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.

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)

In Canada, as in many developed countries, healthcare conscientious objection is growing in visibility, if not in incidence. Yet the country's health professional policies on conscientious objection are in disarray. The article reports the results of a comprehensive review of policies relevant to conscientious objection for four Canadian health professions: medicine, nursing, pharmacy and dentistry. Where relevant policies exist in many Canadian provinces, there is much controversy and potential for confusion, due to policy inconsistencies and terminological vagueness. Meanwhile, in Canada's (...) three most northerly territories with significant Aboriginal populations, whose already precarious health is influenced by funding and practitioner shortages, there are major policy gaps applicable to conscientious objection. In many parts of the country, as a result of health professionals' conscientious refusals, access to some legal health services – including but not limited to reproductive health services such as abortion – has been seriously impeded. Although policy reform on conscientious conflicts may be difficult, and may generate strenuous opposition from some professional groups, for the sake of both patients and providers, such policy change must become an urgent priority. (shrink)

Freedom of Conscience and Freedom of Religion should be taken to protect two distinct sets of moral considerations. The former protects the ability of the agent to reflect critically upon the moral and political issues that arise in her society generally, and in her professional life more specifically. The latter protects the individual's ability to achieve secure membership in a set of practices and rituals that have as a moral function to inscribe her life in a temporally extended narrative. Once (...) these grounds are distinguished, it becomes more difficult to grant healthcare professionals' claims to religious exemptions on the basis of the latter than it is on the basis of the former. While both sets of considerations generate ‘internal reasons’ for rights to accommodation, the relevant ‘external’ reasons present in the case of claims of moral conscience do not possess analogues in the case of claims of religious conscience. However, the argument applies only to ‘irreducibly religious’ claims, that is to claims that cannot be translated into moral vocabulary. What's more, there may be reasons to grant the claims of religious persons to exemptions that have to do not with the nature of the claims, but with the beneficial effects that the presence of religious persons may have in the context of the healthcare institutions of multi-faith societies. (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)

Considering a growing nurse shortage and the need for qualified nurses to handle increasingly complex patient care situations, how ethical beliefs are influenced and the consequences that can occur when moral conflicts of right and wrong arise need to be explored. The aim of this study was to explore influencers identified by nurses as having the most impact on the development of their ethical beliefs and whether these influencers might impact levels of moral distress and the potential for conscientious objection. (...) Nurses whose ethical beliefs were most influenced by their religious beliefs scored higher in levels of moral distress and demonstrated greater differences in areas of conscientious objection than did nurses who developed their ethical beliefs from influencers such as family values, life and work experience, political views or the professional code of ethics. (shrink)

The value of conscience in healthcare ethics is widely debated. While some sources present it as an unquestionably positive attribute, others question both the veracity of its decisions and the effect of conscientious objection on patient access to health care. This paper argues that the right to object conscientiously should be broadened, subject to certain previsos, as there are many benefits to healthcare practice in the development of the consciences of practitioners. While effects such as the preservation of moral integrity (...) are widely considered to benefit practitioners, this paper draws on the work of Hannah Arendt to offer several original arguments in defence of conscience that may more directly benefit patients, namely that a pang of conscience may be useful in rapidly unfolding situations in which there is no time to reflect satisfactorily upon activities and that, given the hierarchical nature of healthcare institutions, a right to defy authority on the basis of conscience may benefit junior staff who lack the institutional power to challenge the orders of superiors. (shrink)

Background and objectives Conscientious refusal of abortion has been discussed widely by medical ethicists but little information on practitioners' opinions exists. The American College of Obstetricians and Gynecologists (ACOG) issued recommendations about conscientious refusal. We used a vignette experiment to examine obstetrician-gynecologists' (OB/GYN) support for the recommendations. Design A national survey of OB/GYN physicians contained a vignette experiment in which an OB/GYN doctor refused a requested elective abortion. The vignette varied two issues recently addressed by the ACOG ethics committee—whether the (...) doctor referred and whether the doctor disclosed their objection to the abortion. Participants and setting 1800 OB/GYN randomly selected physicians were asked to complete a mail survey containing the vignette. The response rate was 66% (n=1154) after excluding 40 ineligible cases. Measurement Physicians indicated their approval for the vignette doctor's decision. Main results Overall, 43% of OB/GYN physicians responded that the conscientious refusal exercised by the vignette physician was appropriate. 70% rated the vignette doctor as acting appropriately when a referral was made. This dropped to 51% when the doctor disclosed objections to the patient, and to 12% when the doctor disclosed objections and refused to make a referral. Consistent with previous research, males were more likely to support disclosure and refusal to refer. Highly religious physicians supported non-referral but not disclosure. Conclusion OB/GYN physicians are less likely to support conscientious refusal of abortion if physicians disclose their objections to patients. This is at odds with ACOG recommendations and with some models of the doctor–patient relationship. (shrink)

Pharmacists who refuse to provide certain services or treatment for reasons of conscience have been criticized for failing to fulfil their professional obligations. Currently, individual pharmacists in Great Britain can withhold services or treatment for moral or religious reasons, provided they refer the patient to an alternative source. The most high-profile cases have concerned the refusal to supply emergency hormonal contraception, which will serve as an example in this article.I propose that the pharmacy profession's policy on conscientious objections should be (...) altered slightly. Building on the work of Brock and Wicclair, I argue that conscientious refusals should be acceptable provided that the patient is informed of the service, the patient is redirected to an alternative source, the refusal does not cause an unreasonable burden to the patient, and the reasons for the refusal are based on the core values of the profession. Finally, I argue that a principled categorical refusal by an individual pharmacist is not morally permissible. I claim that, contrary to current practice, a pharmacist cannot legitimately claim universal exemption from providing a standard service, even if that service is available elsewhere. (shrink)

Objective To explore attitudes towards conscientious objections among medical students in the UK. Methods Medical students at St George's University of London, Cardiff University, King's College London and Leeds University were emailed a link to an anonymous online questionnaire, hosted by an online survey company. The questionnaire contained nine questions. A total of 733 medical students responded. Results Nearly half of the students in this survey stated that they believed in the right of doctors to conscientiously object to any procedure. (...) Demand for the right to conscientiously object is greater in Muslim medical students when compared with other groups of religious medical students. Discussion Abortion continues to be a contentious issue among medical students and this may contribute to the looming crisis in abortion services over the coming years. This project sheds some light on how future doctors view some of their ethical rights and obligations. Using empirical evidence, it reveals that conscientious objection is an issue in the UK medical student body today. These data could help anticipate problems that may arise when these medical students qualify and practise medicine in the community. Conclusion Clearer guidance is needed for medical students about the issue of conscientious objection at medical school. (shrink)

A growing number of medical professionals claim a right of conscience, a right to refuse to perform any professional duty they deem immoral—and to do so with impunity. We argue that professionals do not have the unqualified right of conscience. At most they have a highly qualified right. We focus on the claims of pharmacists, since they are the professionals most commonly claiming this right.

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)

ABSTRACT In a recent (2015) Bioethics editorial, Udo Schuklenk argues against allowing Canadian doctors to conscientiously object to any new euthanasia procedures approved by Parliament. In this he follows Julian Savulescu's 2006 BMJ paper which argued for the removal of the conscientious objection clause in the 1967 UK Abortion Act. Both authors advance powerful arguments based on the need for uniformity of service and on analogies with reprehensible kinds of personal exemption. In this article I want to defend the practice (...) of conscientious objection in publicly‐funded healthcare systems (such as those of Canada and the UK), at least in the area of abortion and end‐of‐life care, without entering either of the substantive moral debates about the permissibility of either. My main claim is that Schuklenk and Savulescu have misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors. However, I acknowledge Schuklenk's point about differential access to lawful services in remote rural areas, and I argue that the health service should expend more to protect conscientious objection while ensuring universal access. (shrink)

Freedom of conscience is a core element of human rights respected by most European countries. It allows abortion through the inclusion of a conscience clause, which permits opting out of providing such services. However, the grounds for invoking conscientious objection lack clarity. Our aim in this paper is to take a step in this direction by carrying out a systematic review of reasons by midwives and nurses for declining, on conscience grounds, to participate in abortion. We conducted a systematic review (...) of ethical arguments asking, “What reasons have been reported in the argument based literature for or against conscientious objection to abortion provision by nurses or midwives?” We particularly wanted to identify any discussion of the responsibilities of midwives and nurses in this area. Search terms were conscientious objection and abortion or termination and nurse or midwife or midwives or physicians or doctors or medics within the dates 2000–2016 on: HEIN legal, Medline, CINAHL, Psychinfo, Academic Search Complete, Web of Science including publications in English, German and Dutch. Final articles were subjected to a rigorous analysis, coding and classifying each line into reason mentions, narrow and broad reasons for or against conscientious objection. Of an initial 1085 articles, 10 were included. We identified 23 broad reasons, containing 116narrow reasons and 269 reason mentions. Eighty one narrow reasons argued in favour of and 35 against conscientious objection. Using predetermined categories of moral, practical, religious or legal reasons, “moral reasons” contained the largest number of narrow reasons. The reasons and their associated mentions in this category outnumber those in the sum of the other three categories. We identified no absolute argument either for or against conscientious objection by midwives or nurses. An invisibility of midwives and nurses exists in the whole debate concerning conscientious objection reflecting a gap between literature and practice, as it is they whom WHO recommend as providers of this service. While the arguments in the literature emphasize the need for provision of conscientious objection, a balanced debate is necessary in this field, which includes all relevant health professionals. (shrink)

Book reviewed in this article: Principles of Biomedical Ethics. By Tom L. Beauchamp and James F. Childress.

While abortion has been legal in most developed countries for many years, the topic remains controversial. A major area of controversy concerns women’s rights vis-a-vis the rights of health professionals to opt out of providing the service on conscience grounds. Although scholars from various disciplines have addressed this issue in the literature, there is a lack of empirical research on the topic. This paper provides a documentary analysis of three examples of conscientious objection on religious grounds to performing abortion-related care (...) by midwives in different Member States of the European Union, two of which have resulted in legal action. These examples show that as well as the laws of the respective countries and the European Union, professional and church law each played a part in the decisions made. However, support from both professional and religious sources was inconsistent both within and between the examples. The authors conclude that there is a need for clear guidelines at both local and pan-European level for health professionals and recommend a European-wide forum to develop and test them. (shrink)

Background: Ethical nursing practice is increasingly challenging, and strategies for addressing ethical dilemmas are needed to support nurses’ ethical care provision. Conscientious objection is one such strategy for addressing nurses’ personal, ethical conflicts, at times associated with conscience. Exploring both conscience and conscientious objection provides understanding regarding their implications for ethical nursing practice, research, and education. Research aim: To analyze the concepts of conscience and conscientious objection in the context of nurses. Design: Concept analysis using the method by Walker and (...) Avant. Research context: Data were retrieved from Philosopher’s Index, PubMed, and CINAHL with no date restrictions. Ethical consideration: This analysis was carried out per established, scientific guidelines. Findings: Ethical concepts are integral to nursing ethics, yet little is known about conscientious objection in relation to conscience for nurses. Of note, both concepts are well established in ethics literature, addressed in various nursing codes of ethics and regulatory bodies, but the meaning they hold for nurses and the impact they have on nursing education and practice remain unclear. Discussion and conclusion: This article discusses the relevance of conscience and conscientious objection to ethical nursing practice and proposes a model case to show how they can be appreciated in the context of nurses. Conscientious objection is an option for ethical transparency for nurses but is situated in contentious discussions over its use and has yet to be fully understood for nursing practice. Conscience is an element in need of more exploration in the context of conscientious objection. Further research is warranted to understand how nurses respond to conscience concerns in morally, pluralistic nursing contexts. (shrink)

Perioperative nurses assist in organ procurement surgery; however, there is a dearth of information of how they encounter making conscientious objection requests or refusals to participate in organ procurement surgery. Organ procurement surgical procedures can present to the operating room ad hoc and can catch a nurse who may not desire to participate by surprise with little opportunity to refuse as a result of staffing, skill mix or organizational work demands. This paper that stems from a larger doctoral research study (...) exploring the experiences of perioperative nurses participating in multi‐organ procurement surgery used a grounded theory method to develop a substantive theory of the nurses’ experiences. This current paper aimed to highlight the experiences of perioperative nurses when confronted with expressing a conscientious objection towards their participation in these procedures. A number of organizational and cultural barriers within the healthcare organization were seen to hamper their ability in expressing a conscience‐based refusal, which lead to their reluctant participation. Perioperative nurses must feel safe to express a conscientious objection towards these types of surgical procedures and feel supported in doing so by their respective hospital organizations and not be forced to participate unwillingly. (shrink)

In a recent Bioethics editorial, Udo Schuklenk argues against allowing Canadian doctors to conscientiously object to any new euthanasia procedures approved by Parliament. In this he follows Julian Savulescu's 2006 BMJ paper which argued for the removal of the conscientious objection clause in the 1967 UK Abortion Act. Both authors advance powerful arguments based on the need for uniformity of service and on analogies with reprehensible kinds of personal exemption. In this article I want to defend the practice of conscientious (...) objection in publicly-funded healthcare systems, at least in the area of abortion and end-of-life care, without entering either of the substantive moral debates about the permissibility of either. My main claim is that Schuklenk and Savulescu have misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors. However, I acknowledge Schuklenk's point about differential access to lawful services in remote rural areas, and I argue that the health service should expend more to protect conscientious objection while ensuring universal access. (shrink)

Conscientious refusal is distinguished by its peculiar attitude towards the obligations that the objector refuses: the objector accepts the authority of the institution in general, but claims a right of conscience to refuse some particular directive. An adequate ethics of conscientious objection will, then, require an account of the institutional obligations that the objector claims a right to refuse. Yet such an account must avoid two extremes: ‘anarchism,’ where obligations apply only insofar as they match individual conscience; and ‘totalitarianism,’ where (...) even immoral obligations bind us. The challenge is to explain institutional obligations in such a way that an agent can be obligated to act against conscience, yet can object if the institution's orders go too far. Standard accounts of institutional obligations rely on individual autonomy, expressed through consent. This paper rejects the Consent model; a better understanding of institutional obligations emerges from reflecting on the intersecting goods produced by institutions and the intersecting autonomy of numerous distinct agents rather than only one. The paper defends ‘Professionalism’ as a grounding of professional obligations. The professional context can justify acting against conscience but more often that context partly shapes the professional conscience. Yet Professionalism avoids totalitarianism by distinguishing between (mere) injustice and abuse. When institutions are – or we conscientiously believe them to be – merely unjust, their directives still obligate us; when they are abusive, however, they do not. Finally, the paper applies these results to the problem of conscientious refusal in general and specifically to controversial reproduction cases. (shrink)

Fulford’s discussion of ‘values-based practice’ as a model for medical ethics is deeply puzzling. First, it remains unclear what exactly he takes values to be or how tyhey can be based in clinical skills. Second, his proposal does not make it clear whose values these are supposed to be. I conclude that his attempt in effect to take the morality out of ethics fails.

Recent survey data gathered from British medical students reveal widespread acceptance of conscientious objection in medicine, despite the existence of strict policies in the UK that discourage conscientious refusals by students to aspects of their medical training. This disconnect demonstrates a pressing need to thoughtfully examine policies that allow conscience objections by medical students; as it so happens, the USA is one country that has examples of such policies. After presenting some background on promulgated US conscience protections and reflecting on (...) their significance for conscience objections by medical students, this paper observes that the dominant approach (following the American Medical Association's conscience clause) is to allow exempted students to instead be evaluated on the basis of alternative curricular activities to learn the associated underlying content. This paper then introduces and discusses an example in which male Muslim students who believe it is wrong to touch members of the opposite sex object to performing physical examinations on female subjects in their medical training. This sort of case, it is argued, causes difficulty for a conscience clause that resolves the dilemma by granting reasonable exemptions in the form of participation in alternative curricular activities: there are cases where one must perform the ‘objectionable’ activity itself in order to learn the necessary content and underlying principles. (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)