'What are the editors of a once fine journal of medical knowledge doing, to let such an opinion piece be published?'asks one reader.[1] Another despairs that,'After 30 years of reading the BMJ, Savulescu's article was the first to make me feel physically sick'.[2]
The cause of the avalanche of protest of which these comments were but a small part, was an article by the utilitarian, Oxford philosopher, Julian Savulescu, in which he attempted to deny a place for conscientious objectors in medicine.[3] From his (possibly ironic and certainly incorrectly referenced) starting point of Shakespeare's Richard III's 'Conscience is but a word cowards use, devised at first to keep the strong in awe', he pursues a curiously ill-thought out path of iconoclastic rhetoric which fully deserved the strong reactions it received.
Savulescu contends that 'a doctor's conscience has little place in the delivery of modern medical care'. Conscientious objection is a hangover from the bad old days of paternalistic medicine. Furthermore, in a system where 'less than half of doctors whose primary job it is to deal with TOP would facilitate a termination at 13 weeks if the woman wanted it for career reasons', conscientious objection results in both inefficiency and inequity. Religious values 'corrupt'the delivery of health care and to allow conscientious objection on the basis of them is clearly discriminatory when 'other values can be as closely held and as central to conceptions of the good life as religious values'.
However Savulescu makes several false assumptions including that what is legal is just. The Nazis would have applauded his assertion that we should not 'allow moral values to corrupt the delivery of a just and legal health service'. It was doctors'compliance with a law they saw as just, that facilitated the Holocaust.[4]
Secondly, he appears to conflate conscientious objection with religious belief. There are many doctors today with no religious belief, as well as many with it, who consider euthanasia and abortion to be intentional killing of the innocent and having no place in the delivery of medical care. Several respondents link the desperation of Savulescu's pleas with the desperation expressed by RCOG President, Allan Templeton, recently over the recruitment crisis in England and Wales in O&G.[5] Only about two in every 100 medical graduates are now opting for the specialty, a figure that needs to be trebled if hospitals are to 'keep pace with increasing expectations from patients'. One such graduate (now a dermatologist) relates how: 'Applying for an obstetric SHO post as part of my GP training in the 1980s, I was informed in the job description that “the unit carries out approximately 1,000 terminations a year and the SHO will be expected to participate”. I didn't apply, and never did an Obs/gynae job, which affected my career. No doubt I could have found an O&G SHO post somewhere, but rightly or wrongly I didn't, due to the real or perceived pressure to be involved in abortions.'[6] I understand from colleagues in Northern Ireland there is no recruitment crisis there.
This ties in with Savulescu's apparent failure to recognise the irony of his reluctant acceptance of conscientious objection only in situations where there are enough other doctors to do the killing (or whatever else may be objected to). If, as Savulescu suggests, conscientious objectors don't become gynaecologists, then the crisis will just deepen. Furthermore some patients only want to be cared for by obstetricians who will not do abortions. It is surely not paternalism to allow them that choice where possible. Pro-choice lobbyists can be remarkably intolerant in some situations. It is because conscientious objectors share Savulescu's belief that 'the primary goal of a health service is to protect the health of its recipients'that they are objectors. It is difficult to see how the abortionist's curette benefits the recipient fetus.
If values have no place in determining medical care, on what basis does Savulescu attempt to impose his own moral values on conscientious objectors? His own paternalism and his ideal of 'statute-driven medicine' appear more 'idiosyncratic, bigoted and discriminatory' than the moral values he is so intolerant of.
However he is not alone and his editorial appears to be just the most widely-criticised element of a concerted campaign against conscientious objection in medicine. Recent reviews in several GP weeklies of a paper indicating that 15% of doctors would pass a woman requesting an abortion onto a colleague to arrange the referral were universally outraged that this was the case and called for the number of such doctors to be reduced! Sam Rowlands, in an otherwise helpful overview on caring for women seeking abortion, suggests that 'Abortion can no longer be considered an area of medicine where personal beliefs can be expressed'.[7]
Last year The Times reported on Prof Wendy Savage's 'campaign to expose pro-life doctors'.[8] A glance at the Voice for Choice website will give a good insight into the supporters of the campaign, though very little information as to its plans.[9] It is certain however that, as the number of abortions continues to rise and the number of doctors willing to carry them out falls, the abortion industry will do all in its power to try and prevent doctors' exercising their right of conscientious objection in this area.Vigilance is required both at GMC level and government level to save conscientious objectors from the assault of those who know not that 'conscience is born of love'.[10]
