Freedom of Conscience
American College of Pediatricians – February 2009
ABSTRACT: The American College of Pediatricians (The College) affirms that no health professional should be required to provide, or participate in, any medical service that violates his/her conscience or causes moral distress. This affirmation includes declining to perform “hands-on” action as well as declining to participate through referral to a different health professional for the purpose of procuring such service.
There has recently been a concerted effort in this country, most notably by a variety of special interest groups (including the American College of Obstetricians and Gynecologists) to enact legislation requiring physicians and other health professionals to provide and/or refer for medical services that they consider immoral or unethical. “Such healthcare services may include, but are not limited to, abortion, artificial birth control, artificial insemination, assisted reproduction, human cloning, euthanasia, human embryonic stem cell research, fetal experimentation, physician-assisted suicide, and sterilization.”1
The College views these coercive efforts as no less than an attempt to mandate and then enforce a code(s) of ethics that violate(s) the belief system of many individuals who comprise a large segment of the population. It also violates both the free exercise and the non-establishment clauses of the U.S. Constitution.
Furthermore, it is unethical and constitutionally illicit to request that State Medical Boards deny licensure to individuals based on their unwillingness to provide healthcare services they know to be unethical. It is similarly unethical to request certifying entities to deny Board Certification for this same unwillingness. While these Boards have the duty and the authority to ensure that physicians maintain both technical competency and the ability to practice according to scientifically demonstrated standards of care, they overstep their mandate when they enforce their own belief system on individual health professionals.
Thomas Jefferson wrote, “No provision in our Constitution ought to be dearer to man than that which protects the rights of conscience against the enterprises of the civil authority.”2 Like Mr. Jefferson, the College recognizes freedom of conscience to be a fundamental right. Nevertheless, we also acknowledge that there are limits, dictated by science, as well as ethics, to which a physician can exercise freedom of conscience in medical practice, just as there are limits to other fundamental rights such as freedom of speech. For example, one should censure a person who libels another, or yells “fire” in a crowded theater without cause, as these may directly cause injury with no anticipation of benefit.
In the same way, it is appropriate to censure a physician who deviates from an accepted standard of care when it can be reasonably argued that the standard of care provides benefit to the patient disproportionate to its burden to the patient or others, and when the standard of care has been scientifically demonstrated to be superior to alternative treatments. For example, a physician has no right to refuse antibiotics to a patient in septic shock based on a personal belief that antibiotics are inefficacious. A medical board would rightly censure such a physician since this practice would violate standards of care established by the scientific method.
Where medical boards overstep their authority is when they move from medical to moral questions. While the scientific method may answer the question of how we can clone human beings or how we can terminate a child in the womb, it can never answer the question of whether it is morally correct to do these things.
The College believes that human law (in this case the laws enacted by a civil legislature, or the regulations of a medical board) answer to a higher law, the natural law. Natural law refers to the existence of a statute or regulation in which “content is set by nature and that therefore has validity everywhere.”3 This law (aka moral law) is based on an order in the universe apprehended by reason. It is universal to all humans because humans can reason. Man-made (human) law may be proposed to protect society and promote the common good, but it is never to supersede the natural law.
Many physicians have reservations about performing or referring for certain services because they violate natural law. Some of these physicians make natural law arguments informed by or consistent with a set of religious beliefs. Atheists and agnostics invoke natural law as well. Our very founding as a nation was built upon incidents of violation of natural law by human laws enacted by King and Parliament. In the Declaration of Independence, Mr. Jefferson refers to the rights to which the “Laws of Nature” entitle us. The signers of the Declaration observed that these were “self-evident” and “inalienable” rights and that no government had the authority to abrogate them. One needs to look no further than the past century to see the interplay between natural and human law. The elected regime of Nazi Germany enacted statues that permitted, and at times mandated, physician participation in certain practices under the euphemistic label of eugenics. Yet the application of natural law at the Nuremberg Trials correctly characterized these legally sanctioned acts as crimes against humanity.
Many physicians today know that, by the very nature of our humanity, there are certain actions taken by us or against us that harm our integrity and ability to reach our full potential. These can be strictly material insults (e.g. toxins or bacteria) or insults that may not directly injure our organic integrity but cause harm at other levels of human experience (e.g. emotional or spiritual). For example, no pediatrician would question the harm that might come to a child witnessing a violent crime, but documentation of such harm with objective measures such as laboratory tests or an MRI would be difficult or impossible. We know this through reason and experience in much the same way as natural law is known.
While physicians may differ in opinion as to the application of natural law in medical decision-making, such beliefs do and should inform their daily practice of medicine. The College believes it is a false anthropology that claims to separate core values and ethics from the practice of medicine. Some activists advocate a policy of putting one’s belief system aside when a health professional encounters a patient. They intimate that a physician is merely a technician providing services and not a healer in the traditional sense of the word. The patient, they argue, should come to a moral conclusion without physician influence, and as a dutiful vending machine the physician should provide technical services devoid of a belief system. It is impossible and unethical in practice to separate one’s unified view of reality from one’s actions. Furthermore, it is clear that such advocates are disingenuous and merely wish to proscribe some (those who hold timeless worldviews, i.e., natural law) but not others (apparently, themselves) from having particular views inform their medical decision-making.
Imagine the following scenario: A 40 year old man and 12 year-old girl come to the obstetrician’s office seeking a tubal ligation. The couple claims they are married in the eyes of their church. In theory, patient’s rights activists would have the physician ignore personal values, give deference to patient autonomy, and argue that this tubal ligation should be done based on existing law related to a minor’s right to consent for reproductive services.. We hope, however, that even those who advocate for a separation of belief from a physician’s practice would see this situation differently. Clearly, conscience and scientific knowledge must work in concert to allow the physician to reach the very best decision for the patient and society as a whole. If it isn’t proper or ethical to do should we do it simply because we have the ability to do so?
It is unfortunate that not all physicians accept the notion of natural law. They may approach questions of medical ethics from utilitarian, consequentialist, or relativistic schools of thought. It is their right to hold such beliefs. Nevertheless, the systematic attempt to discriminate against physicians who practice according to belief systems that may not be shared by the small number of physicians who may hold majority positions on Medical Boards or organization committees cannot be permitted. It violates the principles of natural law as well as freedom of conscience, causing moral distress in the health professional.
Such attempted coercion also puts this country at odds with the prevailing worldview. The United Nations Declaration on Human Rights, for example, states that, “All human beings are born free and equal in dignity and rights. They are endowed with reason and conscience and should act towards one another in a spirit of brotherhood. [emphasis added]”4 Furthermore “Everyone has the right to freedom of thought, conscience and religion; this right includes freedom to change his religion or belief, and freedom, either alone or in community with others and in public or private, to manifest his religion or belief in teaching, practice, worship, and observance. [emphasis added]”5 Consequently, physicians must be free to act in accord with their personal belief of what constitutes the human good. The public exercise of those beliefs extends to their practice of medicine. To require otherwise, asks the physician to act in a manner that the physician believes will cause harm to the patient. This violates the first principle of medical ethics, “First, do no harm.”6
Freedom of Conscience, with its base in Natural Law, is all that separates our society from the atrocities of autocratic societies, past and present. Hate crimes in the broadest sense become not just possible but normative when conscience bends to the rule of uninformed “law”. The College will work to assure that children and their families are never burdened by the harm that will come if this Freedom is lost, while also working to protect physicians from moral distress.
Originally posted August 16, 2003
Revised February 23, 2009
The American College of Pediatricians is a national medical association of licensed physicians and healthcare professionals who specialize in the care of infants, children, and adolescents. The mission of the College is to enable all children to reach their optimal physical and emotional health and well-being.” More information is available at www.BestforChildren.org.
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1Healthcare Rights of Conscience, Americans United for Life
2Thomas Jefferson to New London Methodist, 1809.
3“Natural Law,” International Encyclopedia of the Social Sciences
4United Nations Declaration on Human Rights, Article 1
5United Nations Declaration on Human Rights, Article 18
6Hippocrates, “Epidemics”, Bk I, Sect XI