Lidia Casas, Lori Freedman, Alejandra Ramm, Sara Correa, C Finley Baba, M Antonia Biggs
Abstract CONTEXT: In 2017, Chile reformed its abortion law to allow the procedure under limited circumstances. Exploring the views of Chilean medical and midwifery faculty regarding abortion and the use of conscientious objection (CO) at the time of reform can inform how these topics are being taught to the country’s future health care providers.
METHODS: Between March and September 2017, 30 medical and midwifery school faculty from universities in Santiago, Chile were interviewed; 20 of the faculty taught at secular universities and 10 taught at religiously affiliated universities. Faculty perspectives on CO and abortion, the scope of CO, and teaching about CO and abortion were analyzed using a grounded theory approach.
RESULTS: Most faculty at secular and religiously affiliated universities supported the rights of clinicians to refuse to provide abortion care. Secular-university faculty generally thought that CO should be limited to specific providers and rejected the idea of institutional CO, whereas religious-university faculty strongly supported the use of CO by a broad range of providers and at the institutional level. Only secular-university faculty endorsed the idea that CO should be regulated so that it does not hinder access to abortion care.
CONCLUSIONS: The broader support for CO in abortion among religious-university faculty raises concerns about whether students are being taught their ethical responsibility to put the needs of their patients above their own. Future research should monitor whether Chile’s CO regulations and practices are guaranteeing people’s access to abortion care..
Extract Institutional conscience–based objection (in which a hospital’s religious affiliation or mission influences the services it provides) differs materially from the more familiar concept of individual conscience–based objection.
Rachel Kogan, Katherine L Kraschel, Claudia E Haupt
Abstract This article canvasses laws protecting clinicians’ conscience and focuses on dilemmas that occur when a clinician refuses to perform a procedure consistent with the standard of care. In particular, the article focuses on patients’ experience with a conscientiously objecting clinician at a secular institution, where patients are least likely to expect conscience-based care restrictions. After reviewing existing laws that protect clinicians’ conscience, the article discusses limited legal remedies available to patients.
Extract If the courts rule that the Constitution allows hospitals to exert control over individual physicians’ claims of professional conscience, it will be a victory for corporate medicine. But if the state law is upheld, the case could establish that physicians’ professional conscience claims hold or take precedence over the ethical and religious directives of religiously affiliated hospitals. It is possible that at least some religiously affiliated health systems might rather close than allow that outcome.
Abstract “Conscience clauses” define conscience as “religious beliefs” or “moral convictions,” and they come up, therefore, usually in relation to women’s reproductive rights. This article argues that conscience is better understood as a feeling of integrity, rightness, and self, and that we need it especially now, as huge corporations take over health care. After an illustrative story, the author reviews the history of patients’ rights and also the health-care consumer movement, which introduced the idea that health care is a commodity, and the doctor, therefore, simply a tradesman, whose duty is to provide what his patient wants. The author examines where this new commercial model of medicine leads: Patients demanding treatments that are bad for them and expensive for the health-care system; doctors who are forced to do what they think is wrong; a world where patients cannot trust their physicians to do their best for them. Patients need their doctors to have consciences. But in this time of expanding corporate power in health care, can the right to have a conscience also be a Trojan horse? Protecting corporate entities who legally are also entitled to have a conscience? The author proposes that the most powerful rule of conscience is the oldest, the Hippocratic oath’s formulation that doctors should enter the exam room solely for the benefit of their patients. When the definition of “benefit” comes into question, then we should use the strategies developed over the past 45 years—shared decision making, ethics committees, media oversight—all of which will become ever more important as technology creates ever new dilemmas for conscience.
Extract . . . Over the past five years, however, public and private health insurance coverage for transition-related surgery has increased exponentially.2 As available funds have increased, so has demand for services.3 American institutions are now struggling to meet a growing demand for competent, efficient, and effective transgender healthcare that they had denied for decades. . . . The rapid expansion of Catholic hospitals is a concern for transgender people, their advocates, and the insurers who provide their health coverage because Catholic hospitals do not provide transition-related care. . .
Carey DeMichelis, Randi Zlotnik Shaul, Adam Rapoport
Abstract This article explores the ethical challenges of providing Medical Assistance in Dying (MAID) in a paediatric setting. More specifically, we focus on the theoretical questions that came to light when we were asked to develop a policy for responding to MAID requests at our tertiary paediatric institution. We illuminate a central point of conceptual confusion about the nature of MAID that emerges at the level of practice, and explore the various entailments for clinicians and patients that would flow from different understandings. Finally, we consider the ethical challenges of building policy on what is still an extremely controversial social practice. While MAID is currently available to capable patients in Canada who are 18 years or older—a small but important subsection of the population our hospital serves—we write our policy with an eye to the near future when capable young people may gain access to MAID. We propose that an opportunity exists for MAID-providing institutions to reduce social stigma surrounding this practice, but not without potentially serious consequences for practitioners and institutions themselves. Thus, this paper is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID. We offer a view of the roads taken and considered along the way, and our justifications for travelling the paths we chose. By providing a record of our in-progress thinking, we hope to stimulate wider discussion about the issues and questions encountered in this work.
Abstract The Supreme Court of Canada’s decision to allow medical assistance in dying (MAiD) has created a crisis of conscience for religious hospitals that refuse MAiD based on religious beliefs and conscience. This paper argues that when the law is revised concerning fundamental human life issues (FHLI), such as assisted suicide, liberal democracies must tolerate religious communities and institutions that refuse to accept the law’s revision. This toleration for religious belief and practice is predicated on the idea that the religious practice at issue remains legal and forms part of the religious community’s moral framework to which the state remains neutral. A refusal to tolerate the religious position is a rejection of the collective wisdom of liberal democratic thought that has emphasized religious individual and, by extension, religious institutional freedom. The Christian hospital, having been around for millennia, forms a necessary part of civil society. Robert Putnam’s research on the importance of religion to civic society is used to make the argument that society as a whole benefits from the norm of reciprocity, (“I’ll do this for you now, with the expectation that you (or perhaps someone else) will return the favour”). As the state continues to allow the religious community to have “its” hospital, the community, as a whole, will continue to maintain a high level of trust toward the state. Radical positions from our historical norms require thoughtful reflection of their presuppositions. It would serve us well to maintain a humble appreciation of our cultural heritage even when we think we are right in our newfound positions on FHLI.
Timothy Christie, John Sloan, Dylan Dahlgren, Fred Koning
Abstract Background: The Supreme Court of Canada (SCC) has ruled that the federal government is required to remove the provisions of the Criminal Code of Canada that prohibit medical assistance in dying (MAID). The SCC has stipulated that individual physicians will not be required to provide MAID should they have a religious or conscientious objection. Therefore, the pending legislative response will have to balance the rights of the patients with the rights of physicians, other health care professionals, and objecting institutions.
Objective: The objective of this paper is to critically assess, within the Canadian context, the moral probity of individual or institutional objections to MAID that are for either religious or conscientious reasons.
Methods: Deontological ethics and the Doctrine of Double Effect.
Results: The religious or conscientious objector has conflicting duties, i.e., a duty to respect the “right to life” (section 7 of the Charter) and a duty to respect the tenets of his or her religious or conscientious beliefs (protected by section 2 of the Charter).
Conclusion: The discussion of religious or conscientious objections to MAID has not explicitly considered the competing duties of the conscientious objector. It has focussed on the fact that a conscientious objection exists and has ignored the normative question of whether the duty to respect one’s conscience or religion supersedes the duty to respect the patient’s right to life.
Debra B. Stulberg, Rebecca A. Jackson, Lori R. Freedman
Abstract Context: Catholic hospitals control a growing share of health care in the United States and prohibit many common reproductive services, including ones related to sterilization, contraception, abortion and fertility. Professional ethics guidelines recommend that clinicians who deny patients reproductive services for moral or religious reasons provide a timely referral to prevent patient harm. Referral practices in Catholic hospitals, however, have not been explored.
Methods: Twenty-seven obstetrician-gynecologists who were currently working or had worked in Catholic facilities participated in semistructured interviews in 2011–2012. Interviews explored their experiences with and perspectives on referral practices at Catholic hospitals. The sample was religiously and geographically diverse. Referral-related themes were identified in interview transcripts using qualitative analysis.
Results: Obstetrician-gynecologists reported a range of practices and attitudes in regard to referrals for prohibited services. In some Catholic hospitals, physicians reported that administrators and ethicists encouraged or tolerated the provision of referrals. In others, hospital authorities actively discouraged referrals, or physicians kept referrals hidden. Patients in need of referrals for abortion were given less support than those seeking referrals for other prohibited services. Physicians received mixed messages when hospital leaders wished to retain services for financial reasons, rather than have staff refer patients elsewhere. Respondents felt referrals were not always sufficient to meet the needs of low-income patients or those with urgent medical conditions.
Conclusions: Some Catholic hospitals make it difficult for obstetrician-gynecologists to provide referrals for comprehensive reproductive services.