The Advent of Ethical Imperialism in Healthcare
Stephen J Genuis
Originally published in FOCUS in November 2014
A letter copied from the local abortion clinic recently appeared in my office inbox. The clinic staff was thanking the referring family physician for arranging the procedure, commenting that the abortion had gone well without complications. My name was copied on the woman’s chart, as I had seen her for an ectopic pregnancy years before. Despite being accustomed to the reality of induced abortion, I was taken aback when I read the name of the referring doctor – a respected Christian colleague who openly identifies as being pro-life. I reacted with myriad sentiments including sadness and compassion, but puzzled as to why a pro-life Christian physician would refer for a procedure that many believers consider a tragedy.
Without disclosing the event, I spoke to several colleagues and residents in family medicine who share the faith, and asked about factors influencing physician behaviour. It became evident that under the umbrella of professionalism, the pressure to conform to regulatory guidelines and succumb to patient expectations is palpably mounting. Rather than abiding by their conscience, medical practitioners and trainees are being persuaded that, as contemporary professionals, we must set aside our conscience, values, and morals in order to comply with regulatory expectations and patient demands. The more one digresses from such expectations, the more one experiences marginalization, hassle, and animosity.
I found this new professionalism for healthcare providers to be perplexing on many fronts. Throughout medical history, celebrated advancements in medicine have generally occurred because conscientious practitioners courageously diverged from the status quo. Will the new professionalism crush iconoclasm and demand a preparedness to do what one believes to be wrong or unethical as a professional responsibility? A policy to coerce health professionals to act against their judgments will convert doctors into skilled technological servants, not professionals who, first and foremost, guard the health and well-being of each patient. As I explored different perspectives on the conscience issue, I came to appreciate the importance of considering the growing challenge of ethical diversity.
IS COMPULSORY CONFORMITY GOOD FOR PATIENTS AND SOCIETY?
When health providers disagree with their patients, colleagues, or regulatory professional bodies about the suitability of specific types of care, it is increasingly suggested by authorities that professionals must abide by the prevailing wisdom of the medical community. Going ‘against the flow’ due to conscientious or ethical conviction is often portrayed as ‘unprofessional’ and disparagingly depicted as serving personal interests rather than providing optimal care. Paradoxically, however, respect for diversity is still ostensibly revered in society. In order to enable contrarian practitioners to ethically participate in professional medical practice while respecting diversity and personal beliefs, a recommendation has emerged. Health providers can allegedly sustain their beliefs privately yet fully function in contemporary medicine by maintaining a distinctive ‘professional conscience’ that may supplant ‘personal conscience’ in professional situations. This ‘professional conscience’ would purportedly allow physicians to abide by the standard-of-care delineated by the profession in actions and approaches to healthcare, while retaining their personal moral code in their own private life.
While some accept the notion of divorcing personal values from professional behaviour, others contend that upholding incongruous moral perspectives within the same individual is illogical. Maintaining modifiable contradictory values depending on circumstances appears to defy the definition of ‘conscience’ – that decision-making faculty founded on a desire to live an honourable life which promotes good and avoids harm in all situations. It would seem contradictory to ask someone to ‘do no harm,’ and do what one sincerely believes is harmful at the same time.
Contemporary philosopher Alasdair Macintyre contends that “encouraging physicians to separate themselves and their values from the roles they perform is a recipe for the dissolution of character.” Whereas conscience may dictate actions, actions may also dictate conscience: denial of personal morality may be a pathway to nullification or euthanization of conscience. Compromise of conscience and personal moral integrity may inevitably lead to an erosion of ethical behaviour – a prospect not conducive to optimal provision of healthcare.
It is unlikely that individual patients or society would support a situation in which physicians were being coerced to make decisions they felt were wrong or unethical, or to act contrary to what they perceived was best for their patients.
Denial of conscience freedom also facilitates doctors as instruments of the state. History is rife with instances where delivery of independent, ethical medical care was compromised with disastrous results. Under the Apartheid regime in South Africa, for example, some physicians succumbed to hierarchical pressures to condone ongoing acts of state-sanctioned violence. The atrocities committed by Nazi physicians are another testament to the potential brutal activity that can occur when governments stifle the consciences of physicians. Furthermore, with escalating industry influence on the practice of medicine and standard-of-care decrees, medical decisions are increasingly being swayed by vested interests. Widespread denial of conscience rights socializes physicians to potentially become muted participants in atrocities and suboptimal care rather than advocates for health and humanity. Alternatively, protection of conscience rights permits a culture of advocacy in which health providers have liberty to advocate for patients in defiance of authoritarian dictates or outside influences.
Our culture has also experienced shifting lines in the sand. A medical act may have been frowned upon yesterday, with legislative or social changes resulting in support of the same act tomorrow. Furthermore, policies often conflict between regions. Some jurisdictions, for example, vehemently oppose euthanasia while others embrace this practice. Similarly, female genital mutilation is abhorrent in many cultures, but routinely practiced in others. Does something become good or evil based on modifiable opinion or geography? It is doubtful whether a physician’s conscience should be dictated by region or legislative whim. It is also doubtful whether strangling individual conscience is best for patients, society or practitioners.
IS MORAL CAPITULATION GOOD FOR PRACTITIONERS?
Authors Webster and Bayliss describe moral residue as “that which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised.” Consideration of the personal trauma which may be done to individuals compelled to act against conscience is an important part of this discussion. To date, however, analyses of the impact of coerced complicity have focused on outcomes for healthcare systems and recipients rather than providers – a notable deficiency considering the importance of medical professionals as key stakeholders in the healthcare system.
There is evidence of personal sequelae when contradiction exists between one’s values and one’s actions. In addition to immediate feelings which might include powerlessness, anger, resentment, or sorrow, there is growing attention to the emerging concept of moral trauma or ‘moral injury’ – described by Litz et al. as the consequence resulting from “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs or expectations. Anecdotal evidence to date suggests that emotional disregulation, alterations in approach to patient care, job dissatisfaction, and relational challenges often result from moral injury to health professionals.
For some, psychological strain associated with moral injury may have a detrimental impact on the essence of personhood. Coercion to engage in behaviour that violates one’s moral code may represent an assault on one’s moral ecosystem and a violation of personal integrity that threatens essential humanity. In military situations, for example, moral injury is recognized to be associated with ongoing alienation, intense shame, and sustained distress. Can healthcare systems afford to have more walking-wounded among healthcare providers, a profession with high rates of burnout and about one-quarter of physicians, according to recent data, already feeling depressed?
WHAT IS THE CHRISTIAN PERSPECTIVE ON CONSCIENTIOUS REFUSAL?
Among Christians, there are diverse perspectives on the freedom of conscience issue. Some suggest that believers should necessarily obey authority, not judge the actions of patients, and demonstrate exemplary empathy, tolerance and collegiality by working together to facilitate patients’ wishes. Some question the ability to be credible witnesses if we deviate from the standard-of-care and become alienated and marginalized within our profession. We have more influence, apparently, by staying in the game rather than perching on the sidelines. These are important considerations when responding to evolving medical ethics. I sometimes worry, however, about living a lukewarm life (Rv 3:16) and perhaps being fooled by a secular gospel that has little if anything to do with the Gospel of Christ. With the understanding that ‘Christian’ means ‘little Christ,’ challenging questions arise.
Did Jesus go with the flow? Did He exhort His apostles to fit into the culture, to accept and participate in man-made ideas that might conflict with His teaching? Does the admonition “do not be conformed to this world” (Rom 12:2) reflect a consistency or a contradiction between the ethos of God’s kingdom and the prevailing mindset of the world? When our Lord cautioned that narrow is the path that leads to life (Mt 14:7), might we need at times to respectfully walk in a direction different from mainstream? Did the heroes of scripture separate their personal life from their ministry life? Did John the Baptist, described by Jesus as the greatest among men, succumb to authoritarian dictates in order to maintain a voice? When Christian perspectives on truth and morality intersect with professional ideals such as tolerance, sobering introspection regarding priorities may be required.
The potential sequelae of our behavior also warrant consideration. What about the impact of our choices on colleagues, medical students and patients? Many of the hot button issues of our contemporary world – euthanasia, abortion, AIDS, sexuality, environmental exposures – have much to do with medicine and medical ethics. We have an enormous opportunity to be light on such issues. If we are not mentors and do not model our faith for medical trainees, who will? If we capitulate under duress, how will they stand in difficult situations? We also represent the Lord to each patient we encounter: our words, behaviour, and counsel are a witness to them. In a world that has become increasingly antithetical to our faith, our example and witness at a time when patients are hurting and in pain, may be the only representation of Christ they will ever encounter.
Queries about purpose and meaning also arise. Do we, as Christians, deserve ease and comfort in this life, or did we sign up for Christlikeness – the road of self-denial, sacrifice, and the cross (Lk 9:23)? Are we to pursue the self-serving ‘good life’, or have we enlisted to follow the one who “did not come to be served, but to serve” (Mark 10:45)? What about the ridicule and scorn of others? Did the Lord not say “Blessed are you when people hate you, avoid you, insult you, and slander you because you are committed to the Son of Man.” (Lk 6:22)? Faithful Christian servants have sustained all kinds of persecution throughout history – are we immune because we belong to a respected profession, make a significant income, and live in a developed country?
In order to personally respond to this litany of queries, it is fundamentally important to reflect on our primary task of representing Christ to the world, and to thus establish: “Am I a doctor who happens to be a Christian, or a Christian who happens to be a doctor?” If the latter, our utmost priority must be to humbly discern the Lord’s will in each situation and to reflect His image in everything we do. believe we are invited to stand and live the truth of God’s word, no matter the consequences or opposition. From this stance, our decisions may crystallize, whilst perhaps being more difficult and inconvenient at times. Living by such principles sometimes carries a price – it always has, it always will. Furthermore, as physicians we have the opportunity to be ministers of the Gospel in our actions and words. We are perceived as leaders and garner much respect from the community by virtue of having a medical degree. Perhaps with all that we have been given, much is expected (Lk 12:48) in our ultimate commission to represent the Lord in this confused world.
CAN OUR MEDICAL CULTURE THRIVE WITH ESCALATING ETHICAL DIVERSITY?
As a final query, I wish to explore the question of the sustainability of our profession amidst escalating ethical diversity. Mutually exclusive morality is the natural consequence of a culture that facilitates freedom of thought, independent thinking, and individual moral autonomy outside the constraints of a foundational unifying ethic. Eventually, however, a ‘Tower of Babel’ speaking different ethical languages cannot stand. It is impossible to maintain law with no common sense of right and wrong – contradictory perspectives cannot be equally credible within the same room. Noted philosophers such as Nietzsche and Dostoevsky have observed that with the passage of time, freedom of diversity within a culture might be anarchic, destructive, and impossible to sustain. Societies and institutions have historically been constrained with power, authority and sometimes tyranny in order to maintain stability. Are we headed in that direction professionally and perhaps societally?
Economist and historian Paul Craig Roberts has observed that the empowerment of the individual is a product of Christianity and Western civilization. Our faith system uniquely elevates the worth of each individual person, rather than acceding to the ‘might makes right’ paradigm of the pre-Christian past. Christianity encourages the humble, the lowly, the weak, the gentle and the righteous – the emphasis is on individuals, rather than groups or establishments that wield raw power. Within the framework of a Christian ethos, individuality of ideas, thoughts, and action is encouraged, but always under the Lordship of Christ – a foundational unifying ethic undergirds the celebration of diversity.
Throughout much of history, Western medicine has also functioned under the shadow of unifying ethical codes such as the Hippocratic Oath. Escalating moral diversity in the absence of such a foundational ethic, however, has the potential to dismantle the unity of the medical culture, which in turn may provoke regulators to establish authoritarian dogma and ethical imperialism in order to maintain professional constancy. Without a foundational ethic, unbridled diversity may ultimately lead to enforced uniformity – tolerance for non-adherents may be sacrificed. The creeping inclination to constrain those who challenge authoritarian guidelines and standard-of-care pronouncements is evidence of this trend. While some suggest that faith systems are exclusive and that secularism is tolerant of diversity, the drive to eliminate freedom of conscience suggests that, unlike Christianity, secularism can be intolerant of minorities and willing to discriminate on the basis of moral conviction and ethical orientation.
In review, there are signs our evolving culture is becoming unhinged. We celebrate diversity, but demand conformity; we advocate inclusiveness, but reject those who dissent from prevailing ideology; we esteem critical thinking and free speech, but muzzle ideas that deviate from official dogma. Ironically, in an era of expanding initiatives dedicated to ending intolerance and bullying, official regulatory bodies are becoming intolerant of doctors for being faithful to their conscience and try to bully them into doing what they believe is wrong. It is hard to believe that a culture with such systemic inconsistency and duplicity will flourish.
Believers who succumb to pressure in the face of ethical conflict sometimes face a crisis of faith. Barbs from various directions may exacerbate internal dissonance. Secular colleagues not infrequently belittle Christians, claiming they routinely abrogate pious proclamations and fall into line when confronted with situations that extract a cost. From the other direction, sanctimonious Christians sometimes vociferously criticize the sincerity of fellow believers who capitulate when difficulty arises in medical practice. From within, transgression of Christian tenets may disturb our internal moral compass – compelling some to disengage from the practice of faith. Evaluation of such challenges is in order.
Critics confuse the Lord’s teachings with mankind’s failings. It is disingenuous to judge Christianity by the weaknesses and abuses of its adherents. We contradict what we believe all the time. Every sincere believer, notably myself, is imperfect and regularly confesses Christian principles that he or she fails to live up to. Peter’s denial of Christ is a testament to this. Confusion, cowardice, and failure are part and parcel of the human experience and Christians continually need to prayerfully introspect, repent when necessary, and humbly discern how to move forward.
Most importantly, no matter what we have done or what ethical choices we have previously made personally or professionally, the invitation to be born again and to start anew lies before us. We have the opportunity within our profession to go against the wind when necessary and to walk the narrow and sometimes lonely path. Sustained moral trauma is the result of sin, when we fail to live up to what we are called to be and know in our conscience to be in unison with a character rooted in Christ. The miraculous is that we are blessed to follow One who offers to take that injury upon Himself and, in return, provides healing and liberation.
Dr. Stephen Genuis is a clinician and researcher who practices environmental medicine and is a Clinical Professor in the Faculty of Medicine at the University of Alberta. He previously served as co-director of medical services in a West African mission hospital and currently writes scientific publications for assorted medical journals. Stephen plays piano and sings in a doctor’s band called DixieDocs and, most importantly, enjoys ballroom dancing with his wife Shelagh, and being his five kids’ “Pa.