Ethics Archives - Page 13 of 81 - Protection of Conscience Project Library

An Unholy Mess: Why ‘The Sanctity of Life Principle’ Should Be Jettisoned.

David Albert Jones

Abstract
The aim of this article is to present an account of an important element of medical ethics and law which is widely cited but is often confused. This element is most frequently referred to as ‘the principle of the sanctity of life’, and it is often assumed that this language has a religious provenance. However, the phrase is neither rooted in the traditions it purports to represent nor is it used consistently in contemporary discourse. Understood as the name of an established ‘principle’ the ‘sanctity of life’ is virtually an invention of the late twentieth century. The language came to prominence as the label of a position that was being rejected: it is the name of a caricature. Hence there is no locus classicus for a definition of the terms and different authors freely apply the phrase to divergent and contradictory positions. Appeal to this ‘principle’ thus serves only to perpetuate confusion. This language is best jettisoned in favour of clearer and more traditional ethical concepts.

Jones DA, An Unholy Mess: Why ‘The Sanctity of Life Principle’ Should Be Jettisoned. The New Biothics, Vol. 22, 2016, Issue 3.

Rationing conscience

Dominic Wilkinson

Abstract
Decisions about allocation of limited healthcare resources are frequently controversial. These decisions are usually based on careful analysis of medical, scientific and health economic evidence. Yet, decisions are also necessarily based on value judgements. There may be differing views among health professionals about how to allocate resources or how to evaluate existing evidence. In specific cases, professionals may have strong personal views (contrary to professional or societal norms) that treatment should or should not be provided. Could these disagreements rise to the level of a conscientious objection? If so, should conscientious objections to existing allocation decisions be accommodated? In the first part of this paper, I assess whether resource allocation could be a matter of conscience. I analyse conceptual and normative models of conscientious objection and argue that rationing could be a matter for conscience. I distinguish between negative and positive forms: conscientious non-treatment and conscientious treatment. In the second part of the paper, I identify distinctive challenges for conscientious objections to resource allocation. Such objections are almost always inappropriate.

Wilkinson D. Rationing conscience. J Med Ethics doi:10.1136/medethics-2016-103795

Further clarity on cooperation and morality

David S. Oderberg

Abstract
I explore the increasingly important issue of cooperation in immoral actions, particularly in connection with healthcare. Conscientious objection, especially as pertains to religious freedom in healthcare, has become a pressing issue in the light of the US Supreme Court judgement in Hobby Lobby. Section ‘Moral evaluation using the basic principles of cooperation’ outlines a theory of cooperation inspired by Catholic moral theologians such as those cited by the court. The theory has independent plausibility and is at least worthy of serious consideration—in part because it is an instance of double-effect reasoning, which is also independently plausible despite its association with moral theology. Section ‘Case study: Burwell v. Hobby Lobby’ examines Hobby Lobby in detail. Even if the judgement was correct in that case the reasoning was not, as it involved applying a ‘mere sincerity’ test to the cooperation question. The mere sincerity test leads to absurd consequences, whereas a reasonableness test applied using the theory of cooperation defended here would avoid absurdity. Section ‘A question of remoteness: “accommodations” and opt-outs’ explores the post-Hobby Lobby problem further, examining opt-outs and accommodations: the Little Sisters of the Poor case shows how opt-outs are misunderstood on a mere sincerity test, which the court rightly rejected. Section ‘Application to the medical field: Doogan and Wood’ discusses the UK case of Doogan and Wood, concerning participation in abortion. Again, a judicially recognised ethic of cooperation, if it were part of the fabric of legal reasoning in such cases, would have enabled the conscientious objectors in this and similar situations to have their freedom of conscience and religion respected in a way that it currently is not.

Oderberg DS, Further clarity on cooperation and morality. J Med Ethics doi:10.1136/medethics-2016-103476

Conscientious objection in healthcare, referral and the military analogy

Steve Clarke

Abstract
An analogy is sometimes drawn between the proper treatment of conscientious objectors in healthcare and in military contexts. In this paper, I consider an aspect of this analogy that has not, to my knowledge, been considered in debates about conscientious objection in healthcare. In the USA and elsewhere, tribunals have been tasked with the responsibility of recommending particular forms of alternative service for conscientious objectors. Military conscripts who have a conscientious objection to active military service, and whose objections are deemed acceptable, are required either to serve the military in a non-combat role, or assigned some form of community service that does not contribute to the effectiveness of the military. I argue that consideration of the role that military tribunals have played in determining the appropriate form of alternative service for conscripts who are conscientious objectors can help us to understand how conscientious objectors in healthcare ought to be treated. Additionally, I show that it helps us to address the vexed issue of whether or not conscientious objectors who refuse to provide a service requested by a patient should be required to refer that patient to another healthcare professional.

Clarke S. Conscientious objection in healthcare, referral and the military analogy. J Med Ethics 2016;0:1–4. doi:10.1136/medethics-2016-103777

Reasons, reasonability and establishing conscientious objector status in medicine

Robert F. Card

Abstract
This paper builds upon previous work in which I argue that we should assess a provider’s reasons for his or her objection before granting a conscientious exemption. For instance, if the medical professional’s reasoned basis involves an empirical mistake, an accommodation is not warranted. This article poses and begins to address several deep questions about the workings of what I call a reason-giving view: What standard should we use to assess reasons? What policy should we adopt in order to evaluate the reasons offered by medical practitioners in support of their objections? I argue for a reasonability standard to perform the essential function of assessing reasons, and I offer considerations in support of a policy establishing conscientious objector status in medicine.

Card RF. Reasons, reasonability and establishing conscientious objector status in medicine. J Med Ethics doi:10.1136/medethics-2016-103792

Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception

Julian Savulescu, Udo Schuklenk

Abstract
In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors’ personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: (1) removing a right to conscientious objection; (2) selecting candidates into relevant medical specialities or general practice who do not have objections; (3) demonopolizing the provision of these services away from the medical profession.

Savulescu J, Schuklenk U. (2016) Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics. doi:10.1111/bioe.12288

Rationing and professional autonomy

George J Agich

Extract
Rationing is an inevitable consequence of practicing medicine under conditions of scarcity of resources. Unfortunately, appeals to professional autonomy have muddled the issues associated with limited resource availability in medicine by alleging conflicts that are irresolvable in principle between rationing under prospective payment systems and medical ethics. Such appeals do little to address the real problems involved or to help clarify the important ethical and public policy issues that surround this ineliminable fact of life. Careful analysis of rationing and professional autonomy, however, leads to the conclusion that rationing is a problem for medical ethics at least in the sense that it forces important and difficult questions to the surface regarding the proper nature and structure of medical practice. Some of these questions are precisely the ones at which prospective payment initiatives are aimed.

Agich GJ. Rationing and professional autonomy. J Law Med Ethics. 1989;18(1-2):77-84.

Beneficent Voluntary Active Euthanasia: A Challenge to Professionals Caring for Terminally Ill Patients

Ann-Marie Begley

Abstract
Euthanasia has once again become headline news in the UK, with the announcement by Dr Michael Irwin, a former medical director of the United Nations, that he has helped at least 50 people to die, including two between February and July 1997. He has been quoted as saying that his ‘conscience is clear’ and that the time has come to confront the issue of euthanasia.

For the purposes of this article, the term ‘beneficent voluntary active euthanasia’ (BVAE) will be used: beneficent from the prima facie principle of beneficence, to do good, and voluntary to indicate that this must be carried out at the request of a competent client. This implies adherence to another prima facie principle, that of respect for autonomy. Active implies that something is done or given with the intention of hastening death. The word euthanasia itself simply means ‘good death’.

This article examines the moral positions of two nurses and one junior doctor towards the subject of BVAE and an attempt is made to represent the main conflicting moral positions. The central arguments against BVAE and counterarguments are presented. The conclusion reached is that consenting adults should not be prevented from availing themselves of BVAE if another consenting adult (a medical doctor) is available and capable of carrying out their wishes. This being the case, it is suggested that BVAE should be available as an option in hospices and in the community.

The aims of this article are: to generate debate among professionals; to present a three-way discussion that might be useful as a focus for educational purposes, particularly at undergraduate level; to challenge professionals to confront the issue of euthanasia; and to plead the case of those who request assistance in exercising autonomy by gaining control over their own deaths.

Begley A-M. Beneficent Voluntary Active Euthanasia: A Challenge to Professionals Caring for Terminally Ill Patients. Nurs Ethics. 1998;5(4):294-306.

Meeting ethical challenges in acute nursing care as narrated by registered nurses

Venke Sørlie, Annica Kihlgren, Mona Kihlgren

Abstract
Five registered nurses were interviewed as part of a comprehensive investigation by five researchers into the narratives of five enrolled nurses (study 1, published in Nursing Ethics 2004), five registered nurses (study 2) and 10 patients (study 3) describing their experiences in an acute care ward at one university hospital in Sweden. The project was developed at the Centre for Nursing Science at Örebro University Hospital. The ward in question was opened in 1997 and provides care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The registered nurses were interviewed concerning their experience of being in ethically difficult care situations in their work. Interpretation of the theme ‘ethical problems’ was left to the interviewees to reflect upon. A phenomenological hermeneutic method (inspired by the French philosopher Paul Ricoeur) was used in all three studies. The most prominent feature revealed was the enormous responsibility present. When discussing their responsibility, their working environment and their own reactions such as stress and conscience, the registered nurses focused on the patients and the possible negative consequences for them, and showed what was at stake for the patients themselves. The nurses demonstrated both directly and indirectly what they consider to be good nursing practices. They therefore demand very high standards of themselves in their interactions with their patients. They create demands on themselves that they believe to be identical to those expected by patients.

Sørlie V, Kihlgren A, Kihlgren M. Meeting ethical challenges in acute nursing care as narrated by registered nurses. Nurs Ethics. 2005;12(2):133-142.

Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections

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.

Christie T, Sloan J, Dahlgren D, Koning F. Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections. Bioethique Online. 2016 Aug 17;5(14):1-9.