Ethics Archives - Page 14 of 81 - Protection of Conscience Project Library

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

Dylan Dahlgren, Fred Koning, John Sloan, Timothy Christie

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, Konging F. Medical Assistance in Dying in Canada: An Ethical Analysis of Conscientious and Religious Objections. BioéthiqueOnLine, 2016, 5/14

Referrals for Services Prohibited In Catholic Health Care Facilities

Debra B. Stulberg, Rebecca A. Jackson, Lori R. Freedman

Perspectives on Sexual and Reproductive Health

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.

Stulberg DB, Jackson RA, Freedman LR. Referrals for Services Prohibited In Catholic Health Care Facilities. Perspect Sex Repro H, 48:111–117. doi:10.1363/48e10216

Nurses’ Participation in the Euthanasia Programs of Nazi Germany

Susan Benedict,Jochen Kuhla

Abstract
During the Nazi era, so-called euthanasia programs were established for handicapped and mentally ill children and adults. Organized killings of an estimated 70,000 German citizens took place at killing centers and in psychiatric institutions. Nurses were active participants; they intentionally killed more than 10,000 people in these involuntary euthanasia programs. After the war was over, most of the nurses were never punished for these crimes against humanity-although some nurses were tried along with the physicians they assisted. One such trial was of 14 nurses and was held in Munich in 1965. Although some of these nurses reported that they struggled with a guilty conscience, others did not see anything wrong with their actions, and they believed that they were releasing these patients from their suffering.

Benedict S, Kuhla J. Nurses’ Participation in the Euthanasia Programs of Nazi Germany. West J Nurs Res. 1999;21(2).

Conscientious Objection in Healthcare Provision: A New Dimension

Peter West-Oram, Alena Buyx

Abstract
The right to conscientious objection in the provision of healthcare is the subject of a lengthy, heated and controversial debate. Recently, a new dimension was added to this debate by the US Supreme Court’s decision in Burwell vs. Hobby Lobby et al. which effectively granted rights to freedom of conscience to private, for-profit corporations. In light of this paradigm shift, we examine one of the most contentious points within this debate, the impact of granting conscience exemptions to healthcare providers on the ability of women to enjoy their rights to reproductive autonomy. We argue that the exemptions demanded by objecting healthcare providers cannot be justified on the liberal, pluralist grounds on which they are based, and impose unjustifiable costs on both individual persons, and society as a whole. In doing so, we draw attention to a worrying trend in healthcare policy in Europe and the United States to undermine women’s rights to reproductive autonomy by prioritizing the rights of ideologically motivated service providers to an unjustifiably broad form of freedom of conscience.

West-Oram P, Buyx A. Conscientious Objection in Healthcare Provision: A New Dimension. Bioethics. 2016 Jun;30(5):336-343.

The Limits of Conscientious and Religious Objection to Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada

Amir Attaran

Extract
[The Supreme Court of Canada decision to legalize euthanasia and assisted suicide “is in abeyance until June 2016.”]. . . Trouble is, not many physicians seem willing to assist. . . . overall, it is clear that a majority of Canadian doctors polled refuse to participate in physician assisted dying.

. . . This article argues that whether doctors do or do not have the right to refuse to treat patients on conscientious or religious grounds is neither a difficult nor a novel legal issue. Patients and doctors have clashed on this issue before, and when they have, tribunals and courts have overwhelmingly sided with the patients over the doctors. . .

Attaran A. The Limits of Conscientious and Religious Objectionto Physician-Assisted Dying after the Supreme Court’s Decision in Carter v. Canada. Health Law Can. 2016 Feb;36(3):86-98.

From women’s ‘irresponsibility’ to foetal ‘patienthood’: Obstetricians-gynaecologists’ perspectives on abortion and its stigmatisation in Italy and Cataluña

Silvia De Zordo

Abstract
This article explores obstetricians-gynaecologists’ experiences and attitudes towards abortion, based on two mixed-methods studies respectively undertaken in Italy in 2011–2012, and in Spain (Cataluña) in 2013–2015. Short questionnaires and in-depth interviews were conducted with 54 obstetricians-gynaecologists at 4 hospitals providing abortion care in Rome and Milan, and with 23 obstetricians-gynaecologists at 2 hospitals and one clinic providing abortion care in Barcelona. A medical/moral classification of abortions, from those considered ‘more acceptable’, both medically and morally – for severe foetal malformations – to the ‘least acceptable’ ones – repeated ‘voluntary abortions’, emerged in the discourse of most obstetricians-gynaecologists working in public hospitals, regardless of their religiosity. I argue that this is the result of the increasing medicalisation of contraception as well as of reproduction, which has reinforced the stigmatisation of ‘voluntary abortion’ (in case of unintended pregnancy) in a context of declining fertility rates. This contributes to explain why obstetricians-gynaecologists working in Catalan hospitals, which provide terminations only for medical reasons, unlike Italian hospitals, do not experience abortion stigma and do not object to abortion care as much as their Italian colleagues do.

Zordo SD. From women’s ‘irresponsibility’ to foetal ‘patienthood’: Obstetricians-gynaecologists’ perspectives on abortion and its stigmatisation in Italy and Cataluña. Glob Public Health. 2018 May 27;13(6).

Cross Cultural Perspectives on Dignity, Bioethics, and Human Rights

Maria Isabel Cornejo-Plaza, Darryl RJ Macer

Eubios Journal of Asian and International Bioethics

Abstract
The concept of dignity is the foundation of fundamental rights expressed in international declarations on human rights and bioethics. Sometimes there are collisions of rights, which must be weighed. However, more often dignity is invoked in order to argue for or against the same issue. Is it possible that a concept can be so broad that it becomes meaningless? What do we mean when we argue for moral decisions based on dignity? This paper aims at understanding dignity as a construct, in an analytical and evolutionary cross-cultural approach, from a Western and Eastern view, and then considers its impact on the teaching of human rights and biolaw.

Cornejo-Plaza MI, Macer DR. Cross Cultural Perspectives on Dignity, Bioethics, and Human Rights. Eubios J Asian & Int Bioethics. 2016 May;26(3):90-95.

Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies

Udo Schuklenk, Ricardo Smalling

Abstract
We describe a number of conscientious objection cases in a liberal Western democracy. These cases strongly suggest that the typical conscientious objector does not object to unreasonable, controversial professional services—involving torture, for instance—but to the provision of professional services that are both uncontroversially legal and that patients are entitled to receive. We analyse the conflict between these patients’ access rights and the conscientious objection accommodation demanded by monopoly providers of such healthcare services. It is implausible that professionals who voluntarily join a profession should be endowed with a legal claim not to provide services that are within the scope of the profession’s practice and that society expects them to provide. We discuss common counterarguments to this view and reject all of them.

Schuklenk U, Smalling R. Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. J Med Ethics. 2016 Apr 22; 43(4) (online)(1-7.

When Policy Produces Moral Distress: Reclaiming Conscience

Nancy Berlinger

Abstract
For too long, bioethics has followed law in reducing “conscience” to “conscientious objection,” in other words, to laws and policies permitting and protecting refusal. In “Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide,” Mara Buchbinder and colleagues draw our attention to one dimension of the problem of reducing conscience to refusal to provide certain forms of medical care: what about the conscience problems experienced by the professionals who are attempting to provide safe, effective health care that includes services that others associate with conscientious objection? In seeking to disrupt a specific medical practice – one that is legal, desired by the patient, and conducted in accordance with medical standards – North Carolina House Bill 854, The Women’s Right to Know Act, and laws like it, appear to be designed to produce moral distress in physicians and other professionals involved in the provision of abortions. For abortion providers in North Carolina and other states, conscientious objection to the mandates of laws like HB 854 isn’t a realistic option. So what can bioethics offer to professionals bound by such laws? We can start by reclaiming the idea of “conscience” as something that can say “yes” to providing health care.

Berlinger, N. (2016), When Policy Produces Moral Distress: Reclaiming Conscience. Hastings Center Report, 46: 32–34. doi: 10.1002/hast.547

Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide

Mara Buchbinder, Dragana Lassiter, Rebecca Mercier, Amy Bryant, Anne Drapkin Lyerly

Abstract
“It’s almost like putting salt in a wound, for this person who’s already made a very difficult decision,” suggested Meghan Patterson (an alias), a licensed obstetrician-gynecologist whom we interviewed in our qualitative study of the experiences of North Carolina abortion providers practicing under the state’s Woman’s Right to Know Act (House Bill 854; 2011). The act requires that women receive counseling with state-mandated information at least twenty-four hours prior to obtaining an abortion. After the law was passed, Patterson worked with clinic administrators, in consultation with a lawyer, to write a script to be used in the state-mandated counseling procedure. She and her colleagues took particular steps to mitigate the effects of what she described as HB 854’s “forced language” – such as referring to the “father of the child.” While HB 854 stipulated that patients must be informed of the medical risks associated with the particular abortion procedure as well as those of carrying the child to term, Patterson’s script made explicit the magnitude of comparative risks, emphasizing that the risks of carrying a pregnancy to term are substantially greater than the risks of an early-term abortion. She felt that these contextualization strategies helped to facilitate trust and rapport in a clinical care situation that proved relationally and morally challenging.

In this article, we take up and expand on this point by elucidating an empirically grounded approach to ethically justified care when health care providers face legal or institutional policy mandates that raise possible moral conflicts. Our approach builds on recent bioethics discourse addressing conscience in the practice of medicine. While the concept of conscience has broad philosophical underpinnings relating to moral judgment, agency, and discernments of right and wrong, debates in bioethics have tended to engage the concept primarily vis-à-vis rights of conscientious objection or refusal. Here, we suggest a broader frame for thinking about claims of conscience in health care. Our approach draws on the feminist bioethics and the ethics of care literatures to highlight how providers may be motivated by matters of conscience, including relational concerns, in the active provision of certain forms of care. What emerges are two possibilities: not only conscientious refusal to comply with a policy mandate but also conscientious compliance – working conscientiously within a mandate’s confines.

Buchbinder, M., Lassiter, D., Mercier, R., Bryant, A. and Lyerly, A. D. (2016), Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide. Hast Cent Rep , 46: 22–30. doi: 10.1002/hast.545