The Declaration of Geneva: Conscience, Dignity and Good Medical Practice

Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding, Rene Leiva

World Medical Journal

Since 1948 the Declaration of Geneva (the Declaration) has insisted that physicians must practise medicine “with conscience and dignity.” In 2017 this provision was modified by adding, “and in accordance with good medical practice” [1].

Good medical practice in Canada is said to include providing euthanasia and assisted suicide or arranging for someone else to do so. From this perspective, physicians who cannot in conscience kill their patients or collaborate in killing are not acting “in accordance with good medical practice,” and – some might say – the revised Declaration.

However, this merely literal application of the text cannot be correct, since the WMA later reaffirmed its support for physicians who refuse to provide or refer for euthanasia and assisted suicide even where they are considered good medical practice [2]. A reading informed by the history of the document is necessary and consistent with the care taken in its revision [1]. This yields a rational and coherent account of the relationship of conscience and dignity to medical practice.


Murphy S, Coelho R, Violette PD, Goligher EC, Lau T, Harding SR, Leiva R. The Declaration of Geneva: Conscience, Dignity and Good Medical Practice . WMJ [Internet]. 2020 Aug; 66(4): 43-47.

The WMA and the Foundations of Medical Practice

Declaration of Geneva (1948), International Code of Medical Ethics (1949)

Sean Murphy, Ramona Coelho, Philippe D. Violette, Ewan C. Goligher, Timothy Lau, Sheila Rutledge Harding

The WMA and the Foundations of Medical Practice

Practising Medicine “with conscience and dignity”

Beginning with the Declaration of Geneva (the Declaration), for over 70 years the World Medical Association (WMA) has maintained that physicians must practise medicine with conscience and dignity [1]. On the Declaration’s 70th anniversary, seven associate WMA members raised serious concerns about their ability to remain in medical practice if they fulfil this obligation by refusing to support or collaborate in the killing of their patients by euthanasia and assisted suicide (EAS)[2].The physicians practise in Canada, where euthanasia and assisted suicide (EAS) are legal, [3,4] recognized as therapeutic medical services by the national medical association [5,6] and provided through a public health care system controlled by the state, which also regulates medical practice and medical ethics. The national government is now poised to make EAS available for any serious and incurable medical condition, vastly increasing the number of patients legally eligible for the service [7].

In these circumstances, it is urgent to reassert that the duty to practise medicine “with conscience and dignity” includes unyielding refusal to do what one believes to be wrong even in the face of overwhelming pressure exerted by the state, the medico-legal establishment and even by medical leaders and colleagues. That the founders of the WMA not only supported but expected such principled obstinacy is evident in the WMA’s early history and the development of the Declaration, all of which remain surprisingly relevant . . .


Murphy S, Coelho R, Violette PD, Goligher EC, Lau T, Harding SR. The WMA and the Foundations of Medical Practice: Declaration of Geneva (1948), International Code of Medical Ethics (1949) . WMJ [Internet]. 2020 Aug; 66(3): 2-8.

CMA’s “third way” may be a third rail

Responding to articles by CMA officials (BMJ 2019; 364)

Sean Murphy*

British Medical Journal

It is disconcerting to find that the CMA’s President-Elect thinks that Canadian law “does not compel any physician to be involved in an act or procedure that would violate their values or faith.” The state medical regulator in Canada’s largest province has enacted policies that do just that, requiring physicians who refuse to kill their patients to find a colleague who will. These policies do have the force of law, and objecting physicians were forced to launch an expensive constitutional challenge to defend themselves. The Protection of Conscience Project and others have intervened in the case to support them; the CMA has not.

Further, the Canadian Medical Association’s assertion that it has successfully adopted a “neutral” position on euthanasia and assisted suicide (EAS) is challenged in a World Medical Journal article by seven Canadian physicians. “For refusing to collaborate in killing our patients,” they write, “many of us now risk discipline and expulsion from the medical profession,” are accused of human rights violations and “even called bigots.” . . .


Murphy S. CMA’s “third way” may be a third rail. Rapid Response to articles by CMA officials (BMJ 2019; 364).

Canadian physicians warned to get ready for euthanasia and assisted suicide

Sean Murphy*

Canadian physicians warned to get ready for euthanasia and assisted suicide

Three physicians and a lawyer have written an article published in the May issue of the Canadian Medical Association Journal.[1] The lead author, Dr. James Downar, is co-chair of a euthanasia/assisted suicide advocacy group.

Anticipating a change in the law, the authors warn that “well-rehearsed debates” about sanctity of life and personal autonomy “may become obsolete.”

“We need to start to answer some challenging questions in preparation for the possibility that physician-assisted death will be available in Canada soon,” they write.

Among the questions they pose, one raises two particularly sensitive issues:

Will physicians who are conscientious objectors be obliged to present physician-assisted death as an option to patients and facilitate transfers of patients to other physicians or facilities?

As a matter of law and ethics, physicians are expected to advise patients of all reasonable legal options for treatment so that patients can provide informed consent to it.  However, many physicians who are strongly opposed to euthanasia and assisted suicide may view the “presentation of an option” for either procedure as inherently abusive of vulnerable patients.  This problem does not usually arise with respect to other morally contested procedures, like abortion or contraception.

A requirement to “facilitate transfers” of patients would probably be acceptable if it involved only the kind of  cooperation normally involved in the transfer of records when a patient is taken on by a different physician; this is all that is required in Belgium, Oregon and Washington State.  However, a demand that objecting physicians refer patients or actively initiate transfers would be resisted by those who would consider such actions to involve unacceptable complicity in killing.  The Supreme Court of the Philippines recognized this issue when it struck down a mandatory referral requirement in the country’s Reproductive Health Law as an unconstitutional violation of freedom of conscience.

Murphy S. Canadian physicians warned to get ready for euthanasia and assisted suicide [Internet]. Powell River, BC: Protection of Conscience Project; 2014 May 13 [Updated 2021 Mar 09].

Notes

1. Downar J, Bailey TM, Kagan J, Librach SL.  Physician-assisted death: time to move beyond Yes or No.  CMAJ 2014 May 13;186(8):567-8. doi: 10.1503/cmaj.140204. Epub 2014 Apr 7.

Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise

Sean Murphy*

Conflicts of Conscience in Health Care: An Institutional Compromise

Lynch HF. Conflicts of Conscience in Health Care: An Institutional Compromise. Boston: The MIT Press; 2008. 368 p. ISBN: 9780262123051

Conflicts of Conscience in Health Care was published in 2008 as the 24th volume in the Basic Bioethics series from the Massachusetts Institute of Technology. It is an American book dealing with the American political and legal controversies over freedom of conscience in health care. However, the discussion of the American experience by Holly Fernandez Lynch is relevant elsewhere, since the United States has the most extensive and varied network of protection of conscience legislation in the world.

While acknowledging that freedom of conscience is of concern to all health care workers and institutions, Fernandez Lynch focuses exclusively on physicians. This carefully and deliberately restricted focus is one of the strengths of the book.

After a preface and introduction, discussion and argument occupy about 260 pages, supplemented by 53 pages of end notes, many of which offer expanded comment on the text. A good 12 page index has been included, as well as four pages of cited statutes and cases. The earliest source found in a list of 300 references is from 1951; the rest date from 1972 to 2007.

Goal

The author introduces her subject with a statement from Pope John Paul II:

. . . to refuse to take part in committing an injustice is not only a moral duty, it is also a basic human right. Were this not so, the human person would be forced to perform an action intrinsically incompatible with human dignity, and in this way human freedom itself, the authentic meaning and purpose of which are found in its orientation to the true and the good, would be radically compromised.

Fernandez-Lynch does not argue from a Catholic or even religious perspective. Nonetheless, she describes this as “a powerful statement about the nature of conscience, complicity in morally objectionable actions, and avoidance of injustice.” She adds that it is generally acceptable to religious and nonreligious people alike, regardless of their political views.

This reflects the spirit in which she pursues her project. As the subtitle of the book indicates, she is seeking a compromise that will provide “maximal liberty for all parties.” She believes that freedom of conscience for physicians and the provision of legal medical services are both important social goals, and that they are not incompatible. Thus, she rejects “all-or-nothing” strategies that seek “total victory.” Ultimately, quoting the Protection of Conscience Project, she affirms that all legitimate concerns can be met by “dialogue, prudent planning, and the exercise of tolerance, imagination and political will.”

Context of the discussion

The author recognizes that she writes with the abortion controversy more or less continuously in the background. But she insists – correctly, in the Project’s view – that “limiting the debate to tired abortion rhetoric could be quite dangerous if it prevents meaningful discussion” of broader issues. Referring to a number of other controversial issues and the impact of ongoing technological developments, Fernandez Lynch predicts that these, combined with “increasing diversity of health-care providers” have “the potential to create a perfect storm.”

Overview

The shape of the compromise proposed by Fernandez Lynch can be outlined while describing the book’s structure. It consists of three main parts.

The first reviews American protection of conscience laws and examines four paradigms of medical professionalism. The author selects one of these paradigms – physician as gatekeeper – as most suited to the compromise she seeks.

In Part II, Fernandez Lynch explains what she believes to be the source of the current controversy. Applying the professional model of physician as gatekeeper, she observes that an objecting physician may sometimes be the only available “gatekeeper” who can open the gate to a desired service. Her solution: tell patients about other gates and gatekeepers, redistribute them, and, if necessary, provide more gates and more gatekeepers. Or, to paraphrase anti-euthanasia activists, if access is the problem, eliminate barriers to access, not objecting physicians.

To accomplish this, the author suggests that a designated institution ensure access to services through effective distribution of health care resources and connect patients with willing physicians. Hence, the subtitle of the book: an institutional compromise. Fernandez-Lynch identifies state licensing boards as the institutions best placed to accomplish this. The last two thirds of the book describes how the compromise might be implemented in practice. It includes a model statute and extended discussions about calculating patient demand and meeting it through the supply of willing physicians. . .


Murphy S. Book Review: Conflicts of Conscience in Health Care: An Institutional Compromise. Protection of Conscience Project; 2009 Dec 17.