ACOG's Definition of Conscience and Good Medical Practice

We have been examining the definition of conscience forwarded by the American College of Obstetricians and Gynecologists' (ACOG) Ethics Committee and the consequences of taking this definition to its logical conclusion. If one may forgive a medical ethics committee for not being moral theologians, the consequences their statement has on medical practice is perhaps less forgivable. Even the committee’s view of the medical profession is a dangerous paradigm shift rooted in an anemic materialistic philosophy. Not only does this philosophy endanger individual rights of conscience it also endangers the quality of health care for all of us.

Traditionally, professionals were highly educated, specifically trained and highly paid to be experts in their field. Their expertise gave them authority and was the foundation for the trust that we placed in them. Trust was strengthened through demonstrated competence and rapport built through a personal but professional relationship. Think back to the days of the private family practice, when the entire family went to the same doctor who knew every member, remembered their past conditions, and sometimes even came up with their own medicinal concoctions for specific ailments.

ACOG promotes a different view of the professional in support of its reformulation of the moral conscience. A professional is a merchant in a capitalist system whose purpose is to provide to the client (no longer called a patient) products and services in the health market. ACOG says, “A second important consideration in evaluating conscientious refusal is the impact such a refusal might have on well-being as the patient perceives it – in particular, the potential for harm” (3) (emphasis added).

This materialistic definition of the professional has a very important but subtle effect on the principle of patient autonomy. Under the traditional understanding of the medical professional, patient autonomy meant that the patient had the power to make final decisions about whether or not to accept extraordinary means of treatment (treatment with little chance of success or with burdens that outweighed their benefits). Such decisions were always to be made after full consultation with medical professionals so the patient could be fully informed of the choices available. However, patient autonomy did not extend to the refusal of ordinary means of treatment, and certainly did not mean that the patient could request any treatment he or she wanted. However, ACOG’s understanding of the professional changes its understanding of patient autonomy. “One of the guiding principles in the practice of medicine is respect for patient autonomy, a principle that holds that persons should be free to choose and act without controlling constraints imposed by others” (3). Theoretically, a client could walk into a doctor’s office and request an amputation – and the doctor would be obligated to perform the operation as long as the patient was convinced it was necessary. I’m sure that no member of ACOG would extend their principle to this ridiculous extent. However, the very fact that they cannot follow the principle to its logical conclusion shows the error of the principle. ACOG’s redefinition of the professional and of patient autonomy strips the professional of his expertise. The doctor has little more authority than the store clerk.

According to ACOG, a patient requesting contraception or even sterilization has the right to receive the desired treatment just because she wants it. The doctor’s role is only to provide the desired service. If contraception and sterilization are against a doctor’s conscience, the doctor must ignore his or her conscience. Many doctors who oppose contraception and sterilization do so because they judge these “treatments” to be medically bad for patients in addition to being morally evil. However, these doctors do not have the right to deny these treatments even on medical grounds. Why? Because social values, the patient’s opinion, and “accepted medical practice” (which is often directed by political and social tides rather than by science) all outweigh professional judgment. Medical judgments are being made by everyone except those who are most qualified (and best paid) to make apply medical knowledge to specific conditions of the patient.

ACOG’s redefinitions of conscience and of the medical professional are dangerous. They give the power to define medical care to capricious social and political influences rather than to the trained professionals. They thus redefine even the ethical standards that traditionally guided the use of the power that medical professionals have over our bodies. “By virtue of entering the profession of medicine, physicians accept a set of moral values – and duties – that are central to medical practice” (3). Traditionally, these “moral values” and duties were expressed through the Hippocratic Oath, derived from a reasoned understanding of the human person and the nature of the healing arts. The Hippocratic Oath bound doctors to protect all human life and dignity, to not take advantage of the intimacy or authority of the patient-doctor relationship, and to do no harm. This oath is rarely taken in medical schools anymore. Today, these “moral values” and duties are defined by ambiguous and shifting social and political influences. Thus, proper medical care includes contraception, sterilization and abortion because these things are socially and politically favored, even though these treatments violate the basic principle of totality and integrity – the principle that states that the goal of medicine is to make sure the body is kept whole and that it is treated as part of the whole person rather than as a machine or an object. Forcing a woman to accept an “unplanned pregnancy” by refusing contraception, sterilization or abortion is now considered doing harm to the patient. Killing a child in the womb is not considered doing harm because “the moral status of the fetus and the obligations that status confers differs widely.” So, if the moral status of blacks or of women were to differed widely in public opinion, the doctor would be morally justified or even obligated to kill blacks or women? Taken to its logical conclusion, ACOG’s logic would say yes.

If it becomes the norm, ACOG’s reasoning will do serious harm to the medical profession and to the care we receive. Making medical care into a commodity market, removing prudential decision making power from trained professionals, allowing patients and society to decide what is or is not acceptable treatment are sure ways to erode our standard of care. Destroying the solid ethical principles that provide checks and balances to the incredible power that doctors hold over life and death and the intimate nature of the patient-doctor relationship is a sure road to abuse. What was ACOG thinking?