Religion, conscience and clinical decisions.

Consider the following three cases: A paediatrician is called to the delivery room as a woman is about to give birth to a premature baby at 24 weeks. The mother and father request that the baby not be resuscitated. The baby weighs 760 grams and has an Apgar score of 6 at 1 min. The paediatrician ignores the parents’ requests for comfort care and intubates the baby. A full-term baby with Trisomy 18 develops cyanosis. An echocardiogram reveals a large ventricular septal defect. The parents request surgery. The cardiac surgeon refuses to operate based upon the baby’s poor prognosis for a ‘reasonable quality of life.’ A 15-year old girl is seen for a sports physical. She asks for a prescription for birth control pills and asks the paediatrician not to tell her parents that she is sexually active or using oral contraceptives. The doctor refuses to prescribe the pills without parental permission. In each situation, the doctor refuses to do what a patient or surrogate requests and instead, insists upon the right to do what he or she believes is the best. In each case, there is ethical controversy. Reasonable practitioners may disagree about the right thing to do. In cases like these, paediatricians make judgments about the rightness or wrongness of clinical actions and sometimes choose a course of action that goes against the stated wishes of a competent patient or surrogate. The examples chosen highlight the role of the clinician’s conscience in the practice of paediatrics. The Oxford English Dictionary defines conscience as, ‘The faculty or principle which pronounces upon the moral quality of one’s [own] actions or motives, approving the right and condemning the wrong.’ The idea that physicians ought to practice ‘conscientiously’ seems uncontroversial. Ethical practice and professional behaviour depend upon the ability of doctors to morally scrutinize their own behaviour and to resist any