Should doctors be allowed to conscientiously object to euthanasia? Voluntary euthanasia for patients with terminal illness is now legal in dozens of jurisdictions. A significant portion of doctors, however, believe that euthanasia is not part of medicine; opposition is especially high amongst palliative care specialists—the doctors who are closest to terminally ill patients. Some doctors wonder whether euthanasia will have a counterproductive impact on suicide prevention and social reform.
Respect for reasonable disagreement is a basic tenet of liberal democracies; it is difficult to see why this principle ought not apply in the medical profession. We do well to consider the place of respectful disagreement among the medical fraternity and whether liberal societies ought to protect physicians’ right to conscientious objection.
Conscientious objection and healthcare
Conscientious objection refers to the right of healthcare professionals to opt out of participation in the provision of medical interventions to which they have an ethical or religious objection. As a rule, healthcare professionals have responsibilities to provide treatments that are safe, legal, clinically indicated, and desired by patients. Good medical practice is not just a matter of professional expertise but also respect for the rights of patients. Indeed, patient autonomy has become a preeminent medical principle governing the interactions between care teams and patients. Thus, Julian Savulescu and Udo Schuklenk—prominent critics of conscientious objection—assert that:
“[i]f a service a doctor is requested to perform is a medical practice, is legal, consistent with distributive justice, requested by the patient or their appointed surrogate, and is plausibly in their interests, the doctor must ensure the patient has access to it.”
Physician discretion, however, remains a cornerstone of good medical practice. Doctors can and should be allowed to withhold treatment where such treatment is deemed to be inimical to patient well being. The point is not just one of clinical appropriateness. Doctors ought to be allowed to act in accordance with their best judgment about what constitutes good medical care, and this judgement involves ethical as well as technical considerations.
Conscientious objection is often described with reference to neuralgic social issues such as abortion, euthanasia, sterilizations, and the provision of emergency contraceptives. But in theory a doctor could have a conscientious objection to any medical procedure. Conscientious objection is not uncommon in critical care, for example, where clinicians are having to regularly make complex, value-laden treatment decisions about seriously ill patients. Doctors might also object to utilizing new treatments for which there is limited evidence, such as analgesic medicinal cannabis, or where the treatment might only make a patient feel worse, as may be the case with cosmetic surgery.
In the last analysis, conscientious objection is one manifestation of the prudential judgement that a physician must make about the best interests of their patients.
Conscientious objection is not an absolute right. Conscientious objection pertains to procedures rather than to classes of patients. It should not be used to justify racist, sexist, homophobic beliefs or religious prejudices. Appeals to conscience ought to be justified with reference to ethical reasoning or faith commitments. Appeals to conscience should be distinguished from mere laziness or a dislike for discharging one’s professional duties.
Conscientious objection guidelines typically advise conscientious objectors to ensure that patients can access the medical service in question in a safe and timely fashion (see, for example, here and here). But these provisions ought not amount to a violation of the integrity of conscientiously objecting physicians. This would defeat the purpose of attempting to accommodate conscientious objection.
Voluntary Euthanasia
Voluntary euthanasia refers to the intentional and consensual ending of a patient’s life either by or with the assistance of a medical professional. Strictly speaking, euthanasia—where a doctor ends the patient’s life – ought to be distinguished from assisted suicide—where the patient themselves ends their own life.
Euthanasia is legal in several jurisdictions around the world, including in the Netherlands, Belgium, Luxembourg, Canada, Columbia, Spain, New Zealand, and in every Australian state. Assisted suicide is legal in several US states. Typically, access to euthanasia and assisted suicide is confined to patients with a terminal illness, but in some jurisdictions eligibility criteria are more expansive. Both Belgium and the Netherlands allow euthanasia for psychiatric reasons and also permit euthanasia for minors. Canada recently expanded access to euthanasia to include patients with chronic illness as well as patients with mental illness. (The implementation of euthanasia for mental illness has been paused due to concerns that the Canadian healthcare system is not yet prepared to handle such requests.)
Physician objections to euthanasia
Many doctors are opposed to the intentional killing of other human beings, even where this is done under the auspices of liberal medical norms. Life is the most basic of human goods and the sanctity of life is a fundamental civilizing principle even for liberal societies. Euthanasia violates this principle by sanctioning the killing of patients.
Many doctors argue that euthanasia does not belong in medicine. It is not uncommon to hear doctors invoking the first precept of the Hippocratic Oath, primum non nocere (do no harm), as an argument against physician participation in euthanasia. Palliative care physicians argue that the refractory pain that is the supposed target of euthanasia legislation can in fact be alleviated with appropriate analgesics. In any case, it is a basic dictum of palliative care that death is a natural part of life that ought not be hastened nor inappropriately prolonged.
Physicians also raise more specific concerns about the regulation of euthanasia. Some argue that euthanasia is unsafe and will lead to wrongful deaths. Many are concerned that patients are not being adequately assessed for depression or that patients with complex mental illnesses are utilizing euthanasia on account of a lack of appropriate social support. Others have warned of suicide contagion as a result of euthanasia—a concern for which there is at least some evidence.
The permissibility of conscientious objection to euthanasia
What is important is not so much whether one finds these arguments ultimately persuasive. What matters is whether they are reasonable. The notion of reasonableness and its close cousin reasonable disagreement have been the subject of much contention within philosophical circles in recent decades. Such philosophical speculation need not concern us here. What matters is whether it is reasonable for a doctor to hold concerns about the risks and potential harms inherent in state sanctioned voluntary euthanasia. I believe the answer is yes. There is at least some evidence to suggest that euthanasia has been poorly regulated in jurisdictions where it is legal. In the Netherlands, for example, data suggests that upwards of 20% of euthanasia cases go unreported. Experts have also raised concerns that “evaluating patients’ [euthanasia] requests requires complicated judgements in implementing criteria that are intentionally open-ended, evolving and fraught with acknowledged interpretive difficulties”. In Canada, family members of euthanized patients have raised concerns about the way that doctors appear to ‘approve of’ situations of depression and social isolation.
And whatever one thinks of the ethics of physician assistance in suicide, it is undeniable that medicine’s participation in euthanasia constitutes a seismic shift—a movement away from a view of medicine as oriented toward the goals of health and well being and a movement toward the view that medicine is ancillary to the realization of patient preferences regardless of whether these preferences are conducive to health and well being. Indeed, the medical good just is what the patient wants in this new era of liberal medical norms.
One might argue that euthanasia is healthcare and that a right to access healthcare is fundamental. But considered on its own it is hard to see how this argument is anything more than question begging.
Some theorists express concern at the religious character of some instances of conscientious objection. It could be argued that religion has no place in healthcare and that objections based on religious belief ought not be permitted. But the distinction between what we might call ‘ethical’ and ‘religious’ objections is tenuous at best. It seems that many doctors hold views that have both an ethical and religious dimension, and it is not easy to separate these two elements. If anything, it seems that arguments across the spectrum in the euthanasia debate—even those in favor of euthanasia—have a quasi-religious character, particularly where they are motivated by a concern for human dignity.
The regulation of conscientious objection
Conscientious objection to euthanasia is tightly regulated in some jurisdictions. In Ontario, Canada, for example, doctors with a conscientious objection are obliged to provide an ‘effective referral’ to patients seeking access to euthanasia. Institutional conscientious objection—i.e., the non-participation of whole institutions in the provision of euthanasia—is also difficult in Canada and in some cases hospices have had their contracts revoked based on their opposition to euthanasia. In the Australian state of Queensland, institutional conscientious objection is highly restricted and faith-based healthcare providers cannot prevent doctors from accessing their facilities to assess patients for euthanasia eligibility.
We need to think carefully about how we regulate conscientious objection to euthanasia. Conscientious objectors may be thought by some to be bad faith actors. I would argue that the major concerns that motivate conscientious objection to euthanasia are in fact reasonable and worthy of our respect. Institutions are not the same as individual healthcare practitioners but analogous arguments can be made for their right to conscientious objection.
Conclusion
The accommodation of conscientious objection in healthcare reflects a mature understanding of moral disagreement in society. Euthanasia is no exception. Euthanasia constitutes a fundamental shift in the ethical orientation of end-of-life care and has proved difficult to regulate. Considering this, individual physicians and institutions ought to be allowed to opt out of the provision of euthanasia. Doctors and institutions with a conscientious objection should not be subject to punitive measures. Authentic liberalism in healthcare requires that we respect the values of doctors and institutions in addition to promoting patient interests.
Xavier Symons
Xavier Symons, Ph.D., is a Postdoctoral Research Fellow at the Human Flourishing Program at Harvard University. He previously worked as a bioethicist at the Australian Catholic University and The University of Notre Dame Australia. Xavier's research interests include ethical issues at the beginning and end of life, conscientious objection, the ethics of healthcare resource allocation, and pandemic ethics. His first book, Why Conscience Matters: A Defence of Conscientious Objection in Healthcare, was published in July 2022 by Routledge. Dr Symons is the recipient of a 2020 Fulbright Future Postdoctoral Scholarship and was a scholar in residence at Georgetown University’s Kennedy Institute for Ethics from September 2021 to March 2022. He holds degrees from the University of Sydney, the University of Oxford, and the Australian Catholic University.
