Junior doctors and conscientious objection to voluntary assisted dying: ethical complexity in practice

Abstract

In jurisdictions where voluntary assisted dying (VAD) is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture.

Ethical Diversity and Practical Uncertainty: A Qualitative Interview Study of Clinicians’ Experiences in the Implementation Period Prior to Voluntary Assisted Dying Becoming Available in their Hospital in Victoria, Australia

“…When these data were collected in the final weeks of the implementation period, many participants had significant concerns about how the system would translate to their clinical setting and impact their own work. The data also provide further support for previously identified specific practical issues such as the impact of VAD on end-of-life care (Fuscaldo et al 2021 ; Philip et al 2021 ; Waran and William 2020 ) and enabling conscientious objection (Haining, Keogh, and Gillam 2021 ; Booth, Eleftheriou, and Moody 2021 ; McDougall et al 2021 ) or non-participation (Brown et al 2021 ) in a hospital setting.…”

Conscientious objection – a cross-sectional, vignette-based, mixed methods exploration of Australian pharmacists’ perspectives

“…An interesting perspective expressed by some, was regarding the relationship between employer and employee pharmacists, and the issue of practicing with professional autonomy (Blanks Hindman, 1999 ). This was also mirrored in a 2020 study, which identified the difference in agency between junior doctors and their senior counterparts, where there may be a compromise in moral integrity by participating/accepting, or compromise career-trajectory by objecting (McDougall et al, 2022 ). Having clear professional protocols/guidelines to follow would enable CO to be enacted safely, without discrimination to the objector.…”

Conscientious refusal or conscientious provision: We can't have both

“…Typically, those who defend a right to conscientious refusal apply their arguments to specific procedures that are, at the very least, consistent with some plausible view of professional obligations, the moral (im)permissibility of which is subject to reasonable disagreement. For instance, most of the discussion surrounding conscientious refusals centers around a clinician's ability to refuse to provide morally contentious services such as abortion, 14 end-of-life decisions, 15 emergency contraception, 16 and various treatments for gender dysphoria. 17 In this sense, their arguments and conclusion match the legal frameworks that currently regulate conscientious refusals, as presented above.…”