Unbiased treatment for all
New York Times columnist Professor Stanley Fish, (April 12, 2009) wrote about 'Conscience vs Conscience', where he discussed the conundrum about how people in general and physicians in particular, under different circumstances should or shouldn't abide by their own conscience per se.
The contending issue was that physicians should not refuse treatment or procedures based on their own personal moral or religious grounds. Conversely, any doctor should not be differential or partisan when treating patients who may have a different predisposition, political or religious leaning from oneself.
Fish argued that there is such a thing as a collective “public conscience” which should supersede that of one's personal conscience and value systems, no matter how entrenched these may seem to be.
During the George W Bush administration, the culpable clause, called the Provider Refusal Rule, allows healthcare providers to refuse to participate in procedures they find objectionable for moral or religious reasons. The main bone of contention was of course regarding freedom to choose abortion, pro-choice, or conversely to advocate pro-life.
In Fish's article, he underscored an earlier statement by Mike Leavitt, Bush's secretary of health and human services, who had said that, “Doctors and other health providers should not be forced to choose between good professional standing and violating their conscience.”
The direction of the Bush doctrine was of course to urge the conservative right against unfettered abortion on demand, which continues to divide the American people.
Fish reviewed the etymology of “conscience” as ascribed to English philosopher Thomas Hobbes. Here one of the earliest definitions of conscience, referred to those occasions “when two or more men know of one and the same fact . . . which is as much to know it together”, and where, violation of conscience meant that knowing together, men prefer their “secret thoughts” to what has been publicly established.
Fish acknowledged that Hobbes understood that many people define conscience as being the private arbiter of right and wrong. But Hobbes regards this as a corrupted usage invented by those who wished to elevate “their own . . . opinions” to the status of reliable knowledge and try to do so by giving “their opinions . . . that reverenced name of Conscience”.
Hobbes's main argument is that if one can prefer one's own judgments to the judgments of authorised external bodies (legislatures, courts, professional associations), the result will be the undermining of public order and the substitution of personal whim for general decorum: “. . . because the Law is the public Conscience . . . in such diversity as there is of private Consciences, which are but private opinions, the Commonwealth must needs be distracted, and no man dare to obey the Sovereign Power farther than it shall seem good in his own eyes”.
It must be borne in mind that during that era, the word of the King and his aristocrats were considered sacrosanct, which must be obeyed on pain of severe punishment or even death. In most modern societies however, the rule of law necessarily dictates that the nation's laws and constitution must reign supreme, although varying interpretations and amendments are now allowed based of intellectual arguments of merit.
In Fish's article, he underscored an earlier statement by Mike Leavitt, Bush's secretary of health and human services, who had said that, “Doctors and other health providers should not be forced to choose between good professional standing and violating their conscience.”
The direction of the Bush doctrine was of course to urge the conservative right against unfettered abortion on demand, which continues to divide the American people.
Fish reviewed the etymology of “conscience” as ascribed to English philosopher Thomas Hobbes. Here one of the earliest definitions of conscience, referred to those occasions “when two or more men know of one and the same fact . . . which is as much to know it together”, and where, violation of conscience meant that knowing together, men prefer their “secret thoughts” to what has been publicly established.
Fish acknowledged that Hobbes understood that many people define conscience as being the private arbiter of right and wrong. But Hobbes regards this as a corrupted usage invented by those who wished to elevate “their own . . . opinions” to the status of reliable knowledge and try to do so by giving “their opinions . . . that reverenced name of Conscience”.
Hobbes's main argument is that if one can prefer one's own judgments to the judgments of authorised external bodies (legislatures, courts, professional associations), the result will be the undermining of public order and the substitution of personal whim for general decorum: “. . . because the Law is the public Conscience . . . in such diversity as there is of private Consciences, which are but private opinions, the Commonwealth must needs be distracted, and no man dare to obey the Sovereign Power farther than it shall seem good in his own eyes”.
It must be borne in mind that during that era, the word of the King and his aristocrats were considered sacrosanct, which must be obeyed on pain of severe punishment or even death. In most modern societies however, the rule of law necessarily dictates that the nation's laws and constitution must reign supreme, although varying interpretations and amendments are now allowed based of intellectual arguments of merit.
Ethical underpinnings
Where does this leave the medical professional when it comes to ethical underpinnings of doing what's right or wrong? Would our personal conscience suffice?
Or, should we subsume to the greater wisdom of our collective professional voice (for example, national medical associations, professional bodies, world medical association, medical councils, etc), which through the long arduous passage of time and historical experiences, would have honed a burnished if strait-jacketed version of what's generally accepted as “ethically and publicly correct”? Or should he or she bow to the will of a superior authority - in other words, simply listen and obey orders?
Be that as it may, does this mean that the medical professional would then have no right to rely on his own personal conscience and moral standing? Obviously, the answer must be 'No', because the physician while suppressing his own conscience would have to bow in no uncertain terms to the interests and will of the patient, whom he has undertaken to look after, to assess or to treat.
The main tenet of medical professionalism is to advocate the best interests and benefit of the patient, with the most dispassionate and independent proficiency as possible. On one hand, if one's convictions appear to run counter to public expectations, then surely - if these are so diametrically opposed to the greater wisdom of peers - one has to justify one's personal convictions all the more.
Again, this cannot be taken out of context. In certain circumstances, the medical professional is called upon to make extreme judgement calls, which can be sorely tested by either undue influence, threats from or fears of authority (for example, police, superior officers, military, even political powers) or worse, direct or indirect 'rewards' for passive compliance, obedience.
Doctors shouldn't be biased
The 1st century AD Hindu code, 'Caraka Samhita', exhorts doctors to “endeavour for the relief of patients with all thy heart and soul; thou shall not desert or injure thy patient for the sake of thy life or living”, which have been restated in many codes of professional conduct, including our own.
Yet, these are often pushed to the backburner when conflicts of duties arise.
Recent public spats over medical testimonials and reports have arguably cast long shadows as to the so-called impartiality, ethics or professionalism of some of our medical colleagues. Forensic pathologists are facing some intense scrutiny of late, due to questionable lapses, incoherent practices and perhaps even perceived selective memories, and slipshod standards of duty of care.
Other physicians making medical reports have also been put under the microscope for their perceived bias or slant of their reports, one way or the other, until the truthfulness of one vs. the other, appears difficult or impossible to discover!
Such ambiguous if disingenuous medical findings or reports cast a dismal if disappointing view on our profession, our health service. While some of these appear coerced, some might conceivably be simply venal, just as if medical veracity can be made to sway according to the purchasing power of the most damning and powerful!
Physicians must be reminded that for that patient (deceased or detainee) under his/her charge, there is frequently no other person whom the victim's interests can be represented, except from the physician's unbiased assessment.
Sadly, some of these dubious practices place us at odds with the perceived wisdom and conventions of some greater external collective conscience. These conventions although seemingly unenforceable, have long been articulated by world authorities such as the World Medical Association and even the United Nations Human Rights Commission.
The Istanbul Protocol of the UN High Commission for Human Rights is categorical in stating that: “Dilemmas arising from these dual obligations are particularly acute for health professionals working with the police, military, other security services or in the prison system. The interests of their employer and their non-medical colleagues may be in conflict with the best interests of the detainee patients.
“Such health professionals with dual obligations, owe a primary duty to the patient to promote that person's best interests and a general duty to society to ensure that justice is done and violations of human rights prevented. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat.
“They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient's health interests and act accordingly.”
Unfortunately, this protection by convention appears so remote to the lonely physician standing in the clutches of perceived authoritarian powers, whose oppressive influence can seem imaginably overpowering.
Society to lend a hand
Seen in this context, society must exert its moral imperative of the public good on a universal basis, and demand the application of such universal conventions and norms, to protect the hapless physician at the centre of such political or partisan storms, lest such pressure lead to further erosion of already debilitated institutions, and demean justice.
Similarly, the onus is on members of the medical profession to remain steadfast to the doctrine of public conscience and universal principles rather than personal ones, when carrying out our duties, including when making judgement or pronouncement on some of our possibly errant patients under our charge or even our own colleagues. Sectarian perceptions whether religious or political, clearly must take a back seat, and should not be allowed to colour our thinking or decision making.
Personal bias or experience or even conviction should yield to the more nuanced, perhaps more balanced decisions based on strict interpretations of medical truths, diagnostic facts and findings, proper statutes, codes of professional conduct, and perhaps legal precedents.
The US Supreme Court has ruled that when the personal imperatives of one's religion or morality lead to actions in violation of generally applicable laws - laws not promulgated with the intention of affronting anyone's conscience - the violations will not be allowed and will certainly not be celebrated; because: “To permit this would be to make the professed doctrines of religious belief superior to the law of the land, and in effect to permit every citizen to become a law unto himself.”
Therefore, we must be quite clear to dissect our dilemma as to which is the superior right - doctors must be truth-seekers, and ultimate final independent arbiters of medical discovery.
Similarly, in the context of political or authoritarian pressure, where risk to the individual may seem likely, it behooves the professional to be reminded about the World Medical Association's 'Declaration of Geneva', which is a modern restatement of the Hippocratic values, as well as to be cognizant of UN Conventions such as the 'Istanbul Protocol'.
Doctors are reminded that the health of their patients is their primary consideration and that they must devote themselves to the service of humanity with conscience and dignity.
We must learn and adhere to our historical memories, that which are collectively acknowledged as 'correct' and first and foremost for our patients' interests. Certainly, in this context, every professional should not let religious, political or sectarian persuasions from influencing his/her decision making, that choice of what is right, or wrong.
But does this mean that these are 'moral' fixtures, which cannot or should not be modified with the passage of time. Or, could these perhaps shift in tandem with the 'fashion' or faddism of current perceptions or even societal movement or direction?
Clearly this will depend on the circumstances and the human aspects of all patient-physician interactions. Although ethics these days are not as immovable or as permanently cast in stone, societal views do evolve. Like sometimes shifting tides, ethical perceptions may very gradually ebb and flow, gradually nudging sand dunes of outlook one way or the other, but often anchored solidly via moorings and underpinnings of moral public good, and greater and greater foundations of universal values.
So changes may occur, but again these must be based on contextual interpretation which should be carefully justified so that the newer interpretation can withstand scrutiny and/or rigorous re-examination, by an increasingly knowledgeable public and also by even more discerning generations of similar professionals.
Thus, personal conscience and public conscience must be employed together to shape our moral compass when we are dealing with ethics and medical professionalism. It helps when we all undertake to reexamine our own values and learn more and more as to how these ethical dilemmas and questions are evolving in this day and age.
We must not be cowed into a mindset of choosing the most convenient way out, or of personally safe, but callous even corrupt expediency.
Where does this leave the medical professional when it comes to ethical underpinnings of doing what's right or wrong? Would our personal conscience suffice?
Or, should we subsume to the greater wisdom of our collective professional voice (for example, national medical associations, professional bodies, world medical association, medical councils, etc), which through the long arduous passage of time and historical experiences, would have honed a burnished if strait-jacketed version of what's generally accepted as “ethically and publicly correct”? Or should he or she bow to the will of a superior authority - in other words, simply listen and obey orders?
Be that as it may, does this mean that the medical professional would then have no right to rely on his own personal conscience and moral standing? Obviously, the answer must be 'No', because the physician while suppressing his own conscience would have to bow in no uncertain terms to the interests and will of the patient, whom he has undertaken to look after, to assess or to treat. The main tenet of medical professionalism is to advocate the best interests and benefit of the patient, with the most dispassionate and independent proficiency as possible. On one hand, if one's convictions appear to run counter to public expectations, then surely - if these are so diametrically opposed to the greater wisdom of peers - one has to justify one's personal convictions all the more.
Again, this cannot be taken out of context. In certain circumstances, the medical professional is called upon to make extreme judgement calls, which can be sorely tested by either undue influence, threats from or fears of authority (for example, police, superior officers, military, even political powers) or worse, direct or indirect 'rewards' for passive compliance, obedience.
Doctors shouldn't be biased
The 1st century AD Hindu code, 'Caraka Samhita', exhorts doctors to “endeavour for the relief of patients with all thy heart and soul; thou shall not desert or injure thy patient for the sake of thy life or living”, which have been restated in many codes of professional conduct, including our own.
Yet, these are often pushed to the backburner when conflicts of duties arise.
Recent public spats over medical testimonials and reports have arguably cast long shadows as to the so-called impartiality, ethics or professionalism of some of our medical colleagues. Forensic pathologists are facing some intense scrutiny of late, due to questionable lapses, incoherent practices and perhaps even perceived selective memories, and slipshod standards of duty of care.
Other physicians making medical reports have also been put under the microscope for their perceived bias or slant of their reports, one way or the other, until the truthfulness of one vs. the other, appears difficult or impossible to discover!
Such ambiguous if disingenuous medical findings or reports cast a dismal if disappointing view on our profession, our health service. While some of these appear coerced, some might conceivably be simply venal, just as if medical veracity can be made to sway according to the purchasing power of the most damning and powerful!
Physicians must be reminded that for that patient (deceased or detainee) under his/her charge, there is frequently no other person whom the victim's interests can be represented, except from the physician's unbiased assessment.
Sadly, some of these dubious practices place us at odds with the perceived wisdom and conventions of some greater external collective conscience. These conventions although seemingly unenforceable, have long been articulated by world authorities such as the World Medical Association and even the United Nations Human Rights Commission.
The Istanbul Protocol of the UN High Commission for Human Rights is categorical in stating that: “Dilemmas arising from these dual obligations are particularly acute for health professionals working with the police, military, other security services or in the prison system. The interests of their employer and their non-medical colleagues may be in conflict with the best interests of the detainee patients. “Such health professionals with dual obligations, owe a primary duty to the patient to promote that person's best interests and a general duty to society to ensure that justice is done and violations of human rights prevented. Whatever the circumstances of their employment, all health professionals owe a fundamental duty to care for the people they are asked to examine or treat.
“They cannot be obliged by contractual or other considerations to compromise their professional independence. They must make an unbiased assessment of the patient's health interests and act accordingly.”
Unfortunately, this protection by convention appears so remote to the lonely physician standing in the clutches of perceived authoritarian powers, whose oppressive influence can seem imaginably overpowering.
Society to lend a hand
Seen in this context, society must exert its moral imperative of the public good on a universal basis, and demand the application of such universal conventions and norms, to protect the hapless physician at the centre of such political or partisan storms, lest such pressure lead to further erosion of already debilitated institutions, and demean justice.
Similarly, the onus is on members of the medical profession to remain steadfast to the doctrine of public conscience and universal principles rather than personal ones, when carrying out our duties, including when making judgement or pronouncement on some of our possibly errant patients under our charge or even our own colleagues. Sectarian perceptions whether religious or political, clearly must take a back seat, and should not be allowed to colour our thinking or decision making. Personal bias or experience or even conviction should yield to the more nuanced, perhaps more balanced decisions based on strict interpretations of medical truths, diagnostic facts and findings, proper statutes, codes of professional conduct, and perhaps legal precedents.
The US Supreme Court has ruled that when the personal imperatives of one's religion or morality lead to actions in violation of generally applicable laws - laws not promulgated with the intention of affronting anyone's conscience - the violations will not be allowed and will certainly not be celebrated; because: “To permit this would be to make the professed doctrines of religious belief superior to the law of the land, and in effect to permit every citizen to become a law unto himself.”
Therefore, we must be quite clear to dissect our dilemma as to which is the superior right - doctors must be truth-seekers, and ultimate final independent arbiters of medical discovery.
Similarly, in the context of political or authoritarian pressure, where risk to the individual may seem likely, it behooves the professional to be reminded about the World Medical Association's 'Declaration of Geneva', which is a modern restatement of the Hippocratic values, as well as to be cognizant of UN Conventions such as the 'Istanbul Protocol'.
Doctors are reminded that the health of their patients is their primary consideration and that they must devote themselves to the service of humanity with conscience and dignity.We must learn and adhere to our historical memories, that which are collectively acknowledged as 'correct' and first and foremost for our patients' interests. Certainly, in this context, every professional should not let religious, political or sectarian persuasions from influencing his/her decision making, that choice of what is right, or wrong.
But does this mean that these are 'moral' fixtures, which cannot or should not be modified with the passage of time. Or, could these perhaps shift in tandem with the 'fashion' or faddism of current perceptions or even societal movement or direction?
Clearly this will depend on the circumstances and the human aspects of all patient-physician interactions. Although ethics these days are not as immovable or as permanently cast in stone, societal views do evolve. Like sometimes shifting tides, ethical perceptions may very gradually ebb and flow, gradually nudging sand dunes of outlook one way or the other, but often anchored solidly via moorings and underpinnings of moral public good, and greater and greater foundations of universal values.
So changes may occur, but again these must be based on contextual interpretation which should be carefully justified so that the newer interpretation can withstand scrutiny and/or rigorous re-examination, by an increasingly knowledgeable public and also by even more discerning generations of similar professionals.
Thus, personal conscience and public conscience must be employed together to shape our moral compass when we are dealing with ethics and medical professionalism. It helps when we all undertake to reexamine our own values and learn more and more as to how these ethical dilemmas and questions are evolving in this day and age.
We must not be cowed into a mindset of choosing the most convenient way out, or of personally safe, but callous even corrupt expediency.
DR DAVID KL QUEK was the editor-in-chief of the MMA News (bulletin of the Malaysian Medical Association) for 11 years and is currently president of the MMA.
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