In the context of medical assistance in dying (MAiD), a framework allowing clinicians to communicate their ethical concerns may have benefits for both patients and providers, authors argue in an essay published in the Journal of Medical Ethics.

In June 2016, MAiD was legalized in Canada, a development that revived debates regarding physicians’ rights to conscientious objection to performing procedures that may cause them moral distress. Although delivery of quality care to patients remains imperative, authors Mary Kathleen Deutscher Heilman, MD, and Tracy J. Trothen, MD, asserted that denying clinicians the ability to “self-recuse” from MAiD may cause undue moral distress due to the fact that they are unable to act in a way consistent with their beliefs. Moral distress can precipitate poorer clinical performance. A 2017 systematic review concluded that moral distress correlated with poorer institutional collaboration, low work satisfaction, and “low psychological empowerment.”

Authors advocated for a clinical system that protects the right to conscientious objection while still prioritizing patient care. Such a system would have 2 primary features: (1) an avenue through which physicians can express objection and, if necessary, recuse themselves, and (2) a pathway through which patients can access a willing practitioner directly. A centralized coordination system of MAiD access would lessen the need for referrals and empower patients to make their own healthcare decisions. This centralized system also respects the “relational nature of conscience,” the authors wrote, a cornerstone of ethical decision-making. Several bioethics publications have framed MAiD as a matter of patient rights, but it is also important to consider the impact of conscience and moral distress. Policies that respect conscience could minimize moral distress, improve team communication, and “[foster] a culture of ethical awareness.” Authors also advocated for the creation of peer support groups and other avenues to express moral distress.

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Allowing physicians to express their concerns—rather than denying recusal altogether—will also allow the cultivation of moral resilience, authors argued. “There is no shame in admitting that sometimes the values [of patients and providers] are not a perfect fit,” authors wrote. “[A] healthcare system that respects the relational dimension of conscience is best suited to [minimize] moral distress…[and] provide excellent patient care.”


Heilman MKD, Trothen TJ. Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada [published online December 6, 2019]. J Med Ethics. doi: 10.1136/medethics-2019-105855