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End of life. Iannone (Fatebenefratelli): “Conscience prevails over law because life is at the heart of civil coexistence”

The Legislative Decree concerning Provisions on voluntary physician-assisted dying, approved by the Chamber of Deputies on March 10, pending the Senate vote, provides for conscientious objection in Article 6. Conscientious objection does not arise on a purely subjective basis but within the value-system underpinning the legal system," says bioethicist Maria Teresa Iannone. The importance of the "conscience clause " and "conscience affirmation"

foto SIR/Marco Calvarese

“On a purely ethical level, conscientious objection represents the formal recognition of the primacy of conscience over Law, which the legislator himself concedes may not always reflect the common good. But precisely for this reason, in addition to being an unquestionable achievement in terms of civilisation, tolerance and democracy, it risks appearing as an inherent shortcoming of the Bill, whose inherent rationale is that it might not reflect the best interest of all citizens, thereby providing for legitimate disobedience”, said Maria Teresa Iannone, director of the Bioethics and Privacy Unit at Fatebenefratelli Hospital in Rome, board member of Cattolica University’s Interdisciplinary Group for Clinical Bioethics and Ethical Counselling in Health Care (GIBCE), promoter of a meeting held a few days ago at the same University to discuss in greater depth the subject of ethical counselling with regard to end-of-life issues. The event also offered the opportunity to reflect on the draft law concerning ‘Provisions on voluntary physician-assisted dying’, passed at a first reading by the Chamber of Deputies last March 10, pending Senate approval.

Objection effectuates the principle of freedom of conscience, and it ensures that freedom of opinion is consistent with action in cases where legally binding obligations impact on a person’s ingrained beliefs, the expert explains. Thus, the conscientious objector is someone who intends to promote a value or principle through the exercise of conscientious objection.” Commonly applied in the context of military service; animal testing; voluntary pregnancy interruption; assisted reproduction practices; suspension of essential life-saving treatment, conscientious objection is thus “the subjective right” of a person who cannot “be forced to act against his/her conscience. Consequently, it is recognised by law.

However, the bioethicist points out, conscience “is not the realm of what is debatable”, but “the place where an objective and universal value is realised.Consequently, it would be wrong to conceive conscientious objection as being confined to an individual dimension. A State that “for each law” envisaged a norm that, “in the name of freedom of conscience, allowed for disregarding provisions imposed by law, risks nullifying its very purpose and invalidating the legal system as a whole.” Instead, “precisely because the issues at stake are incorporated into the public dimension of political choices, the subjective dimension of conscience alone is not enough to justify non-compliance with the law.” Rather,

it is necessary to provide conscientious objection with an objective foundation, which means that the objection of conscience is not based on a merely subjective evaluation, but on a value system underpinning the legal system per se.

This means that a person’s conscience is challenged over a value that is at the heart of civil coexistence, namely the value of life.” 

Disobedience is thus “justified.”

In a broader sense, Iannone points out, it is necessary to

“identify another form of objection that should perhaps be more appropriately referred to as a conscience clause, involving all those situations which, especially in the field of healthcare, provide strictly ethical legitimacy (albeit not formally laid down by law) for refusing to engage in a specific conduct for reasons of conscience.”

Said legitimacy is rooted also in universal Charters and Declarations”. Pursuant to this, practitioners “have the right and duty to abstain from practices that run counter to their moral convictions, as stipulated in the Italian Code of Medical Deontology and in the Deontology Codes of many other countries.” If the value at stake is human life, then that reflection ceases to be merely an ethical issue and becomes a legal question, both ontologically and in structural terms.”

However, for Iannone, the right to abstain is not enough. First of all, it is necessary to have a clear understanding of ”Medical practice. In fact, the patient should be helped to understand, which implies a major commitment and openness to listening and caring. Such effort requires a cultural alliance with the patient that extends beyond the therapeutic alliance, so as to avoid trivialising fundamental aspects of life that appear to have lost their inherent value – granted only when coupled with adjectives connoting usefulness and efficiency.” According to the expert,

“the instrument of the affirmation of conscience can be helpful to healthcare institutions, both in tackling the gaps that the law leaves in institutional conscientious objection and in training practitioners to adopting a shared and consistent moral discourse.”

It may also be instrumental to transforming individual decisions “into management and organisational processes.” In the face of tendencies that “appear to pursue utilitarian drifts that are far removed from the sacred vision of life – Iannone concludes – projects that combine the analysis of enriching beliefs with the complexities of reality by reviving the values underpinning human activity,  must be set in motion.

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