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Tolerance, Professional Judgment, and the Discretionary Space of the Physician

  • DANIEL P. SULMASY
Abstract:

Arguments against physicians’ claims of a right to refuse to provide tests or treatments to patients based on conscientious objection often depend on two premises that are rarely made explicit. The first is that the protection of religious liberty (broadly construed) should be limited to freedom of worship, assembly, and belief. The second is that because professions are licensed by the state, any citizen who practices a licensed profession is required to provide all the goods and services determined by the profession to fall within the scope of practice of that professional specialty and permitted by the state, regardless of any personal religious, philosophical, or moral objection. In this article, I argue that these premises ought to be rejected, and therefore the arguments that depend on them ought also to be rejected. The first premise is incompatible with Locke’s conception of tolerance, which recognizes that fundamental, self-identifying beliefs affect public as well as private acts and deserve a broad measure of tolerance. The second premise unduly (and unrealistically) narrows the discretionary space of professional practice to an extent that undermines the contributions professions ought to be permitted to make to the common good. Tolerance for conscientious objection in the public sphere of professional practice should not be unlimited, however, and the article proposes several commonsense, Lockean limits to tolerance for physician claims of conscientious objection.

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Notes

1. Savulescu, J. Conscientious objection in medicine. British Medical Journal 2006;332(7536):294–7.

2. Schuklenk, U. Conscientious objection in medicine: Private ideological convictions must not supercede public service obligations. Bioethics 2015;29(5):iiiii.

3. Cantor, JD. Conscientious objection gone awry––restoring selfless professionalism in medicine. New England Journal of Medicine 2009;360:1484–5.

4. Charo, RA. The celestial fire of conscience –– refusing to deliver medical care. New England Journal of Medicine 2005;352:2471–3.

5. West-Oram, P. Freedom of conscience and health care in the United States of America: The conflict between public health and religious liberty in the patient protection and affordable care act. Health Care Analysis 2013;21:237–47.

6. Swartz MS. “Conscience clauses” or “unconscionable clauses”: Personal beliefs versus professional responsibilities. Yale Journal of Health Policy, Law & Ethics 2006;6:269–350.

7. Department of the Treasury, Department of Labor, and Department of Health and Human Services. Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services Under the Patient Protection and Affordable Care Act. February 15, 2012 (77 FR 8725), at 8726.

8. See note 5, West-Oram 2013.

9. See note 6, Swartz 2006.

10. Locke, J. A letter concerning toleration. In: Goldie, M, ed. A Letter Concerning Toleration and Other Writings. Indianapolis: Liberty Fund;2010:168.

11. Locke J. An essay concerning toleration. In: Goldie 2010 (see note 10), at 105–40.

12. See note 11, Locke 2010, at 105–17.

13. See note 11, Locke 2010, at 110.

14. See note 11, Locke 2010, at 111.

15. See note 11, Locke 2010, at 111.

16. Giubilini, A. The paradox of conscientious objection and the anemic concept of ‘conscience’: Downplaying the role of moral integrity in health care. Kennedy Institute of Ethics Journal 2014;24:159–85.

17. See note 10, Locke 2010, at 21.

18. See note 10, Locke 2010, at 111.

19. See note 1, Savulescu 2006.

20. See note 2, Schuklenk 2015.

21. See note 3, Cantor 2009.

22. See note 4, Charo 2005.

23. See note 2, Schuklenk 2015.

24. Barker SF. What is a profession? Professional Ethics 1992;1:73–92.

25. See note 24, Barker 1992.

26. See note 24, Barker 1992.

27. Flexner A. Is social work a profession? School and Society 1915;1:901–11.

28. Hoogland, J, Jochemsen, H. Professional autonomy and the normative structure of medical practice. Theoretical Medicine 2000;21:457–75.

29. See note 24, Barker 1992.

30. See note 27, Flexner 1915.

31. See note 28, Hoogland, Jochemsen 2000.

32. Kass, LR. Professing ethically: On the place of ethics in defining medicine. JAMA 1983;249:1305–10.

33. See note 27, Flexner 1915.

34. See note 28, Hoogland, Jochemsen 2000.

35. See note 32, Kass 1983.

36. Cf. MacIntyre A. After Virtue, 2nd ed. Notre Dame, IN: University of Notre Dame Press; 1984:186.

37. See note 27, Flexner 1915.

38. See note 27, Flexner 1915.

39. See note 28, Hoogland, Jochemsen 2000.

40. Pellegrino ED. The expansion and contraction of ‘discretionary space.’ Priorities for the Use of Resources in Medicine, National Institutes of Health, DHEW Publication No. 77–1288. Washington, DC: United States Government Printing Office; 1977:99–112.

41. See note 40, Pellegrino 1977.

42. Centers for Disease Control. International Classification of Diseases, (ICD-10-CM/PCS) Transition—Background, Oct 1, 2015. Available at http://www.cdc.gov/nchs/icd/icd10cm_pcs_background.htm (last accessed 19 Feb 2016).

43. Sulmasy DP. What is conscience and why is respect for it so important? Theoretical Medicine and Bioethics 2008;29:135–49.

44. Zane, S, Creanga, AA, Berg, CJ, Pazol, K, Suchdev, DB, Jamieson, DJ, et al. Abortion-related mortality in the United States: 1998–2010. Obstetrics and Gynecology 2015;126:258–65.

45. See note 28, Hoogland, Jochemsen 2000.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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