That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause (...) dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

Auch unter Befürwortern der Zulässigkeit einer Suizidassistenz durch Ärzte unter bestimmten Bedingungen besteht weitgehendes Einverständnis darüber, dass kein Arzt zu einer Suizidassistenz rechtlich oder berufsrechtlich verpflichtet sein sollte. Auch das Bundesverfassungsgericht hat in seinem Urteil vom Februar 2020 Suizidwilligen unter bestimmten Bedingungen nicht mehr als ein ungerichtetes in rem-Recht auf Suizidhilfe zugesprochen, das keinen Anspruch gegen einen einzelnen Arzt begründet. Mit dem letzten Satz seines Urteils hat es vielmehr die Freiheit jedes einzelnen Arztes – wie auch jedes anderen potenziellen Helfers (...) –, Nein zu sagen, nachdrücklich bekräftigt. Auf dem Hintergrund einer empirischen Untersuchung der Gründe, die in der Schweiz für die Ablehnung entsprechender Patientenanfragen gegeben werden, untersucht und gewichtet der Beitrag die Gründe, die für diese Freiheit sprechen, unter ethischen Gesichtspunkten und verteidigt ein bedingtes Recht auf Ablehnung gegen dessen jüngste Kritiker. In Fällen, in denen die Bedingungen erfüllt sind, durch die das Bundesverwaltungsgericht in seinem Urteil vom März 2017 „extreme Notlagen“ definiert hat, sollte jedoch zumindest eine moralische Pflicht anerkannt werden, den Patienten an einen Arzt zu verweisen, der zu einer Unterstützung bereit ist. (shrink)

Background Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider Objective To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria. Methods Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically (...) analysed using the framework method. Results The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice. Conclusion This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions’ public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions. (shrink)

Ethically challenging or controversial medical procedures have prompted increasing requests for the exercise of conscientious objection, and caused concerns about how and when it should be practised. This paper clarifies definitions, especially with regard to discrimination, and explores the restrictions, duties, and practical limitations, in order to suggest criteria for its practice. It also argues that a conscientious refusal to treat, where there is therapeutic doubt, is a valid form of conscientious objection. An email survey sent to General Practitioners (GPs), (...) explored the adherence to the suggested criteria, and assessed the outcomes, in terms of acceptability, impact, and difficulties experienced by the GPs, their colleagues and their patients. The results demonstrate high acceptability of conscientious objection, and better outcomes when the suggested criteria are adhered to. The GPs would support education to improve the practice of conscientious objection to a professional level, which could further improve outcomes and acceptability. (shrink)

Background: While employers are increasingly considering and implementing COVID-19 vaccination requirements, little is known about the reasons offered by employees seeking religious exemptions.Methods: We conducted a mixed methods analysis of all the requests for religious exemptions submitted during the initial implementation of a COVID-19 vaccination requirement at a single academic medical center in the United States.Results: Five hundred sixty-five (3.4%) employees requested religious exemptions. At least 305 (54.0%) requesters had job titles suggesting that they had direct patient contact. Four hundred (...) ninety-nine (88.3%) of requesters self-identified as Christian, of whom 120 (21.2%) identified as Roman Catholic. Requesters offered 0 to 8 (mean 2.7) categories of reasons for their request. The most frequently stated reasons pertained to the use of fetal cell lines in vaccine development and manufacturing (382, 67.6%), interest in maintaining purity (221, 39.1%), or belief in divine healing (172, 30.4%). Some requesters also volunteered evidence of the sincerity of their beliefs including examples of their religious practices (116, 20.5%), other practices (66, 11.7%), and emotional states (32, 5.7%). One hundred fifty-two applications (26.9%) contained text copied without attribution, primarily from sample religious exemption request letters available on the Internet.Conclusions: Most requesters focused on the use of fetal cell lines in the development or manufacturing of the vaccines as the justification for their request. The development of vaccines that are not reliant on fetal cell lines may increase vaccination rates. Understanding reasons for religious exemption requests may inform vaccine education and vaccination policies. (shrink)

A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care, and a proposed bill in the British House of Lords, the Conscientious Objection Bill, may well warrant a concern that—to borrow a phrase Daniel Callahan applied to self-determination—conscientious objection in health care has “run amok.” Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated “conscience absolutism.” There are two common strategies to counter (...) conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation. (shrink)

In the debate on conscientious objection in healthcare, proponents of conscience rights often point to the imperative to protect the health professional’s moral integrity. Their opponents hold that the moral integrity argument alone can at most justify accommodation of conscientious objectors as a “moral courtesy”, as the argument is insufficient to establish a general moral right to accommodation, let alone a legal right. This text draws on political philosophy in order to argue for a legal right to accommodation. The moral (...) integrity arguments should be supplemented by the requirement to protect minority rights in liberal democracies. Citizens have a right to live in accordance with their fundamental moral convictions, and a right to equal access to employment. However, this right should not be unconditional, as that would unduly infringe on the rights of other citizens. The right must be limited to cases where the moral basis is more fundamental in a sense that all reasonable citizens in a liberal democracy should accept, such as the constitutive role of the inviolability of human life in liberal democracies. There should be a legal, yet circumscribed, right to accommodation for conscientious objectors refusing to provide healthcare services that they reasonably consider to involve the intentional killing of a human being. (shrink)

This study aims to develop a valid and reliable scale to assess whether a physician is inclined to take conscientious objection when asked to perform medical services that clash with his/her personal beliefs. The scale, named the Inclination toward Conscientious Objection Scale, was developed for physicians in Turkey. Face validity, content validity, criterion-related validity, and construct validity of the scale were evaluated in the development process. While measuring criterion-related validity, Student’s t-test was used to identify the groups that did and (...) did not show inclination toward conscientious objection. There were 126 items in the initial item pool, which reduced to 42 after content validity evaluation by five experts. After necessary adjustments, the scale was administered to 224 participants. Both exploratory and confirmatory factor analyses were performed to investigate factor structure. The split-half method was employed to assess scale reliability, and the Spearman-Brown coefficient was calculated. Cronbach’s alpha reliability coefficient was used to estimate the internal consistency of the scale items. The distinctiveness of the items was evaluated using Student’s t-test. The lower and upper 27% groups were compared to assess the distinctiveness of the scale. The items were loaded on four factors that explained 85.46% of the variance: “Conscientious Objection – Medical Profession Relationship,” “Conscientious Objection in Medical Education and Medical Practice,” “Conscientious Objection with regard to the Concept of Rights” and “Conscientious Objection – Physician’s Professional Identity and Role.” The final scale has 40 items, and was found to be valid and reliable with high internal consistency. (shrink)

Robert Card’s “Reasonability View” is a significant contribution to the debate over the place of conscientious objection in health care. In his view, conscientious objections can only be accommodated if the grounds for the objection meet a reasonability standard. I identify inconsistencies in Card’s description of the reasonability standard and argue that each version he specifies is unsatisfactory. The criteria for reasonability that Card sets out most frequently have no clear underpinning principle and are too permissive of immoral objections. Card (...) has also claimed that petitioners must justify their positions with Rawlsian public reason. I argue that, although the resulting reasonability standard is principled, it is overly restrictive. I also show that a reasonability standard built on Rawls’ more lenient conception of reasonableness would be overly permissive of objections at odds with professional healthcare standards. Finally, I argue for my favored solution, which bases the reasonability standard on minimal professional standards. (shrink)

Is conscientious objection necessarily incompatible with the role and duties of a healthcare professional? An influential minority of writers on the subject think that it is. Here, we outline...

By way of a case story, two common presuppositions in the academic debate on conscientious objection in healthcare are challenged. First, the debate typically presupposes a sharp division between conscience-based refusals based on personal core moral beliefs and refusals based on professional reasons. Only the former might involve the moral gravity to warrant accommodation. The case story challenges this division, and it is argued that just as much might sometimes be at stake morally in refusals based on professional reasons. The (...) objector's moral integrity might be equally threatened in objections based on professional reasons as in objections based on personal beliefs. Second, the literature on conscientious objection typically presupposes that conflicts of conscience pertain to well-circumscribed and typical situations which can be identified as controversial without attention to individualising features of the concrete situation. However, the case shows that conflicts of conscience can sometimes be more particular, born from concrete features of the actual situation, and difficult, if not impossible, to predict before they arise. Guidelines should be updated to address such ‘situation-based’ conscientious refusals explicitly. (shrink)

During the debates about the legalization of Voluntary Assisted Dying in Victoria, Australia, the presence of anti-VAD health professionals in the medical community and reported high rates of conscientious objection to VAD suggested access may be limited. Most empirical research on CO has been conducted in the sexual and reproductive health context. However, given the fundamental differences in the nature of such procedures and the legislation governing it, these findings may not be directly transferable to VAD. Accordingly, we sought to (...) understand how CO operates in the context of VAD. Prior to the implementation of the VAD legislation in June 2019, we conducted semi-structured interviews with seventeen health professionals with a self-declared CO to VAD, to explore what motivated their CO. Participants identified multiple motivations, which can be broadly categorized as: concerns for oneself; concerns for patients; concerns about the current Victorian legislation; and concerns for the medical profession. Participants’ moral commitments included personal, professional, and political commitments. In some cases, one’s CO was specific to Victoria’s current legislation rather than VAD more broadly. Our findings suggest CO motivations extend beyond those traditionally cited and suggest a need to better understand and manage CO in the healthcare context. (shrink)

Although one can argue that they do not represent a radical departure from existing practices, protocols for reverse triage certainly step beyond what is ordinarily done in medicine and healthcare. Nevertheless, there seems to be some degree of moral concern regarding the ethical legitimacy of practicing reverse triage in the context of a pandemic. Such concern can be taken as a reflection of the moral antipathy some exhibit towards current practices of withdrawing treatment—that is, when withdrawal of treatment is arguably (...) in the best interests of patients—and a rejection of the purported normative insignificance of withholding and withdrawing. Given that the relevance of the psychological attitudes of some healthcare professionals to the moral assessment of withdrawing and withholding treatment continues to be debated, it would seem that some thought should be given to the introduction and implementation of reverse triage decisions in response to a pandemic. This brief paper will consider if provision should be made for healthcare professionals to conscientiously refuse to participate in reverse triage. (shrink)

In a recent article in this journal, Steve Clarke (2017) identifies two different bases for conscience-based refusals in healthcare: (1) all-things-considered moral judgments, and (2) the dictates of conscience. He argues that these two bases have distinct roles in justifying conscientious objection. However, accepting that there are these two bases, I argue that both are not able to justify conscientious objection. In particular, I argue that the second basis of the dictates of conscience cannot justify conscience-based refusal in a healthcare (...) context. Even if someone objects in a healthcare context on the basis of the dictates of her conscience, and even if we can explain why she objects with reference to the dictates of her conscience, her objection will only be justified if she makes a judgment. (shrink)

BackgroundDealing with end of life is challenging for patients and health professionals alike. The situation becomes even more challenging when a patient requests a legally permitted medical service that a health professional is unable to provide due to a conflict of conscience. Such a scenario arises when Victorian health professionals, with a conscientious objection (CO) to voluntary assisted dying (VAD), are presented with patients who request VAD or merely ask about VAD. The Voluntary Assisted Dying Act 2017 (Vic) recognizes the (...) inherent conflict of conscience that may arise for some health professionals when asked to provide VAD and responds by affording broad protection to conscientious objectors who wish to refuse to take part in the VAD process.MethodsSeventeen semi-structured qualitative interviews were conducted with Victorian health professionals with a self-identified CO to VAD in the lead-up to the implementation of VAD in Victoria. Interviews explored how participants anticipated they would manage their CO in practice. Interviews were transcribed verbatim and analyzed thematically.ResultsOur results reveal that the way in which health professionals claimed they would approach CO conversations is variable and was dependant on the strength of their opposition to VAD. We categorized conscientious objectors according to their approach as either dissuasive non-referrers, passive non-referrers, facilitators or negotiators. Our study also explores the perceived difficulties of exercising one’s CO as identified by our participants.ConclusionThe broad protection offered by the Voluntary Assisted Dying Act 2017 (Vic) encourages a range of behaviors from conscientious objectors, due to the minimal obligations imposed. In order to assist conscientious objectors, more policy, institutional guidance, and education needs to be available to conscientious objectors explicitly addressing how to effectively manage one’s CO. Such guidance is imperative to ensuring that their moral integrity is preserved and that they are exercising their CO appropriately. (shrink)

Sometimes healthcare professionals conscientiously refuse to treat patients despite the patient requesting legal, medically indicated treatments within the professionals’ remit. Recently, there has been a proliferation of views using the concept of public reason to specify which conscientious refusals of treatment should be accommodated. Four such views are critically assessed, namely, those of Robert Card, Massimo Reichlin, David Scott, and Doug McConnell. This paper argues that McConnell’s view has advantages over the other approaches because it combines the requirement that healthcare (...) professionals publicly justify the grounds of their conscientious refusals of treatment with the requirement that those grounds align with minimally decent healthcare. This relatively restrictive approach accommodates conscientious refusals from minimally decent healthcare professionals while still protecting good healthcare, the independence of the healthcare professions, and the fiduciary relationships. (shrink)

Healthcare professionals often face ethical conflicts and challenges related to decision-making that have necessitated consideration of the use of conscientious objection (CO). No current guidelines exist within Spain’s healthcare system regarding acceptable rationales for CO, the appropriate application of CO, or practical means to support healthcare professionals who wish to become conscientious objectors. As such, a procedural framework is needed that not only assures the appropriate use of CO by healthcare professionals but also demonstrates its ethical validity, legislative compliance through (...) protection of moral freedoms and patients’ rights to receive health care. Our proposal consists of prerequisites of eligibility for CO (individual reference, specific clinical context, ethical justification, assurance of non-discrimination, professional consistency, attitude of mutual respect, assurance of patient rights and safety) and a procedural process (notification and preparation, documentation and confidentiality, evaluation of prerequisites, non-abandonment, transparency, allowance for unforeseen objection, compensatory responsibilities, access to guidance and/or consultative advice, and organizational guarantee of professional substitution). We illustrate the real-world utility of the proposed framework through a case discussion in which our guidelines are applied. (shrink)

Conscientious refusal involves decisions by healthcare workers, on grounds of their conscience, to refuse to provide legal, professionally permissible and safe health interventions to patients. Conscientious provision involves decisions by healthcare workers, also on grounds of conscience, to provide safe and beneficial healthcare to patients that is prohibited by law or policy. Some bioethicists believe that the moral issues governing both are identical, and that if one permits conscientious refusals, one should also permit conscientious provisions. This article argues that this (...) assumption of symmetry is incorrect. To demonstrate this, it does the following: first, it establishes why it matters that we understand the difference between them; second, it describes three recent cases of conscientious provision in Canadian healthcare to help characterize its nature and scope; third, it situates these cases in a socio-economically nuanced analysis of the role of the conscientious provider under conditions or privilege and oppression; finally, it applies insights from the cases and the intersectional analysis to common criticisms of conscientious refusal to reinforce the fundamental asymmetries between conscientious refusal and conscientious provision. (shrink)

This paper builds upon previous work in which I argue that we should assess a provider's reasons for his or her objection before granting a conscientious exemption. For instance, if the medical professional's reasoned basis involves an empirical mistake, an accommodation is not warranted. This article poses and begins to address several deep questions about the workings of what I call a reason-giving view: What standard should we use to assess reasons? What policy should we adopt in order to evaluate (...) the reasons offered by medical practitioners in support of their objections? I argue for a reasonability standard to perform the essential function of assessing reasons, and I offer considerations in support of a policy establishing conscientious objector status in medicine. (shrink)

This paper reports of a case where a physician conscientiously objected to prescribing PrEP to a bisexual patient so as not to “enable immoral sexual behavior.” The case represents an instance of conscience creep, a phenomenon whereby clinicians invoke conscientious objection in sometimes objectionable ways that extend beyond the traditional contexts of abortion, sterilization, or physician aid in dying. This essay uses a reasonability view of conscientious objection to argue that the above case represents a discriminatory instance of conscience creep (...) that should not be permitted. (shrink)