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An Institutional Solution to Conflicts of Conscience in Medicine
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One of the most intriguing questions in medical ethics is whether individual physicians ought to be able to refuse conscientiously to provide services that patients seek. The issue requires us to delve into difficult problems, such as the extent to which physicians must subordinate their interests to those of their current or prospective patients, and how essential the services physicians object to are as new medical technologies develop. Despite the difficulty that surrounds this issue, many bioethicists—like Dan Brock and Mark Wicclair—have tried to address it in a single journal article. But Holly Fernandez Lynch is an exception. She gives conscientious objection in medicine (hereafter, “conscientious objection”) the book-length treatment that it deserves.

on conscientious objection. Among her reasons are that patients are not well served by physicians who have serious moral qualms about services that the patients need, and that medical professionalism does not require physicians to take all comers or to accede to all requests—even legitimate ones. She further explains that some refusals—such as a refusal to assist a sixty-year-old woman in conceiving a child—may be appropriate. We should not prevent physicians from making good objections, and we can probably think of some regardless of what our moral commitments are.

Lynch concludes that we need to allow some conscientious objection; however, some readers will find that she exaggerates this need. For example, some will object to what she says is the “strongest argument for retaining room for moral refusers”: the inability to know the answers to many of the moral questions that create controversy in medicine, such as whether a fetus is a person. Some readers will have more faith than Lynch does in the resources of moral philosophy to provide proofs for such claims.

Some may also feel that she overstates the importance of allowing conscientious objection by defining the term too broadly. For her, conscientious objection includes “refusals grounded in values that are widely held within the profession and have been accepted as clinical standards” (p. 34). An example would be a refusal to allow a sick child to decide on his own what his treatment will be. This unusually broad conception allows Lynch to say that taking a strong stand against conscientious objection commits one to the unhappy view that physicians are mere technicians who have no personal autonomy or morality of their own. If the professional standard is no conscientious objection, then physicians can never object to patient requests on grounds of conscience, even when their conscience aligns with what their profession requires of them. But is such absurdity a consequence of refusing to condone conscientious objection? Not if the category refers, as Dan Brock believes it does, only to objections to what is legal and professionally accepted.

Even those of us who feel she exaggerates, however, could agree with Lynch that a strict prohibition on conscientious objection is inappropriate. The question then becomes: How are we to make room for conscientious objection without eliminating patients’ access to important medical care? Lynch develops an “institutional solution” to this problem, the details of which take up much of her book.

The book has three main parts. In part one, Lynch describes the legal situation and the debate about conscientious objection in the United States. She argues in favor of resolving the debate by determining whether physicians have professional obligations that preclude them from exercising freedom of conscience in their capacity as physicians. She favors a model of medical professionalism that she calls the “gatekeeping paradigm.” It does not confer such obligations on physicians, but rather gives them significant latitude in which services they offer their patients. This model places the responsibility for ensuring that patients get the care they deserve on the profession, which is the true gatekeeper to medical services and is entrusted with a “legal monopoly” over medical care.

Part one and part two both lay the foundation for Lynch’s solution to the problem of conscientious objection. In part two, she argues that an institutional solution is better than an individual one, in part because it permits “morals matching”: that is, matching physicians with patients based on whether they have similar moral values. In...



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