd and do ad they are told. Or is it that only people who agree with you should be allowed to be doctors?'

    Where is that suggested, or even implied? As a number of comments have pointed out, you don't enter a profession if you know that by its nature it will require you to do things you object to. Spoiled, whiny, squeamish little prigs should avoid medecine.

  10. RE "going through the motions of not allowing". I would say inthat example, the doctor is not doing that - they are allowing, but they aren't DOING.
    Someone has to actually weild the curete to kill the fetus. They are objecting to doing that. It is different to preventing the abortion taking place at all.

  11. Ok, understood: But the essential point is that the CO refuses to carry out the abortion because they believe it is wrong. How determined are they to see that their dearly held beliefs on the sanctity of life are enacted in their daliy life? Enough to compromise their lucrative career, or only enough to appear morally upstanding whilst still drawing the paycheque? I have my own views on the sanctity of life, but they are further up (down?) the sliding scale, nevertheless, I would definitely act out of conscience and not perform a form of surgey that would end the life of a formed and conscious child. Those are within my limits and, if the Pro-lifers are to be believed, they would act in the same way towards an unformed foetus, otherwise their conscientious objections are just so much hot air and moral posturing. To be fair to the majority of Pro-lifers, they do make their views known - it is the hypocritical posturing of the COs that I object to.