In the course of three days, the Representative Body of the Norwegian Medical Association must discuss and resolve important issues of health policy. Unanimous decisions are often a strong side of the association, but they may also conceal deep-seated disagreement.
The Representative Body of the Norwegian Medical Association will hold its annual conference at the end of May. The Representative Body is the association’s highest decision-making body. This is the forum where important issues are being debated, the president and the Central Board are elected, accounts and budgets are approved and key decisions are made. The policies adopted during these three days will be decisive for the work of the association’s Central Board and secretariat over the coming year.
At the moment, the Representative Body has 142 members, elected according to a distribution formula between the professional associations, the local associations and the specialist associations. The Association of Retired Doctors and the Medical Students’ Association are also represented. In other words, this is a highly diverse group of doctors – ranging from those employed by the public sector to those who are working full time in the privatised health service, from retirees to students, from generalists at small local hospitals to highly specialised doctors and professors, doctors from all over, from big cities and not-so-big towns. Not unexpectedly, this group has differing views on a number of issues.
Even though opinions may differ, the Representative Body has a long and proud tradition of reaching consensus and unanimous decisions in major matters of principle that affect all doctors. This has been a key part of the association’s recipe for success. Thorough processes and discussions that involve a wide range of participants internally constitute a good foundation for ensuring that good decisions are made and the best proposals for solutions are put forward. The Norwegian Medical Association can speak as one with a single, distinctive voice, and this imbues it with weight and credibility as a health-policy actor. Consensus is crucial to maintaining unity in a large association. If distinct factions are forming internally and a minority is repeatedly overruled in important issues, there is a risk that the association will split. Consensus is hard to achieve, but those that succeed in reaching it will also have more influence. The Representative Body therefore has a demanding task in identifying solutions that the entire association can endorse.
Problems arise when the desire for unanimity comes at the cost of the quality of the decision. When numerous conflicting views need to be taken into consideration, a decision that permits various interpretations and ways of understanding may be the final result. General and vague decisions may complicate the job of those who will implement them and continue to work with them, and this may cause internal tension and dissatisfaction.
One of the key topics for discussion during last year’s conference of the Representative Body was the doctors’ right to conscientious objection. This arose as an issue in 2011, when the Ministry of Health and Care Services issued a circular making clear that according to the regulations, general practitioners could not object to referring patients for abortion or assisted fertilisation, or to prescribing certain forms of contraception (1), despite the fact that such objection had been practised by some GPs for many years. After thorough preparation by a working group appointed by the Representative Body, a round of consultations that encompassed all levels of the association and an exhaustive discussion in the Representative Body, it became clear that there were strongly differing opinions regarding this issue. This notwithstanding, a unanimous decision could be reached (2). The resolution was held in fairly general terms – without any specification of what group of doctors should be permitted to object, what types of situations that would qualify as «serious matters of conscience associated with life or death» or what was meant by saying that the patient should be encountered with respect and compassion. Thus, both adherents and opponents of the GP’s right to object to referring patients to an abortion – such as the government later proposed – could endorse the decision.
This decision is also an example of the Norwegian Medical Association’s importance as a health-policy actor. The association is the only professional organisation which is referred to in the cooperation agreement between the government parties, the Christian Democratic Party and the Liberal Party. The agreement states: «Following dialogue with the Norwegian Medical Association, GPs will be given the opportunity to make reservations against certain actions». The association’s decision was used as an argument to introduce a right to conscientious objection against referrals for abortion, and the Minister of Health stated that hereby the Norwegian Medical Association’s policy had prevailed (4). The discussion that ensued in the aftermath of the agreement and the subsequent proposal for a legal amendment (5) is well known. The Norwegian Medical Association was not very visible in this discussion, in spite of its prominent role in the cooperation agreement. What was the association supposed to think about this matter? The decision of the Representative Body did not provide a clear mandate to express an opinion in specific cases in which doctors may wish to object.
The Norwegian Medical Association never submitted a final consultation response, since the government withdrew its proposal before the deadline had expired. Judging from the responses submitted by the sub-associations during the internal consultation, however, it can be assumed that the Norwegian Medical Association would have been unable to endorse the proposal. The association’s membership was also engaged and provoked by the matter, and during winter it became clear that the issue needed to be discussed by Representative Body again this year.
We can learn a lot from this case, for example about situations when consensus has its limitations. Consensus is a good thing, but only when it is real. If opinions differ so strongly that the resolution must be held in too general terms and is open to varying interpretations, consensus is of little worth. Then, it might be better to sacrifice the consensus. When ethical dilemmas are being discussed, one can rarely plead for unanimity – if so, it would not be a dilemma.