A number of health care professionals assert a right to be exempt from performing some actions currently designated as part of their standard professional responsibilities. Most advocates claim that they should be excused from these duties simply by averring that they are conscientiously opposed to performing them. They believe that they need not explain or justify their decisions to anyone; nor should they suffer any undesirable consequences of such refusal. Those who claim this right err by blurring or conflating three (...) issues about the nature and role of conscience, and its significance in determining what other people should permit them to do (or not do). Many who criticize those asserting an exemption conflate the same questions and blur the same distinctions, if not expressly, by failing to acknowledge that sometimes a morally serious agent should not do what she might otherwise be expected to do. Neither side seems to acknowledge that in some cases both claims are true: a conscientious professional should not do her professional duty AND others need not permit or excuse her refusal. I identify these conflations and specify conditions in which a professional might reasonably refuse to do what she is required to do. Then I identify conditions in which the public should exempt a professional from some of her responsibilities. I argue that professionals should refuse far less often than most advocates do . . . and that they should be even less frequently exempt for that failure. Finally, there are compelling reasons why we could not implement a consistent moral policy giving advocates what they want, likely not even in qualified form. (shrink)

“It's almost like putting salt in a wound, for this person who's already made a very difficult decision,” suggested Meghan Patterson, a licensed obstetrician-gynecologist whom we interviewed in our qualitative study of the experiences of North Carolina abortion providers practicing under the state's Woman's Right to Know Act. The act requires that women receive counseling with state-mandated information at least twenty-four hours prior to obtaining an abortion. After the law was passed, Patterson worked with clinic administrators, in consultation with a (...) lawyer, to write a script to be used in the state-mandated counseling procedure. She and her colleagues took particular steps to mitigate the effects of what she described as HB 854's “forced language”—such as referring to the “father of the child.” While HB 854 stipulated that patients must be informed of the medical risks associated with the particular abortion procedure as well as those of carrying the child to term, Patterson's script made explicit the magnitude of comparative risks, emphasizing that the risks of carrying a pregnancy to term are substantially greater than the risks of an early-term abortion. She felt that these contextualization strategies helped to facilitate trust and rapport in a clinical care situation that proved relationally and morally challenging. In this article, we take up and expand on this point by elucidating an empirically grounded approach to ethically justified care when health care providers face legal or institutional policy mandates that raise possible moral conflicts. Our approach builds on recent bioethics discourse addressing conscience in the practice of medicine. While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious objection or refusal. Here, we suggest a broader frame for thinking about claims of conscience in health care. Our approach draws on the feminist bioethics and the ethics of care literatures to highlight how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. What emerges are two possibilities: not only conscientious refusal to comply with a policy mandate but also conscientious compliance—working conscientiously within a mandate's confines. (shrink)

Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on (...) one’s conscience. Second, I sketch an account of the basis of the medical and pharmacy professions’ responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the “conventional compromise” as a reasonable accommodation to conflicts between these professions’ responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: “Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?”. (shrink)

This paper investigates the meaning of conscience in providing healthcare and Slovak healthcare workers’ lived experience of conscience. It draws on data from semi-structured interviews with eleven healthcare professionals. The data was analyzed using a phenomenological hermeneutic interpretation. Two main themes relating to the lived experience of conscience were derived—preserving one’s conscience integrity, by satisfying one’s conscience in order to sustain it, using defense mechanisms for protection, following one’s inner conviction, and respecting the patient’s individuality and having a troubled conscience (...) in relation to external factors, medical procedures and options, and demands by the authorities. The results are discussed in relation to the literature. (shrink)

Answers to the questions of what justifies conscientious objection in medicine in general and which specific objections should be respected have proven to be elusive. In this paper, I develop a new framework for conscientious objection in medicine that is based on the idea that conscience can express true moral claims. I draw on one of the historical roots, found in Adam Smith’s impartial spectator account, of the idea that an agent’s conscience can determine the correct moral norms, even if (...) the agent’s society has endorsed different norms. In particular, I argue that when a medical professional is reasoning from the standpoint of an impartial spectator, his or her claims of conscience are true, or at least approximate moral truth to the greatest degree possible for creatures like us, and should thus be respected. In addition to providing a justification for conscientious objection in medicine by appealing to the potential truth of the objection, the account advances the debate regarding the integrity and toleration justifications for conscientious objection, since the standard of the impartial spectator specifies the boundaries of legitimate appeals to moral integrity and toleration. The impartial spectator also provides a standpoint of shared deliberation and public reasons, from which a conscientious objector can make their case in terms that other people who adopt this standpoint can and should accept, thus offering a standard fitting to liberal democracies. (shrink)

Recently, debate over whether health care providers should have a protected right to conscientiously refuse to offer legal health care services—such as abortion, elective sterilization, aid in dying, or treatments for transgender patients—has grown exponentially. I advance a modified compromise view that bases respect for claims of conscientious refusal to provide specific health care services on a publicly defensible rationale. This view requires health care providers who refuse such services to disclose their availability by other providers, as well as to (...) arrange for referrals or facilitate transfers of care. This requirement raises the question of whether providers are being forced to be complicit in the provision of services they deem to be morally objectionable. I conclude by showing how this modified compromise view answers the most significant objections mounted by critics of the right to conscientious refusal and safeguards providers from having to offer services that most directly threaten their moral integrity. (shrink)

Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: Three common (...) themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection. (shrink)

Background: Conscience is an important concept in ethics, having various meanings in different cultures. Because a growing number of healthcare professionals are of immigrant background, particularly within the care of older people, demanding multiple ethical positions, it is important to explore the meaning of conscience among care providers within different cultural contexts. Research objective: The study aimed to illuminate the meaning of conscience by enrolled nurses with an Iranian background working in residential care for Persian-speaking people with dementia. Research design: (...) A phenomenological hermeneutical method guided the study. Participants and research context: A total of 10 enrolled nurses with Iranian background, aged 33–46 years, participated in the study. All worked full time in residential care settings for Persian-speaking people with dementia in a large city, in Sweden. Ethical considerations: The study was approved by the Regional Ethical Review Board for ethical vetting of research involving humans. Participants were given verbal and written study information and assured that their participation was voluntary and confidential. Findings: Three themes were constructed including perception of conscience, clear conscience grounded in relations and striving to keep a clear conscience. The conscience was perceived as an inner guide grounded in feelings, which is dynamic and subject to changes throughout life. Having a clear conscience meant being able to form a bond with others, to respect them and to get their confirmation that one does well. To have a clear conscience demanded listening to the voice of the conscience. The enrolled nurses strived to keep their conscience clear by being generous in helping others, accomplishing daily tasks well and behaving nicely in the hope of being treated the same way one day. Conclusion: Cultural frameworks and the context of practice needed to be considered in interpreting the meaning of conscience and clear conscience. (shrink)

Our study provides a review of argument-based scientific literature to address conscientious objections to end-of-life procedures. We also proposed a taxonomy based on this study that might facilitate clarification of this discussion at a basic level. The three clusters of our taxonomy include (1) nonconventional compatibilists that claim that conscientious objection against morally repugnant social conventions is compatible with professional obligation, (2) conventional compatibilists that suggest that conscientious objection against social convention is permissible under certain terms of compromise, and (3) (...) conventional incompatibilists that aver that conscientious objection is incompatible with the privileges and obligations of a health care provider. We conclude with three moments of reflective pause. The first pause reflects on the question of the health of a society's pluralism. The second pause results in suggested practice guidelines for conscientious objection to facilitate cooperation. The final pause reveals the need for further research to uncover a global perspective. (shrink)

Certain health care services and goods, although legal and often generally accepted in a society, are by some considered morally problematic. Debates on conscientious objection in health care try to resolve whether and when physicians, nurses and pharmacists should be allowed to refuse to provide medical services and goods because of their ethical or religious beliefs. These debates have most often focused on issues such as how to balance the interests of patients and health care professionals, and the compatibility of (...) conscientious objection with professional obligations, but it is also possible to think about conscientious objection in terms of how to respond to moral disagreement and the requirements of liberal neutrality. (shrink)

Religious considerations in medical decision-making have enjoyed newfound attention in recent years, challenging the assumption that the domains of biological and spiritual flourishing can be cleanly separated in clinical practice. A surprising majority of patients desire their physicians to engage their religious and spiritual concerns, yet most never receive such attention, particularly in cases near the end of life where such attention seems most warranted.1–3 As physicians Aparna Sajja and Christina Puchalski recently wrote in the AMA Journal of Ethics theme (...) issue on ‘Religion and Spirituality in Healthcare Practice’, modern medical training is ‘falling short of preparing physicians to help patients with the metaphysical needs of their illness’.4 It would seem then that both patients and physicians might challenge the conclusions proffered by philosophers Jake Greenblum and Ryan Hubbard in ‘Responding to Religious Patients: Why Physicians Have No Business Doing Theology’, in which they claim that physicians ought not to engage religious reasoning for medical decisions. Their conclusion relies on two core arguments: a ‘public reason’ argument and a ‘fiduciary argument’, both of which contend that theology and religious considerations have no place in medical reasoning. We find that two central errors undergird these arguments. First is the fraught notion of an epistemically and ethically normative public reason, and second is a fundamental mischaracterisation of the fiduciary nature of the patient–physician relationship and the nature of medicine itself. In response, we argue that all physicians essentially ‘do theology’ and that, rather than divorcing theology from medical practice, clinicians should make it their business to do theology well. To support the exclusion of religious reasoning from medical decision-making, the authors open with a ‘public reason argument’, suggesting that physicians serve in roles closely resembling those of public officials. As such, the physician as public official ought to limit himself …. (shrink)

What role should the physician's conscience play in the practice of medicine? Much controversy has surrounded the question, yet little attention has been paid to the possibility that disputants are operating with contrasting definitions of the conscience. To illustrate this divergence, we contrast definitions stemming from Abrahamic religions and those stemming from secular moral tradition. Clear differences emerge regarding what the term conscience conveys, how the conscience should be informed, and what the consequences are for violating one's conscience. Importantly, these (...) basic disagreements underlie current controversies regarding the role of the clinician's conscience in the practice of medicine. Consequently participants in ongoing debates would do well to specify their definitions of the conscience and the reasons for and implications of those definitions. This specification would allow participants to advance a more philosophically and theologically robust conversation about the means and ends of medicine. (shrink)

The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the dictates of regulatory bodies and administrators. Increasing (...) attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom. (shrink)

Conscience and Conscientious Objection of Health Care Professionals Refocusing the Issue Content Type Journal Article Pages 351-364 DOI 10.1007/s10730-009-9113-x Authors Natasha T. Morton, The University of Western Ontario Ontario Canada N6A 5B9 Kenneth W. Kirkwood, Arthur and Sonia Labatt Health Sciences Building London Ontario Canada N6A 5B9 Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4.

Ethical reasoning is an integral part of the work of a clinical ethics consultant. Ethical reasoning has a close relationship with an individual’s beliefs and values, which, for religious adherents, are likely to be tightly connected with their spiritual perspectives. As a result, for individuals who identify with a religious tradition, the process of thinking through ethical questions is likely to be influenced by their religious worldview. The connection between ethical reasoning and one’s spiritual perspective raises questions about the role (...) that CECs’ personal religious worldviews should play in their professional lives and their consultative work. This paper offers numerous arguments critiquing the inclusion of a consultant’s own spiritual perspective in her work and has identified only limited circumstances under which such inclusion might be permissible. In particular, these arguments lead to the conclusion that a CEC’s personal beliefs should never influence her ethical analysis or development of a recommendation. Further, religious appeals should not be used in communication during decision-making conversations other than to describe the patient or surrogate’s stated perspective. There may be limited cases in which a CEC may share her spiritual worldview with a patient with the intent of building a collaborative relationship, but such situations should be approached with extreme caution. (shrink)