Ethics Archives - Page 12 of 81 - Protection of Conscience Project Library

Tolerance, Professional Judgment, and the Discretionary Space of the Physician

Daneil P. Sulmasy

Cambridge Quarterly of Healthcare Ethics

Abstract
Arguments against physicians’ claims of a right to refuse to provide tests or treatments to patients based on conscientious objection often depend on two premises that are rarely made explicit. The first is that the protection of religious liberty (broadly construed) should be limited to freedom of worship, assembly, and belief. The second is that because professions are licensed by the state, any citizen who practices a licensed profession is required to provide all the goods and services determined by the profession to fall within the scope of practice of that professional specialty and permitted by the state, regardless of any personal religious, philosophical, or moral objection. In this article, I argue that these premises ought to be rejected, and therefore the arguments that depend on them ought also to be rejected. The first premise is incompatible with Locke’s conception of tolerance, which recognizes that fundamental, self-identifying beliefs affect public as well as private acts and deserve a broad measure of tolerance. The second premise unduly (and unrealistically) narrows the discretionary space of professional practice to an extent that undermines the contributions professions ought to be permitted to make to the common good. Tolerance for conscientious objection in the public sphere of professional practice should not be unlimited, however, and the article proposes several commonsense, Lockean limits to tolerance for physician claims of conscientious objection.

Sulmasy DP. Tolerance, Professional Judgment, and the Discretionary Space of the Physician. Camb Q Healthc Ethics. 2017 Jan;26(1):18-31.

Conscientious non-objection in intensive care

Dominic Wilkinson

Abstract
Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

Wilkinson D. Conscientious non-objection in intensive care. Camb. Q. Healthc. Ethics. 2017;26(1):132-142.

How to Allow Conscientious Objection in Medicine While Protecting Patient Rights

Aaron Ancell, Walter Sinnott-Armstrong

Abstract
Paradigmatic cases of conscientious objection in medicine are those in which a physician refuses to provide a medical service or good because doing so would conflict with that physician’s personal moral or religious beliefs. Should such refusals be allowed in medicine? We argue that (1) many conscientious objections to providing certain services must be allowed because they fall within the range of freedom that physicians have to determine which services to offer in their practices; (2) at least some conscientious objections to serving particular groups of patients should be allowed because they are not invidiously discriminatory; and (3) even in cases of invidiously discriminatory conscientious objections, legally prohibiting individual physicians from refusing to serve patients on the basis of such objections is not always the best solution.

Ancell A, Sinnott-Armstrong W. How to Allow Conscientious Objection in Medicine While Protecting Patient Rights. Camb Q Healthc Ethics. 2017 Jan;26(1):120-131.

The cost of conscience: Kant on Conscience and Conscientious Objection

Jeanette Kennett

Abstract
The spread of demands by physicians and allied health professionals for accommodation of their private ethical, usually religiously based, objections to providing care of a particular type, or to a particular class of persons, suggests the need for a re-evaluation of conscientious objection in healthcare and how it should be regulated. I argue on Kantian grounds that respect for conscience and protection of freedom of conscience is consistent with fairly stringent limitations and regulations governing refusal of service in healthcare settings. Respect for conscience does not entail that refusal of service should be cost free to the objector. I suggest that conscientious objection in medicine should be conceptualized and treated analogously to civil disobedience.

Kennett J. The cost of conscience: Kant on Conscience and Conscientious Objection. Cam Quart Healthcare Ethics 2017 Jan;26(1):69-81.

The Legal Ethical Backbone of Conscientious Refusal

Christian Munthe, Morten Ebbe Juul Nielsen

Abstract
This article analyzes the idea of a legal right to conscientious refusal for healthcare professionals from a basic legal ethical standpoint, using refusal to perform tasks related to legal abortion (in cases of voluntary employment) as a case in point. The idea of a legal right to conscientious refusal is distinguished from ideas regarding moral rights or reasons related to conscientious refusal, and none of the latter are found to support the notion of a legal right. Reasons for allowing some sort of room for conscientious refusal for healthcare professionals based on the importance of cultural identity and the fostering of a critical atmosphere might provide some support, if no countervailing factors apply. One such factor is that a legal right to healthcare professionals’ conscientious refusal must comply with basic legal ethical tenets regarding the rule of law and equal treatment, and this requirement is found to create serious problems for those wishing to defend the idea under consideration. We conclude that the notion of a legal right to conscientious refusal for any profession is either fundamentally incompatible with elementary legal ethical requirements, or implausible because it undermines the functioning of a related professional sector (healthcare) or even of society as a whole.

Munthe C, Nielsen MEJ. The Legal Ethical Backbone of Conscientious Refusal. Cambridge Quarterly of Healthcare Ethics. Cambridge Quarterly of Healthcare Ethics. 2017 Jan; 26(1): 59-68. doi:10.1017/S0963180116000645

The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine

Robert F. Card

Abstract
This article first critically reviews the major philosophical positions in the literature on conscientious objection and finds that they possess significant flaws. A substantial number of these problems stem from the fact that these views fail to assess the reasons offered by medical professionals in support of their objections. This observation is used to motivate the reasonability view, one part of which states: A practitioner who lodges a conscientious refusal must publicly state his or her objection as well as the reasoned basis for the objection and have these subjected to critical evaluation before a conscientious exemption can be granted (the reason-giving requirement). It is then argued that when defenders of the other philosophical views attempt to avoid granting an accommodation to spurious objections based on discrimination, empirically mistaken beliefs, or other unjustified biases, they are implicitly committed to the reason-giving requirement. This article concludes that based on these considerations, a reason-giving position such as the reasonability view possesses a decisive advantage in this debate.

Card RF. The Inevitability of Assessing Reasons in Debates about Conscientious Objection in Medicine. Cambridge Quarterly of Healthcare Ethics. 2017 Jan; 26(1): 82-96. DOI: https://doi.org/10.1017/S0963180116000669.

Objection to conscience. An argument against conscience exemptions in healthcare

Alberto Giubilini

Abstract
I argue that appeals to conscience do not constitute reasons for granting healthcare professionals exemptions from providing services they consider immoral (e.g. abortion). My argument is based on a comparison between a type of objection that many people think should be granted, i.e. to abortion, and one that most people think should not be granted, i.e. to antibiotics. I argue that there is no principled reason in favour of conscientious objection qua conscientious that allows to treat these two cases differently. Therefore, I conclude that there is no principled reason for granting conscientious objection qua conscientious in healthcare. What matters for the purpose of justifying exemptions is not whether an objection is ‘conscientious’, but whether it is based on the principles and values informing the profession. I provide examples of acceptable forms of objection in healthcare.

Giubilini A. Objection to conscience. An argument against conscience exemptions in healthcare. Bioethics. 2016;31(5):400-408.

Conscience and Agent-Integrity: A Defence of Conscience-Based Exemptions in the Health Care Context

Mary Neal, Sara Fovargue

Abstract
The issue of conscientious refusal by health care practitioners continues to attract attention from academics, and was the subject of a recent UK Supreme Court decision. Activism aimed at changing abortion law and the decision to devolve governance of abortion law to the Scottish Parliament both raise the prospect of altered provision for conscience in domestic law. In this article, building on earlier work, we argue that conscience is fundamentally connected to moral integrity and essential to the proper functioning of moral agency. We examine recent attempts to undermine the view of conscience as a matter of integrity and argue that these have been unsuccessful. With our view of conscience as a prerequisite for moral integrity and agency established and defended, we then take issue with the ‘incompatibility thesis’ (the claim that protection for conscience is incompatible with the professional obligations of health care practitioners). We reject each of the alternative premises on which the incompatibility thesis might rest, and challenge the assumption of a public/private divide which is entailed by all versions of the thesis. Finally, we raise concerns about the apparent blindness of the thesis to issues of power and privilege, and conclude that conscience merits robust protection.

Neal M, Fovargue S. Conscience and Agent-Integrity: A Defence of Conscience-Based Exemptions in the Health Care Context. Med Law Rev. 2016 Nov 1;24(4):544-570. doi: 10.1093/medlaw/fww023

Patient’s Autonomy, Physician’s Convictions and Euthanasia in Belgium

Raphael Cohen-Almagor

Abstract
The aim of this paper is to show the inherent contradiction in the Belgian euthanasia practice. While stressing patient’s autonomy, medical professionals exhibit paternalism in deciding the patient’s fate. First, background information is provided. Then the 2014 Belgian Society of Intensive Care Medicine Council Statement Paper will be considered. Concerns are voiced about euthanizing people who fail to find meaning in their lives, including those who underwent unsuccessful sex-change operation and blind people, euthanizing patients who did not give their consent, and euthanizing people with dementia. Finally, some suggestions designed to improve the situation are offered.

Cohen-Almagor R. Patient’s Autonomy, Physician’s Convictions and Euthanasia in Belgium. Annual Rev Law Ethics. 2016 Dec;24:343-356.

Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community

Joan Liaschenko, Elizabeth Peter

Abstract:
It may be the case that the most challenging moral problem of the twenty-first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker’s and Hilde Lindemann’s concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one’s identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing’s morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency.

Liaschenko J, Peter E. Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community. The Hastings Center Report, Volume 46, Issue S1, September/October 2016, Pages S18–S21.