Conscientious Objection with Sarah Hull, MD
What you should know about your physician’s rights and duties
By Taruni Tangirala
A special thanks to Dr. Sarah Hull for lending her expertise to this blog post
Being a physician is a privilege, not a right—according to Dr. Sarah Hull, this is a central consideration regarding ethical clinical care. While there are cases in which physicians are justified in their rights to refuse to provide certain types of treatment, their professional duties undoubtedly include thoughtful consideration for patient well-being. Consequently, simply refusing to provide care to patients, or plain objection, is not analogous to conscientious objection.
But what is conscientious objection?
Two moral values that have a constant need to be resolved in the clinic are beneficent paternalism (“doctor knows best”) and autonomy above all (“patient knows best”). Paternalism has received a bad reputation as a concept over the years; of course, this is a completely valid perspective, especially in cases of excess/unjust paternalism. However, paternalism, applied in tandem with beneficence, should be treated in a more nuanced manner.
Ultimately, according to Dr. Hull, the physician’s general ethos towards the patient should be: “I am the expert, but you are the boss”; it is patient goals and values that should dictate treatment while being supplemented with the knowledge and experience of the clinician practitioner. This leads to the moral imperative that doctors should not force treatments upon patients that conflict with patient values. However, the onus of carrying out ethical care does not lie fully on the physician. On the receiving end of treatment, patients should not try to coerce doctors into providing medically inappropriate treatment, and they should not verbally or physically abuse clinicians.
Attempting to resolve all of these values can sometimes lead to conscientious objection.
Conscientious objection is a framework for ethical refusal on a clinician’s part— it can occur when either 1) clinicians are subjected to abusive treatment, 2) when requested treatment outside of the clinician’s scope of practice, or 3) when a request directly conflicts with the physician ethos, including principles of respecting patient autonomy, beneficence, and non-maleficence.
There are instances where physicians have to resolve their professional duties and personal rights while dealing with abusive behavior from patients. Dr. Hull explains that abuse from patients can consist of threatening or hateful language, violent behavior, or sexually inappropriate behavior. Sometimes, we can understand why patients would act out in an abusive manner towards clinicians— perhaps one feels frustrated about not receiving the treatment they believe they need.
However, a physician should not be obligated to provide care in such instances in order to account for their own well-being. As much as a patient may be suffering, either physically due to an ailment or mentally due to weariness of a system they feel has treated them unfairly, it is important to understand that clinicians are people with emotional needs, too. Furthermore, we must acknowledge that many times, what frustrates a patient is not necessarily the fault of the clinician who has treated them. Clinicians do have an obligation to try to redirect unproductive behavior on the part of a patient into a more constructive conversation, but this does not always work towards the best end. As Hull indicates, there are, of course, exceptions to the physician's right to refuse; perhaps a patient is in the middle of a mental health crisis, or the patient is critically ill and in need of urgent care.
The patient ethos of suffering is deservedly well-known, but patients must also keep in mind that clinicians are not gods, and as Dr. Hull cites her predecessor in the Yale Bioethics program saying, they certainly are not glorified vending machines either (“you can’t just ask, I want [some medication]– give this to me”). Physicians do have a scope of practice limitations.
In the case of Dr. Hull, as a cardiologist, there are many cases where she is not supposed to provide requested care simply due to the limitations of her area of expertise; for example, in most cases, she should not “prescribe pain medications for lower back strain or antibiotics for an ear infection”. Considering that there is a potential for maleficence if a physician’s scope of practice is ignored, it is important for patients to take into account a physician’s area of specialization when they can. Understanding what your practitioner’s area of expertise is and, consequently, the areas in which they can help you the most can lead to a more constructive patient-physician dynamic. Furthermore, understanding the physician’s time as a limited resource can help patients better optimize having their medical concerns addressed.
To this end, Hull underlines some core physician duties that take priority: first, we must consider that patients seek care not only to treat illness but also to promote wellness, and physicians have a duty to provide this care to the best of their abilities. Second, there are broad moral imperatives that physicians must follow, including respecting patient autonomy, improving quality of life and longevity when possible and desired, alleviating suffering, promoting fair allocation of medical resources, and avoiding doing net harm. When patient requests come into conflict with these duties, physicians may exercise their right of conscientious objection— examples mentioned by Dr. Hull include asking for antibiotics to treat a viral infection, which would not only be ineffective but could also have harmful side effects, as well as promote antibiotic resistance with no net gain. Another example would be asking for opioids not intended or effective for pain control— here, there is a potential for addiction and other adverse side effects. As Dr. Hull pithily put it, “Patient satisfaction should not supersede appropriate clinical care.”
In regards to conscientious objection, we must also understand that refusal due to professional duty violation is not the same as refusal due to personal reasons. Personal beliefs, whether religious or non-religious, should not cloud professional judgment. Hull provides the example that it is not okay for a cardiologist to refuse statin therapy or PCI (percutaneous coronary intervention) to a patient who will not give up eating meat. However, an appropriate application of physician duties would consist of counseling on the cardiovascular benefits of a plant-based diet.
Another significant consideration when it comes to conscientious objection according to Dr. Hull is that we shouldn’t manipulate a patient into doing anything, but we can act in good faith and try to make the best decision possible as it relates to the patient.
Dr. Sarah Hull emphasizes a balance between professional obligations, clinician rights, and patient rights. Specifically, in regards to conscientious objection, she says that we need to codify a clear framework for when the exercise of conscientious objections is permissible or impermissible; being inconsistent in our application of conscientious objection can lead to the facilitation of inequities among patients. A range of subjective factors can influence when a physician exercises conscientious objection; however, as a patient, understanding the framework of conscientious objection, as well as options such as ethics committees, can help one feel more educated and empowered in regards to their care.
See Dr. Sarah Hull’s piece in STAT News for more information on Conscientious Objection here.
sarah hull, md
Sarah C. Hull, MD, MBE is a board-certified cardiologist and echocardiographer whose clinical practice is focused on echocardiography and cardio-oncology (cardiac care of cancer patients). She is the cardiology course director at Yale School of Medicine (YSM) where she also teaches medical ethics to students and cardiology fellows. Additionally, she has served as an ethics consultant to the advanced heart failure and cardiac transplant team at Yale New Haven Hospital (YNHH). She was appointed Associate Director of the Program for Biomedical Ethics at YSM in 2019, and she also serves on the ethics committee at YNHH. Her most recent scholarly work has focused on ethical issues involving ventricular assist devices as destination therapy, ethical considerations in the care of patients with recurrent injection drug use related endocarditis, shared decision making in cardio-oncology, nutrition ethics, and ethical issues raised during the COVID pandemic.