Ethics Archives - Page 17 of 81 - Protection of Conscience Project Library

Your morality, my mortality: conscientious objection and the standard of care

Ben A. Rich

Abstract
Recently the scope of protections afforded those healthcare professionals and institutions that refuse to provide certain interventions on the grounds of conscience have expanded, in some instances insulating providers (institutional and individual) from any liability or sanction for harms that patients experience as a result. With the exponential increase in the penetration of Catholic-affiliated healthcare across the country, physicians and nurses who are not practicing Catholics are nevertheless required to execute documents pledging to conform their patient care to the Ethical and Religious Directives for Health Care Services as a condition of employment or medical staff privileges. In some instances, doing so may result in patient morbidity or mortality or violate professional standards for respecting advance directives or surrogate decisionmaking. This article challenges the ethical propriety of such institutional mandates and argues that legal protections for conscientious refusal must provide redress for patients who are harmed by care that falls below the prevailing clinical standards.

Rich, B. (2015). Your Morality, My Mortality: Conscientious Objection and the Standard of Care. Cambridge Quarterly of Healthcare Ethics,24(2), 214-230. doi:10.1017/S0963180114000528

Opinions on conscientious objection to induced abortion among Finnish medical and nursing students and professionals

Petteri Nieminen, Saara Lappalainen, Pauliina Ristimäki, Markku Myllykangas, Anne-Mari Mustonen

Abstract
Conscientious objection (CO) to participating in induced abortion is not present in the Finnish health care system or legislation unlike in many other European countries.

Methods: We conducted a questionnaire survey with the 1st- and the last-year medical and nursing students and professionals (548 respondents; response rate 66-100%) including several aspects of the abortion process and their relation to CO in 2013.

Results: The male medical respondents chose later time points of pregnancy than the nursing respondents when considering when the embryo/fetus ‘becomes a person’. Of all respondents, 3.5-14.1% expressed a personal wish to CO.

The medical professionals supported the right to CO more often (34.2%) than the nursing professionals (21.4%), while ≥62.4% could work with someone expressing CO. Yet ≥57.9% of the respondents anticipated social problems at work communities caused by CO.

Most respondents considered self-reported religious/ethical conviction to be adequate for CO but, at the same time, 30.1-50.7% considered that no conviction would be sufficient. The respondents most commonly included the medical doctor conducting surgical or medical abortion to be eligible to CO.

The nursing respondents considered that vacuum suction would be a better justification for CO than medical abortion. The indications most commonly included to potential CO were second-trimester abortions and social reasons.

Among the medical respondents, the men were more willing to grant CO also in case of a life-threatening emergency of the pregnant woman.

Conclusions: While the respondents mostly seemed to consider the continuation of adequate services important if CO is introduced, the viewpoint was often focused on the staff and surgical abortion procedure instead of the patients. The issue proved to be complex, which should be taken into consideration for legislation.

Nieminen P, Lappalainen S, Ristimäki P, Myllykangas M, Mustonen A-M. Opinions on conscientious objection to induced abortion among Finnish medical and nursing students and professionals. BMC Medical Ethics 2015, 16:17 doi:10.1186/s12910-015-0012-1

A relational view of conscience and physician conscientious action

Françoise Baylis

Abstract
The dominant approach to conscience in contemporary bioethics presumes that conscience functions to promote personal moral integrity, and therefore presumes that the relevant values are inherently personal. This approach fails to demonstrate when and why claims of conscience should be taken seriously by others. I draw on Hannah Arendt’s deliberative model of conscience and Cheshire Calhoun’s social model of integrity to develop an alternative relational view of conscience – one that demonstrates that the relevant values are social as well as personal. I show how the goal of improving ethical practice over time constrains which conscience claims should be taken seriously by others.

Baylis F. A relational view of conscience and physician conscientious action. International Journal of Feminist Approaches to Bioethics. 2015;8(1):18-36.

Physicians can justifiably euthanize certain severely impaired neonates

Udo Schuklenk

Journal of Thoracic and Cardiovascular Surgery

Extract
Once we have concluded that death is what is in the best interest of an infant, it is unreasonable not to bring about this death as painlessly and as much controlled in terms of timing by the parents as is feasible.

Schuklenk U. Physicians can justifiably euthanize certain severely impaired neonates. J Thorac Cardiovasc Surg. 2015 Feb;149(2):535-537.

Ethical Issues Experienced by Hospice and Palliative Nurses

Jooyoung Cheon, Nessa Coyle, Debra L. Wiegand, Sally Welsh

Abstract
Nurses encounter ethical dilemmas in their clinical practice especially those associated with palliative and end-of-life care. The Hospice and Palliative Nurses Association (HPNA) members were asked to participate in an ethics survey. The survey aimed to identify ethical issues experienced by hospice and palliative nurses, identify resources available to them and barriers if any to their use, and to identify how HPNA can be of support to hospice and palliative nurses.

One hundred twenty-nine (n = 129) HPNA members completed the online survey. The information from each of the surveys was carefully reviewed, and responses were collapsed into 6 themes.

The ethical dilemmas included inadequate communication, provision of nonbeneficial care, patient autonomy usurped/threatened, issues with symptom management and the use of opioids, issues related to decision making, and issues related to discontinuing life-prolonging therapies.

Approximately two-thirds of the nurses used resources in an attempt to resolve the ethical issues, including a formal ethics consultation, involvement of the palliative/hospice team, consulting with other professionals, and use of educational resources.

One-third of the nurses said there were institutional or personal barriers that prevented the ethical dilemma from being resolved. Participants suggested ways that HPNA could help them to effectively manage ethical dilemmas.

Cheon J, Coyle N, Wiegand DL, Welsh S. Ethical Issues Experienced by Hospice and Palliative Nurses. J Hospice and Palliative Nursing. 2015;17(1):7-13.

Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living?

Eva Elizabeth Bolt, Marianne C Snijdewind, Dick L Willems, Agnes van der Heide, Bregje D Onwuteaka-Philipsen

Abstract
Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases.

Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists.

Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS.

Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.

Bolt EE, Snijdewind MC, Willems DL, van der Heide A, Onwuteaka-Philipsen BD. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics doi:10.1136/medethics-2014-102150

Why physicians ought not to perform virginity tests

Kevin Gary Behrens

Abstract
In this article I argue that it is not morally justified for physicians to perform virginity tests. First, I contend that, on the basis of the principle of non-maleficence, physicians should not perform virginity tests, because of the potential harms to those who are tested that can result from such tests. Second, I highlight some of the social harms that the practice causes, and argue that physicians ought not to be complicit in causing these harms. Third, I argue that physicians ought not to perform virginity tests on the grounds that testing for virginity is scientifically impossible, and physicians are morally obliged to practise according to scientific principles. Finally, I contend that an ethically sound response to virginity testing requires that the medical profession as a whole should follow the example of the Quebec College of Physicians in declaring this practice by physicians as unethical.

Behrens KG. Why physicians ought not to perform virginity tests. J Med Ethics doi:10.1136/medethics-2014-102344

An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine

Mithya Lewis-Newby, Mark R Wicclair, Thaddeus Mason Pope, Cynda Rushton, Farr A Curlin, Douglas Diekema, Debbie Durrer, William Ehlenbach, Wanda Gibson-Scipio, Bradford Glavan, Rabbi Levi Langer, Constantine Manthous, Cecile Rose, Anthony Scardella, Hasan Shanawani, Mark D Siegel, Scott D. Halpern, Robert D Truog, Douglas B White

American Journal of Respiratory and Critical Care Medicine

Abstract
Rationale: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs.

Objectives: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting.

Methods: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law.

Main Results: The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield ” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting.

Conclusions: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians’ COs in the critical care setting.

Lewis-Newby M, Wicclair MR, Pope TM, Rushton C, Curlin FA, Diekema D et al.. An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med. 2015;191(2):219-227.

Political Justification through Democratic Participation: The Case for Conscientious Objection

Emanuela Ceva

Abstract
On a proceduralist account of democracy, collective decisions derive their justification-at least in part-from the qualities of the process through which they have been made. To fulfill its justificatory function, this process should ensure that citizens have an equal right to political participation as a respectful response to their equal status as agents capable of self-legislation. How should democratic participation be understood if it is to offer such a procedural justification for democratic decisions? I suggest that, in order to overcome the structural procedural disadvantages affecting the actual, effective opportunities that citizens who hold nonmainstream views have to exercise their right to political participation, the enhancement of such opportunities requires securing space for contestation. Against this background, I vindicate the (currently underestimated) role of conscientious objection as a form of political participation.

Ceva E. Political Justification through Democratic Participation: The Case for Conscientious Objection. Social Theory and Practice. 2015 Jan;41(1):26-50

Medical ethics and more: ideal theories, non-ideal theories and conscientious objection

Florencia Luna

Abstract
Doing ‘good medical ethics’ requires acknowledgment that it is often practised in non-ideal circumstances! In this article I present the distinction between ideal theory (IT) and non-ideal theory (NIT). I show how IT may not be the best solution to tackle problems in non-ideal contexts. I sketch a NIT framework as a useful tool for bioethics and medical ethics and explain how NITs can contribute to policy design in non-ideal circumstances. Different NITs can coexist and be evaluated vis-à-vis the IT. Additionally, I address what an individual doctor ought to do in this non-ideal context with the view that knowledge of NITs can facilitate the decision-making process. NITs help conceptualise problems faced in the context of non-compliance and scarcity in a better and more realistic way. Deciding which policy is optimal in such contexts may influence physicians’ decisions regarding their patients. Thus, this analysis-usually identified only with policy making-may also be relevant to medical ethics. Finally, I recognise that this is merely a first step in an unexplored but fundamental theoretical area and that more work needs to be done.

Luna F. Medical ethics and more: ideal theories, non-ideal theories and conscientious objection. J Med Ethics. 2015 Jan;41(1):129-33. doi: 10.1136/medethics-2014-102295. PMID: 25516954.