Overview
This lecture distinguishes personal values from professional values and examines what happens when they conflict in medical practice. It works through three constructed clinical case scenarios, several real-world examples (a tow-truck driver, an anti-vaccination GP, an “Irish conscientious objector” doctor), and then focuses on conscientious objection (CO): what it is, its ethical basis, its treatment in New Zealand law, and the NZ Medical Council’s position on doctors bringing personal beliefs into the consultation.
Personal values vs professional values
- Values come from culture, religion, upbringing, peers and personal choices.
- Personal values represent what is important to you; they structure your sense of what you should and should not do, and in a deep sense define who you are. They are particular to you and may not be shared by others.
- Professional values are intrinsic to the profession. They are defined by Codes of Ethics (an expression of the Social Contract), by those in authority, and by peer consensus.
- Personal and professional values must agree in some minimal sense, otherwise a person could not take on the profession. Where they conflict, a decision must be made about which values have priority.
- Values considered important to (or intrinsic to) being a good doctor: commitment, integrity, compassion, respect, competence, responsibility.
- These values are expressed through authorised statements such as the New Zealand Medical Council Code of Ethics.
- Good Medical Practice (NZMC standard): “A doctor’s first concern is to take care of their patient, and to do so with respect, honesty and professionalism.”
Case discussions: personal values in the clinical encounter
Case 1 — immunisation opinion. A mother asks a GP what he thinks she should do about immunising her newborn, and whether he has immunised his own children.
- A personal value is being brought into the consultation at the patient’s request.
- Giving a recommendation when asked is an obligation (Right 6(3)(b) of the Code of Rights), but it must be a professional recommendation based on professional standards, not a personal opinion.
- Anything a doctor says carries authority; a patient may take a doctor’s personal view as having the status of medical opinion.
- Good practice is to avoid discussing personal issues in this context.
Case 2 — refusal of care over non-compliance. An oral health therapist tells a heavy-smoking patient with gum disease that she will refuse to see him unless he quits.
- This goes beyond professional standards in pursuit of a professional goal; the response may reflect personal values or a misunderstanding of professional standards.
- Relevant professional values here: commitment to improving the patient’s health, patient advocacy, and ensuring patients are not abandoned.
- Legitimate reasons to refuse to care for a patient: futility, personal safety, unreasonable requests.
Case 3 — prayer as treatment. A doctor suggested prayer as treatment, persisted despite the patient’s objection, told the patient all science pointed to religion and God as the truth; the Health and Disability Commissioner found this breached the patient’s right to informed consent and required an apology.
- The doctor offered a form of “treatment” the patient neither expected nor wanted.
- Discussing personal beliefs may be acceptable in some circumstances, but should usually be patient-initiated.
- A doctor should not use their position to impose their values or beliefs.
- Doctors must be careful that when acting in the “doctor” role, they represent that role appropriately.
- Spirituality is recognised as important to health (whole-person care), but doctors should reflect on their particular role and refer on where appropriate.
Personal values intruding into professional/public life: further examples
- A neurosurgeon (Dr Charlie Teo) publicly claimed that complaints leading to disciplinary proceedings against him send the wrong message to “good, young, aggressive neurosurgeons,” ahead of a Professional Standards Committee hearing into his patient management.
- A tow-truck driver refused to tow a stranded woman’s car on discovering she supported a rival political candidate (Bernie Sanders), telling her she was “obviously a socialist” and to “call the government” for a tow; he described himself afterwards as proud to have “drawn a line in the sand.”
- An Irish GP (Whitehorn Clinic, Celbridge) describing himself as a “conscientious objector” was suspended by his regulatory council for continued refusal to vaccinate patients against Covid-19 and refusal to refer symptomatic patients for testing.
- NZDSOS (“New Zealand Doctors Speaking Out With Science”) is a group of health professionals opposed to censorship and coercion in the Covid-19 response, asserting rights to refuse medical intervention and to freedom of expression (cited: over 49,300 declaration signatories, over 4,800 health-professional signatories).
Conscientious objection: concept and ethics
- Conscientious objection is an objection, based on conscience, to an activity one would otherwise be obliged to do.
- Conscience refers to a person’s internal (personal) sense of right and wrong — more than simply a “little voice in your head.”
- A person making a CO indicates that an expected activity is contrary to their personal sense of right and wrong.
- [!important] Key ethical points on CO:
- CO in general is a fundamental tenet of a liberal democracy such as New Zealand: citizens, as citizens, have the right not to be forced to do things they consider immoral.
- Some argue CO should not be permitted for healthcare professionals specifically.
- There is debate about the scope and application of the right to CO, and new problems arise as it is extended to new areas.
- Historical illustration: Archibald Baxter, a New Zealand conscientious objector (World War I).
Conscientious objection in New Zealand law
- CO is referenced in several NZ Acts of Parliament, including the New Zealand Bill of Rights Act 1990, the Health Practitioners Competence Assurance Act 2003, the End of Life Choice Act 2019, and the Abortion Legislation Act 2020.
- Contraception, Sterilisation and Abortion Act 1977, s.46: no medical practitioner, nurse, or other person is under any obligation to perform or assist in an abortion or sterilisation, or to fit, supply, administer or advise on contraception, if they object on grounds of conscience — this overrides any other enactment, rule of law, oath or contract. It is unlawful for an employer to deny employment, accommodation, goods, services or benefits because a person objects on grounds of conscience, or to make such things conditional on the person not objecting. A person who suffers loss from such unlawful treatment can recover damages.
- Abortion Legislation Act 2020, s.14: applies to a person requested to provide/assist with contraception services, sterilisation services, abortion services, or information/advisory services about continuing or terminating a pregnancy. If the person has a conscientious objection, they must, at the earliest opportunity, tell the requester of their objection and how to access the contact details of the nearest alternative provider.
- Limit on CO (Abortion Legislation Act 2020, s.14(4)): CO does not override a health practitioner’s professional and legal duty to provide prompt and appropriate medical assistance to any person in a medical emergency.
- Abortion Legislation Act 2020, s.15 (employer duty to accommodate CO): an employer providing s.14(1) services may not, on the basis of an employee’s or applicant’s conscientious objection: refuse/omit to employ them for available work; offer less favourable employment terms/conditions/benefits/training/promotion/transfer opportunities than comparable employees; terminate their employment in circumstances where others would not be terminated; subject them to detriment where others would not be; or force/cause their retirement or resignation. However, if accommodating the objection would unreasonably disrupt the employer’s provision of health services, the employer may take these actions.
NZ Medical Council’s position on personal beliefs
From Good Medical Practice (NZMC, December 2016), section “Personal beliefs and the patient”:
- You must not refuse or delay treatment because you believe a patient’s actions contributed to their condition, nor unfairly discriminate against patients by letting your personal views affect your relationship with them.
- Personal beliefs (political, religious, moral) should not affect your advice or treatment. If you feel your beliefs might affect the advice or treatment you provide, you must explain this to the patient and tell them about their right to see another doctor, and be satisfied they have enough information to exercise that right.
- Do not express your personal beliefs to patients in ways that exploit their vulnerability or are likely to cause them distress.
Summary of learning points
- Doctors and patients have experiences and values that may differ.
- Patients are often vulnerable, whereas doctors have status, so their views are given extra weight.
- A doctor may not recognise when they are bringing personal values into the consultation.
- There may be dissonance between a doctor’s personal values and those of the profession.
- A doctor needs to learn to distinguish professional values from personal values in the context of clinical practice.
- This requires self-awareness, ongoing reflection, and respect for professional boundaries.
Self-test
- Define the difference between personal values and professional values.
- In Case One (the immunisation consultation), what obligation does a doctor have when a patient directly asks for the doctor’s personal opinion, and how should that obligation be fulfilled?
- List the legitimate reasons given for refusing to continue caring for a patient.
- Explain what went wrong, ethically, in the “praying doctor” case (Case Three), and what right was found to have been breached.
- Define conscientious objection and explain what “conscience” means in this context.
- Under the Contraception, Sterilisation and Abortion Act 1977 s.46, what services can a practitioner object to providing on grounds of conscience, and what protection does the Act give an objecting employee?
- Describe the steps a person must follow under Abortion Legislation Act 2020 s.14 when they have a conscientious objection to a request.
- What limit does s.14(4) of the Abortion Legislation Act 2020 place on conscientious objection?
- Under s.15 of the Abortion Legislation Act 2020, when may an employer take adverse action against an employee despite their conscientious objection?
- According to the NZ Medical Council’s Good Medical Practice, what must a doctor do if they feel their personal beliefs might affect the advice or treatment they give a patient?
- Distinguish an acceptable expression of personal belief in the clinical encounter from an unacceptable one, using the course’s case examples.
Answers
Reveal answers
- Personal values are what is important to an individual, shaped by culture, religion, upbringing, peers and choice, and define who they are; they may not be shared by others. Professional values are intrinsic to the profession, defined by Codes of Ethics, those in authority, and peer consensus. The two must agree in some minimal sense to enter the profession, but can conflict, requiring a decision on which takes priority.
- Providing a recommendation when asked is an obligation under Right 6(3)(b) of the Code of Rights, but the recommendation must be a professional one grounded in professional standards, not the doctor’s personal view, since anything the doctor says carries authority and may be taken as medical opinion; it is good practice to avoid discussing personal issues.
- Futility, personal safety, and unreasonable requests.
- The doctor offered a form of treatment (prayer) the patient neither expected nor wanted, persisted despite the patient’s objection, and used the consultation to promote his own religious view; this breached the patient’s right to give informed consent.
- Conscientious objection is an objection, based on conscience, to an activity one would otherwise be obliged to perform. Conscience is a person’s internal, personal sense of right and wrong (more than just an inner “voice”).
- A practitioner can object on conscience grounds to performing or assisting in an abortion or sterilisation, and to fitting, supplying, administering or advising on contraception. Employers may not deny employment, accommodation, goods, services or benefits (or make them conditional) because of such an objection; a person who suffers loss from unlawful treatment can recover damages.
- The person must, at the earliest opportunity, tell the requester (a) of their conscientious objection, and (b) how to access the contact details of the nearest alternative provider of the requested service.
- It does not override a health practitioner’s professional and legal duty to provide prompt and appropriate medical assistance to any person in a medical emergency.
- Only if accommodating the applicant’s or employee’s conscientious objection would unreasonably disrupt the employer’s provision of health services.
- They must explain this to the patient, tell them about their right to see another doctor, and be satisfied the patient has sufficient information to exercise that right.
- Acceptable: discussing personal beliefs when patient-initiated and done without imposing views (e.g. responding professionally rather than personally to the immunisation question). Unacceptable: initiating unwanted religious “treatment” against the patient’s wishes (praying doctor case), or letting personal/political views override professional obligations to serve someone (tow-truck driver refusing service, GP refusing vaccination/testing).