Conscientiously objecting to conscientious objection | Timothy Paris

Dr Timothy Paris is a Maltese psychiatry trainee working in the UK 

I write in response to the ‘conscientious objection’ clause proposed by the Maltese Medical Council to the recent equality law.

Impartial, evidence-based medical and ethical objection is essential to safeguard patient rights and welfare. However, as a practicing doctor, I find the proposed clause dangerous on several levels, which shall be highlighted in this letter.

To begin with, the very term ‘conscientious objection’ is a misnomer. A doctor who is truly conscientious takes patients’ own beliefs and wishes into account, even if it means putting aside their own beliefs when consulting patients on treatment options. Indeed, there is nothing conscientious about imposing one’s own values on patients. ‘Conscientiously objecting’ to treatment options involves denying patients the treatment they are entitled to receive by law. A phrase which frequently comes up in ethical debates in medicine is ‘primum non nocere’: ‘first, do no harm’. In the case of ‘conscientious objection’, limiting patients’ legal treatment options is harmful to patient care.

In their statement, the Maltese Medical Council said that certain medical scenarios “require sound clinical and ethical judgement, based on the values of the medical profession, which include the value of life, justice, respect for others and equality.” This statement seems to be at odds with doctors who ‘conscientiously object’ to treating patients as it appears that they place a greater premium on their own egos and belief systems, than the rights of their patients. This attitude could have devastating effects on patients’ lives.

Furthermore, selecting which treatments (which are legal and in-keeping with national and/ or international guidelines) to offer patients based on the belief system of the clinician, hardly appears to be promoting values of justice or equality. In order for patients to make capacitous decisions, patients must be able to understand, retain, weigh, and communicate information effectively. How are patients supposed to weigh information objectively if the information they are presented with is skewed by the views of the professional providing them with information?

Additionally, ‘conscientious objection’ raises important questions with regards to its limitations and boundaries: where does ‘conscientious objection’ begin and where does it end? Should doctors be allowed to refuse to prescribe contraception to women, or hormone therapy to transgender patients based on their own ‘conscientious’ beliefs? Should doctors be allowed to refuse to refer LGBTQI+ patients for IVF services? Should doctors be allowed to refuse to treat asylum seekers because of their ‘conscientious’ beliefs that public health funds should only be used by Maltese nationals or taxpayers?

Moreover, it is obvious that the vast majority of ‘conscientious objections’ Maltese doctors have are for religious reasons. While there is substantial common ground between religion and

modern medicine, there are also areas where they stand on opposing ends of ‘the debate’. Unfortunately, in these instances, doctors with strong religious beliefs inevitably find themselves at a crossroads: do they follow national/ international medical guidelines or do they adhere to their own religious beliefs and ‘conscientiously object’?

Living in an increasingly diverse and multicultural world, patients’ own beliefs, religious or non-religious, frequently do not align with those of clinicians. Ultimately, it boils down to who the law gives priority to – is it doctors having the right to ‘conscientiously object’ or is it patients having the right to access treatment that is legal and in-keeping with standard medical practice? The old cliche is true, with great power comes great responsibility; and yet, being able to ‘conscientiously object’, gives doctors more power and less responsibility, which can very easily lead to a violation of patient rights, and is detrimental to patient care.

Making difficult ethical, medico-legal decisions is an integral part of medical practice. If we, as clinicians, are unable to put our own personal beliefs aside and act in patients’ best interests in-line with evidence-based guidelines, then what is the point of being a doctor in the first place? It is about time we got down from the pulpit and stepped into the world of holistic, patient-centered medicine.