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Medical Schools, Students, and the Conscience Policy

September 27, 2010

Most medical students enter their professional educations with a “moral integrity” or “conscience”, but can they keep it and their careers?

Not long ago, March 2009, a counseling student was dismissed from her graduate studies when she refused to see a patient regarding his same-sex relationship. Julea Ward insisted that advising the client would conflict with her religious convictions. Insisting that her refusal to treat the patient violated her obligations as a counselor, Eastern Michigan University asked Ward to leave the program. Claiming that her constitutional rights of freedom of religion and speech had been violated, Ward sued the school. (The case was dismissed earlier this year. For more about Ward v. Eastern Michigan University, visit: ACA/Julea Ward case: Eastern Michigan University.)

Not every conflict between personal conscience and professional ethics leads to a lawsuit, but Ward v. Eastern Michigan University is a reminder of what is at stake for students and educators in an increasingly pluralistic culture. Although Ward was not enrolled in a medical school, it also prompts some interesting questions for medical educators and students, including: What should medical students do when they object on moral or religious grounds to an aspect of their professional education? How should medical schools respond to these conscience-based objections? And why should any of us care about the divergent scruples of a medical-student-ethics-outlier here and there?

To address questions like these, Mark R. Wicclair, in “Conscience-based exemptions for medical students”, reviews the most current professional standards for respecting and responding to the conscientious objections of medical students. Wicclair reminds us of the recent history of policy development regarding conscience-based exemptions (CBE); addresses the reasons for and against granting medical students CBEs; and stresses the importance of clear institutional policies on the subject.

According to Wicclair, good reasons for permitting CBEs for medical students, include:

1. Allowing objections on “conscience” preserves student’s professional sensitivity to ethical issues. (Wicclair notes that 62% of medical students feel that their education has led to an erosion of their ethical principles.)
2. Granting CBEs will sometimes lead to a more ethical medical school and profession. (Wicclair provides, as an example, the student-driven opposition to the use of animal laboratories for student training. Today, only a few medical schools still use animals in this way.)
3. Denying CBEs discourages building and keeping a diverse student body.
4. Outright denials of all CBEs undermines students’ moral integrity. (Given the importance of the conscience to self-perception and identity, such undermining could be considered a harm and a violation of the principle of respect for persons.)

After building the case for CBEs in medical education, Wicclair turns to the challenges of validating and addressing objections without compromising a rigorous professional curriculum. Schools have grounds for denying CBEs when these objections:

1. Conflict with core educational requirements. (Both the LCME and the AAMC provide curricular standards and guidelines which can serve as a basis for denying conscience-based exemptions.)
2. Conflict with local core requirements. (Some medical schools serve unique populations or have missions which necessitate local curricular requirements. These too could serve as a basis for denying CBEs.)
3. When the objection is not “conscience-based”, but, rather, is based on “invidious discrimination”. (To refuse a patient in disdain of their personal characteristics, is not an act based on conscience.)
4. When granting the CBE would unavoidably harm a patient or colleague.

Even with Wicclair’s criteria in mind, deciding when to grant and when to deny a conscience-based exemption for a medical student is a tricky task. To anticipate these decisions and to support the moral integrity of current and future students, Wicclair advises the implementation of clear, readily accessible policies on how a medical school will address conscience-based objections. In addition to complying with AMA guidelines (see: AMA Policy H-295.896), maintaining an operational policy on CBEs gives prospective students an opportunity to make good choices about the school to attend. A policy on conscience-based objections shows that universities are sensitive to the developing professional consciences of its students. Perhaps a proactive CBE policy would have averted the impasse between Julea Ward and the Eastern Michigan University. At the very least, a conscience sensitive medical education builds a stronger profession–one that values the moral integrity of the provider while protecting patients; one that benefits everyone.

Reference:

Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics. 2010 Winter;19(1):38-50. PubMed PMID: 20025801.

Related:

AMA Policy H-295.896: Conscience Clause: Final Report

Gaffney M, Galvin M, Stilwell B. Conscience sensitive medical education. The Conscience Project, Indiana University School of Medicine. 2002. [PDF – 837 KB]

Meg Gaffney and Eric Meslin. Sound Ethics: Medical ConscienceSound Medicine. April 5, 2009.

Guttmacher Institute. Refusing to Provide Health Services. State Policies in Brief. September 1, 2010. [PDF – 241 KB]

Hicks LK, Lin Y, Robertson DW, Robinson DL, Woodrow SI. Understanding the clinical dilemmas that shape medical students’ ethical development: questionnaire survey and focus group study. BMJ. 2001 Mar 24;322(7288):709-10. PubMed Central PMCID: PMC30097.

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