Bioethics @ TIU

Charlie Gard, the New England Journal of Medicine, and the Limits of “Conscience”

Posted July 6th, 2017 by Jon Holmlund

I would venture that most bioethicists would agree it would be ethically permissible to remove life support and active care from little Charlie Gard, and let him die.   The hospital in Britain where he has been receiving his care wants to do that, and the courts agree.  But why do they insist on this action when his parents want to transfer him for another try at experimental treatment, have raised the money, and reportedly have a center in the US willing to accept him for such an attempt?

I can think of two reasons.  One is a frank utilitarian insistence on limiting costs.  It has been publicly charged that is precisely the motive for this and similar recent cases in the U.S.

Or it could be that those caregivers who argue against the futility of such care do so on conscience grounds.  This is at least a more charitable reading.

But if that is the case, then might we not ask:  on what grounds do such conscience concerns mandate blocking the wishes of the baby’s parents—setting aside just how quickly the futility of further care would be evident?  It is commonly argued that practitioners who wish not to provide abortions or participate in assisted suicide retain a professional obligation to refer to someone who will perform the procedure in question.

So why don’t we demand that the British hospital actively refer Charlie’s parents to another facility?  Just wondering…

Maybe the parents in this case are the ones appealing to conscience, but, in the view of the medicolegal authorities, wrongly so.  In postings dated June 2 and June 6 of this year, this blog carried a 2-part rejoinder to an April 6 article in the New England Journal of Medicine that took the position that conscientious objection by medical practitioners should be considered unethical.

The NEJM has now published correspondence in response to that “Sounding Board” article.  Unlike the initial article, a subscription is not needed to read these letters and the responses of the authors.  Three letters were published.  One argues that the initial article relied on “reflective equilibrium” as the critical process by which medical practice standards are established, but to do so and reject conscientious objectors is wrongly to restrict that process, which in any case does not indubitably lead toward moral truth.  The second wondered aloud about whether construing the doctor-patient relationship as covenantal matters, whether doctors also have some degree of autonomy that commands respect, and whether the consensus of the medical profession is always ethical.  In the third, a clearly irritated correspondent complains that it is rich to offer, as the authors of the initial article stated, that potential practitioners just avoid moral issues by voluntarily excluding themselves from specialties in question; i.e., would-be OB-GYNs who consider it immoral to perform an abortion need not apply.  In response, the authors say that objectors need not be silenced but must comply, and that society expects physicians to act against their personal beliefs if necessary.

Most tellingly, the authors in question, Stahl and Emanuel, claim that the doctor-patient relationship is NOT a covenant precisely because it is not a relationship of equals; doctors hold immense power of different sorts.  Physicians must respect this inequality by avoiding specialties that pose moral conflicts to them.

I thought that the patient’s special need was precisely why a covenantal relationship is the only framework sufficient to guarantee that the patient as person is appropriately cared for.  Stahl and Emanuel are quite explicit; doctors may not stand in the way of societal calculations, on their patients’ behalf.  They have to get out of the way.

Can there be a new society of physicians dedicates to the categorical rejection of this thinking?  Could such a group possibly practice in today’s legal environment, and in the political-economic spirit that has turned medicine into a centrally-managed public utility?

Dr. Cheyn Onarecker, in the two posts in early June, addressed these points, in opposition to Stahl and Emanuel and, in fact, anticipating their responses in the new correspondence.  Read those again.

But we need to go further, and attempt to restore the covenantal view of medicine.  I’d like to hear more from Dr. Onarecker and other real doctors on this blog about that.

4 Responses

  1. Susan Aiello says:

    I don’t hire lawyers, landscape artists, general contractors, house cleaners, psychotherapists, nor anyone else who lacks moral integrity. Why would I want to hire a doctor who doesn’t have any?

  2. Susan Aiello says:

    Very good article. MD’s have immense power not simply because they deal with life and death, but because we have allowed them to amass this power. Some are just too arrogant to be working with people.

    Emanuel and Stahl are attempting to move our culture further along the all-powerful federal government road, where all people are subject to the State’s decisions on how everyone must practice their trade and run their business. This isn’t just about medical practice.

    America ceases to be America without a strong conscience clause. No doctor should be forced to do anything that is against his or her moral values.

  3. Mark McQuain says:

    Here is great web page of many of Dr. John Patrick’s lectures on Hippocrates (and many other bioethical topics)

    Dr. John Patricks Audio Lectures

  4. Mick Vanden Bosch says:

    John Patrick, and a physician and apologist from Canada, has for over a decade recommended that we offer two separate medical treatment options: a Hippocratic physician and hospital track, and a non-Hippocratic track, ie the current North American system. And then we let patients decide by where they want to be treated. They may choose a physician that will follow the original Hippocratic Oath and treat them accordingly, or they can choose a medical system that will treat them according to the current cultural beliefs and practices.

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