Conscientious objection to enforcing living wills: A conflict between beneficence and autonomy and a solution from Indian philosophy

Abstract

Living wills document how patients wish to be treated in the event of becoming incompetent to make their medical decisions. Living wills are legally enforceable in India, nonetheless, doctors can claim conscientious objection to implementing any aspect of such directives; however, the buck stops with the hospital to ensure that the patient’s wishes are carried out. In enforcing advance care directives, beneficence and autonomy usually come into conflict. In a paternalistic model of medicine, beneficence and nonmaleficence take precedence over autonomy, and there is a danger that the patient’s wishes are ignored. Even if a physician is not trained to give equal importance to autonomy, beneficence, and nonmaleficence, they can rationalize the enforcement of an advance care directive under the principle of nonmaleficence rather than under autonomy. The ethical principles of ahimsa—the principle of not being the cause of physical or mental injury of others—and raja dharma—the principle where a person in a position of power puts the wishes of the person whom they have power over ahead of their own wishes—which are derived from Hindu, Buddhist, and Jain philosophical traditions, can help physicians who practice Indic faiths resolve their moral dilemma when faced with a possibility of enforcing a patient’s wishes that are not in line with their personal views. Such moralizing is especially important during public health emergencies when a patient may not be able to transfer to the care of another doctor who does not have an objection to enforcing their living will.