Intensive Care Archives - Protection of Conscience Project Library

Conscientious non-objection in intensive care

Dominic Wilkinson

Cambridge Quarterly of Healthcare Ethics

Abstract
Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

Wilkinson D. Conscientious non-objection in intensive care. Camb. Q. Healthc. Ethics. 2017;26(1):132-142.

An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine

Mithya Lewis-Newby, Mark R Wicclair, Thaddeus Mason Pope, Cynda Rushton, Farr A Curlin, Douglas Diekema, Debbie Durrer, William Ehlenbach, Wanda Gibson-Scipio, Bradford Glavan, Rabbi Levi Langer, Constantine Manthous, Cecile Rose, Anthony Scardella, Hasan Shanawani, Mark D Siegel, Scott D. Halpern, Robert D Truog, Douglas B White

American Journal of Respiratory and Critical Care Medicine

Abstract
Rationale: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs.

Objectives: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting.

Methods: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law.

Main Results: The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield ” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting.

Conclusions: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians’ COs in the critical care setting.

Lewis-Newby M, Wicclair MR, Pope TM, Rushton C, Curlin FA, Diekema D et al.. An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med. 2015;191(2):219-227.

Best evidence in critical care medicine. Early versus late parenteral nutrition in the adult ICU: feeding the patient or our conscience?

Jeff P Kerrie, Sean M Bagshaw, Peter G Brindley

Abstract
Background: Critical illness increases the risk of malnutrition, which can increase infections, prolong mechanical ventilation, delay recovery, and increase mortality. While enteral nutrition (EN) is considered optimal, this is not always an option. Furthermore, algorithms for parenteral nutrition (PN) vary significantly, and it is unclear whether early initiation or delay of parenteral feeding is preferable.

Objective: This study compares intensive care unit (ICU) duration of stay in adults randomized to early initiation of PN (within 48 hr of ICU admission) vs delayed (at eight days or later after ICU admission), as consistent with European and North American guidelines, respectively. . . .

Conclusions: While ICU and 90-day survival were not significantly different, patients in the late PN group were discharged earlier from both the ICU and the hospital. Late PN initiation was also associated with fewer infections, shorter mechanical ventilation time, shorter RRT time, and lower overall healthcare costs. While there were more episodes of hypoglycemia and more inflammation in the late PN group, there was no apparent clinical consequence. No primary or secondary end points showed that early PN was superior.

Kerrie JP, Bagshaw SM, Brindley PG. Best evidence in critical care medicine. Early versus late parenteral nutrition in the adult ICU: feeding the patient or our conscience? Can J Anesthesia. 2012 Feb 03;59(5):494-498.

Should we allow organ donation euthanasia? Alternatives for maximizing the number and quality of organs for transplantation

Dominic Wilkinson, Julian Savulescu

Abstract
There are not enough solid organs available to meet the needs of patients with organ failure. Thousands of patients every year die on the waiting lists for transplantation. Yet there is one currently available, underutilized, potential source of organs. Many patients die in intensive care following withdrawal of life-sustaining treatment whose organs could be used to save the lives of others. At present the majority of these organs go to waste. In this paper we consider and evaluate a range of ways to improve the number and quality of organs available from this group of patients. Changes to consent arrangements (for example conscription of organs after death) or changes to organ donation practice could dramatically increase the numbers of organs available, though they would conflict with currently accepted norms governing transplantation. We argue that one alternative, Organ Donation Euthanasia, would be a rational improvement over current practice regarding withdrawal of life support. It would give individuals the greatest chance of being able to help others with their organs after death. It would increase patient autonomy. It would reduce the chance of suffering during the dying process. We argue that patients should be given the choice of whether and how they would like to donate their organs in the event of withdrawal of life support in intensive care. Continuing current transplantation practice comes at the cost of death and prolonged organ failure. We should seriously consider all of the alternatives.

Wilkinson D, Savulescu J. Should we allow organ donation euthanasia? Alternatives for maximizing the number and quality of organs for transplantation. Bioethics. 2012 Jan;26(1):32-48.

Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders That Cause Suffering at the End of Life? Study of a Concept

Anita Catlin, Deborah Volat, Mary Ann Hadley, Ranginah Bassir, Christine Armigo, Elnora Valle, Wendy Gong, Kelly Anderson

Abstract
This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, fi.itility, and the concept of conscientious objection from the perspective of the nurse’s potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.

Catlin A, Volat D, Hadley MA, Bassir R, Armigo C, Valle E et al. Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders That Cause Suffering at the End of Life? Study of a Concept. Neonatal Netw. 2008 Mar;27(2):101-108. Available from:

Conscience and Clinical Care

Leah L Curtin

Extract
If the state itself does not presume to order the consciences of its citizens, how can employers, physicians or hierarchical superiors assume such authority? For those in positions of power, it is all too easy to stifle the criticisms and consciences of subordinates by a summons to authority – or by an accusation of insubordination. The irony of it is that whether you succeed or fail in your attempts to force obedience through such tactics, you will have lost your most valuable asset – a man or woman of integrity. Within the ethical, professional and legal restraints to which all of us are subject, we can and must create a system that allows for respectful dissent and conscientious objection.

Curtin LL. Conscience and Clinical Care. Nurs Manag. 1993 Aug;24(8):26-28.