The literature on conscientious objection in medicine presents two key problems that remain unresolved: Which conscientious objections in medicine are justified, if it is not feasible for individual medical practitioners to conclusively demonstrate the genuineness or reasonableness of their objections? How does one respect both medical practitioners’ claims of conscience and patients’ interests, without leaving practitioners complicit in perceived or actual wrongdoing? My aim in this paper is to offer a new framework for conscientious objections in medicine, which, by bringing (...) medical professionals’ conscientious objection into the public realm, solves the justification and complicity problems. In particular, I will argue that: an “Uber Conscientious Objection in Medicine Committee” —which includes representatives from the medical community and from other professions, as well as from various religions and from the patient population—should assess various well-known conscientious objections in medicine in terms of public reason and decide which conscientious objections should be permitted, without hearing out individual conscientious objectors; medical practitioners should advertise their conscientious objections, ahead of time, in an online database that would be easily accessible to the public, without being required, in most cases, to refer patients to non-objecting practitioners. (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)

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)

This paper comes out of a panel honoring the work of Anne Donchin (1940-2014), which took place at the 2016 Congress of the International Network on Feminist Approaches to Bioethics (FAB) in Edinburgh. My general aim is to highlight the contributions Anne made to feminist bioethics, and to feminist reproductive ethics in particular. My more specific aim, however, is to have a kind of conversation with Anne, through her work, about whether reproductive justice could demand insurance coverage for in vitro (...) fertilization. I quote liberally from Anne’s work for this purpose, but also to shower the reader with her words, reminding those of us who knew her well what a wonderful colleague she was. (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)

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)

It is argued that the primary aim of institutional management is to protect the moral integrity of health professionals without significantly compromising other important values and interests. Institutional policies are recommended as a means to promote fair, consistent, and transparent management of conscience-based refusals. It is further recommended that those policies include the following four requirements: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) Conscience-based (...) refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on colleagues, supervisors, department heads, other administrators, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. Formal review may not be required in all cases, but when it is appropriate, several recommendations are offered about standards and the review process. A key recommendation is that when reviewing an objector’s reasons, contrary to what some have proposed, it is not appropriate to adopt an adversarial approach modelled on military review boards’ assessments of requests for conscientious objector status. According to the approach recommended, the primary function of reviews of objectors’ reasons is to engage them in a process of reflecting on the nature and depth of their objections, with the objective of facilitating moral clarity on the part of objectors rather than enabling department heads, supervisors, or ethics committees to determine whether conscientious objections are sufficiently genuine. (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)

In this paper I defend the Reasonability View: the position that medical professionals seeking a conscientious exemption must state reasons in support of their objection and allow those reasons to be subject to evaluation. Recently, this view has been criticized by Jason Marsh as proposing a standard that is either too difficult to meet or too easy to satisfy. First, I defend the Reasonability View from this proposed dilemma. Then, I develop this view by presenting and explaining some of the (...) central criteria it uses to assess whether a conscientious objection is proper grounds for extending an exemption to a medical practitioner. (shrink)

There is a regulatory option for conscientious objection in health care that has yet to be systematically examined by ethicists and policymakers: granting a liberty to request exemption from prescribed work tasks without a companion guarantee that the request is accommodated. For the right-holder, the liberty’s value lies in the ability to seek exemption without duty-violation and a tangible prospect of reassignment. Arguing that such a liberty is too unreliable to qualify as a right to conscientious objection leads to the (...) problem of consistently distinguishing its effects from those of a right to conscientious objection that is made conditional on an individual assessment of the objector’s motivation. These properties require that we distinguish the liberty to request exemption from more restrictive policy choices, and that we subject it to greater scrutiny in the wider moral discourse as a possible variant of a right to conscientious objection. (shrink)

Conscience-based refusals by health care professionals to provide care to eligible patients are problematic, given the monopoly such professionals hold on the provision of such services. This article reviews standard ethical arguments in support of conscientious refuser accommodation and finds them wanting. It discusses proposed compromise solutions involving efforts aimed at testing the genuineness and reasonability of refusals and rejects those solutions too. A number of jurisdictions have introduced policies requiring conscientious refusers to provide effective referrals. These policies have turned (...) out to be unworkable. They subject patients to a health care delivery lottery, which is incompatible with the fundamental values of medical professionalism. This paper sheds light on transnational efforts aimed at undermining progress made in reproductive health by means of conscientious refusal accommodation claims. The view that the accommodation of conscientious refusers is indefensible on consequentialist ethical grounds, as well as on grounds related to medical professionalism itself, is defended. (shrink)

Conscientious objection to participating in induced abortion is not present in the Finnish health care system or legislation unlike in many other European countries.

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)

In Victoria, Australia, the law regulating abortion was reformed in 2008, and a clause was introduced requiring doctors with a conscientious objection to abortion to refer women to another provid...

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)

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)

A recent focus of the debate on conscientious objection in healthcare is the question of whether practitioners should have to justify their refusal to perform certain functions. A recent article by Cowley addresses a practical aspect of this controversy, namely the question of whether doctors claiming conscientious objector status in relation to abortion should be required, like their counterparts claiming exemption from military conscription, to defend their claim before a tribunal. Cowley argues against the use of tribunals in the medical (...) case, on the grounds that there are likely to be fewer unjustified claims to conscientious objection in this context than in the military, and that in any case tribunals will not be an effective way of distinguishing genuine and false cases. I reject these arguments and propose a different conception of the role of a medical conscientious objection tribunal. (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)

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)

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)

An analogy is sometimes drawn between the proper treatment of conscientious objectors in healthcare and in military contexts. In this paper, I consider an aspect of this analogy that has not, to my knowledge, been considered in debates about conscientious objection in healthcare. In the USA and elsewhere, tribunals have been tasked with the responsibility of recommending particular forms of alternative service for conscientious objectors. Military conscripts who have a conscientious objection to active military service, and whose objections are deemed (...) acceptable, are required either to serve the military in a non-combat role, or assigned some form of community service that does not contribute to the effectiveness of the military. I argue that consideration of the role that military tribunals have played in determining the appropriate form of alternative service for conscripts who are conscientious objectors can help us to understand how conscientious objectors in healthcare ought to be treated. Additionally, I show that it helps us to address the vexed issue of whether or not conscientious objectors who refuse to provide a service requested by a patient should be required to refer that patient to another healthcare professional. (shrink)

Robert Card has proposed a reasonability view of conscientious objection that asks providers to state the reasons for their objection for evaluation and approval by a review board. Jason Marsh has challenged Card to provide explicit criteria for what makes a conscientious objection reasonable, which he claims will be too difficult a task given that such objections often involve contentious metaphysical or religious claims. Card has responded by outlining standards by which a conscientious objection could be judged reasonable. In this (...) paper, I extend Marsh’s critique to key concepts in the standards outlined by Card such as abortifacient, harm, emergency, and discrimination, showing they can be given radically different interpretations given different metaphysical or religious presumptions. To resolve these conflicting interpretations, a reasonability view of conscientious objection will need more than the criteria outlined by Card, it will need the resources to evaluate the reasonability of metaphysical or religious claims. (shrink)