The Unwilling Ethicist and Assisted Dying

Lori Seller and Veronique Fraser explore whether clinical ethicists should have the right to conscientiously object to ethics consultations for assisted dying.

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On December 10, 2015, An Act Respecting End-of-Life Care came into force, and Quebec became the first jurisdiction in Canada to allow physician-assisted death. This Act, which legislates medical aid in dying in Quebec, states that physicians (and other health care professionals) may refuse to administer (or take part in administering) medical aid in dying. When this is the case, the physician must inform the Director General of the institution of the request for assisted death, who must then identify a willing physician.

As professional ethicists working for the Centre for Applied Ethics of the McGill University Health Centre, we participated in the challenging task of bringing an ethics perspective to the local implementation of Quebec’s medical aid in dying legislation. Not surprisingly, the passionate debate that discussion of physician-assisted death often engenders was reflected within the walls of our Health Centre. We were however, somewhat taken aback when our involvement revealed that the ethicists at our Health Center held deep and disparate convictions about the moral justifiability of physician-assisted death.

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The Old Burying Ground, Halifax Nova Scotia. Photo Credit: Angel Petropanagos

Conscientious objection is something our ethicists routinely identify as an option for health care professionals who find themselves in situations that challenge their moral integrity or religious beliefs, but is this option also available to clinical ethicists? We found ourselves asking the following questions: Should a clinical ethicist have the right to conscientious objection in cases of medical aid in dying? Can the role of the clinical ethicist to provide ethics analysis in matters of moral ambiguity be reconciled with a right to opt-out on the basis of personal convictions?

On the one hand, many health care professionals’ codes of ethics recognize conscientious objection. Specifically, they recognize that forcing professionals to participate in acts that compromise their personal morality causes significant moral harm. Presumably this reasoning also applies to clinical ethicists, unless there is something unique to the role of clinical ethicists that would mitigate their claim to conscientious objection. In our view, it is plausible to suggest that individuals who devote their professional careers to clinical ethics have a strong sense of personal moral integrity and therefore may be particularly vulnerable to threats to their conscience. Accordingly, perhaps clinical ethicists should have the same right to act on their personal convictions as other health care professionals.

On the other hand, there is a growing consensus that clinical ethics expertise is grounded in the competence of the clinical ethicist to facilitate a robust process aimed at ensuring fair and transparent healthcare decisions. The clinical ethicist is expected to adopt a stance of neutrality which allows her to facilitate discussion of competing values without allowing her own beliefs to influence the discussion. On this view, it is not the “rightness” or “wrongness” of the final outcome by which the clinical ethicist is professionally judged, but rather her skill in guiding various stakeholders through a reasonable process; a clinical ethicist’s personal convictions should not impact on her ability to facilitate this process. In this sense, perhaps the right to conscientious objection is antithetical to the provision of clinical ethics consultation, as it seems to call into question the profession’s ability to remain neutral on morally contentious issues.

Professional standards for health care ethicists recommend keeping in check personal value judgments and moral preferences, managing conflict of interest and preserving integrity when providing ethics consultation services. What interests us here is whether, in the face of strong personal convictions on a particular issue, a clinical ethicist might remove herself not simply as a procedural caution to protect against prejudice or bias, but as a matter of principle to protect her own moral integrity.

In light of the Supreme Court of Canada ruling in Carter v. Canada (Attorney General) and the increasing focus on the professionalization of clinical ethics, this topic may be particularly relevant to Canadian clinical ethicists. If conscientious objection is a right for clinical ethicists, as for most other health professionals, then we should begin to direct our attention to outlining circumstances under which it is justified and how it should be put into practice. If conscientious objection is not a right for clinical ethicists, then a strong justification for this position should be clearly articulated.

To our knowledge, the question of whether clinical ethicists can conscientiously object has not been widely discussed. Now is an ideal time for us to consider this matter with particular attention to the practical and substantive challenges of providing clinical ethics expertise in situations that run counter to one’s moral values.

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Lori Seller is a practicing Healthcare Ethicist at the Centre for Applied Ethics at McGill University Health Centre.

Veronique Fraser is a practicing Healthcare Ethicist at the Centre for Applied Ethics at McGill University Health Centre.