Published online by Cambridge University Press: 22 December 2009
Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities. In 1996, the Medical Student Section of the American Medical Association (AMA) introduced a resolution calling on the AMA to adopt a policy in support of exemptions for students with ethical or religious objections. In that report, students identified abortion, sterilization, and procedures performed on animals as examples of activities that might prompt requests for conscience-based exemptions (CBEs). In response to the student initiative, the Council on Medical Education recommended the adoption of seven “principles to guide exemption of medical students from activities based on conscience.” The House of Delegates adopted these principles in their entirety.
1. This paper draws on some material that will be published in Conscientious Objection in Healthcare: An Ethical Analysis (Cambridge University Press; forthcoming).
2. American Medical Association Student Section Resolution 7-I-96, “Respect for Individual Student's Beliefs” 1996 (in AMA archives).
3. AMA Council on Medical Education Report 4 (A-98), 1998 (in AMA archives). With two exceptions, the recommended principles are procedural. The exceptions are a requirement that patient care not be compromised and a requirement that students “learn the basic content or principles underlying procedures or activities that they exempt.” However, even the latter requirement has a procedural escape clause: “Any exceptions to this principle should be explicitly described by the school.”
4. AMA Policy H-295.896, “Conscience Clause: Final Report” 1998. Available at http://www.ama-assn.org/ama/no-index/advocacy/8152.shtml.
5. Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students' ethical development: Questionnaire survey and focus group study. British Medical Journal 2001;322(24):709–10.
7. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Academic Medicine 1994;69(8):670–9.
8. Dodge S. Under pressure from students, medical schools offer alternatives to use of live animals in experiments. The Chronical of Higher Education 1989 Nov 15:A41, A43.
9. Physicians Committee for Responsible Medicine. Medical school curricula with live animal laboratories; available at http://www.pcrm.org/resch/meded/ethics_medlab_list.html (last accessed 30 Jun 2009).
10. There are, of course, external checks and balances that place limits on the discretion of accreditation organizations.
11. Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Washington, DC: Liaison Committee on Medical Education; 2008 Jun:8(ED-11); available at http://www.lcme.org/functions2008jun.pdf (last accessed 30 Jun 2009).
13. Medical School Objectives Project. Report I: Learning Objectives for Medical Student Education: Guidelines for Medical Schools. Washington, DC: American Association of Medical Colleges; 1998 Jan; available at https://services.aamc.org/publications/index.cfm?fuseaction=Product.displayForm&prd_id=198&cfid=1&cftoken=32975D3D-9FEB-7545-A14A9722B4D2FFFD (last accessed 30 June 2009).
15. Some Muslim students in the United Kingdom reportedly have refused to treat patients of the opposite sex. See Foggo D, Taher A. Muslim medical students get picky. Times Online 2007 Oct 7; available at http://www.timesonline.co.uk/tol/news/uk/health/article2603966.ece (last accessed 15 Mar 2009).
16. Nondiscrimination might provide another basis for denying requests for CBEs from performing physical examinations on members of the opposite sex. This reason will be considered below.
18. This conclusion is consistent with the position of the AMA Council on Medical Education: “It would not be appropriate for an organization other than the medical school attended by the student to define, a priori, a set of activities for which medical students may be granted an exemption because of conscience or a specific process by which an exemption may be granted. This is because medical schools differ in a variety of ways that could affect the types of exemptions that they grant and the way that exemptions are granted. These differences could include their core mission, religious affiliation, state legal and regulatory requirements, organizational structures, and student body characteristics. Medical schools should be free to develop their own policies related to what activities come under a ‘conscience clause,’ and how students should go about gaining an exemption from the specified activities”; see note 3, AMA Council on Medical Education Report 4 (A-98) “Conscience Clause.”
19. 42 USC § 238n(c)(2) (1996).
20. 42 USC § 300a-7(e) (1973).
21. See note 11, Liaison Committee on Medical Education 2008:20 (emphasis added). The AMA recommended adding gender identity to the list of characteristics that constitute invidious discrimination in relation to admissions (H-295.969, “Nondiscrimination Toward Medical School and Residency Applicants”).
23. “Physicians cannot refuse to care for patients based on race, gender, sexual orientation, gender identity, or any other criteria that would constitute invidious discrimination…” (AMA Code of Medical Ethics, “Potential Patients,” E-10.05 [2-b]). Available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1005.shtml (accessed 23 Sept 2009).
24. H-295.896 “Conscience Clause: Final Report.”