Abstract This paper argues that healthcare aims at the good of health, that this pursuit of the good necessitates conscience, and that conscience is required in every practical judgement, including clinical judgment. Conscientious objection in healthcare is usually restricted to a handful of controversial ends (e.g. abortion, euthanasia, contraception), yet the necessity of conscience in all clinical judgements implies the possibility of conscientious objection to means. The distinction between conscientious objection to means and ends is explored and its implications considered. Based on this, it is suggested that conscientious objection, whether to means or ends, occurs when a proposed course of action comes into irreconcilable conflict with the moral principle ‘do no harm’. It is, therefore, concluded that conscientious objection in healthcare can be conceived as a requirement of the moral imperative to do no harm, the right to refuse to harm in regard to health.
Abstract Most discussions of conscientious objection in healthcare assume that the objection is universal: a doctor objects to all abortions. I want to investigate selective objections, where a doctor objects to one abortion but not to another, depending on the circumstances. I consider not only objections to abortion, but also objections to the withdrawal of life-saving treatment at the request of a competent patient, which is almost always selective. I explore how the objector might articulate the selective objection, and what impact it might have on the patient, within the conceptual space of relevant statutes and professional guidelines.
Abstract Is conscientious objection (CO) necessarily incompatible with the role and duties of a healthcare professional? An influential minority of writers on the subject think that it is. Here, we outline the positive case for accommodating CO and examine one particular type of incompatibility claim, namely that CO is fundamentally incompatible with proper healthcare professionalism because the attitude of the conscientious objector exists in opposition to the disposition (attitudes and underlying character) that we should expect from a ‘good’ healthcare professional. We ask first whether this claim is true in principle: what is the disposition of a ‘good’ healthcare professional, and how does CO align with or contradict it? Then, we consider practical compatibility, acknowledging the need to identify appropriate limits on the exercise of CO and considering what those limits might be. We conclude that CO is not fundamentally incompatible – either in principle or in practice – with good healthcare professionalism.
Abstract The vigorous legal and ethical debates over conscientious objection have taken place largely within the domain of health care. Is this because conscience in medicine is of a special kind, or are there other reasons why it tends to dominate these debates? Beginning with an analysis of the analogy between medical conscience and conscientious objection in wartime, I go on to examine various possible grounds for distinguishing between medicine and other professional contexts (taking law and accountancy as examples). The conclusion is that no principled difference exists between the military and medical cases, nor between the health professions and other professions. Nevertheless, there are practical reasons why medical conscience has distinctive importance, mainly concerning the rapid advance of medical technology. Medical conscience will, for these reasons, continue to drive the debate over conscientious objection, even though legal protection should in principle extend to all professions.
Abstract Conscientious objection in healthcare has come under heavy criticism on two grounds recently, particularly regarding abortion provision. First, critics claim conscientious objection involves a refusal to provide a legal and beneficial procedure requested by a patient, denying them access to healthcare. Second, they argue the exercise of conscientious objection is based on unverifiable personal beliefs. These characteristics, it is claimed, disqualify conscientious objection in healthcare. Here, we defend conscientious objection in the context of abortion provision. We show that abortion has a dubitable claim to be medically beneficial, is rarely clinically indicated, and that conscientious objections should be accepted in these circumstances. We also show that reliance on personal beliefs is difficult to avoid if any form of objection is to be permitted, even if it is based on criteria such as the principles and values of the profession or the scope of professional practice.
Résumé Depuis décembre 2015, l’aide médicale à mourir, une pratique au centre de nombreux débats éthiques, est légalisée dans la province du Québec, au Canada. Ce nouveau type de décès a créé un tout nouveau contexte pour le don d’organes, soit le don d’organes après l’aide médicale à mourir. Le prélèvement des organes s’effectue alors suivant le protocole habituel du don d’organes après décès cardiocirculatoire contrôlé (catégorie Maastricht III), un protocole qui suscitait déjà de nombreux questionnements médico-éthiques. En outre, l’amalgame des deux pratiques soulève de nouveaux enjeux éthiques qui peuvent se traduire par des objections de conscience chez les médecins directement impliqués dans l’aide médicale à mourir et/ou le don d’organes. Or, une telle objection de conscience peut-elle être acceptable ? Nous tenterons de répondre à cette question en trois temps : d’abord, par un bref historique de l’objection de conscience ; ensuite, par une revue des débats actuels sur ce sujet ; enfin, par l’examen, à l’aide de critères recensés dans la littérature, de cas où les médecins refuseraient de participer au don d’organes après l’aide médicale à mourir.
Summary
Medical assistance in dying, a much debated practice in ethical literature, is practiced since 2015 in the province of Québec, Canada. Its practice has opened the door to organ donation after medical assistance in dying. This type of donation is possible through donation after controlled cardiocirculatory death (Maastricht III category), a procedure that also raises many ethical questions. Combining these two practices raises new ethical issues and could therefore generate conscientious objections from physicians directly involved in medical assistance in dying and/or organ donation. Would conscientious objection be acceptable in this context? To answer this question, we present a brief history of conscientious objection, an overview of the actual debates on conscientious objection and we will examine the case of the physician who would object to participate in organ donation after medical assistance in dying using existing criteria.
Extract Al Rabadi et al1 compare statistics on physician-assisted suicide (PAS) available from public databases for the states of Washington and Oregon and find similar profiles and trends, which is unsurprising given the similarity of the laws and demographic characteristics of these states. Among the unanswered questions are what such a study can contribute to medical ethics (about PAS or any other ethical controversy) and what the limits are of such work.
Cautions: First, it should be noted that the medical literature is, in general, favorably disposed toward the empirical and the new. Although this predilection is often advantageous for scientific progress, it introduces a problematic bias when applied to ethical questions. The appeal of the study by Al Rabadi et al1 is that it is empirical, and by comparing data from 2 states for the first time, it can be considered novel. Because there are new reports each year and the practice of PAS is legal in only a few states, descriptive reports about PAS are published frequently. This means, however, that articles defending the ethical status quo (ie, against PAS) tend to be shut out of the medical literature because they are not reporting anything new and, therefore, cannot have any data. The result is an impression of growing acceptance of PAS, but it really represents an artifact of a scientific bias. . . .
Marike E De Boer, Marja FIA Depla, Marjolein Den Breeje,Pauline Slottje, Bregje D Onwuteaka-Philipsen, Cees MPM Hertogh
Journal of Medical Ethics
Abstract The majority of Dutch physicians feel pressure when dealing with a request for euthanasia or physician-assisted suicide (EAS). This study aimed to explore the content of this pressure as experienced by general practitioners (GP). We conducted semistructured in-depth interviews with 15 Dutch GPs, focusing on actual cases. The interviews were transcribed and analysed with use of the framework method. Six categories of pressure GPs experienced in dealing with EAS requests were revealed: (1) emotional blackmail, (2) control and direction by others, (3) doubts about fulfilling the criteria, (4) counterpressure by patient’s relatives, (5) time pressure around referred patients and (6) organisational pressure. We conclude that the pressure can be attributable to the patient-physician relationship and/or the relationship between the physician and the patient’s relative(s), the inherent complexity of the decision itself and the circumstances under which the decision has to be made. To prevent physicians to cross their personal boundaries in dealing with EAS request all these different sources of pressure will have to be taken into account.
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.
Abstract What is conscience, and when should we let it be our guide? Only when it threatens indictment for nonadherence to an ethically valid duty? How do we know when that is? Doesn’t conscience change? And shouldn’t we change it intentionally sometimes, for example, on the basis of an all-things-considered judgment? Is conscience subject to reason-guided amendment? Mightn’t it be immune to change based on a cost-benefit analysis? Isn’t that its deontic characteristic? Suppose we can’t help fearing conscience, should we be excused for knuckling under to it? Is conscience then a bully we can’t evade? When should society and the law respect physicians’ divergent consciences? Mustn’t physicians subordinate their interest in being on good terms with conscience to the fiduciary duty owed to patients? Isn’t that what fidelity to the goals of medicine requires? Whose medicine? Wouldn’t dogmatism about this eradicate physicians’ moral agency? This essay provides partial and tentative answers to these questions.
