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Professional discretionary space refers to the range of situations in which a professional is fre to act on her own judgment without deferring to patients’ wishes or authorities. There are several reasons to think that some discretionary space is needed for good medicine. If the physician had no discretionary space, then they would be like non-professional service providers who sell their services to any client who will pay for them. If we think that medical professionals should prioritise good medicine over client satisfaction, then they need the freedom to deny patient requests in order to pursue those goods. For example, they should be able to prevent medicine being detrimentally used for non-medical purposes, e.g. amputating an ear may be medically justified to remove a cancer but not to achieve an edgy ‘Van-Gogh-look’. Similarly, to respect the patient’s autonomy, the physician needs the discretionary space to judge when the patient has sufficient understanding of the clinical situation to make an informed choice. If physicians unquestioningly provide services requested by patients, they risk damaging the patient’s interests because the patient may be ignorant of the risks or overly optimistic about the prospects of treatment. Physicians can also better promote distributive justice if they have the discretionary space to refuse services that they judge will be futile or unnecessary, such as when a patient with a muscle tension headache requests a CT scan. Good medicine will tend not to be promoted if the physician must do what the patient requests because, unlike the physician, the patient is not professionally committed to good medicine and, typically, lacks the training to promote it anyway. Of course, one might also doubt physicians’ capacity to promote good medicine. We could set strict, comprehensive professional rules to prevent physicians from undermining good medicine. One problem here, though, is that we cannot anticipate the variety of clinical situations that will arise. In novel cases, there is a risk that strict rules will guide actions that the physician can see are at odds with good medicine. Therefore, to promote good medicine, one should not attempt to excessively regulate medical practice.

But what has all this got to do with conscientious objection in medicine? Sulmasy claims that anti-conscientious objection views require the physician to unreflectively do as the patient requests, thereby wrongly reducing professional medicine to a service-providing occupation (2017, 22-26). On his view, this severe restriction of discretionary space leaves professionals unable to protect and further good medicine.

However, Sulmasy has been attacking a strawman because one can rule out conscientious objections without eliminating the physician’s discretionary space. Anti-conscientious objection views usually require the physician to act in accordance with the law, professional policies, and the principles of good medicine. This entails that, ‘if a service a doctor is requested to perform is a medical practice, is legal, consistent with distributive justice, requested by the patient or their approved surrogate, and is plausibly in their interests, the doctor must ensure the patient has access to it’ (Savulescu & Schuklenk, 2016, 167, note 1). These restrictions hardly eliminate discretionary space. The professional is left to judge which laws, professional policies, and principles of good medicine apply in any given situation and how to resolve conflicts between them. This means that the physician can refuse to provide CT scans for headaches or Van Gogh style cosmetic surgeries. One is free to act on one’s conscience to the extent that it aligns with the law, professional policies, and professional ideals.

…continue reading ‘Conscientious Objection, Professional Discretionary Space, and Good Medicine’

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