Daniel Sulmasy has recently argued that good medicine depends on physicians having a wide discretionary space in which they can act on their consciences. The only constraints Sulmasy believes we should place on physicians’ discretionary space are those defined by a form of tolerance he derives from Locke whereby people can publicly act in accordance with their personal religious and moral beliefs as long as their actions are not destructive to society. Sulmasy also claims that those who would reject physicians’ (...) right to conscientious objection eliminate discretionary space thus undermining good medicine and unnecessarily limiting religious freedom. I argue that, although Sulmasy is correct that some discretionary space is necessary for good medicine, he is wrong in thinking that proscribing conscientious objection entails eliminating discretionary space. I illustrate this using Julian Savulescu and Udo Schuklenk’s system for restricting conscientious objections as a counter-example. I then argue that a narrow discretionary space constrained by professional ideals will promote good medicine better than Sulmasy’s wider discretionary space constrained by his conception of tolerance. Sulmasy’s version of discretionary space would have us tolerate actions that are at odds with aspects of good medicine, including aspects that Sulmasy himself explicitly values, such as fiduciary duty. Therefore, if we want the degree of religious freedom in the public sphere that Sulmasy favours then we must decide whether it is worth the cost to the healthcare system. (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)

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)

This paper makes two main claims: first, that the need to protect health professionals' moral integrity is what grounds the right to conscientious objection in health care; and second, that for a given claim of conscientious objection to be acceptable to society, a certain set of criteria should be fulfilled. The importance of moral integrity for individuals and society, including its special role in health care, is advocated. Criteria for evaluating the acceptability of claims to conscientious objection are outlined. The (...) precise content of the criteria is dictated by the two main interests that are at stake in the dilemma of conscientious objection: the patient's interests and the health professional's moral integrity. Alternative criteria proposed by other authors are challenged. The bold claim is made that conscientious objection should be recognised by society as acceptable whenever the five main criteria of the proposed set are met. (shrink)

I debatten om fastlegers adgang til reservasjon mot henvisning til abort hevdet noen at reservasjonslegenes ønske er selvmotsigende og utilstrekkelig begrunnet. Det ble hevdet at reservasjonslegenes foreslåtte balansegang – å nekte henvisning til abort, men i stedet legge til rette for at en kollega henviser – er etisk inkonsistent og innebærer et særegent etisk hykleri, som har blitt kalt «de rene henders etikk». Ved nærmere ettersyn viser det seg at denne viktige kritikken har brodd mot noen måter å praktisere reservasjon (...) på, men ikke mot alle. Selv om den konkrete saken fikk en løsning som ikke innebærer reservasjonsadgang, er anklagen om «de rene henders etikk» prinsipielt interessant og kan anspore en diskusjon om samvittighetsfrihetens og toleransens grenser, et tema som vil vende tilbake til offentlighetens søkelys i stadig nye former.Nøkkelord: medisinsk etikk, naturrett, reservasjonsrett, samvittighetsfrihetEnglish summary: Conscientious objection for general practitioners – hypocritical or well-justified?In the Norwegian debate about General Practitioners’ right to conscientious objection to referrals for abortion, some claimed that the GPs’ request was self-contradictory and inadequately justified. It was claimed that the GPs’ suggested balancing act, that is, refusing referral for abortion, while instead facilitating referral by a colleague, is ethically inconsistent and implies a particular kind of ethical hypocrisy, termed ‘the ethics of clean hands’. Upon closer inspection, however, it turns out that this important critique applies to some ways of practicing conscientious refusal, but not to all. Even though this particular case was resolved in a way that does not involve toleration of conscientious objection, the charge of ‘ethics of clean hands’ is fundamentally interesting, and may spur a discussion of freedom of conscience and the limits of tolerance, a topic that will be recurring in the public square in ever new shapes. (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...

Research and writing at the intersection of faith and medicine by now include thousands of published studies, review articles, books, chapters, and essays. Yet this emerging field has been described, from within, as disheveled on account of imprecision and lack of careful attention to conceptual and theoretical concerns. An important source of confusion is the fact that scholarship in this field constitutes two distinct literatures, or rather meta-literatures, which can be termed faith as a problematic for medicine and medicine as (...) a problematic for faith. These categories represent distinct theoretical lenses for viewing the intersection of faith and medicine. Observations about these two approaches are offered, along with insights about why the discourse on faith and medicine should become better integrated into discussions of religion and science. (shrink)

The ability of nurses to act as moral agents in accordance with their conscience is both an essential human freedom and an important part of professional ethics. Recent developments in Canada related to Medical Assistance in Dying have revealed new and important challenges related to conscientious objection – challenges that may require rethinking of how nurses do professional ethics. Notably, the inclusion of a personalist bioethical approach is needed to introduce and explicate what conscience is for nurses to be able (...) to apply it to nursing practice. In this article, we explore the importance of conscience and conscientious objection as ethical concepts to support nurses in addressing issues of conscience amid ethically challenging situations. We discuss how a personalist basis for conscience can support nurses to inclusively engage with one another across diverse moral perspectives. (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)

Australia’s punitive policy towards people seeking asylum deliberately causes severe psychological harm and meets recognised definitions of torture. Consequently, there is a tension between doctors’ obligation not to be complicit in torture and doctors’ obligation to provide best possible care to their patients, including those seeking asylum. In this paper, we explore the nature of complicity and discuss the arguments for and against a proposed call for doctors to boycott working in immigration detention. We conclude that a degree of complicity (...) is unavoidable when working in immigration detention, but that it may be ethically justifiable. We identify ways to minimise the harms associated with complicity and argue that it is ethical to continue working in immigration detention as long as due care and attention is paid to minimising the harms of complicity. (shrink)

Those arguing that conscientious objection in medicine should be declared unethical by professional societies face the following challenge: conscientious objection can function as an important reforming mechanism when it involves health care workers refusing to participate in certain medical interventions deemed standard of care and legally sanctioned but which undermine patients’ rights. In such cases, the argument goes, far from being unethical, conscientious objection may actually be a professional duty. I examine this sort of challenge and ultimately argue that these (...) acts of conscience done in the interest of reforming professional norms or medical regulations are best understood as episodes of civil disobedience rather than episodes of conscientious objection. In contrast to the private, exempting nature of conscientious objection, civil disobedience is a public breach of a norm or law undertaken with the aim of bringing about a change in governmental policies or professional standards. Consequently, clinicians may have a duty to engage in civil disobedience even while professional societies are right to declare limitations on the ethical appropriateness of conscientious objection. (shrink)

Doctors, nurses, and pharmacists who refuse on grounds of conscience to participate in certain legal, expected, and standard practices have been accused of unprofessionally introducing their personal views into medicine. My first response is that they often are not engaging in conscientious objection because that involves invoking convictions external to those of the medical community. I contend that medicine, properly construed, is pathocentric, and so refusing to induce a pathology via abortion, contraception, euthanasia, etc., is actually being loyal to the (...) internal morality of medicine. My second response is that even if such refusals are best considered conscientious objection, there is still no personal hijacking of medicine. Doctors refusing to induce pathologies need not refuse qua Christian, but can do so qua doctor. A pathocentric account of medicine provides a principled way of distinguishing conscientious objection from religious, idiosyncratic, and bigoted refusals. Patients’ refused pathology-inducing procedures are not medically harmed. (shrink)

Most arguments about conscientious objections in medicine fail to capture the full scope and complexity of the concept before drawing conclusions about their permissibility in practice. Arguments favoring and disfavoring the accommodation of conscientious objections in practice tend to focus too narrowly on prima facie morally contentious treatments and religious claims of conscience, while further failing to address the possibility of moral perspectives changing over time. In this paper, I argue that standard reasons against permitting conscientious objections in practice—that their (...) permission may result in harm to patients, the idea that medical providers willingly enter into the medical field, and that conscientious objections stand contrary to medical professionalism—do not apply in all cases and that the medical field and health systems in which many physicians now practice should continue to tolerate conscientious objections in practice. (shrink)

This article critically evaluates the conception of conscience underlying the debate about the proper place and role of conscience in the clinical encounter. It suggests that recovering a conception of conscience rooted in the Catholic moral tradition could offer resources for moving the debate past an unproductive assertion of conflicting rights, namely, physicians’ rights to conscience versus patients’ rights to socially and legally sanctioned medical interventions. It proposes that conscience is a necessary component of the moral life in general and (...) a necessary resource for maintaining a coherent sense of moral agency. It demonstrates that an earlier and intellectually richer conception of conscience, in contrast with common contemporary formulations, makes the judgments of conscience accountable to reason, open to critique, and protected from becoming a bastion for bigotry, idiosyncrasy, and personal bias. (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)

The paper presents an argument for respecting conscientious refusals based on the Thomistic account of conscience; the argument does not employ the notion of right. The main idea is that acting against one’s conscience necessarily makes the action objectively wrong and performed in bad faith, and expecting someone to act against his or her conscience is incompatible with requiring him or her to act in good faith. In light of this idea I also examine the issue of obligations imposed on (...) objectors as well as the claims that conscientious objectors should change their profession. (shrink)

Conscientious objection in health care is a form of compromise whereby health care practitioners can refuse to take part in safe, legal, and beneficial medical procedures to which they have a moral opposition (for instance abortion). Arguments in defense of conscientious objection in medicine are usually based on the value of respect for the moral integrity of practitioners. I will show that philosophical arguments in defense of conscientious objection based on respect for such moral integrity are extremely weak and, if (...) taken seriously, lead to consequences that we would not (and should not) accept. I then propose that the best philosophical argument that defenders of conscientious objection in medicine can consistently deploy is one that appeals to (some form of) either moral relativism or subjectivism. I suggest that, unless either moral relativism or subjectivism is a valid theory—which is exactly what many defenders of conscientious objection (as well as many others) do not think—the role of moral integrity and conscientious objection in health care should be significantly downplayed and left out of the range of ethically relevant considerations. (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)

ABSTRACT Through an interdisciplinary literature review, this propositional paper explores the emergence and unfolding of professionals’ moral identity conflicts involving important but contrasting values. Building on the exemplary case of physicians’ professional-religious dilemmas in End-of-Life circumstances, we develop a multilevel model of professional-personal identity conflict dynamics in ethically-charged situations in which we integrate individual-level mechanisms with organizational-level boundary conditions, namely peer social support and ethical climate, in relation to psychological well-being. Our conceptual model contributes to the ethics, identity and human (...) behavior literature by advancing suggestions of how professionals may prevent or/and resolve moral conflicts concerning also other identities and contexts. (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)

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)

This paper examines a legal case arising from a workplace grievance that progressed to being heard at the UK’s Supreme Court. The case of Doogan and Wood versus Greater Glasgow and Clyde Health Board concerned two senior midwives in Scotland, both practicing Roman Catholics, who exercised their perceived rights in accordance with section 4 of the Abortion Act not to participate in the treatment of women undergoing abortions. The key question raised by this case was: “Is Greater Glasgow and Clyde (...) Health Board entitled to require the midwives to delegate, supervise and support staff in the treatment of patients undergoing termination of pregnancy?” The ethical issues concerning conscientious objection to abortion have been much debated although the academic literature is mainly concerned with the position of medical practitioners rather than what the World Health Organization terms “mid-level professionals” such as midwives. This paper examines the arguments put forward by the midwives to justify their refusal to carry out tasks they felt contravened their legal right to make a conscientious objection. We then consider professional codes, UK legislation and church legislation. While the former are given strong weighting the latter was been ignored in this case, although cases in other European countries have been prevented from escalating to such a high level by the intervention of prominent church figures. The paper concludes by stating that the question put to the courts remains as yet unanswered but offers some recommendations for future policy making and research. (shrink)

This paper examines a legal case arising from a workplace grievance that progressed to being heard at the UK’s Supreme Court. The case of Doogan and Wood versus Greater Glasgow and Clyde Health Board concerned two senior midwives in Scotland, both practicing Roman Catholics, who exercised their perceived rights in accordance with section 4 of the Abortion Act not to participate in the treatment of women undergoing abortions. The key question raised by this case was: “Is Greater Glasgow and Clyde (...) Health Board entitled to require the midwives to delegate, supervise and support staff in the treatment of patients undergoing termination of pregnancy?” The ethical issues concerning conscientious objection to abortion have been much debated although the academic literature is mainly concerned with the position of medical practitioners rather than what the World Health Organization terms “mid-level professionals” such as midwives. This paper examines the arguments put forward by the midwives to justify their refusal to carry out tasks they felt contravened their legal right to make a conscientious objection. We then consider professional codes, UK legislation and church legislation. While the former are given strong weighting the latter was been ignored in this case, although cases in other European countries have been prevented from escalating to such a high level by the intervention of prominent church figures. The paper concludes by stating that the question put to the courts remains as yet unanswered but offers some recommendations for future policy making and research. (shrink)

Physicians, nurses, and healthcare professional students openly participated in the medical atrocities of the Shoah. In this paper, a physician-bioethicist and nurse-bioethicist examine the role of hierarchical power imbalances in medical education, which often occur because trainees are instructed ‘to do so’ by their superiors during medical education and clinical care. We will first examine the nature of medical and nursing education under National Socialism: were there cultural, educational, moral and legal pressures which entrenched professional hierarchies and thereby commanded obedience (...) in the face of an ever-diminishing individual and collective conscience? We will then outline relevant parallel features in modern medical education, including the effects of hierarchy in shaping ethical decision making and conscience formation. We then propose several solutions for the prevention of the negative effects of hierarchical power imbalances in medical education: universal Holocaust education in medical and nursing schools; formative and experiential ethics instruction, which teaches students to ‘speak up’ when ethical issues arise; acceptance of, and adherence to, a personalistic philosophical anthropology in healthcare; support for rigorous conscience protection laws for minority ethical views that respect the role of integrity without compromising patient care. (shrink)

Introduction to a special issue of _Theoretical Medicine and Bioethics_ on whether health care professionals should have a legally-protected right to conscientiously refuse to provide legal services that are autonomously requested by patients. Outlines the parameters of the current debate in the bioethics literature and orients readers to the articles the special issue comprises.

3 Abstract This paper is about modeling morality, with a proposal as to the best 4 way to do it. There is the small problem, however, in continuing disagreements 5 over what morality actually is, and so what is worth modeling. This paper resolves 6 this problem around an understanding of the purpose of a moral model, and from 7 this purpose approaches the best way to model morality.