The literature on conscience in medicine has paid little attention to what is meant by the word ‘conscience.’ This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating (...) would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed. (shrink)

We describe a number of conscientious objection cases in a liberal Western democracy. These cases strongly suggest that the typical conscientious objector does not object to unreasonable, controversial professional services—involving torture, for instance—but to the provision of professional services that are both uncontroversially legal and that patients are entitled to receive. We analyse the conflict between these patients' access rights and the conscientious objection accommodation demanded by monopoly providers of such healthcare services. It is implausible that professionals who voluntarily join (...) a profession should be endowed with a legal claim not to provide services that are within the scope of the profession's practice and that society expects them to provide. We discuss common counterarguments to this view and reject all of them. (shrink)

John Rawls, among others, has argued that one of aims political philosophy is that it provides reasonable hope in the possibility of justice in the future. But what makes hope reasonable? What sorts of theories of justice are best suited to foster reasonable hope in us? To answer these questions, this paper investigates Rawls’s conception of reasonable hope and the kinds of unreasonableness Rawls sought to guard against with his account of a realistic utopia. Rawls's idea of reasonable hope goes (...) beyond the weaker kind of “reconciliation” put forward by Rousseau’s account of a conjectural history that sketches a picture of how we could have developed into the kind of people and the kind of society where justice is possible. It is one thing to believe, with Rousseau, that our deep natures are not incompatible with the possibility of a just society. It is something further to harbor any hope for this in the future. I argue that this temporal aspect, which is built into what Kant and Rawls mean by reasonable hope, is useful approach to the practice of political philosophy. An approach that takes the need for reasonable hope seriously is one that moves political theorizing from a more passive framework of theoretical imagination toward a more active one that entails political anticipation. (shrink)

Though the revised edition of A Theory of Justice, published in 1999, is the definitive statement of Rawls's view, so much of the extensive literature on Rawls's theory refers to the first edition. This reissue makes the first edition once again available for scholars and serious students of Rawls's work.

Theories of social justice are necessarily abstract, reaching beyond the particular and the immediate to the general and the timeless. Yet such theories, addressing the world and its problems, must respond to the real and changing dilemmas of the day. A brilliant work of practical philosophy, Frontiers of Justice is dedicated to this proposition. Taking up three urgent problems of social justice neglected by current theories and thus harder to tackle in practical terms and everyday life, Martha Nussbaum seeks a (...) theory of social justice that can guide us to a richer, more responsive approach to social cooperation. The idea of the social contract--especially as developed in the work of John Rawls--is one of the most powerful approaches to social justice in the Western tradition. But as Nussbaum demonstrates, even Rawls's theory, suggesting a contract for mutual advantage among approximate equals, cannot address questions of social justice posed by unequal parties. How, for instance, can we extend the equal rights of citizenship--education, health care, political rights and liberties--to those with physical and mental disabilities? How can we extend justice and dignified life conditions to all citizens of the world? And how, finally, can we bring our treatment of nonhuman animals into our notions of social justice? Exploring the limitations of the social contract in these three areas, Nussbaum devises an alternative theory based on the idea of capabilities. She helps us to think more clearly about the purposes of political cooperation and the nature of political principles--and to look to a future of greater justice for all. (shrink)

Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any action contrary to (...) their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care. (shrink)

This essay explores some of the conceptual and moral issues raised by illegal actions in health care. The author first identifies several types of illegal action, concentrating on civil disobedience, conscientious objection or refusal, and evasive noncompliance. Then he sketches a framework for the moral justification of these types of illegal action. Finally, he applies the conceptual and normative frameworks to several major cases of illegal action in health care, such as "mercy killing" and some decisions not to treat incompetent (...) patients. Keywords: illegal actions, mercy killing, non-treatment of incompetent patients, civil disobedience, conscientious objection, evasive non-compliance, moral justification and disobedience, dissent in health care CiteULike Connotea Del.icio.us What's this? (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)

Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on (...) one’s conscience. Second, I sketch an account of the basis of the medical and pharmacy professions’ responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the “conventional compromise” as a reasonable accommodation to conflicts between these professions’ responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: “Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?”. (shrink)

People may have open minds on whether a life-extending drug or technology is going to be developed before their sixties and may strongly desire that development. Do they therefore hope that it occurs? Do they hope for it in the substantive sense of “pinning their hopes” on the development? No, they do not. Hoping for a prospect in that sense certainly presupposes having an open mind on whether it will occur and having a desire for its occurrence. But, more crucially, (...) it means investing the prospect with a characteristic, galvanizing, and orientating role: it involves setting aside doubts about the possible nonoccurrence of the prospect and acting accordingly. This article offers a characterization of hope in that substantive sense and argues both that it can be rational and that it is ubiquitous. (shrink)