The physician as a conscientious objector.

I. ACCOMMODATION OF THE CONSCIENTIOUS OBJECTOR Rabbinic lore relates an anecdote, probably apocryphal, portraying a lively student who flits from person to person in the study hall. To each one he says, I have an answer. Ask me a question! I do not claim to have a resolution to the dilemma posed when a conflict arises between a patient's rights and a physician's conscience, certainly not a facile one. My real task is to convince those in a position to implement a solution that a problem exists and that it merits serious consideration. Patient autonomy certainly deserves both moral respect and legal protection, but to demand of a physician that she act in a manner she deems to be morally unpalatable not only compromises the physician's ethical integrity, but is also likely to have a corrosive effect upon the dedication and zeal with which she ministers to patients. Society has long recognized and been forced to come to grips with the conflict arising from a woman's right to terminate a pregnancy as announced by the United States Supreme Court in Roe v. Wade, (1) and the moral convictions of a health care practitioner that constrain her to refuse to participate in the extinguishing of nascent human life. A physician's belief that certain forms of assisted reproduction constitute a violation of natural law does not impact an infertile couple's right of procreation for the simple reason that a physician who espouses such views will choose another area of specialization. Yet, the issue of whether an employer who finds such forms of procreation to be morally offensive that must nevertheless include coverage of such forms of fertility treatment in health care insurance provided to employees represents an unresolved moral dilemma as evidenced by a recent debate in the New York legislature. (2) Finally, the courts in Tarasoff v. Regents of the University of California (3) and its progeny have long since recognized and addressed the issue of maintaining professional confidentiality in the face of imminent criminal activity. H. CONSCIENTIOUS OBJECTION VS. PATIENT AUTONOMY There remain two areas in which conflicts do exist, but are largely ignored. First, is the treatment of the terminally ill, in both the broad sense of the term and the more narrow sense, the determination of the time of death at which continued treatment is regarded as inappropriate. The second is in the field of neonatology with regard to the institution of measures designed to assure the survival of an unborn infant suffering from a serious congenital anomaly. Contemporary society has long conscientiously subscribed to the tongue-in-cheek adage formulated by Arthur Clough: "Thou shalt not kill; but needs't not strive officiously to keep alive." (4) However, there are individuals who sincerely believe that the preservation of life is a paramount value, and that the quality of life preserved is irrelevant to fulfillment of the moral imperative generated by that value. For these individuals, failure to provide aggressive treatment for even the most premature neonate, for instance the infant afflicted with spina bifida, (5) or a severe chromosomal defect, (6) is the moral equivalent of infanticide. Likewise, failure to intubate (7) a terminally comatose patient, or even to administer cardiopulmonary resuscitation, (8) when there is a realistic possibility of clinical success, constitutes passive euthanasia. These individuals would also consider employment of neurological criteria in pronouncing death nothing but a deceptive subterfuge designed to disguise an immoral act by means of semantic sleight of hand. There have been a number of instances where hospitals have declined to honor a request for discontinuance of a feeding tube and other life supporting technology. (9) However, such occurrences have been few and far between and have involved matters of institutional policy rather than an expression of the qualms of an individual physician or nurse. …