Extract The chair of the President’s Council on Bioethics, Edmund Pellegrino, has insisted that medical ethics are and must be the same for civilian and military physicians, “except in the most extreme contingencies.” There is no special medical ethics for active-duty military physicians any more than there is for Veterans Affairs physicians, National Guard physicians, public health physicians, prison physicians, or managed care physicians. The only question is whether there are “extreme contingencies” that justify physicians’ suspension of their medical–ethical obligations.
Extract Conscience is a tricky business. Some interpret its personal beacon as the guide to universal truth. But the assumption that one’s own conscience is the conscience of the world is fraught with dangers. As C. S. Lewis wrote, “Those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.” As nations become more ethnically and religiously diverse, and science and medicine develop new and more complex health interventions, new forms of conscientious objections are likely to emerge. Conscientious objection is not simply a matter for individual pharmacists; it is a matter that must engage the entire profession of pharmacy and society as a whole. Professional associations, boards of pharmacy, and state legislatures must work together to prevent patients from bearing the burdens of excusing pharmacists from delivering the full measure of pharmaceutical care.
Abstract The literature on conscience in medicine has paid little attention to what is meant by the word ‘conscience.’ This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed.
Abstract Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on one’s conscience. Second, I sketch an account of the basis of the medical and pharmacy professions’ responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the “conventional compromise” as a reasonable accommodation to conflicts between these professions’ responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: “Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?”.
Abstract In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician’s professional obligations (the “incompatibility thesis”). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal morality (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician’s professional obligations unequivocally supports the incompatibility thesis.
Abstract Physicians sometimes refuse to provide legally permitted medical services on the grounds that they cannot do so in good conscience. Such conscientious refusals are at least as old as the Hippocratic movement. Yet new events, such as the refusal by health care professionals to prescribe or dispense post-coital (‘‘emergency’’) contraception, have kindled new debates about what physicians are obligated to do when patients request legal medical interventions to which their physicians have moral objections. In a recent national survey, we found that a large majority of physicians believe they are obligated in such circumstances to present all possible options to the patient, including information about obtaining the requested intervention, and to refer the patient to a clinician who does not object to the requested intervention. Yet a substantial minority of physicians—particularly those who are more religious and/or who themselves object to common controversial practices—disagree with these majority opinions.
Abstract In Nancy B. v. Hotel-Dieu de Quebec, the Quebec Superior Court held that a patient was legally entitled to discontinue and decline medical treatment when she found it unacceptable. The author discusses how this case is consistent with several other, decisions, yet distinguishable from certain Canadian decisions which contributed to its outcome. Through an analysis of Criminal Code provisions against homicide and on the duty to preserve life, the doctrine of informed consent, and related jurisprudence, the author argues that the Nancy B. decision narrows the gap between allowing a patient to suffer natural death and medically assisting death. The author also raises issues associated with the notion of medical futility. He concludes that “the Nancy B. case moves the discourse in medical ethics and law towards the feminist “carebased” paradigm and suggests that the carefully- circumscribed judicial response was an appropriate legal answer to the question of how best to care for Nancy B..
Abstract Referral of pregnant patients for termination of pregnancy by physicians morally opposed to the procedure is ethically controversial, with polarized positions taken by physician organizations. Based on the ethical principles of beneficence and respect for autonomy, we establish the distinction between direct and indirect referral. Direct referral is beneficence based and requires the referring physician to ensure that the referral occurs. Indirect referral is autonomy based, with a beneficence-based component that requires that the physician provide information to the patient about health care organizations that will provide competent medical care. We show that only indirect referral is ethically required in healthy women for termination of an unwanted pregnancy or a pregnancy complicated by fetal anomalies because the indications for this procedure are solely autonomy based. Direct referral for termination of pregnancy is not ethically required but is permissible. Conscience-based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral do not.
Extract In posing the question of whether it is morally right for the only pharmacist in town to refuse healthcare services based on his or the community’s religious convictions, I could not help but think of “the conscience clause.” While many states across the United States support the conscience clause, which protects healthcare professionals from discrimination when refusing to dispense birth control pills or performing abortions and sterilizations, such clauses have different implications in the rural setting.When a physician or pharmacist refuses to prescribe or dispense birth control pills, the urban patient is able to acquire birth control from another healthcare provider with less difficulty than the rural patient. The rural patient may have to drive a great distance to acquire birth control even if it is needed for a medical condition rather than to prevent pregnancy.
Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin
Journal of Clinical Nursing
Abstract Aims. The aim was to study the relationship between conscience and burnout among care-providers in older care, exploring the relationship between stress of conscience and burnout, and between perceptions of conscience and burnout.
Background. Everyday work in healthcare presents situations that influence care-providers’ conscience. How care-providers perceive conscience has been shown to be related to stress of conscience (stress related to troubled conscience), and in county council care, an association between stress of conscience and burnout has been found.
Method. A questionnaire study was conducted in municipal housing for older people. A total of 166 care-providers were approached, of which 146 (50 registered nurses and 96 nurses’ aides/enrolled nurses) completed a questionnaire folder containing the stress of conscience questionnaire, the perceptions of conscience questionnaire and the maslach burnout inventory. Multivariate canonical correlation analysis was used to explore relationships.
Result. The relationship between stress of conscience and burnout indicates that experiences of shortcomings and of being exposed to contradictory demands are strongly related to burnout (primarily to emotional exhaustion). The relationship between perceptions of conscience and burnout indicates that a deadened conscience is strongly related to burnout.
Conclusion. Conscience seems to be of importance in relation to burnout, and suppressing conscience may result in a profound loss of wholeness, integrity and harmony in the self.
Relevance to clinical practice. The results from our study could be used to raise awareness of the importance of conscience in care.
