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

In this response to Christian Smith's What Is a Person?, I raise questions about his conception of the human life as a narrative quest and his account of change in social structures and institutions. The metaphor of life as a quest suggests a solid, isolated, and integrated moral agent. I wonder whether the experiences of most moral agents render a different picture—one where life is fragmented and characterized by complex webs of relationships. Smith provides a detailed account of how social (...) institutions change. I pose examples of more subtle and complex types of change as a way to press him to think about whether his account of change is too linear. (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...

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)

The dispute over professional conscientious objection presumes a picture of medicine as a practice governed by rules. This rule-based conception of medical practice is identifiable with John Rawls’s conception of social practices. This conception does not capture the character of medical practice as experienced by practitioners, for whom it is a sensibility or “form of life” rather than rules. Moreover, the sensibility of medical practice as experienced by physicians is at best neutral, and at worst hostile, to the demands of (...) those who would override physician conscientious objection to the provision of currently contested services. That being so, calls for overriding physician conscientious objection are much more demanding of the medical profession than they appear in light of Rawls’s view. As such overriding may entail the forcible transformation of medicine’s form of life, the author contends that it would be more prudent to provide contested services by circumventing the medical profession than by compelling it. (shrink)

Douglas Diekema has argued that it is not the best interest standard, but the harm principle that serves as the moral basis for ethicists, clinicians, and the courts to trigger state intervention to limit parental authority in the clinic. Diekema claims the harm principle is especially effective in justifying state intervention in cases of religiously motivated medical neglect in pediatrics involving Jehovah’s Witnesses and Christian Scientists. I argue that Diekema has not articulated a harm principle that is capable of justifying (...) state intervention in these cases. Where disagreements over appropriate care are tethered to metaphysical disagreements, it is moral-metaphysical standards, rather than merely moral standards, that are needed to provide substantive guidance. I provide a discussion of Diekema’s harm principle to the broader end of highlighting an inconsistency between the theory and practice of secular bioethics when overriding religiously based medical decisions. In a secular state, ethicists, clinicians, and the courts are purportedly neutral with respect to moral-metaphysical positions, especially regarding those claims considered to be religious. However, the practice of overriding religiously based parental requests requires doffing the mantle of neutrality. In the search for a meaningful standard by which to override religiously based parental requests in pediatrics, bioethicists cannot avoid some minimal metaphysical commitments. To resolve this inconsistency, bioethicists must either begin permitting religiously based requests, even at the cost of children’s lives, or admit that at least some moral-metaphysical disputes can be rationally adjudicated. (shrink)

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)

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)

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)

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)

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)

A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care, and a proposed bill in the British House of Lords, the Conscientious Objection Bill, may well warrant a concern that—to borrow a phrase Daniel Callahan applied to self-determination—conscientious objection in health care has “run amok.” Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated “conscience absolutism.” There are two common strategies to counter (...) conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation. (shrink)

¿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)

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)

Person-centered care offers a promising way to manage clinicians’ conscientious objection to providing services they consider morally wrong. Health care centered on persons, rather than patients, recognizes clinicians and patients on the same stratum. The moral interests of clinicians, as persons, thus warrant as much consideration as those of other persons, including patients. Interconnected moral interests of clinicians, patients, and society construct the clinician as a socially embedded and integrated self, transcending the simplistic duality of private conscience versus public role (...) expectations. In this milieu of blurred boundaries, person-centered care offers a constructive way to accommodate conscientious objection by clinicians. The constitutionally social nature of clinicians commits and enables them, through care mechanisms such as self-care, to optimize the quality of health care and protect the welfare of patients. To advance these conditions, it is recommended that the medical profession develop a person-centered culture of care, along with clinician virtues and skills for person-centered communication. (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)

Volume 20, Issue 7, July 2020, Page 204-207.

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)

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)

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...

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...