Voluntary assisted dying: should conscientious objection be unconditional?

Abstract

In the debate about whether to allow conscientious objection for voluntary assisted dying (VAD), there are two extreme positions. One maintains that it should be prohibited altogether;1 the other, that it should be allowed without any conditions, such as a requirement to refer a patient on to another health practitioner who does not conscientiously object, or to inform the patient of the existence of such practitioners.2 In practice, the argument about whether to permit conscientious objection has already been won, and the remaining issue in contention is solely one of scope: what limitations or conditions should be imposed on the right to object? In Victoria, the right to conscientious objection is unconditional whereas in Western Australia, the objector has an obligation to give the patient some basic information about their options (the nature of the information has yet to be determined but is likely to include information about the availability of VAD). In this editorial, I argue that it is a mistake to allow conscientious objection unconditionally. To make my case, I will target the strongest argument in favour of unconditional conscientious objection: that any obligation to inform a patient of, or refer a patient on to, a participating VAD practitioner amounts to forced complicity, undermining the very point of permitting conscientious objection in the first place. To begin to see what is wrong with this argument, it is necessary to understand the nature of the VAD debate. Some ethical issues concern matters about which people can reasonably disagree.3 You and I can have strong personal opinions about these matters, but the existence of this disagreement does not imply that one of us is irrational. Even in ideal conversation conditions and with fully informed parties, residual disagreement is still possible. Note that this is not true about all ethical issues. We could not have a rational debate whether we can deny life-saving treatment to people from certain backgrounds, or whether we should legalise the torture of innocent people for fun. Debate about these matters would not be reasonable: there could be no remaining disagreement after a conversation in ideal conditions between fully informed parties. It is because people can reasonably disagree about some issues – abortion is another example – that our democratic society recognises the right of each one of us to make up our own minds about them. We are entitled to hold our own views about these issues, and act accordingly in our own lives. This is why, in the VAD and related debates, we hear so much about the importance of autonomy. If the debate about whether to legalise VAD came down to matters of personal conscience alone, the default position would be to legislate to allow VAD, so that each of us can make up our own minds for ourselves about whether VAD is appropriate for us and our loved ones, should it ever come to it. A prohibition based on personal conscience holds everyone hostage to one view, but permitting VAD does not since it allows each of us to act on our own conscience instead. However, the decision to legalise VAD cannot be based on conscience alone: the state has an interest in protecting potentially vulnerable people from accessing VAD if they clearly ought not to do so (if they are coerced, for example).3 Concern about whether safeguards can be adequate has been the main issue dividing legislators in the past. This issue, however, is an empirical one, which ought not to be decided on conscience grounds, but on empirical ones. Differences of opinion about safety may remain, but they are amenable to empirical resolution. It is essential to keep these empirical matters separate from matters of personal conscience. Let us now turn to the right of conscientious objection by medical practitioners, in legislation permitting VAD. A legal right to conscientious objection reflects the fact that people are free to act in accordance with their own personal beliefs about this matter (this being an ethical issue on which reasonable minds may disagree); they should not be compelled to participate in a practice they feel is contrary to those beliefs. These beliefs can include beliefs about the role of the medical profession and the compatibility of VAD with that role. The debate is, however, about whether limits can be imposed on the practitioner’s right to object, given that the patient – as someone requesting, or who may wish to request, VAD – may reasonably have different personal beliefs from the practitioner on this matter. For some practitioners, being absolved from having to partake in the VAD scheme themselves is not enough; they may feel complicit in the practice if they are required to refer a patient who has approached them about VAD to another practitioner, or to give the patient prescribed information about VAD. The argument for unconditional conscientious objection relies on just this point, and proceeds as follows: if I believe VAD is murder, then it is equally wrong for me to play any part in it,2, 4 not just the part that involves administering the lethal drug or being part of the assessment regime to determine whether a patient qualifies for VAD. The better view is that it is not possible convincingly to demonstrate these two things and, with them, that VAD is murder. Certainly, I can reasonably believe it is against my profession’s role to end someone's life,5 just as I can believe that the only way to respect the miracle of life is to allow it to end naturally. Nevertheless, I must, in ideal conversation conditions and being fully informed, acknowledge competing conceptions of that role and of how to respect the miracle of life, which can reasonably be held by people who support VAD. The reasonableness of any such disagreement about VAD requires that I respect my patients’ rights to act on their own beliefs, which in turn entails an obligation adequately to inform my patients to enable them to act on their own conscience. An obligation to inform strikes the appropriate balance between the respective rights of practitioner and patient, especially since, as others have noted, practitioners have role obligations to provide a service that is legal.1 The author declare that he has no conflicts of interest.