DIFFICULT MORAL QUESTIONS

Question 82: May medical trainees participate in immoral procedures?

I am a medical student in my third year. Soon I will be interning and then doing a residency, probably in family practice. I accept the Church’s teaching on contraception and abortion, and expect to encounter pressures as I finish my training to participate in immoral procedures. I have read that formal cooperation always is wrong and material cooperation sometimes is permissible, but do not understand how to draw the line. Perhaps you could show how to do that in three situations described to me by doctors who experienced crises of conscience at one or another stage of their training.

As a student during the 1960s in a Catholic medical school, one physician was expected, during a two-week obstetrics rotation at a public hospital, to do a postpartum physical exam to make sure there was no medical reason why the women—mostly teenage blacks—should not be given a birth control method, usually the pill or an IUD. A black resident from another university then selected the method and supplied it, although she regarded the program as an attack on women and on her race. When the resident said this, the student decided to refuse to do the exam; the physician in charge of the program asked if he meant to report the matter to the authorities at his Catholic medical school. He said no, and the physician in charge did not insist he do the exam. Now, years later, he wonders whether he did the right thing. In promising under pressure not to report the matter, he tolerated the program. Was that justified by his fear of failing that segment of his training if he pressed his position that contraception is wrong, especially when it is virtually forced on women?

A second physician, interning in a non-Catholic hospital, was expected to scrub up and assist at various operations, including abortions and surgical sterilizations by hysterectomy, which were done on various pretexts. Because he was not specializing, his actual involvement was limited; he never was asked to wield the instruments that actually destroy a baby or remove a woman’s uterus. Afraid of being dismissed from the internship, he did what he was told to do. Had he been dismissed, he might never have completed his training and gone into practice, since he already had been dismissed from a previous internship for criticizing what he believed to be unjustified obstetrical aggressiveness—inducing labor as soon as a woman was a few days beyond her “due date,” using heavy sedation during labor followed by a forceps delivery, and a very high percentage of caesarean sections. He wonders now if he should have refused to scrub up and assist, even at the sacrifice of his medical career.

A third physician was dismissed from her nearly completed residency in psychiatry for opposing the chief of service and a nurse over aborting a retarded woman. The patient, twenty-four years old with the intelligence of an average child of ten, eighteen weeks into her fifth pregnancy with three previous abortions, was brought to the psychiatric emergency service where the resident was on duty. The patient wanted the baby, especially since she had been forced to give up her two-year-old son about ten months before, and had been grieving his loss until she again became pregnant. She was sent to psychiatric services to be tranquilized and persuaded to accept an abortion. The nurse said this was how the chief of service would want the case handled and prepared the tranquilizer. But the resident thought that the tranquilizer might cause fetal damage and that the chief’s policy wrongly anticipated such patients’ decisions. She also judged that an abortion might endanger the woman’s life by disposing her to commit suicide. The resident therefore refused to administer the tranquilizer; instead, she calmed the pregnant woman by talking with her and then encouraged her not to change her mind. Next day, the chief of service confronted the resident; she refused to back down, insisting that abortion not only is wrong but would be dangerous for this particular patient; and she was dismissed. This physician now is in general practice, and she still thinks she did the right thing. I wonder: Could she have taken another way out?

Analysis:

This question concerns cooperation in the immoral procedures. In the first case, the medical student probably should have reported the contraception program to the authorities at his Catholic medical school. However, had he been compelled to choose between failing that segment of his training or doing the examination, the latter would have been material cooperation with the contraceptive program; judged by the usual criteria, that material cooperation could have been justified. In the second case, the resident’s involvement in abortions and sterilizations by hysterectomy was, in my judgment, morally unacceptable material cooperation, and he ought to have sacrificed his career, if necessary, to avoid it. In the third case, the resident’s compliance with the wishes of the chief of service would have been formal cooperation in abortion. Still, she could have remained silent about the intrinsic evil of abortion and taken her stand on the risk that the mentally handicapped patient would commit suicide and on her right to bear her baby.

The reply could be along the following lines:

You are wise to consider in advance moral problems likely to arise as you complete your medical training. All too often, people fail to think ahead, with the bad result that they confront grave moral challenges with no prior preparation and little time to reflect. Then they are likely either to give in where they should not or to take stands where they need not, and also are likely in later years to feel guilty or have doubts about what they did and did not do.²⁶⁵

I turn first to the case of the medical student who promised under pressure not to report a virtually compulsory contraceptive program, conducted in a public hospital, to the authorities at his Catholic medical school. It seems to me he should not have made the promise and had no obligation to keep it. His fear of failing that segment of his program probably was excessive, since he was entitled to his own medical school’s protection against retaliation. The authorities there were responsible for arranging the rotation to this public hospital, and they should have been told what their students were being asked to do there. While it very likely would not have blocked the program if the student had reported what was going on, his doing so might have led to the termination of the Catholic medical school’s involvement.

What should the student have done if compelled to choose between doing such an examination and failing that segment of his training? Considered in itself, doing the examination was not wrong, for it involved nothing more than observing and truthfully reporting. In context, the examination cleared the way for the main business of the program: imposing contraception on women, mostly teenage blacks. Thus, what the student was called on to do was an instance of material cooperation in wrongdoing. The material cooperator does not share, even reluctantly, the wrongful will of those who do the wrong to which his or her action contributes. Rather, he or she only accepts the contribution that his or her action, good in itself, makes to another’s wrongdoing. Material cooperation is sometimes morally excluded but sometimes acceptable. In this case, it seems to me, it would have been morally acceptable for the student to do the examination, especially since he then would have had the opportunity and duty to look carefully for medical contraindications and to protect women from being given contraceptives likely to harm them. At the same time, his refusal to do the examination was a courageous act of witness to his belief that contraception is gravely wrong and a serious injustice when virtually forced on women.

What about the resident who carried out her assigned role though regarding the program as an attack on women and on her race? Someone fulfilling her role could hardly avoid instructing patients how to use the chosen method of contraception and encouraging them to use it effectively. Though the resident may have lacked sufficient reflection about the immorality of contraception, in choosing to do her assigned part in the program, she shared its contralife intention. So, her cooperation was formal. Moreover, for someone who considered the program an attack on women and her race, cooperating with it meant reluctantly participating in those injustices—a serious moral compromise.

Your second case is that of an intern in a non-Catholic hospital who was expected to scrub up and assist in abortions and surgical sterilizations by hysterectomy. Had he refused, he might never have completed his training and gone into practice, since he had been dismissed from a previous internship. My first comment is that this doctor’s earlier criticism of what he considered unjustified obstetrical aggressiveness, while perhaps medically sound, probably was not morally required. His primary responsibility was to complete his studies, and it seldom is reasonable to expect that a single student’s criticism will bring about reforms in an established program. Therefore, I think he should have kept quiet rather than risked provoking those in charge.

Assisting at abortions and hysterectomies (where the latter are not medically necessary but are done as a method of sterilization) is far more questionable, morally speaking, than is doing a postpartum physical examination in the context of a contraception program. Abortion is a very grave injustice to the unborn individual who is killed, and hysterectomy as a method of sterilization is both wrong in itself and more mutilating than necessary for the purpose. Moreover, even though assisting in such operations did not require that the intern wield the instruments used to destroy the baby or remove the uterus, his involvement was closer and his contribution more direct than that of the intern doing the postpartum exam in the contraception program.

That closer involvement and more direct contribution were morally significant in several ways. First, while the student doing the examination was unlikely to be called on to go further, the intern in some circumstances, such as an emergency, might well have been expected to take a more direct part in the surgery; and then he would have been strongly tempted to participate so closely that he could not have avoided intending its success, and so formally cooperating in the killing or mutilation. Again, the intern’s behavior was more likely than the medical student’s to be taken by others as a model, and so lead them into sinful participation in abortion and sterilization. Then too, the intern’s involvement was more at odds than the student’s with clear and credible witness to relevant moral truths. Finally, since anyone totally innocent and defenseless facing death would want most others who recognize the injustice to refuse to participate closely, the intern’s involvement in the abortions almost certainly was unfair. Therefore, even if the intern’s assisting was not formal but only material cooperation (as I think it probably was), I do not think it was morally justifiable.

The main lesson for you in this case is to do what you can to plan and arrange your further training so as to avoid being pressured to assist in morally unacceptable operations. Even if refusing to participate so closely in such operations would mean risking your medical career, I believe that would be the right thing to do. If you do refuse and are threatened with unjust consequences, I advise you to put up as strong a fight as possible, not only for yourself but in the hope that your effort will help limit the serious injustice that those in charge of training programs do in forcing trainees to choose between their careers and their consciences. Also, if worse comes to worst and you must sacrifice your career, I think you should use every available means to publicize your decision, so that it will serve as a good example for others.

Your third case is that of a physician dismissed from her nearly completed residency in psychiatry for refusing to administer a tranquilizer and persuade a retarded woman to accept an abortion. The resident could not have given in to this pressure without intending, however reluctantly, that the patient agree to the abortion; thus, she would have formally cooperated in trying to bring about the abortion, and so she had no morally acceptable option but to refuse.

While her refusal was morally necessary and notably courageous, I wonder whether she fully followed through by fighting the dismissal and publicizing her decision and its consequences. If not, I think she should have, unless she had compelling reasons not to. By being dismissed, she was freed to bear strong witness, just as St. Thomas More was by being unjustly convicted. Since Christian life should be apostolic, a person who does so good a deed should make its light shine, both to enlighten others and to encourage them to resist evil.

It also seems to me that the chief of service’s policy of using a tranquilizer to get patients to undergo abortion is medically indefensible and constitutes a very grave wrong to patients, which would call for professional disciplinary action and warrant a lawsuit on behalf of a victim. In the particular case, the danger that abortion might lead the patient to commit suicide provided an additional argument against following that policy. Without conceding the acceptability of abortion, the resident could have focused on those points and made them the central issue, while keeping to herself her conviction that abortion as such is evil. Perhaps in this way she could have avoided the dismissal without giving in to the pressure to act against her conscience. Doing that would not have involved any moral compromise and would have enabled her to continue to fulfill what she had accepted as her vocation. Consequently, though it would not have borne witness to the evil of abortion, it would not have violated the duty to bear witness.

The moral to be drawn from this case: Living among wolves, those undergoing professional training must “be wise as serpents and innocent as doves” (Mt 10.16). A Christian should invoke commonly accepted standards when they are compatible with moral truth and helpful in safeguarding his or her vocation, but when necessary should absolutely refuse to conform to those standards.

265. Anyone confronted with pressure to participate in immoral procedures should obtain advice from a competent, prolife lawyer. In many hospitals receiving money under federal programs, physicians, including interns and residents, who refuse to be involved in sterilization and abortion are protected by federal law (see 42 U.S.C. 300 A–7.); state law also may offer protection.