Mark Pickering

Acting with a clear conscience? WMA, GMC, BMA, and moral injury

Mark Pickering has been CMF Chief Executive since 2019. Prior to that he has been a CMF Board member and was CMF Head of Student Ministries in the 2000s. Mark originates from Yorkshire but did his medical school and GP training in London. After GP training, Mark gravitated into secure environment medicine, working as a GP in prisons and secure psychiatric units. He has been a regional lead GP for two large UK offender healthcare providers. He continues a small amount of secure environment GP work alongside his CMF responsibilities.
The views expressed do not necessarily reflect those of CMF.

compassHaving reasonable freedom to act in accordance with our conscience is something that Christian healthcarers rightly value. A number of recent events and reviews over the last year or so highlight some of the perennial vulnerabilities of conscience provision but also some reasons for hope and optimism.

WMA International Code of Medical Ethics

The World Medical Association (WMA) has just come to the end of a lengthy revision process for its International Code of Medical Ethics (ICoME). Originating in 1949 as a companion to its Declaration of Geneva, the ICoME has undergone various revisions over the decades.

Concerns were raised in 2021 when the draft revision included the phrase: ‘Conscientious objection must only be considered if…undelayed continuity of care is ensured through effective and timely referral to another qualified physician.’ Such ‘effective referral’ requirements have caused huge problems in jurisdictions such as Canada, where some physicians who object to involvement in euthanasia have been forced out of practice, because they refuse to refer on to a colleague who will do the deed. There is little moral difference between doing an immoral action yourself and recommending someone to a person you know will do it for you. Ask anyone who has been jailed for hiring a hitman to kill their business rival…

CMF responded to the 2021 consultation, as did numerous other International Christian Medical and Dental Association (ICMDA) member movements. A slightly improved draft went to a dedicated conference in Indonesia in July, where various experts and members of the WMA working group debated for and against various options.

Thankfully, a better draft emerged from this process, which was further honed at another WMA meeting in Washington, USA, in August 2022. Excellent coordinated action by allies, including ICMDA member movements in the USA and Canada, and the Anscombe Bioethics Centre, was instrumental in ensuring this better draft came about.

The final step in the process was ratification at the WMA General Assembly in Berlin on 8 October. The final version of the section reads:

This Code represents the physician’s ethical duties. However, on some issues there are profound moral dilemmas concerning which physicians and patients may hold deeply considered but conflicting conscientious beliefs… Physician conscientious objection to provision of any lawful medical interventions may only be exercised if the individual patient is not harmed or discriminated against and if the patient’s health is not endangered.

The physician must immediately and respectfully inform the patient of this objection and of the patient’s right to consult another qualified physician and provide sufficient information to enable the patient to initiate such a consultation in a timely manner.

This agreed revision represents a much more balanced approach. It talks about the need for respect and the provision of information that will enable a patient to seek out another physician who may take a different view. This rightly places the moral onus on the patient rather than the physician. It recognises that in issues of conscience, there are ‘profound moral dilemmas’ in which the requests of patients and the moral integrity of physicians must be appropriately balanced.

We should be encouraged to see how wide consultation by the WMA, and sustained engagement by partner organisations, has produced an improvement. We can be tempted to think that ‘nothing will ever change’, that consultations are stacked against those with Christian views, and that it is fruitless engaging in these processes. In some situations, this may well be true, but the approach of the WMA here shows that there is often every reason to engage positively.

General Medical Council guidance

Good Medical Practice (GMP) is the foundational guidance by which UK doctors are bound, including its internal summary, ‘The Duties of a Doctor Registered with the GMC’. The current version is from 2013 and it is currently going through a periodic review process, which will result in a revised version coming out in 2023.

Paragraph 52 of GMP states, ‘You must explain to patients if you have a conscientious objection to a particular procedure. You must tell them about their right to see another doctor and make sure they have enough information to exercise that right. In providing this information you must not imply or express disapproval of the patient’s lifestyle, choices or beliefs. If it is not practical for a patient to arrange to see another doctor, you must make sure that arrangements are made for another suitably qualified colleague to take over your role.’

This current guidance also strikes a reasonable balance between doctor and patient. There is an expectation about giving information, but it stops short of ‘effective referral’. Even when a patient is not practically able to arrange to see another doctor, the role of the ‘objecting’ doctor is only to arrange for a ‘suitably qualified colleague’ to take over. There is no explicit assumption that they will necessarily agree to provide the procedure in question. It implies that the second doctor will not have exactly the same objection but that they would be willing to consider a request that the ‘objecting’ doctor might not.

GMP Para 52 is further fleshed out in the more detailed guidance, Personal Beliefs and Medical Practice (also published in 2013)mostly in Paras 8-16. Para 12 states that you should provide information to a patient about how to see another doctor ‘who does not hold the same objection as you’, and in the circumstances above where you have to make arrangements yourself, this is to ‘another suitably qualified colleague to advise, treat or refer the patient‘ (emphasis mine).

Again, I think this gets the balance pretty much spot on in the delicate and nuanced situations that we may come across.

During 2022 the GMC also consulted widely on their proposed review of GMP; CMF made a submission to the review process.

Currently the only proposal to amend the section on Conscientious Objection is a reasonable one:

Paragraph 24 – We have removed the requirement for medical professionals to explain to a patient if they have a conscientious objection to a particular treatment. This reflects feedback we’ve had about the impact it can have on patients to be told about the personal beliefs of the medical professional. So, we’re proposing to change the guidance to allow medical professionals to use their discretion when deciding whether to tell the patient the reason they are unable to provide care themselves.

There are currently no published plans for a formal review of Personal Beliefs and Medical Practice – periodic reviews of the supplementary guidance would be expected to occur once the new version of GMP is agreed upon.

BMA guidance on conscience

The British Medical Association (BMA) has its own guidance on conscience. This has tended to be somewhat more restrictive or limited than GMC guidance.

However, its recently revised guidance is more detailed, and better aligned with the GMC’s guidance above. It states in summary:

The BMA does not want to unnecessarily restrict doctors from seeking to exercise a conscientious objection, or other expressions of their belief. We seek to balance doctors’ freedom with the rights of patients to receive appropriate treatment in a non-judgmental fashion.

The primary means of setting BMA policy is the Annual Representatives Meeting (ARM). At the September 2021 ARM, I was able to propose the following policy changes through my local division:

Motion 296 – That this meeting:

(i) believes that the moral and ethical integrity of doctors is an essential component of wellbeing and morale in the medical workforce; Carried

(ii) holds that reasonable and proportionate provision for the exercise of individual conscience should be provided for within medicine; Carried

(iii) is concerned that inadequate conscience provision within medicine may on occasion be a cause of significant moral injury for clinicians; Carried

(iv) requests the BMA to align its policy on conscience provision with that of the General Medical Council, in paragraphs 8-16 of their 2013 guidance, Personal Beliefs in Medical Practice. Carried as a Reference to Council.

Part iv) was carried ‘as a Reference to Council’, which means there was some concern about the exact wording, but agreement with the spirit. The concern was mostly over directly linking BMA policy to that of another organisation, especially when that policy may change in the future. However, the current published policy, shown in the above weblink, has been redrafted to align more closely with that of the GMC, and makes multiple references to it.

Conscience, moral distress, and moral injury

Part iii) of the above motion, which was carried in full and is now BMA policy, links inadequate conscience provision to a risk of moral injury for clinicians.

The language of moral distress and injury has been part of military ethics for some time, but for most healthcarers, it only entered their vocabulary during the Covid pandemic. One of the key ideas is being either constrained to do something you think is unethical or being prevented from doing something you think is ethical. During Covid, resource limitations or infection-prevention restrictions put many clinicians in this situation.

However, making the explicit connection between inadequate conscience provision and moral injury is not something that appears to have come about naturally. Indeed, some who would wish to restrict or downplay provision for conscience in healthcare (eg around assisted suicide and/or abortion), have actively resisted this link being made.

It appears to be a useful new form of language that communicates well in contemporary healthcare. It is as if the whole of the healthcare establishment in the UK and beyond has now woken up to how Christians have always felt when their ability to act according to their conscience is restricted, whether by situation or by regulation. We can and should capitalise on this newfound moral discomfort and the resulting appreciation of the value of conscience; we can make afresh the case for reasonable accommodation of freedom of conscience in all healthcare settings.

Conclusion – the price of liberty

Conscience provision remains a hot topic in healthcare in the UK and around the world. The WMA process shows how fragile this can sometimes be but also that coordinated action can often have a positive effect where consultation is done well.

The UK GMC remains reasonable and balanced, and their current guidance has contributed to improvements in the recent BMA guidance.

The language of moral distress and moral injury is a recent addition to the discussion and has numerous positive elements to it.

Let’s be encouraged – despite many concerns over ethics within the medical profession, there are some reasons for hope and optimism. But we must never forget that ‘the price of liberty is eternal vigilance‘.



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