Ethics Archives - Page 22 of 81 - Protection of Conscience Project Library

Moral distress and moral conflict in clinical ethics

C. Fourie

Abstract
Much research is currently being conducted on health care practitioners’ experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton’s influential description of moral distress.

I will identify and aim to resolve two sources of confusion about moral distress: (1) the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and (2) the distinction drawn between moral dilemma (or, more accurately, moral conflict) and moral distress, which implies that the two are mutually exclusive.

In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both.

Fourie C. Moral distress and moral conflict in clinical ethics. Bioethics. doi: 10.1111/bioe.12064

A neglected aspect of conscience: awareness of implicit attitudes

Chloë Fitzgerald

Abstract
The conception of conscience that dominates discussions in bioethics focuses narrowly on private regulation of behaviour resulting from explicit attitudes. It neglects to mention implicit attitudes and the role of social feedback in becoming aware of one’s implicit attitudes. But if conscience is a way of ensuring that a person’s behaviour is in line with her moral values, it must be responsive to all aspects of the mind that influence behaviour. There is a wealth of recent psychological work demonstrating the influence of implicit attitudes on behaviour. A necessary part of having a well-functioning conscience must thus be awareness and regulation of one’s implicit attitudes in addition to one’s explicit attitudes; this cannot be done by an individual in isolation. On my revised conception of conscience, heeding social feedback, being emotionally self-aware and engaging in self-monitoring are important for the possession of a well-functioning conscience. Health professionals may need specific training to help them develop and maintain a well-functioning conscience, which should involve cultivation of awareness of implicit attitudes, emphasis on social feedback and techniques to enable better control over them.

Fitztgerald C. A neglected aspect of conscience: awareness of implicit attitudes. Bioethics. doi: 10.1111/bioe.12058

Conscientious objection and induced abortion in Europe

Anna Heino, Mika Gissler, Dan Apter, Christian Fiala

The European Journal of Contraception & Reproductive Health Care

Abstract
The issue of conscientious objection (CO) arises in healthcare when doctors and nurses refuse to have any involvement in the provision of treatment of certain patients due to their religious or moral beliefs. Most commonly CO is invoked when it comes to induced abortion. Of the EU member states where induced abortion is legal, invoking CO is granted by law in 21 countries. The same applies to the non-EU countries Norway and Switzerland. CO is not legally granted in the EU member states Sweden, Finland, Bulgaria and the Czech Republic. The Icelandic legislation provides no right to CO either. European examples prove that the recommendation that CO should not prevent women from accessing services fails in a number of cases. CO puts women in an unequal position depending on their place of residence, socio-economic status and income. CO should not be presented as a question that relates only to health professionals and their rights. CO mainly concerns women as it has very real consequences for their reproductive health and rights. European countries should assess the laws governing CO and its effects on women ’ s rights. CO should not be used as a subtle method for limiting the legal right to healthcare.

Heino A, Gissler M, Apter D, Fiala C. Conscientious objection and induced abortion in Europe. European J Contraception and Reproductive Health Care, 2013; 18: 231–233

Contraception and the birth of corporate conscience

Elizabeth Sepper

Journal of Gender, Social Policy and the Law

Abstract
Corporations — for-profit and non-profit, religiously affiliated and secular — have filed approximately sixty lawsuits challenging the Affordable Care Act’s requirement that employee health insurance plans cover contraception. In this paper, I contend that a dangerous doctrine of “corporate conscience” may be born of the contraception controversy. Already, a number of courts have indicated a willingness to accept that artificial business entities incorporated for secular, profit-making aims have religious beliefs and consciences that excuse them from compliance with law. Their reasoning repudiates longstanding foundations of corporate law. It transforms conscience, which is inherently human, into the province of business entities.

Drawing on health law and policy, I argue that these courts fundamentally misunderstand the nature of health benefits. Health insurance is a form of compensation, earned by and belonging to the employee like wages. By neglecting this economic reality, courts draw incorrect conclusions about the responsibility, legal and moral, of employers for the contents of their employees’ insurance plans, and thus about the burden that any regulation imposes. Moreover, courts fail to recognize that the role the ACA ascribes to private employers bears striking similarity to other comprehensive social insurance schemes, all of which have faced and survived challenges based on free exercise. Any employer responsibility for employer-based insurance should be analyzed under this precedent.

Finally, I suggest that “corporate conscience” would destabilize the rights of employees far beyond the context of contraception. Religiously affiliated commercial actors already assert rights to defy health and safety laws, pay women less, and fire pregnant women. If secular employers succeed in their challenge to the contraception mandate, gender equality and religious freedom will be at risk in all workplaces.

Sepper E. Contraception and the birth of corporate conscience. 22 Am. U. J. Gender, Soc. Pol’y & Law 303 (2014)

Healthcare personnel’s experiences of situations in municipal elderly care that generate troubled conscience

Eva Ericson-Lidman, Astrid Norberg, Birgitta Persson, Gunilla Strandberg

Abstract
Healthcare personnel may perceive troubled conscience when feeling inadequate and powerless. It is important to further explore healthcare personnel’s descriptions of situations in daily work, which generate troubled conscience to increase the awareness of such situations. This study aimed to describe health care personnel’s experiences of situations in municipal elderly care that generate troubled conscience. In this qualitative study, interviews were conducted with Registered and Enrolled nurses and nursing assistants (n = 20) working in municipal elderly care.

The interviews were tape-recorded, transcribed verbatim and analysed with content analysis. Situations that generated troubled conscience was (i) Being caught between different demands, comprising being forced to prioritize between different residents’ needs, being torn between residents’-/relatives’-/and co-workers’ needs and expectations’ and between work and private life, (ii) Being torn away from residents to other ‘must do’s’, comprising stealing time from residents’ to do housekeeping chore’ and to ‘obey’ rules and recommendations, (iii) Feeling unable to relieve suffering, comprising falling short when striving to help, lacking knowledge, advice and support and time to ease residents’ suffering and finally, (iv) Being part of providing care that is or feels wrong, comprising providing poor care and/or witnessing co-workers providing poor care, and being forced to give care that feels wrong.

These findings identify important factors that generate stress of conscience (stress caused by troubled conscience), including difficulties with balancing priorities and following rules and recommendations that seem contrary to best care, and the need for interdisciplinary teamwork. Findings point to that sharing what conscience tells in the work team opens up possibilities for healthcare personnel to constructively deal with troubled conscience. Intervention studies are needed to explore whether such measures contribute to relieve the burden of troubled conscience and increase possibilities to provide high quality care.

Ericson-Lidman E, Norberg A, Persson B, Strandberg G. Healthcare personnel’s experiences of situations in municipal elderly care that generate troubled conscience. Scand J Caring Sci. 2013 Jun;27(2):215-23. doi:
10.1111/j.1471-6712.2012.01017.x. Epub 2012 May 22. PubMed PMID: 22612532.

Freedom of Conscience in Health Care: Distinctions and Limits

Sean Murphy, Stephen Genuis

Abstract
The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the dictates of regulatory bodies and administrators. Increasing attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom.

Murphy S, Genuis S. Freedom of Conscience in Health Care: Distinctions and Limits. J Bioeth Inq. 2013 Oct;10(3):347-54. doi: 10.1007/s11673-013-9451-x. Epub 2013 Jun 21.

Whose Self-Determination? Barriers to Access to Emergency Hormonal Contraception in Italy

Emanuela Ceva, Sofia Moratti

Abstract
In Italy, Emergency Hormonal Contraception (EHC) is a prescription drug, available only in pharmacies. Evidence suggests that a number of doctors and pharmacists refuse to provide EHC, on grounds of conscience, although the exact frequency of this phenomenon is unknown. This creates a barrier to access to EHC for women, thus risking undermining their right to reproductive self-determination. In this article, we aim to offer a clearer empirical and theoretical understanding of the situation and to assess the force of doctors’ and pharmacists’ claims against providing EHC. Unlike standard discussions of the issue, we argue that the category of conscientious objection is not the most appropriate one for making sense of these claims, because they are not grounded in a conflict between two contrasting moral duties. The seemingly forced choice between protecting doctors’ and pharmacists’ professional self-determination and women’s reproductive self-determination could be prevented by distributing EHC without medical prescription and in a number of outlets (including supermarkets), thus relieving doctors and pharmacists from the legal duty to provide it.

Ceva E, Morati S. Whose Self-Determination? Barriers to Access to Emergency Hormonal Contraception in Italy. Kennedy Inst Ethics J. 2013 Jun;23(2):139-167. Available from:

Freedom of conscience and health care in the United States of America

Conflict Between Public Health and Religious Liberty in the Patient Protection and Affordable Care Act

Peter West-Oram

Abstract
The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties.

West-Oram P. Freedom of conscience and health care in the United States of America: Conflict Between Public Health and Religious Liberty in the Patient Protection and Affordable Care Act. Health Care Anal. 2013 Mar 29. [Epub ahead of print] PubMed PMID: 23539432.

Euthanasia is not medical treatment

J Donald Boudreau, Margaret A. Somerville

Abstract
Introduction or background
The public assumes that if euthanasia and assisted suicide were to be legalized they would be carried out by physicians.
Sources of data
In furthering critical analysis, we supplement the discourse in the ethics and palliative care literature with that from medical education and evolving jurisprudence.
Areas of agreement
Both proponents and opponents agree that the values of respect for human life and for individuals’ autonomy are relevant to the debate.
Areas of controversy
Advocates of euthanasia and assisted suicide give priority to the right to personal autonomy and avoid discussions of harmful impacts of these practices on medicine, law and society. Opponents give priority to respect for life and identify such harmful effects. These both require euthanasia to remain legally prohibited.
Growing points
Proposals are emerging that if society legalizes euthanasia it should not be mandated to physicians.
Areas timely for developing research
The impact of characterizing euthanasia as ‘medical treatment’ on physicians’ professional identity and on the institutions of medicine and law should be examined in jurisdictions where assisted suicide and euthanasia have been de-criminalized.

Boudreau JD, Somerville MA. Euthanasia is not medical treatment. Br Med Bull. 2013;106(1):45-66.

Institutional conscience and access to services: can we have both?

Cameron Flynn, Robin Fretwell Wilson

American Medical Association Journal of Ethics

Extract
It appears, at times, that health care and religion do not mix. Consider the sterilization and contraception coverage mandate under the Patient Protection and Affordable Care Act. The mandate requires nearly all employers and health insurers to cover as “essential health care services” certain sterilization procedures and contraceptives, including emergency contraceptives. Members of the Catholic, evangelical Christian, Mennonite, and Muslim faith communities say that the mandate places them “in the untenable position of having to choose between violating the law and violating their consciences.”

Flynn C, Wilson RF. Institutional conscience and access to services: can we have both? Virtual Mentor. 2013;15(3):226-235. doi: 10.1001/virtualmentor.2013.15.3.pfor1-1303.