I will argue that physicians have an ethical obligation to justify their conscientious objection and the most reliable interpretation of the Polish legal framework claims that conscientious objection is permissible only when the justification shows the genuineness of the judgment of conscience that is not based on false beliefs and arises from a moral norm that has a high rank. I will demonstrate that the dogma accepted in the Polish doctrine that the reasons that lie behind conscientious objection in medicine (...) cannot be evaluated or controlled by anyone is based either on a mistaken interpretation of the Constitution or on the unreliable concept of conscience. I will refer to the legal regulations concerning military refusals that require from objectors to reveal and justify their views. Finally, I will demonstrate why conscientious objection under uncertainty does not deserve acceptance, because it is based on a specific version of the precautionary principle. (shrink)

Abstract:Arguments against physicians’ claims of a right to refuse to provide tests or treatments to patients based on conscientious objection often depend on two premises that are rarely made explicit. The first is that the protection of religious liberty (broadly construed) should be limited to freedom of worship, assembly, and belief. The second is that because professions are licensed by the state, any citizen who practices a licensed profession is required to provide all the goods and services determined by the (...) profession to fall within the scope of practice of that professional specialty and permitted by the state, regardless of any personal religious, philosophical, or moral objection. In this article, I argue that these premises ought to be rejected, and therefore the arguments that depend on them ought also to be rejected. The first premise is incompatible with Locke’s conception of tolerance, which recognizes that fundamental, self-identifying beliefs affect public as well as private acts and deserve a broad measure of tolerance. The second premise unduly (and unrealistically) narrows the discretionary space of professional practice to an extent that undermines the contributions professions ought to be permitted to make to the common good. Tolerance for conscientious objection in the public sphere of professional practice should not be unlimited, however, and the article proposes several commonsense, Lockean limits to tolerance for physician claims of conscientious objection. (shrink)

This article attempts to motivate a reorientation of ethical analysis of conscientious objection by physicians. First, it presents an illustrative case from a hospital emergency department for context. Then, it criticizes the standard pro- and anti-CO arguments. It proposes that the fault in standard approaches is to focus on the ethics of the physician’s behavior, and a better way forward on this issue is to ask how the party against whom the physician exercises the CO ought to respond. It connects (...) this question with recent trends in physician employment models, which suggest that CO may become a potential source of conflict in the future. The article then develops a relational account of CO that extends James Childress’ insights about the nature of CO in “Appeals to Conscience”. This relational account characterizes CO as a two-place relation between conscientious objector and expectant party, in which the conscientious objector makes a request of the expectant party, which has implications that will be welcome and unwelcome for both the pro- and anti-CO camps. Finally, the paper applies this relational account of CO to the case when the physician is an employee. This application demonstrates that it is highly context dependent whether or not an employer should accede to the CO requests of physician–employees. (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)

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)

In this article, we offer a rebuttal to a key thesis in Chapter 5 of Engelhardt’s After God: namely, that there exists an “unbridgeable gap” between the dominant secular culture and traditional religious believers. Contra Engelhardt, we argue that it is possible to bridge the gap by employing a strategy that includes, but is not limited to, methods for cultivating understanding and respect and a sense of solidarity. Our argument proceeds in three steps. First, we elucidate Engelhardt’s thesis in light (...) of some of the key concepts he discusses elsewhere in After God. Second, in the hope of developing understanding and respect, we elucidate the history and teachings that form the consciences of traditional Christian medical professionals concerning abortion, euthanasia, and disfiguring surgeries. Third, in the hope of developing a sense of solidarity, we explain the broad scope of the dominant secular culture’s attempt to limit people’s freedom of conscience rights, showing that it includes not only traditional Christians but also members of other traditional religions, members of mainline religious groups, people with alternative conceptions of secularity, and even faithful members of the dominant secular culture. (shrink)

This paper argues that healthcare aims at the good of health, that this pursuit of the good necessitates conscience, and that conscience is required in every practical judgement, including clinical...

In complex, pluralistic societies, different views concerning the moral duties of healthcare professionals inevitably exist: according to some accounts, doctors can and should cooperate in performing abortion or physician-assisted suicide, while according to others they should always defend human life and protect their patients’ health. It is argued that the very plurality of responses presently given to questions such as these provides a liberal argument in favour of conscientious objection, as an attempt to deal with moral diversity by protecting both (...) the professionals’ claim to moral integrity and the patients’ claim to receive lawful and safe medical treatments. A moderate view on CO is defended, according to which none of these claims can be credited with unconditional value. Claims to CO by healthcare professionals can be justified but must be subjected to a reasonableness standard. Both the incompatibility of CO with the medical profession and its unconditional sanctioning by conscience absolutism are therefore rejected. The paper contributes to the definition of the conditions of such reasonableness, particularly by stressing the role played by conceptions of good medicine in discriminating claims to CO; it is argued that respecting these conditions prevents from having the negative consequences dreaded by critics. The objection according to which accepting the physician’s duty to inform and refer is inconsistent with the professed value of moral integrity is also discussed. (shrink)

The vigorous legal and ethical debates over conscientious objection have taken place largely within the domain of health care. Is this because conscience in medicine is of a special kind, or are th...

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...

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)

Definition of the problem: The ethical debate about assisted suicide remains controversial and is also based in part on assumptions that are taken for granted, but which, on closer inspection, lack a justification. Arguments: The article develops a new approach by focusing on the social dimension of the denial of meaning in life, which is often expressed by suicides. For a fundamental social connection is included in the human orientation towards the goal of a meaningful life, namely an implicit appreciation (...) of human beings as potential sources of meaning and as subjects of judgments about the meaningfulness. Suicides tend to deny this connection. Conclusion: This understanding of suicide can, among other things, adequately understand the meaning of (assisted) suicide and justify the widely shared assumptions of a primacy of suicide prevention and a conscientious objection right of doctors. (shrink)

In this response paper, we respond to the criticisms that Michal Pruski raised against our article “Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests.” We defend our original position against conscientious objection in healthcare by suggesting that the analogies Pruski uses to criticize our paper miss the relevant point and that some of the analogies he uses and the implications he draws are misplaced.

We argue that, in certain circumstances, doctors might beprofessionallyjustified to provide abortions even in those jurisdictions where abortion is illegal. That it is at least professionally permissible does not mean that they have an all-things-considered ethical justification or obligation to provide illegal abortions or that professional obligations or professional permissibility trump legal obligations. It rather means that professional organisations should respect and indeed protect doctors’ positive claims of conscience to provide abortions if they plausibly track what is in the best (...) medical interests of their patients. It is the responsibility of state authorities to enforce the law, but it is the responsibility of professional organisations to uphold the highest standards of medical ethics, even when they conflict with the law. Whatever the legal sanctions in place, healthcare professionals should not be sanctioned by the professional bodies for providing abortions according to professional standards, even if illegally. Indeed, professional organisation should lobby to offer protection to such professionals. Our arguments have practical implications for what healthcare professionals and healthcare professional organisations may or should do in those jurisdictions that legally prohibit abortion, such as some US States after the reversal ofRoe v Wade. (shrink)

Conflict of interests in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner’s financial interest conflicts with patients’ interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of “interests” cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of (...) which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners’ moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs. (shrink)

Clinicians have good moral and professional reasons to contribute to pragmatic clinical trials (PCTs). We argue that clinicians have a defeasible duty to participate in this research that takes place in usual care settings and does not involve substantive deviation from their ordinary care practices. However, a variety of countervailing reasons may excuse clinicians from this duty in particular cases. Yet because there is a moral default in favor of participating, clinicians who wish to opt out of this research must (...) justify their refusal. Reasons to refuse include that the trial is badly designed in some way, that the trial activities will violate the clinician’s conscience, or that the trial will impose excessive burdens on the clinician. (shrink)

Conscientious Objection has become a highly contested topic in the bioethics literature and public policy. However, when CO is discussed, it is almost universally referred to as a single entity. Reality reveals a more nuanced picture. Healthcare professionals may object to a given action on numerous grounds. They may oppose an action because of its ends, its means, or because of factors that lay outside of both ends and means. Our paper develops a taxonomy of CO, which makes it possible (...) to describe the refusals of healthcare professional with greater finesse. The application of this development will potentially allow for greater subtlety in public policy and academic discussions – some species of CO could be permitted while others could be prohibited. (shrink)

In 2019, several US states passed “heartbeat” bills. Should such bills go into effect, they would outlaw abortion once an embryonic heartbeat can be detected, thereby severely limiting an individual’s access to abortion. Many states allow health care professionals to refuse to provide an abortion for reasons of conscience. Yet heartbeat bills do not include a positive conscience clause that would allow health care professionals to provide an abortion for reasons of conscience. I argue that this asymmetry is unjustified. The (...) same criteria that justify protecting conscientious refusals to provide abortion also justify protecting positive conscientious appeals regarding abortion. Thus, if the law provides legal exemptions for health care professionals who, as a matter of conscience, refuse to provide abortions where it is legal, it should also provide exemptions for health care professionals who, as a matter of conscience, feel obligated to provide abortions where it is illegal. (shrink)

This article attempts to motivate a reorientation of ethical analysis of conscientious objection by physicians. First, it presents an illustrative case from a hospital emergency department for context. Then, it criticizes the standard pro- and anti-CO arguments. It proposes that the fault in standard approaches is to focus on the ethics of the physician’s behavior, and a better way forward on this issue is to ask how the party against whom the physician exercises the CO ought to respond. It connects (...) this question with recent trends in physician employment models, which suggest that CO may become a potential source of conflict in the future. The article then develops a relational account of CO that extends James Childress’ insights about the nature of CO in “Appeals to Conscience”. This relational account characterizes CO as a two-place relation between conscientious objector and expectant party, in which the conscientious objector makes a request of the expectant party, which has implications that will be welcome and unwelcome for both the pro- and anti-CO camps. Finally, the paper applies this relational account of CO to the case when the physician is an employee. This application demonstrates that it is highly context dependent whether or not an employer should accede to the CO requests of physician–employees. (shrink)

This article attempts to motivate a reorientation of ethical analysis of conscientious objection by physicians. First, it presents an illustrative case from a hospital emergency department for context. Then, it criticizes the standard pro- and anti-CO arguments. It proposes that the fault in standard approaches is to focus on the ethics of the physician’s behavior, and a better way forward on this issue is to ask how the party against whom the physician exercises the CO ought to respond. It connects (...) this question with recent trends in physician employment models, which suggest that CO may become a potential source of conflict in the future. The article then develops a relational account of CO that extends James Childress’ insights about the nature of CO in “Appeals to Conscience”. This relational account characterizes CO as a two-place relation between conscientious objector and expectant party, in which the conscientious objector makes a request of the expectant party, which has implications that will be welcome and unwelcome for both the pro- and anti-CO camps. Finally, the paper applies this relational account of CO to the case when the physician is an employee. This application demonstrates that it is highly context dependent whether or not an employer should accede to the CO requests of physician–employees. (shrink)

Many contributors to debates about professional conscience assume a basic, pre-professional right of conscientious refusal and proceed to address how to ‘balance’ this right against other goods. Here I argue that opponents of a right of conscientious refusal concede too much in assuming such a right, overlooking that the professions in which conscientious refusal is invoked nearly always operate as public cartels, enjoying various economic benefits, including protection from competition, made possible by governments exercising powers of coercion, regulation, and taxation. (...) To acknowledge a right of conscientious refusal is to license professionals to disrespect the profession’s clients, in opposition to liberal ideals of neutrality, and to engage in moral paternalism toward them; to permit them to violate duties of reciprocity they incur by virtue of being members of public cartels; and to compel those clients to provide material support for conceptions of the good they themselves reject. However, so long... (shrink)

Ancell and Sinnott-Armstrong argue that medical providers possess wide freedoms to determine the scope of their practice, and therefore, prohibiting almost any conscientious objections is a bad idea. They maintain that we could create an acceptable system on the whole which even grants accommodations to discriminatory refusals by healthcare professionals. Their argument is premised upon applying a free market mechanism to conscientious objections in medicine, yet I argue their Market View possesses a number of absurd and troubling implications. Furthermore, I (...) demonstrate that the fundamental logic of their main argument is flawed. Thinkers who wish to address the issues raised in this debate in general or by discriminatory conscience objections in particular should avoid the Market View and instead envisage theories that assess the reasons underlying conscientious refusals in medicine. (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)

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)

BackgroundThe public’s attitudes to conscientious objection are likely to influence political decisions about CO and trust towards healthcare systems and providers. Few studies examine the pub...