A central theme of my bioethics research is what I call fully realized patient-centred care. You’d be hard pressed to find a hospital in the United States or Canada that doesn’t use the phrase ‘patient-centred care’, but there are numerous ways that health care doesn’t put patients first.
Here’s the basic case for fully realized patient-centred care. Despite what you might have heard, the main goal of medicine is to promote patient values. Patient-centred care arose as a response to a paternalistic medical system where physicians got to decide on the plan of care and the patients had no say (or even knew what was going on). One reason this approach was bad is that healthcare providers are experts in diseases and their treatment, but deciding on the best treatment is about values. We can only follow the science if we agree on the goal, but people have different medical goals. Some want to pursue aggressive treatment no matter what, while others want to maximize quality time with their loved ones. The patient is best placed to make these decisions, with the physician there to help make sense of the options.
In many cases, patient values are best promoted by interventions aimed at healing, which is the traditional aim of medicine. A patient who breaks her arm snowboarding probably just wants to no longer be in pain and to have a functioning arm again. But lots of common medical interventions are best explained by value promotion, not healing. For instance, vasectomy and tubal ligation don’t involve healing, but they’re uncontroversially part of medicine for the simple reason that medical expertise is the best way to promote these aims.
Thankfully, patient-centred care is no longer the controversial position it once was. Nevertheless, there’s still some way to go before it’s fully realized. Here’s a simple test to see if a policy, proposed intervention, or interaction is patient-centred:
PCC Test: Does the policy, intervention, or interaction prioritize the wishes, values, and beliefs of the patient? If not, then it’s not patient-centred.
Now, sometimes promoting a patient’s values will conflict with other important values, such as the values of other patients. So if a patient says “Look doctor, I know I just tested positive for Ebola, but I really want to go to the Taylor Swift concert tonight”, then the doctor is justified in saying “What? No. That’s a bad idea. Please stay in your room.” But cases like this aren’t really a problem, since we’re trying to find the approach that is most value promoting across all patients (though tough cases will exist in practice).
Patient-centred care should be the default, determined using the test above, and then we can consider counterexamples as they arise. Using this approach, one of the policies that has to go is the broad acceptance of conscientious objection in medicine. Someone conscientiously objects when they refuse to perform a part of their professional role because doing so would conflict with their personal beliefs. The care in these cases is legal, beneficial, and requested by the patient. Conscientious objectors in health care are given wide latitude in the United States, Canada, and Europe, where they can refuse to participate in many different things, though the most common objections are to contraception, abortion, and assisted dying.
Allowing conscientious objection is not patient-centred, since a policy that allows conscientious objection, and the practice of conscientiously objecting in individual cases, is not prioritizing the wishes, values, and beliefs of patients. The effects on treatment access and quality can be significant at a time when these are already major access issues across the healthcare system. As Jacquelyn Shaw and Jocelyn Downie argue, conscientious objection increases the burden and costs for other providers and the broader system.
Conscientious objection also tends to have an especially negative effect on women, including those who are young, low-income, or otherwise marginalized. It is an affront to be told, even only through implication, that you’re acting wrongly by seeking an abortion or the morning after pill. There is an extreme power asymmetry between providers, who experience no burden at all by objecting, and vulnerable patients, who face potentially significant burdens by being refused care. Even in a large city where there are multiple doctors or pharmacists available, waiting at a drop-in clinic only to be told that you cannot receive a legal, beneficial treatment is an injustice.
Proponents of conscientious objection usually reason as follows. Since there’s a fundamental moral right to conscience, which is also legally recognized (e.g., section 2a of the Canadian Charter of Rights and Freedoms), it would be a serious rights violation to force people to perform medical procedures that go against their beliefs. Therefore, we have to allow conscientious objection, regardless of the downsides.
I grant the premise, but the conclusion doesn’t get us to the current state of permissiveness. This is partly due to how we interpret what it means to force people to do something. (What follows is very much not legal advice.) Here’s what I have in mind.
A hospital decides that it’s going to start taking patient-centred care more seriously, so it changes its hiring policies. The application form now reads as follows:
To promote the safety and well-being of our patients, this hospital has the following requirements for employment: you must have suitable training for the role; you must follow all safety requirements, including wearing appropriate personal protective equipment (PPE); you are required to be up to date on the vaccinations listed below; and, if hired, you are required to perform all the functions of the role. If you object to any of these requirements, you will not be hired. If you object to any of these policies in the future, your employment will be terminated.
Are the people who decide to proceed with the application being wrongfully forced? No. The hospital’s criteria are all justified, so it is ethically acceptable for the hospital to screen for people who refuse to get vaccinated or wear appropriate PPE. It’s also acceptable to screen out people who don’t want to prescribe contraception or participate in abortions, assisted dying provisions, gender confirming surgeries, etc.
Notice that this doesn’t necessarily mean that conscientious objectors can no longer work in health care. For example, a pharmacist who’s against prescribing contraception can work in a seniors’ facility, a nurse who doesn’t want to participate in MAiD provisions can find a position that won’t require doing so, etc.
Changing hiring practices and hospital policies will effectively address the issue, as will other structural changes. Medical school and residency admissions can screen for conscientious objection in the same way: e.g., “If you become an OB-GYN, you will be required to learn how to perform abortions and to perform them yourself. Is that something you are okay with?” If not, fine! No one is being forced to become an OB-GYN or to perform abortions. They can choose a different specialization or, if they’re really worried, a different profession.
We can respect the right to conscience by ensuring that people won’t be put in a position that conflicts with their beliefs. We do that by not hiring people for positions for which they’re unsuited.
So the next time you see a hospital promoting patient-centred care, be sure to ask about its conscientious objection policies.
It may be that conscientious objection exercised by practitioners does not prioritize the reflexive wishes of patients. But it may prioritize the goal of medicine, the best care possible. Often patients may seek MAiD after a serious injury or in fear of a progressive illness where those who object to providing the service will instead seek to mitigate those fears and assure proper care. And the final value of patients is their care. Where the system is limited in the access to care in general, the answer isn't to deny conscientious objection by practitioners but ... increase services in the system. MAid isn't 'working great' and those in palliative care who object do so in the belief their goal is, and should be the care of the person, maximizing his or her life quality, and not its ending.
Tom Koch
http://kochworks.com