Adam, a 33-year-old man with AIDS, is in the ICU. He is on a ventilator and has multiple organ system failure. Although conscious, he is unable to make decisions for himself. His parents, as his surrogates, demand that everything possible be done for him. Dr. Davis, the attending physician, believes that additional treatment is actually harming Adam and is prolonging his suffering without offering any hope of recovery. She wants to discontinue all treatment except for palliative care. Nurse Wilson, like Adam's parents, does not share Dr. Davis's view, and he is concerned that he may be required to carry out an order to discontinue life-sustaining treatment, a decision with which he disagrees.
Patients (or their surrogates) have the right to control many aspects of their health care. However, just because patients have a right to decide on their treatment, do caregivers and health care institutions have an absolute ethical obligation to provide that treatment?
The answer is: not necessarily. Under a principle called conscientious objection, caregivers may refuse to provide some medical treatments under certain conditions. Just as patients have views that shape their decisions about the medical care they want, caregivers may have their own moral convictions about the kinds of care they can provide. Some of the ethical considerations underlying a caregiver's request not to participate in specific treatments are discussed below.
First, the principle of conscientious objection applies to caregivers, such as physicians, nurses, and therapists. Some institutions, including Advocate, extend the principle to all staff members who provide services directly to patients. Whether institutions may also object to participating in treatment is controversial. Some people question whether an institution can have the same kind of moral conscience that a person has, and thus whether a principle of conscientious objection would apply to it. And some argue that a health care institution has special obligations to meet health care needs because it has a public status (that is, it receives certain kinds of public benefits, which obligate it to provide services). The majority opinion is that organizations are moral entities, with the rights and obligations moral standing entails.
Second, a caregiver's objection to providing treatment must be based on some significant consideration. Under Advocate's policy, conscientious objection must rest upon the associate's religious beliefs, personal cultural values, or ethics. In this case, it is likely that both Dr. Davis and Nurse Wilson could satisfy this standard. If the hospital were to object to Adam's care, its objections might be based on its mission and values and would be found in its policies. For example, there might be an explicit policy against withdrawing nutrition and hydration that would put Dr. Davis in opposition to the hospital. Or a policy might provide that high-quality medical care be determined by the hospital's physicians, which would support Dr. Davis's wish to discontinue treatment.
Third, conscientious objection must concern a medical or health care treatment. Although abortion and assisted reproduction are commonly thought of in this context, other relevant treatments are either objectionable from the outset (religious objection to organ transplantation) or become objectionable in specific cases (continuing treatment that does not appear to benefit the patient). Conscientious objection does not extend to a patient's status or condition. A caregiver may not, for instance, refuse to care for a person with HIV or AIDS or for an unmarried pregnant woman because the caregiver abhors the disease or the lifestyle of the patient.
Finally, a caregiver's conscientious objection must not result in neglect or abandonment of the patient. Continuity of care must be assured.
In the case of Adam, then, the attending physician and the nurse both have legitimate concerns that fulfill the ethical conditions necessary for conscientious objection—they are caregivers who, because of their personal ethical convictions, question continuing or discontinuing certain treatments. Whether acting on their objections would break the continuity of patient care is not entirely clear and requires careful clinical discernment.
Deciding when care is futile or inappropriate is controversial, and obviously involves both ethical and clinical judgments (there may be, for example, disagreement about Adam's prognosis). Dr. Davis has a duty to inform his parents that she cannot in good conscience continue treatment, and she is ethically obligated to refer him to another physician. Likewise, if the hospital objects to the treatment Adam's parents prefer, it must also aid them in finding alternative care. Finally, Nurse Wilson may also request to withdraw from this case. The result here may be that the parents will seek other providers. Often, however, conscientious objection by caregivers may cause family members or surrogates to reconsider decisions about which course of action is in the patient's best interests. Care must be taken, however, to avoid coercion or the appearance of coercive intent.
Clearly, for all caregivers, conscientious objection is a complex matter. Personal morality, professional codes of ethics, institutional policies, and law may all play important roles in resolving these difficult situations.
