Why conscientious objection merits respect
==========================================

* Ewan C. Goligher
* Lorenzo Del Sorbo
* Angela M. Cheung
* Shabbir M.H. Alibhai
* Lester Liao
* Alexandra Easson
* Janice Halpern
* E. Wesley Ely
* Daniel P. Sulmasy
* Stephen W. Hwang

In his important commentary on respecting conscientious objection to the provision of physician-assisted death (PAD), Dr. Fletcher cites the long-standing tradition of tolerance within the Canadian medical community.1 We wish to point out several more reasons for respecting conscientious objection to PAD.

First, there is no duty in Canadian law or medical ethics for physicians to provide access to PAD. In the Carter decision, the Supreme Court of Canada explicitly stated that legalizing PAD did not entail a duty on the part of physicians to provide PAD.

Second, physicians frequently decline to offer treatments because they deem them nonbeneficial or harmful.2 Insofar as all refusals of therapy are ultimately justified by the ethical belief that the goal of therapy is to provide benefit and avoid harm, all treatment refusals are matters of conscience.

Third, the ethical justification of PAD remains debatable because it relies on uncertain metaphysical assumptions about the benefit of death3–5 and contravenes widely held basic moral intuitions about the inestimable intrinsic value of humans.6 Because it remains distinctly possible that PAD is unethical, objecting physicians should not be forced to facilitate access to PAD for their patients.

Fourth, physicians are ethically complicit when they deliberately refer a patient for a specific intervention.7 For example, it is clearly objectionable to provide a referral for female genital mutilation. Analogously, if one finds PAD similarly unethical, providing a referral for PAD is highly objectionable and undermines one’s moral integrity.

Fifth, respect for conscientious objection upholds the moral integrity of physicians,8,9 the foundation for society’s confidence in the profession. Disregarding conscientious objection prioritizes moral conformity over moral integrity, undermining the trustworthiness of the profession. Prioritizing moral integrity by respecting conscientious objection can foster quality medical care and enhance patient safety.10

## References

1.  Fletcher J. Right to die in Canada: respecting the wishes of physician conscientious objectors. CMAJ 2015;187:1339.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTg3LzE4LzEzMzkiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTg4LzExLzgyMi4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

2.  Downar J, Warner M, Sibbald R. Mandate to obtain consent for withholding nonbeneficial cardiopulmonary resuscitation is misguided. CMAJ 2016;188:245–6.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODgvNC8yNDUiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTg4LzExLzgyMi4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

3.  Schüklenk U, van Delden JJ, Downie J, et al. End-of-life decision-making in Canada: the report by the Royal Society of Canada expert panel on end-of-life decision-making. Bioethics 2011;25(suppl 1):1–73.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=19594724&link_type=MED&atom=%2Fcmaj%2F188%2F11%2F822.2.atom) 

4.  Kortenkamp KV, Moore CF. Ethics under uncertainty: the morality and appropriateness of utilitarianism when outcomes are uncertain. Am J Psychol 2014;127:367–82.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.5406/amerjpsyc.127.3.0367&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=25588277&link_type=MED&atom=%2Fcmaj%2F188%2F11%2F822.2.atom) 

5.  Goligher EC, Ely EW, Sulmasy DP, et al. Physician-assisted suicide and euthanasia in the intensive care unit: a dialogue on core ethical issues. Crit Care Med. In press.
    
    

6.  Crawshaw R, Rogers DE, Pellegrino ED, et al. Patient–physician covenant. JAMA 1995;273:1553.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.1995.03520430089054&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=7739086&link_type=MED&atom=%2Fcmaj%2F188%2F11%2F822.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=A1995QX41800042&link_type=ISI) 

7.  Magelssen M. When should conscientious objection be accepted? J Med Ethics 2012;38:18–21.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6OToibWVkZXRoaWNzIjtzOjU6InJlc2lkIjtzOjc6IjM4LzEvMTgiO3M6NDoiYXRvbSI7czoyMzoiL2NtYWovMTg4LzExLzgyMi4yLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

8.  Sulmasy DP. What is conscience and why is respect for it so important? Theor Med Bioeth 2008; 29:135–49.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1007/s11017-008-9072-2&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=18758994&link_type=MED&atom=%2Fcmaj%2F188%2F11%2F822.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000260221100002&link_type=ISI) 

9.  Lewis-Newby M, Wicclair M, Pope T, et al. An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med 2015; 191:219–27.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1164/rccm.201410-1916ST&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=25590155&link_type=MED&atom=%2Fcmaj%2F188%2F11%2F822.2.atom) 

10. White DB, Brody B. Would accommodating some conscientious objections by physicians promote quality in medical care? JAMA 2011;305:1804–5.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1001/jama.2011.575&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=21540425&link_type=MED&atom=%2Fcmaj%2F188%2F11%2F822.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000290156200023&link_type=ISI)