Protecting claims of conscience can function to fairly balance burdens among relevant parties without first having to resolve an underlying and intractable moral disagreement. Recently, a number of theorists have argued that the relevant criteria for protecting negative appeals to conscience in health care can (suitably modified) be equally well-satisfied in cases of positive appeals. I argue that, when it comes to certain practices, the justification of positive appeals to conscience does in fact depend upon contested claims in the debate (...) over the moral permissibility of those practices. This fact threatens to undermine one of the central functions of protecting appeals to conscience: that we can agree to disagree. (shrink)

Debates about the ethics of health care and medical research in contemporary pluralistic democracies often arise partly from competing religious and secular values. Such disagreements raise challenges of balancing claims of religious liberty with claims to equal treatment in health care. This paper proposes several mid-level principles to help in framing sound policies for resolving such disputes. We develop and illustrate these principles, exploring their application to conscientious objection by religious providers and religious institutions, accommodation of religious priorities in biomedical (...) research, and treatment of patients’ religious views in doctor–patient encounters. Given that no sound set of guiding principles yields precise solutions for every policy dispute, we explore how morally sound democracies might deliberatively resolve such policy issues, following our proposed principles. Taken together and carefully interpreted, these principles may help in guiding difficult decision making in the indefinitely large realm where government, medical providers, and patients encounter problems concerning religion and medicine. (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)

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)

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...

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)

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)

Debate persists over the place of conscience in medicine. Some argue for the complete exclusion of conscientious objection, while others claim an absolute right of refusal. This paper proposes that claims of conscientious objection can and should be permitted if they concern kinds of actions which fall outside of the normative standard of medicine, which is the pursuit of health. Medical practice which meets this criterion we call medicine qua medicine. If conscientious refusal concerns something consonant with the health-restoring aims (...) of medicine, it entails a desertion of professional duty. If, however, it relates to something other than medicine qua medicine, it can rightly be refused. It thus becomes possible to test instances of conscientious objection to determine their validity, and thereby conserve both the principle of conscientious objection and define its scope. This test of conscience prevents arbitrary discrimination, and preserves doctors’ agency. It is a theoretical razor rooted in the pra... (shrink)

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

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)

Vaccine refusal occurs for a variety of reasons. In this article we examine vaccine refusals that are made on conscientious grounds; that is, for religious, moral, or philosophical reasons. We focus on two questions: first, whether people should be entitled to conscientiously object to vaccination against contagious diseases ; second, if so, to what constraints or requirements should conscientious objection to vaccination be subject. To address these questions, we consider an analogy between CO to vaccination and CO to military service. (...) We argue that conscientious objectors to vaccination should make an appropriate contribution to society in lieu of being vaccinated. The contribution to be made will depend on the severity of the relevant disease, its morbidity, and also the likelihood that vaccine refusal will lead to harm. In particular, the contribution required will depend on whether the rate of CO in a given population threatens herd immunity to the disease in question: for severe or highly contagious diseases, if the population rate of CO becomes high enough to threaten herd immunity, the requirements for CO could become so onerous that CO, though in principle permissible, would be de facto impermissible. (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)

In this essay I examine the formal structure of the concept of futility, enabling identification of the appropriate roles played by patient, professional, and society. I argue that the concept of futility does not justify unilateral decisions to forego life-sustaining medical treatment over patient or legitimate surrogate objection, even when futility is determined by a process or subject to ethics committee review. Furthermore, I argue for a limited positive ethical obligation on the part of health care professionals to assist patients (...) in achieving certain restricted goals, including the preservation of life, even in circumstances in which most would agree that that life is of no benefit to the patient. Finally, I address the objection that professional integrity overrides this limited obligation and find the objection unconvincing. In short, my aim in this essay is to see the concept of futility finally buried, once and for all. (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)

Some bioethicists argue that conscientious objectors in health care should have to justify themselves, just as objectors in the military do. They should have to provide reasons that explain why they should be exempt from offering the services that they find offensive. There are two versions of this view in the literature, each giving different standards of justification. We show these views are each either too permissive (i.e. would result in problematic exemptions based on conscience) or too restrictive (i.e. would (...) produce problematic denials of exemption). We then develop a middle ground position that we believe better combines respect for the conscience of healthcare professionals with concern for the duties that they owe to patients. Our claim, in short, is that insofar as objectors should have to justify themselves, they should have to do it according to the standard that we defend rather than according to the standards that others have developed. (shrink)

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities endorse an “ethics facilitation” approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making, which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for presuming (...) contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt’s solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt’s negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise—defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities—from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt’s critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt’s view is an unstable basis for that worry. (shrink)

A peer commentary on an AJOB article by Kyle Fritz called "Unjustified Asymmetry: Positive Claims of Conscience and Heartbeat Bills.".

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)

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...

ABSTRACTSince 2007, when Mexico City decriminalized abortion during the first trimester, a debate has been taking place regarding abortion and the right to conscientious objection. Many people argue that, since the provision of abortions is now a statutory duty of healthcare personnel there can be no place for “conscientious objection.” Others claim that, even if such an objection were to be allowed, it should not be seen as a right, since talk about a right to CO may lead to a (...) slippery slope where we may end up recognizing a right to disobey the law. In this paper, I argue that there is a right to CO and that this may be justified through the notions of autonomy and integrity, which a liberal democracy should respect. However, it cannot be an absolute right, and in the case of abortion, it conflicts with women’s reproductive rights. Therefore, CO should be carefully regulated so that it does not obstruct the exercise o... (shrink)

Decisions about allocation of limited healthcare resources are frequently controversial. These decisions are usually based on careful analysis of medical, scientific and health economic evidence. Yet, decisions are also necessarily based on value judgements. There may be differing views among health professionals about how to allocate resources or how to evaluate existing evidence. In specific cases, professionals may have strong personal views (contrary to professional or societal norms) that treatment should or should not be provided. Could these disagreements rise to (...) the level of a conscientious objection? If so, should conscientious objections to existing allocation decisions be accommodated? In the first part of this paper, I assess whether resource allocation could be a matter of conscience. I analyse conceptual and normative models of conscientious objection and argue that rationing could be a matter for conscience. I distinguish between negative and positive forms: conscientious non-treatment and conscientious treatment. In the second part of the paper, I identify distinctive challenges for conscientious objections to resource allocation. Such objections are almost always inappropriate. (shrink)

In their article “Therapeutic, Prophylactic, Untoward, and Contraceptive Effects of Combined Oral Contraceptives. Catholic Teaching, Natural Law, and the Principle of Double Effect When Deciding to...

¿Por qué recurren las mujeres migrantes a un método abortivo clandestino cuando existen cauces regulados y gratuitos para interrumpir el embarazo? A partir de un caso relatado en una noticia de prensa, el presente trabajo pretende ofrecer argumentos capaces de fundamentar una posible respuesta. Frente al modelo médico hegemónico, el uso del misoprostol extiende el debate no sólo a la identificación de las disfunciones del sistema sanitario español, sino a discursos relacionados con la identidad y a planteamientos autogestionarios de empoderamiento (...) para las mujeres. (shrink)

Background Voluntary assisted dying became lawful in Victoria, the first Australian state to permit this practice, in 2019 via the Voluntary Assisted Dying Act 2017 (Vic). While conscientious objection by individual health professionals is protected by the Victorian legislation, objections by institutions are governed by policy. No research has been conducted in Victoria, and very little research conducted internationally, on how institutional objection is experienced by patients seeking assisted dying. Methods 28 semi-structured interviews were conducted with 32 family caregivers and (...) one patient about the experience of 28 patients who sought assisted dying. Participants were interviewed during August-November 2021. Data from the 17 interviews (all with family caregivers) which reported institutional objection were analysed thematically. Results Participants reported institutional objection affecting eligibility assessments, medication access, and taking the medication or having it administered. Institutional objection occurred across health settings and was sometimes communicated obliquely. These objections resulted in delays, transfers, and choices between progressing an assisted dying application and receiving palliative or other care. Participants also reported objections causing adverse emotional experiences and distrust of objecting institutions. Six mediating influences on institutional objections were identified: staff views within objecting institutions; support of external medical practitioners and pharmacists providing assisted dying services; nature of a patient’s illness; progression or state of a patient’s illness; patient’s geographical location; and the capability and assertiveness of a patient and/or caregiver. Conclusions Institutional objection to assisted dying is much-debated yet empirically understudied. This research found that in Victoria, objections were regularly reported by participants and adversely affected access to assisted dying and the wider end-of-life experience for patients and caregivers. This barrier arises in an assisted dying system that is already procedurally challenging, particularly given the limited window patients have to apply. Better regulation may be needed as Victoria’s existing policy approach appears to preference institutional positions over patient’s choice given existing power dynamics. (shrink)

BackgroundEvolving medical technology, advancing biomedical and drug research, and changing laws and legislation impact patients’ healthcare options and influence healthcare practitioners’ (HCPs’) practices. Conscientious objection policy confusion and variability can arise as it may occasionally be unclear what underpins non-participation. Our objective was to identify, analyze, and synthesize the factors that influenced HCPs who did not participate in ethically complex, legally available healthcare.MethodsWe used Arksey and O’Malley’s framework while considering Levac et al.’s enhancements, and qualitatively synthesized the evidence. We searched (...) Medline, CINAHL, JSTOR, EMBASE, PsychINFO, Sociological Abstracts, and ProQuest Dissertations and Theses Global from January 1, 1998, to January 15, 2020, and reviewed the references of the final articles. We included articles written in English that discussed the factors that influenced physicians and registered nurses (RNs) who did not participate in end-of-life (EOL), reproductive technology and health, genetic testing, and organ or tissue donation healthcare areas. Using Covidence, we conducted title and abstract screening, followed by full-text screening against our eligibility criteria. We extracted the article’s data into a spreadsheet, analyzed the articles, and completed a qualitative content analysis using NVivo12.ResultsWe identified 10,664 articles through the search, and after the screening, 16 articles were included. The articles sampled RNs (n = 5) and physicians (n = 11) and encompassed qualitative (n = 7), quantitative (n = 7), and mixed (n = 2) methodologies. The care areas included reproductive technology and health (n = 11), EOL (n = 3), organ procurement (n = 1), and genetic testing (n = 1). One article included two care areas; EOL and reproductive health. The themed factors that influenced HCPs who did not participate in healthcare were: (1) HCPs’ characteristics, (2) personal beliefs, (3) professional ethos, 4) emotional labour considerations, and (5) system and clinical practice considerations.ConclusionThe factors that influenced HCPs’ who did not participate in ethically complex, legally available care are diverse. There is a need to recognize conscientious objection to healthcare as a separate construct from non-participation in healthcare for reasons other than conscience. Understanding these separate constructs will support HCPs’ specific to the underlying factors influencing their practice participation. (shrink)

This special issue of HEC Forum includes articles on a wide range of specific topics that make significant contributions to conscientious objection scholarship. In this commentary, it is not feasible to provide a comprehensive analysis of each of the articles; and I have not attempted to do so. Instead, for each article, I have selected specific issues and arguments on which to comment.

Conscience clauses typically protect health care providers who cannot in good conscience provide a legal, professionally accepted, and clinically appropriate medical service (negative appeals to co...

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)

Mark Wicclair’s defense of conscientious objection is grounded in an effort to respect the core moral beliefs of health care providers. While such a theoretical schema has merit, this paper argues that core moral beliefs should not serve as the basis of conscientious objection in health care because we, as a community, lack reliable access to a person’s core moral beliefs and because individuals are prone to be confused about the scope and extent of their core moral beliefs. Furthermore, a (...) person’s confusion over their core moral beliefs is likely to be exacerbated when they lack time to investigate those beliefs and are under heightened external pressure to do so—both conditions frequently encountered by health care providers. Finally, the paper considers whether grounding conscientious objection in core moral beliefs might have the unintended consequence of further entrenching the practical problems that the move is aiming to solve. (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)

In a thought-provoking paper, Schuklenk and Smalling argue that no right to conscientious objection should be granted to medical professionals. First, they hold that it is impossible to assess either the truth of conscience-based claims or the sincerity of the objectors. Second, even a fettered right to conscientious refusal inevitably has adverse effects on the rights of patients. We argue that the main problem with their position is that it is not derived from a broader reflection on the meaning and (...) implications of freedom of conscience and reasonable accommodation. We point out that they collapse two related but distinct questions, that is, the subjective conception of freedom of conscience and the sincerity test. We note that they do not successfully show that the standard norm according to which exemption claims should not impose undue hardship on others is unworkable. We suggest that the main reason why arguments such as no one is forced to be a medical professional are flawed is that public norms should not constrain citizens to choose between two of their basic rights unless it is necessary. In fine, Schuklenk and Smalling, who see conscience claims as arbitrary dislikes, sell freedom of conscience short and forego any attempts at balancing the competing rights involved. We maintain the authors neglect that most of legal reasoning is contextual and that the blanket restriction of healthcare professionals' freedom of conscience is disproportionate. (shrink)

This paper presents a proof of concept for a graphical models approach to assessing the moral coherence and moral robustness of systems of social interactions. “Moral coherence” refers to the degree to which the rights and duties of agents within a system are effectively respected when agents in the system comply with the rights and duties that are recognized as in force for the relevant context of interaction. “Moral robustness” refers to the degree to which a system of social interaction (...) is configured to ensure that the interests of agents are effectively respected even in the face of noncompliance. Using the case of conscientious objection of pharmacists to filling prescriptions for emergency contraception as an example, we illustrate how a graphical models approach can help stakeholders identify structural weaknesses in systems of social interaction and evaluate the relative merits of alternate organizational structures. By illustrating the merits of a graphical models approach we hope to spur further developments in this area. (shrink)

This paper argues that the type of conscience claims made in last decade’s spate of cases involving pharmacists’ objections to filling birth control prescriptions and cases such as Ms. Means and Mercy Health Partners of Michigan, and even the Affordable Care Act and the Little Sisters of the Poor, as different as they appear to be from each other, share a common element that ties them together and makes them fundamentally different in kind from traditional claims of conscience about which (...) a practical consensus emerged in the 1980s and 1990s. This difference in kind is profoundly significant; so much so, we contend, that it puts them at odds with the normative basis for protecting conscience claims in United States health care settings in the first place, making them illegitimate. Finally, we argue that, given the illegitimacy of these contemporary claims of conscience, physicians and other health professionals must honor their well-established standing obligations to provide informed consent and refer or transfer care even if the service requested or needed is at odds with their own core moral beliefs—a requirement that is in line with the aforementioned practical consensus on traditional claims of conscience. (shrink)

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)

Although voluntarily stopping eating and drinking as a way to hasten one’s death is not yet a widely recognized practice in the United States, it has received increasing attention in the medical and bioethics literature in recent years. After a brief review of the broader context of human death and dying, this article poses and examines 11 conceptual, personal, and public policy questions about VSED. The article identifies essential features of VSED and discusses whether VSED is a type of suicide. (...) It identifies reasons why people may or may not choose VSED, and it considers responses by family members and professional caregivers to people who have chosen VSED. It also considers how public policies may permit and regulate or restrict the practice of VSED. Examination of these questions is designed to increase understanding of VSED and to inform moral evaluation of this practice. (shrink)

Fritz argues that there is an “unjustified asymmetry” in legislation that allows physicians and health care institutions to refuse to provide elective abortions and other morally contested l...

BackgroundIn 2019, the Constitutional Court of South Korea ruled that the anti-abortion provisions in the Criminal Act, which criminalize abortion, do not conform to the Constitution. This decision will lead to a total reversal of doctors’ legal duty from the obligation to refuse abortion services to their requirement to provide them, given the Medical Service Act that states that a doctor may not refuse a request for treatment or assistance in childbirth. I argue, confined to abortion services in Korea that (...) will take place in the near future, that doctors should be granted the legal right to exercise conscientious objection to abortion.Main textConsidering that doctors in Korea have been ethically and legally obligated to refrain from abortions for many years, imposing a universal legal duty to provide abortions that does not allow exception may endanger the moral integrity of individual doctors who chose a career when abortion was illegal. The universal imposition of such a duty may result in repudiation of doctors as moral agents and damage trust in doctors that forms the basis of medical professionalism. Even if conscientious objection to abortion is granted as a legal right, most patients would experience no impediment to receiving abortion services because the healthcare environment of Korea provides options in which patients can choose their doctors based on prior information, there are many doctors who would be willing to provide an abortion, and Korea is a relatively small country. Finally, the responsibility to effectively balance and guarantee the respective rights of the two agents involved in abortion, the doctor and the patient, should be imposed on the government rather than individual doctors. This assertion is based on the government’s past behaviours, the nature of its relationship with doctors, and the capacity it has to satisfy both doctors’ right to conscientious objection and patients’ right to legal medical services.ConclusionWith regard to abortion services that will be sought in the near future, doctors should be granted the legal right to exercise conscientious objection based on the importance of doctor’s moral integrity, lack of impediment to patients, and government responsibility. (shrink)

Volume 20, Issue 7, July 2020, Page 207-209.

In this paper, I consider the role of conscience in medical practice. If the conscientious practice of individual practitioners cannot be defended or is incoherent or unreasonable on its own merits, then there is little reason to support conscience protection and to argue about its place in the current medical landscape. If this is the case, conscience protection should be abandoned. To the contrary, I argue that conscience protection should not be abandoned. My argument takes the form of an analysis (...) of an essential feature of the conscience dissenter’s argument, the role of disagreement within “the medical profession.” Conscience dissenters make certain assumptions within their arguments about the profession, disagreements within the professions, and how such disagreement should be adjudicated. If it is the case that these assumptions are accurate reflections of the current medical landscape, then the advocate of conscience protection has one less leg to stand on. I aim to show that this is not the case and that the assumptions of the conscience dissenter are not only mistaken but are mistakes of significant magnitude, so significant as to raise serious questions about the merit of their position. If the argument in this paper is sound, then, at the very least, the conversation over conscience protection in medicine, in particular, and health care, in general, must continue. (shrink)

Controversies arise over abortion, assisted dying and conscientious objection in healthcare. The purpose of the study was to examine the relationship between attitudes towards these bioethical dilemmas, and secularity and religiosity. Data were drawn from a 2017 web-based survey of a representative sample of 1615 Norwegian adults. Latent moderated structural equations modelling was used to develop a model of the relationship between attitudes. The resulting model indicates that support for abortion rights is associated with pro-secular attitudes and is a main (...) “driver” for support for assisted dying and opposition to conscientious objection. This finding should be regarded as a hypothesis which ought to be tested in other populations. If the relationship is robust and reproduced elsewhere, there are important consequences for CO advocates who would then have an interest in disentangling the debate about CO from abortion; and for health systems who ought to consider carefully how a sound policy on CO can safeguard both patient trust in the services and the moral integrity of professionals. It is suggested that if religiosity wanes and pro-secular and pro-abortion attitudes become more widespread, support for CO might decline, putting into question whether present policies of toleration of conscientious refusals will remain acceptable to the majority. (shrink)

Conscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis.

This paper aims to demonstrate how public disclosure can be used to balance physicians9 conscientious objections with their professional obligations to patients – specifically respect for patient autonomy and informed consent. It is argued here that physicians should be permitted to exercise conscientious objections, but that they have a professional obligation to provide advance notification to patients about those objections. It is further argued here that public disclosure is an appropriate and ethically justifiable limit to the principle of advance notification. (...) The argument for publicly disclosing physicians9 conscientious objections is made in this paper by discussing three practical benefits of public disclosure in medicine, and then addressing how publicly disclosing physicians9 conscientious objections is not an undue invasion of privacy. Three additional concerns with public disclosure of physicians9 conscientious objections are briefly addressed – potential harassment of physicians, workplace discrimination, and mischaracterising physicians9 professional aptitude – concluding that each of these concerns requires further deliberation in the realm of business ethics. (shrink)

Emergency hormonal contraception (EHC) has been available from pharmacies in the UK without prescription for 11 years. In the Republic of Ireland this service was made available in 2011. In both jurisdictions the respective regulators have included ‘conscience clauses’, which allow pharmacists to opt out of providing EHC on religious or moral grounds providing certain criteria are met. In effect, conscientious objectors must refer patients to other providers who are willing to supply these medicines. Inclusion of such clauses leads to (...) a cycle of cognitive dissonance on behalf of both parties. Objectors convince themselves of the existence of a moral difference between supply of EHC and referral to another supplier, while the regulators must feign satisfaction that a form of regulation lacking universality will not lead to adverse consequences in the long term. We contend that whichever of these two parties truly believes in that which they purport to must act to end this unsatisfactory status quo. Either the regulators must compel all pharmacists to dispense emergency contraception to all suitable patients who request it, or a pharmacist must refuse either to supply EHC or to refer the patient to an alternative supplier and challenge any subsequent sanctions imposed by their regulator. (shrink)

Objective To examine medical students’ views on conscientious objection and controversial medical procedures.Methods Questionnaire study among Norwegian 5th and 6th year medical students.Results Five hundred and thirty-one of 893 students responded. Respondents object to a range of procedures not limited to abortion —notably euthanasia, ritual circumcision for boys, assisted reproduction for same-sex couples and ultrasound in the setting of prenatal diagnosis. A small minority would object to referrals for abortion. In the case of abortion, up to 55% would tolerate conscientious (...) refusals, whereas 42% would not. Higher proportions would tolerate refusals for euthanasia or ritual circumcision for boys.Discussion A majority of Norwegian medical students would object to participation in euthanasia or ritual circumcision for boys. However, in most settings, many medical students think doctors should not be able to refuse participation on grounds of conscience. A minority would accept conscientious refusals for procedures they themselves do not object to personally. Most students would not accept conscientious refusals for referrals.Conclusions Conscientious objection remains a live issue in the context of several medical procedures not limited to abortion. Although most would want a right to object to participation in euthanasia, tolerance towards conscientious objectors in general was moderate or low. (shrink)