Protection of Conscience Project Library
Service, not Servitude
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I am responding to a letter by Dr. Eric Brown about semantics in referring for medical assistance in dying (MAiD). . . The intended implication, it seems, is that any conscientious objectors should simply leave the practice of medicine.
Boschung KF. (Correspondence) Losing doctors with integrity will harm patients and profession. Can Med Assoc. J. 2018;7.
Abstract
Policies and practices have been developed to operationalize assisted dying processes in Canada. This project utilized an environmental scan to determine the spectrum of assisted death reporting practices and medical certificate of death (MCD) completion procedures both nationally and internationally. Findings suggest medically assisted dying (MAiD) is represented on the MCD inconsistently nationally and internationally. Related factors include the specifics of local assisted death legislation and variations in death-reporting legislation, variation in terminology surrounding assisted death and designated oversight agency for assisted dying reporting.
Brown J, Thorpe L, Goodridge D. Completion of Medical Certificates of Death after an Assisted Death: An Environmental Scan of Practices. Healthc Policy. 2018 Nov;14(2):59-67. doi: 10.12927/hcpol.2018.25685.
Abstract
Objectives: In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation?
Methods: We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec.
Results: Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients’ autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death.
Conclusions: This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.
Bélanger E, Towers A, Wright DK, Chen Y, Tradounsky G, Macdonald ME. Of dilemmas and tensions: a qualitative study of palliative care physicians’ positions regarding voluntary active euthanasia in Quebec, Canada. J Med Ethics 2019;45:48-53.
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We must return to our Pythagorean roots and not substitute a secular group conscience to replace individual conscience, and thereby protect the rights of all parties. My hope is that our specialty will uphold the right of individual clinicians to practise according to their consciences and we will continue to welcome Hippocratic clinicians into our ranks.
BJOG: An International Journal of Obstetrics and GynaecologyJr JT. Conscientious objection in reproductive health – an ancient prerogative or harmful practice. BJOG: An International Journal of Obstetrics and Gynaecology. 2018 Oct;125(11):1357-1358.
Abstract
Opioid and sedative use are common ‘active’ practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas’ Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt—and therefore weaken—the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.
Riisfeldt TD. Weakening the ethical distinction between euthanasia, palliative opioid use and palliative sedation. J Med Ethics 2019;45:125-130.
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Aims: To explore the meaning of conscience for nurses in the context of conscientious objection (CO) in clinical practice. Design: Interpretive phenomenology was used to guide this study.
Data sources: Data were collected from 2016 ‐ 2017 through one‐on‐one interviews from eight nurses in Ontario. Iterative analysis was conducted consistent with interpretive phenomenology and resulted in thematic findings. Review methods: Iterative, phased analysis using line‐by‐line and sentence highlighting identified key words and phrases. Cumulative summaries of narratives thematic analysis revealed how nurses made meaning of conscience in the context of making a CO.
Impact: This is the first study to explore what conscience means to nurses, as shared by nurses themselves and in the context of CO. Nurse participants expressed that support from leadership, regulatory bodies, and policy for nurses’ conscience rights are indicated to address nurses’ conscience issues in practice settings.
Results: Conscience issues and CO are current, critical issues for nurses. For Canadian nurses this need has been recently heightened by the national legalization of euthanasia, known as Medical Assistance in Dying in Canada. Ethics education, awareness, and respect for nurses’ conscience are needed in Canada and across the profession to support nurses to address their issues of conscience in professional practice.
Conclusion: Ethical meaning emerges for nurses in their lived experiences of encountering serious ethical issues that they need to professionally address, by way of conscience‐based COs.
Lamb C, Evans M, Babenko-Mould Y, Wong C, Kirkwood Ken. Nurses’ use of conscientious objection and the implications for conscience. J Adv Nurs 2018 Oct 16. doi: 10.1111/jan.13869
Abstract
The process of crafting and passing legislation might be thought to be the locus of compromise par excellence.1 Yet, where the law that results impinges upon moral or religious belief or practice, the issue of compromise arises anew, in both senses of the word: Individuals who oppose the law on moral or religious grounds believe that their political obedience will compromise them in a fundamental way. Their plea for an exemption from the objectionable legal requirement is, then, a bid for further compromise.2 Compromise in the first sense concerns an undercutting of the self, while compromise in the second sense involves a grant of concessions. Yet, unlike compromises that arise in the legislative process, or at least in some ideal version of it,3 the compromise involved in an exemption from a neutral law of general application involves neither an exchange of benefits nor the prospect of mutual benefit-two hallmarks of compromise in, say, political (and other) negotiations.4 There are several reasons to doubt the wisdom or fairness of the requested exemptions, then.
Sepinwall AJ. The Challenges of Conscience in a World of Compromise. In: Knight J, editor. Nomos LIX: Compromise. New York:NYU Press, 2018. pp. 220-247.
Abstract
This study was commissioned by the European Parliament’s Policy Department for Citizens’ Rights and Constitutional Affairs at the request of the FEMM Committee. It aims to provide a comparative overview of the situation in the European Union, with particular focus on six selected Member States, in terms of access to sexual and reproductive healthcare goods (such as medicines) and services (such as abortion and family planning), from both legal and practical perspectives. The study looks at the extent to which conscientious objection affects access to sexual and reproductive rights (SRHR). The study will contribute to formulating a clear framework for the improvement of access to sexual and reproductive healthcare goods and services in the EU
Anedda L, Arora L, Favero L, Meurens N, Morel S, Schofield M. (Report) Sexual and reproductive health rights and the implication of conscientious objection. Policy Department for Citizens’ Rights and Constitutional Affairs,
European Parliament. 2018.
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Nous sommes des médecins canadiens consternés et concernés par les impacts – sur les patients, sur les médecins, sur la pratique médicale – de l’implantation universelle de l’euthanasie dans notre pays, définie comme un « soin de santé » auquel tous les citoyens ont droit (conditionnellement à des critères ambigus et arbitraires). Beaucoup d’entre nous sont si touchés par la difficulté de pratiquer sous ces nouvelles contraintes prescrites que nous pourrions être forcés, pour des raisons d’intégrité et de conscience professionnelle, d’émigrer ou de se retirer complètement de notre pratique. Nous sommes tous profondément inquiets du futur de la médecine au Canada. Nous croyons que ce changement sera non seulement nuisible à la sécurité des patients, mais également à la perception essentielle par le public – et par les médecins eux-mêmes – que nous sommes réellement une profession dédiée seulement à la guérison et au mieux-être. Nous sommes donc très inquiets des tentatives visant à convaincre l’Association Médicale Mondiale (AMM) de modifier sa position qui s’oppose à la participation des médecins à l’euthanasie et au suicide assist . . . . Continuer la lecture dans le World Medical Journal en anglais | Français
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We are Canadian physicians who are dismayed and concerned by the impact – on patients, on doctors, on medical practice – of the universal implementation, in our country, of euthanasia defined as medical “care” to which all citizens are entitled (subject to the satisfaction of ambiguous and arbitrary qualifying criteria). Many of us feel so strongly about the difficulty of practicing under newly prescribed constraints that we may be forced, for reasons of personal integrity and professional conscience, to emigrate or to withdraw from practice altogether. All of us are deeply worried about the future of medicine in Canada. We believe this transformation will not only be detrimental to patient safety, but also damaging to that all-important perception by the public – and by physicians themselves – that we are truly a profession dedicated to healing alone. Thus, we are alarmed by attempts to convince the World Medical Association (WMA) to change its policies against physician participation in euthanasia and assisted suicide. . .
Leiva R, Cottle MM, Ferrier C, Harding SR, Lau T, Scott JF. Euthanasia in Canada: A Cautionary Tale. WMJ 2018 Sep; 64:3 17-23.