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Conscientious objection and the Council of Europe: The right to conscientious objection in lawful medical care. Resolution 1763 (2010)

Resolution adopted by the Council of Europe’s Parliamentary Assembly

Mark Campbell

Journal Extract
The Council of Europe’s Parliamentary Assembly has adopted a resolution on conscientious objection in medicine, ‘The Right to Conscientious Objection in Lawful Medical Care’.¹ In general terms, this resolution (‘the Resolution’) affirms the place of conscientious objection in the medical context while inviting member states to provide appropriate regulation of the practice of conscientious objection. In particular, it provides the following: first, there is a recognition that ‘[n]o person, hospital or institution shall be coerced, held liable or discriminated against in any manner because of a refusal to perform, accommodate, assist or submit to an abortion, the performance of a human miscarriage, or euthanasia or any act which could cause the death of a human foetus or embryo, for any reason’.² Secondly, the right of conscientious objection is affirmed together with the state’s responsibility ‘to ensure that patients are able to access lawful medical care in a timely manner’.³ Thirdly, it is acknowledged that ‘[i]n the vast majority of Council of Europe member states, the practice of conscientious objection is adequately regulated’.⁴ Fourthly, the Resolution invites member states ‘to develop comprehensive and clear regulations that define and regulate conscientious objection with regard to health and medical services’.⁵ Given that the Resolution sets out broad principles in this area and is not binding on member states—the Parliamentary Assembly has the role of a consultative body within the Council of Europe that seeks through its adopted texts to influence legislation and practice at a domestic level—the purpose of this short article is not to provide a line-by-line analysis of the text. It is rather to ‘read between the lines’ of the Resolution by examining its background and significance.

Campbell M. Conscientious objection and the Council of Europe: The right to conscientious objection in lawful medical care. Resolution 1763 (2010). Resolution adopted by the Council of Europe’s Parliamentary Assembly. Med Law Rev. 2011 Summer;19(3):467-475.

Conscientious Objection

Giles Cattermole

Extract
Beware of arguments that appear to accept that CO is just about our ‘personal values’; it isn’t. Beware of relying on our fallen consciences rather than on God’s Word. Beware of resorting to the safety of guidelines and laws which may be changed. By God’s grace, we have the right to CO made explicit in our professional guidance, given concrete examples in the law, supported by a European assembly. We can argue from history or personal example in favour of it. But in the end, we need to be prepared to stand for Christ, and the experience of those before us suggests that this will be costly.

Cattermole G. Conscientious Objection. Nucleus. 2011 Summer; 24-27.

Obstetrician–gynecologists’ beliefs about safe-sex and abstinence counseling

RE Lawrence, Kenneth A Rasinski, John D Yoon, Farr A Curlin

International Journal of Gynecology & Obstetrics

Abstract
Objective
To examine obstetrician–gynecologists’ beliefs about safe-sex and abstinence counseling.

Methods
Between October 2008 and January 2009, a survey was mailed to a national randomized sample of 1800 practicing US obstetrician–gynecologists. Study variables were agreement with 2 statements. (1) “If physicians counsel patients about safe-sex practices, the patients will be less likely to engage in risky sexual behaviors”. (2) “If physicians counsel patients about abstinence, the patients will be much less likely to engage in sexual activity”. Covariates included demographic, clinical, and religious characteristics of the physician.

Results
The response rate was 66% (1154/1760 eligible physicians). Most respondents somewhat (62%) or strongly (25%) agreed that counseling patients about safe-sex practices makes patients less likely to engage in risky sexual behaviors. Fewer agreed strongly (3%) or somewhat (28%) that counseling patients about abstinence makes patients less likely to engage in sexual activity. The belief that safe-sex counseling reduces risky behaviors was less common among males (odds ratio [OR] 0.6) and more common among immigrants (OR 2.0). Religious physicians were more likely to believe that abstinence counseling reduces sexual activity (OR 2.2–5.3).

Conclusions
Most obstetrician–gynecologists believed that counseling about safe sex is effective, and a significant minority endorsed abstinence counseling.

Lawrence RE, Rasinski KA, Yoon JD, Curlin FA. Obstetrician–gynecologists’ beliefs about safe-sex and abstinence counseling. Int J Gyn Obst 2011; 114(3):281-285.

Obstetrician-gynecologists’ opinions about conscientious refusal of a request for abortion: results from a national vignette experiment

Kenneth A Rasinski, John D Yoon, Youssef G Kalad, Farr A Curlin

Abstract
Background and objectives: Conscientious refusal of abortion has been discussed widely by medical ethicists but little information on practitioners’ opinions exists. The American College of Obstetricians and Gynecologists (ACOG) issued recommendations about conscientious refusal. We used a vignette experiment to examine obstetrician-gynecologists’ (OB/GYN) support for the recommendations.

Design: A national survey of OB/GYN physicians contained a vignette experiment in which an OB/GYN doctor refused a requested elective abortion. The vignette varied two issues recently addressed by the ACOG ethics committee–whether the doctor referred and whether the doctor disclosed their objection to the abortion.

Participants and setting: 1800 OB/GYN randomly selected physicians were asked to complete a mail survey containing the vignette. The response rate was 66% (n=1154) after excluding 40 ineligible cases.

Measurement: Physicians indicated their approval for the vignette doctor’s decision.

Main results: Overall, 43% of OB/GYN physicians responded that the conscientious refusal exercised by the vignette physician was appropriate. 70% rated the vignette doctor as acting appropriately when a referral was made. This dropped to 51% when the doctor disclosed objections to the patient, and to 12% when the doctor disclosed objections and refused to make a referral. Consistent with previous research, males were more likely to support disclosure and refusal to refer. Highly religious physicians supported non-referral but not disclosure.

Conclusion: OB/GYN physicians are less likely to support conscientious refusal of abortion if physicians disclose their objections to patients. This is at odds with ACOG recommendations and with some models of the doctor-patient relationship.

Rasinski KA, Yoon JD, Kalad YG, Curlin FA. Obstetrician-gynecologists’ opinions about conscientious refusal of a request for abortion: results from a national vignette experiment. J Med Ethics. 2011;37(12):711-714.

(White Paper) Emergency Contraceptives & Catholic Healthcare: A New Look at the Science and the Moral Question

Thomas V Berg, Marie T Hilliard, Mark F Stegman

Emergency Contraceptives & Catholic Healthcare, Westchester Institute

Conclusion
Concern that provision of emergency contraceptives might occasion the chemical abortion of nascent human life is not only legitimate, but also a genuine expression of the solidarity and stewardship we owe to the most vulnerable members of our society. Catholic moral theologians currently disagree on how that legitimate concern should bear on the formulation of EC protocols in Catholic hospitals. We maintain that, in addition to a pregnancy test, victims of sexual assault should be administered an ovulation test which detects the presence of an LH surge. We sincerely hope that the present study will contribute to the continued substantive discussion of this issue among Catholic moralists. We further trust that it will serve to foster a more cautious approach within the Catholic healthcare establishment to unreasonable incursions by the state that strike at our principled institutional autonomy and identity, and at the very exercise of conscience in Catholic healthcare

Berg TV, Hilliard MT, Stegman MF. (Working Paper) Emergency Contraceptives & Catholic Healthcare: A New Look at the Science and the Moral Question. 2011;2(1)

In Search of a Wide-Angle Lens

Harold Braswell

Extract
That bioethicists had written hundreds of thousands of pages on “autonomy” without writing one article about its relation to subcontracting seemed, by the end of class, an indication that the field had misunderstood its own premises. The goal of bioethics in the next forty years should be to guarantee that such fundamental misunderstandings do not occur. This will happen by stopping the search for new topics and instead becoming more reflective about our methods and more proactive in building institutions that can produce thinkers with the sensitivity and analytical skills to realize the field’s founding ideals. Doing so will require redefining the contours of not only the field, but also our own identity as professionals.

Braswell H. In Search of a Wide-Angle Lens. Hastings Center Report. 2011;3(June):19-21.

Triangular reflective equilibrium: A conscience-based method for bioethical deliberation

Y Michael Barilan, Margherita Brusa

Abstract
Following a discussion of some historical roots of conscience, we offer a systematized version of reflective equilibrium. Aiming at a comprehensive methodology for bioethical deliberation, we develop an expanded variant of reflective equilibrium, which we call ‘triangular reflective equilibrium’ and which incorporates insights from hermeneutics, critical theory and narrative ethics. We focus on a few distinctions, mainly between methods of justification in ethics and the social practice of bioethical deliberation, between coherence in ethical reasoning, personal integrity and consensus formation, and between political and moral deliberation. The ideal of deliberation is explicated as a sharing of conscience within a special commitment to sincerity and openness to persuasion. Personal growth in wisdom is an indirect by-product of the continuous practice of moral deliberation. This is explicated in the light of Sternberg’s balance theory of wisdom and in the context of medicine as a profession embodying altruistic responsibilities of care in democratic and pluralistic societies.

Barilan YM, Brusa M. Triangular reflective equilibrium: A conscience-based method for bioethical deliberation. Bioethics. 2011;25(6):304-319.

Process and Outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey

Yanna Van Wesemael, Joachim Cohen, Johan Bilsen, Tinne Smets, Bregje D Onwuteaka-Philipsen, Luc Deliens

Abstract
Context: Since 2002, the administration of a lethal drug by a physician at the explicit request of the patient has been legal in Belgium. The incidence of euthanasia in Belgium has been studied, but the process and outcomes of euthanasia requests have not been investigated.

Objectives: To describe which euthanasia requests were granted, withdrawn, and rejected since the enactment of the euthanasia law in terms of the characteristics of the patient, treating physician, and aspects of the consultation with a second physician.

Methods: A representative sample of 3006 Belgian physicians received a questionnaire investigating their most recent euthanasia request.

Results: The response rate was 34%. Since 2002, 39% of respondents had received a euthanasia request. Forty-eight percent of requests had been carried out, 5% had been refused, 10% had been withdrawn, and in 23%, the patient had died before euthanasia could be performed. Physicians’ characteristics associated with receiving a request were not being religious, caring for a high number of terminally ill patients, and having experience in palliative care. Patient characteristics associated with granting a request were age, having cancer, loss of dignity, having no depression, and suffering without prospect of improvement as a reason for requesting euthanasia. A positive initial position toward the request from the attending physician and positive advice from the second physician also contributed to having a request granted.

Conclusion: Under the Belgian Act on Euthanasia, about half of the requests are granted. Factors related to the reason for the request, position of the attending physician toward the request, and advice from the second physician influence whether a request is granted or not.

Wesemael YV, Cohen J, Bilsen J, Smets T, Onwuteaka-Philipsen BD, Deliens L. Process and outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey. J Pain Symptom Manage. 2011 May 16;42(5):721-733.

Would Accommodating Some Conscientious Objections by Physicians Promote Quality in Medical Care?

Douglas B White, Baruch Brody

Journal of the American Medical Association

Abstract
Conclusion
The notion that protecting physicians’ consciences benefits physicians at the expense of patients has created an overly simplistic dialogue about conscience in medicine. Viewing the issue from a societal perspective and conceptualizing medical quality as a public good allow a more robust understanding of the relationship between CBR and quality medical care. Policies that allow some CBRs while also ensuring patients’ access to the requested services may yield better overall medical quality by fostering a diverse workforce that possesses integrity, sensitivity to patients’ needs, and respect for diversity. This analysis is necessary for a genuine public discussion about how to handle moral pluralism among patients and physicians. The societal perspective should be incorporated into efforts to develop a comprehensive framework for when CBRs should and should not be accommodated.

White DB, Brody B. Would Accommodating Some Conscientious Objections by Physicians Promote Quality in Medical Care?. J Am Med Ass. 2011 May 4;305(17):1804-1805.

Conscientious commitment to women’s health

Bernard M Dickens, Rebecca J Cook

Abstract
Conscientious commitment, the reverse of conscientious objection, inspires healthcare providers to overcome barriers to delivery of reproductive services to protect and advance women’s health. History shows social reformers experiencing religious condemnation and imprisonment for promoting means of birth control, until access became popularly accepted. Voluntary sterilization generally followed this pattern to acceptance, but overcoming resistance to voluntary abortion calls for courage and remains challenging. The challenge is aggravated by religious doctrines that view treatment of ectopic pregnancy, spontaneous abortion, and emergency contraception not by reference to women’s healthcare needs, but through the lens of abortion. However, modern legal systems increasingly reject this myopic approach. Providers’ conscientious commitment is to deliver treatments directed to women’s healthcare needs, giving priority to patient care over adherence to conservative religious doctrines or religious self-interest. The development of in vitro fertilization to address childlessness further illustrates the inspiration of conscientious commitment over conservative objections.

Dickens BM, Cook RJ. Conscientious commitment to women’s health. Int J Gyn Ob. 2011;113(2):163-166.