A Defence of Conscientious Objection in Medicine: A Reply to Schuklenk and Savulescu

Christopher Cowley

Bioethics
Bioethics

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.


Cowley C. A Defence of Conscientious Objection in Medicine: A Reply to Schuklenk and Savulescu. Bioethics. 2016 Jun;30(5):358-364.

The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses

Venke Sørlie, Lilian Jansson, Astrid Norberg

Scandinavian Journal of Caring Sciences
Scandinavian Journal of Caring Sciences

Abstract
Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the ‘uninteresting’ patients. This may be understood as ethics of memory where their conscience ‘set them a test’. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture.


Sørlie V, Jansson L, Norberg A. The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses. Scand. J. Caring Sci. 2003;17(285-292.

Refusal of Treatment by an Adolescent: The Deliverances of Different Consciences

Sally L Webb, Mary Faith Marshall, Flint Boettcher, Marty Perlmutter

HEC Forum
HEC Forum

Extract
Introduction
This paper describes and analyzes a problematic fictionalized case in health care ethics. Inherent in the case is the complex interplay between adolescent decision-making, clinical uncertainty and religious beliefs that most health care providers find alien and that challenge their professional norms. The paper examines the way the case unfolded, paying special attention to the “consciences” of the health care providers involved in the case, and ends with a few reflections on some of the conflicts of conscience that emerged.


Webb SL, Marshall MF, Boettcher F, Perlmutter M. Refusal of Treatment by an Adolescent: The Deliverances of Different Consciences. HEC Forum. 1998 Mar;10(1):9-23.

Beyond Medical Paternalism and Patient Autonomy: A Model of Physician Conscience for the Physician-Patient Relationship

David C Thomasma

Annals of Internal Medicine
Annals of Internal Medicine

Abstract
Medical paternalism lies at the heart of traditional medicine. In an effort to counteract the effects of this paternalism, medical ethicists and physicians have proposed a model of patient autonomy for the physician patient relationship. However, neither paternalism or autonomy are adequate characterizations of the physician patient relationship. Paternalism does not respect the rights of adults to self-determination, and autonomy does not respect the principle of beneficence that leads physicians to argue that acting on behalf of others is essential to their craft. A model of physician conscience is proposed that summarizes the best features of both models-paternalism and autonomy.


Thomasma DC. Beyond Medical Paternalism and Patient Autonomy: A Model of Physician Conscience for the Physician-Patient Relationship. Ann. Intern. Med.. 1983;98(2):243-248.

(Correspondence) Therapeutic abortion

GJ Froese

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
It is with great distress that many of us are watching what is happening to our medical ethics. . . When I was in medical school (early 1950s) students supposedly subscribed to the Hippocratic oath. . . . At that time abortionists were punished. Today it is quite different and the antiabortionists appear to be in the minority. . .


Froese G. (Correspondence) Therapeutic abortion. Can Med Assoc J. 1974 December 21;111(12):1301.

(Correspondence) Abortion

Arthur ME Kennedy

Canadian Medical Association Journal, CMAJ
Canadian Medical Association Journal

Extract
The appearance of the two letters on abortion in sequence in the Journal . . . illustrated the diverging ethics of the members and future members of our profession. Reading the letter by Dr. Heine was indeed like feeling a breath of fresh unpolluted air in the smog of today’s confused thinking. . . .How different was the letter by the President of the Medical Students’ Society of McGill University stating the unanimous opinion of their Executive Council.


Kennedy AM. (Correspondence) Abortion. Can Med Assoc J. 1971 Jan 09;104(1):70.

(Correspondence) Abortion bill

Gareth Lloyd

British Medical Journal, BMJ
British Medical Journal

Extract

Dr. W. J. Stanley (22 April, p. 247) raises the question of the legal position of the doctor refusing to accede to the termination of a pregnancy on medical grounds. Let us be clear in our minds that, once the Bill becomes law, any doctor refusing to consider abortion on medical or social grounds could be liable to be prosecuted for negligence. . .


Lloyd G.  (Correspondence) Abortion Bill. Br Med J. 1967 May 20; 2(5550): 511

Summary of memorandum by R.M.P.A

British Medical Journal

British Medical Journal, BMJ
British Medical Journal

Extract

The Royal Medico-Psychological Association issued last month a memorandum on possible changes in the law relating to therapeutic abortion. Emphasizing that it would be opposed to legislation which might bring pressure on an individual doctor to act contrary to his conscience, the memorandum states that the Royal Medico-Psychological Association has approached the problem of therapeutic abortion with the firm view that, in addition to traditionally accepted medical and psychiatric criteria, all social circumstances should be taken into account. . . .


Summary of memorandum by R.M.P.A. Br Med J. 1966 July 2; 2(5504): 44