With a licence to doubt

From the editor


    Is our domestic debate on the right to conscientious objection in some way related to the atrocities that were perpetrated during the Second World War? Perhaps.

    Photo: Einar Nilsen
    Photo: Einar Nilsen

    I'm in trouble, she said / to him. That was the first / time in history that anyone / had ever spoken of me.

    Alden Nowlan (1933 – 83)

    «With biomedical progress and changing attitudes in society, it seems reasonable that controversial health services will gradually become rights, and that doctors’ reservations about providing certain options will become a difficult topic in the years to come,» said Markestad and Hytten in their article Where are the boundaries of the right to conscientious objection? in the Journal of the Norwegian Medical Association in 2010 (1). They could hardly have imagined how vociferous and irreconcilable the debate over the right to conscientious objection was to become.

    Maybe a letter to the editor referring to Markedstad and Hytten’s article can provide us with some clues as to why this debate has assumed such a character. In it, the writer was calling for a statutory right to follow one’s conscience (2). He was not alone in calling for this. The Norwegian Christian Medical Association had the right to conscientious objection as the main topic of its General Assembly in 2011. The Ministry of Health and Care Services, on the other hand, was seeking to tighten the prevailing practice, and issued a circular with formulations that did not exactly invite for any dialogue (3): «The provision (in the Regulation relating to a municipal regular GP scheme) does not entitle the GP to deny or refrain from referring the patient to other services for reasons other than that the patient is not in need of such further referral. Moreover, Section 7 of the Regulation relating to a municipal regular GP scheme does not permit the parties, i.e. the municipality and the GP, to waive this provision. The municipality and the GP are not granted the discretion – by way of an agreement – to set limits on the responsibility of the GP for the patients on his/her list, including to agree that the GP for reasons of conscience should be exempt from performing certain tasks.» Was it the «objecting doctors» or the health authorities that pushed this complicated issue to its logical conclusion and reframed it in legal terms? I have no answer to this, but it was unfortunate all the same.

    We here in Norway are obviously not alone in discussing whether and to what extent the preferences, values and conscience of doctors should be permitted to have an impact on their medical practice. This topic is so difficult that not even the World Medical Association (WMA), which was established in 1947 to ensure that doctors could take medical decisions independently of political authorities, has been able to address it (1). The BMJ addressed the issue in an editorial in 2006 (4), and the author – who currently is editor of the Journal of Medical Ethics – took a view which is fairly close to that of the Norwegian opponents of the right to conscientious objection: he claimed that decisions regarding the kinds of health services that doctors should provide should primarily be governed by laws, regulations and principles of fair distribution of limited resources. Emphasis should be placed on the wishes of the patient and society, not on the values and conscience of the doctor. The 61 comments that have been added to the online version of the article illustrate that the matter is not quite as straightforward.

    Hartmut Hanauske-Abel is a German researcher and doctor who has spent most of his professional life in the USA and devoted his time to basic research. One of his most cited articles, however, addresses a completely different issue: how German doctors, the German medical association and the German medical journal were not victims, but rather abettors of the atrocities that were committed during the Second World War (5). He refers to statements issued by the German doctors and their medical association long before the crimes in the concentration camps had been perpetrated. About forced sterilisation they said, for example, that «this is the only safe way to prevent serious hereditary diseases and thus an expression of concern for future generations», and that «the primary task of doctors is to serve the state». The Aktion T4 – the euthanasia programme that killed tens of thousands of «incurably ill people» – was condoned with reference to its cost-efficiency.

    Hanauske-Abel’s main point is not to present all the cruelties committed by German doctors before and during the Second World War, but to demonstrate how easily the same things could happen again. In his opinion, they were made possible by a set of coinciding circumstances: medical progress, economic depression, legal decisions and public regulations. The situation appears frighteningly familiar, and the argumentation is eerily similar to the one propounded by Savulescu in the BMJ in 2006 (4).So how can we prevent history from repeating itself? Primarily by having an open and unprejudiced discussion on the sort of doctors and the sort of society we want, and by acknowledging that solutions other than those we ourselves claim to be the very best may also be beneficial to society – even if we dislike them.

    The quote in the introduction is the first verse of the poem It’s good to be here by the poet Alden Nowlan (6). In this poem, Nowlan describes the situation when his mother, who was 14 years old, told his unemployed father that she was pregnant. This is in 1932, at the height of the Great Depression. It is not a happy story – neither the poem, nor Nowlan’s own life. It would have been easy to understand his parents if they had decided on an abortion. Perhaps this would even have served them better? But Alden Nowlan himself – and we who are reading his poetry – are quite naturally glad that they decided otherwise. What would have been the correct advice for the doctor to give to Nowlan’s mother? It should be legally as well as ethically defensible to remain in doubt about this.


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