Journal’s Extract Discussions of appeals to conscience by healthcare professionals typically focus on situations in which they object to providing a legal and professionally permitted service, such as abortion, sterilization, prescribing or dispensing emergency contraception, and organ retrieval pursuant to donation after cardiac death. “Negative claims of conscience” will designate such appeals to conscience. When healthcare professionals advance a negative claim of conscience, they do so to secure an exemption from ethical, professional, institutional, and/or legal obligations or requirements to provide a healthcare service.
Abstract The influence of conscience on nurses in terms of guilt has frequently been described but its impact on care has received less attention. The aim of this study was to describe nurses’ conceptions of the influence of conscience on the provision of inpatient care. The study employed a phenomenographic approach and analysis method. Fifteen nurses from three hospitals in western Sweden were interviewed. The results showed that these nurses considered conscience to be an important factor in the exercise of their profession, as revealed by the descriptive categories: conscience as a driving force; con- science as a restricting factor; and conscience as a source of sensitivity. They perceived that conscience played a role in nursing actions involving patients and next of kin, and was an asset that guided them in their efforts to provide high quality care.
Extract It is doubtful that moral distress can ever be eradicated from healthcare settings. As increasing evidence accumulates to support the damaging effects associated with this phenomenon over time, however, interventions to decrease moral distress and moral residue become more urgently -needed. The crescendo effect model focuses attention on moral distress and moral residue and the relationships between them. . . . Both providers and healthcare systems need to acknowledge the repetitive nature of morally distressing events, such as prolonged aggressive treatment at the EOL, that occur in clinical settings. The crescendo effect highlights the crushing blow to professional integrity that nurses, physicians, and other disciplines have to manage on a daily basis in settings where moral distress goes unrecognized and unaddressed. It is not appropriate to expect highly skilled, dedicated, and caring healthcare professionals to be repeatedly exposed to morally distressing situations when they have little power to change the system and little acknowledgment of these experiences as personally damaging or career compromising. As evidence for the crescendo effect and its consequences accumulates, healthcare professionals, insurers, patients, and healthcare systems must not assume that damaged moral integrity is an acceptable, natural consequence that must be borne by healthcare providers.
Abstract Antibiotic resistance menaces the population as a dire public health threat and costly social problem. Recent proposals to combat antibiotic resistance focus to a large degree on supply side approaches. Suggestions include tinkering with patent rights so that pharmaceutical companies have greater incentives to discover novel antibiotics as well as to resist overselling their newer drugs already on market. This Article argues that a primarily supply side emphasis unfortunately detracts attention from physicians’ important demand side influences. Physicians have a vital and unavoidably necessary role to play in ensuring socially optimal access to antibiotics. Dismayingly, physicians’ management of the antibiotic supply has been poor and their defense of population health tepid at best. Acting as a prudent steward of the antibiotic supply often seems to be at odds with a physician’s commonly understood fiduciary duties, ethical obligations, and professional norms, all of which traditionally emphasize the individual health paradigm as opposed to population health responsibilities. Meanwhile, physicians face limited incentives for antibiotic conservation from other sources, such as malpractice liability, regulatory standards, and reimbursement systems. While multifaceted efforts are needed to combat antibiotic resistance effectively, physician gatekeeping behavior should become a priority area of focus. This Article considers how health law and policy tools could favorably change the incentives physicians face for antibiotic conservation. A clear lesson from the managed care reform battles of the recent past is that interventions, to have the best chance of success, need to respect physician interest in clinical autonomy and individualized medicine even if, somewhat paradoxically, vigorously promoting population health perspectives. Also, physicians’ legal and ethical obligations need to be reconceptualized in the antibiotic context in order to better support gatekeeping in defense of population health. The principal recommendation is for increased use of financial incentives to reward physicians for compliance with recommended guidelines on antibiotic prescribing. Although not a panacea, greater experimentation with financial incentives can provide a much needed jump-start to physician interest in antibiotic conservation and likely best address physicians’ legitimate clinical autonomy concerns.
Extract In formulating a response to the abortion issue, the nursing profession needs to be careful not to lose sight of its moral obligation to ensure that women receive the care they require. Nurses also need to be wary of the politicisation of conscience and the corrupting influence this can have on authentic debate about complex moral issues.
Holly Fernandez Lynch. Conflicts of Conscience in Health Care: An Institutional Compromise. Boston: The MIT Press, 2008. 368 pp. ISBN: 9780262123051
Extract Conflicts of Conscience in Health Care was published in 2008 as the 24th volume in the Basic Bioethics series from the Massachusetts Institute of Technology. It is an American book dealing with the American political and legal controversies over freedom of conscience in health care. However, the discussion of the American experience by Holly Fernandez Lynch is relevant elsewhere, since the United States has the most extensive and varied network of protection of conscience legislation in the world.
While acknowledging that freedom of conscience is of concern to all health care workers and institutions, Fernandez Lynch focuses exclusively on physicians. This carefully and deliberately restricted focus is one of the strengths of the book.
After a preface and introduction, discussion and argument occupy about 260 pages, supplemented by 53 pages of end notes, many of which offer expanded comment on the text. A good 12 page index has been included, as well as four pages of cited statutes and cases. The earliest source found in a list of 300 references is from 1951; the rest date from 1972 to 2007. . .
. . . . As the subtitle of the book indicates, she is seeking a compromise that will provide “maximal liberty for all parties.” She believes that freedom of conscience for physicians and the provision of legal medical services are both important social goals, and that they are not incompatible. Thus, she rejects “all-or-nothing” strategies that seek “total victory.” Ultimately, quoting the Protection of Conscience Project, she affirms that all legitimate concerns can be met by “dialogue, prudent planning, and the exercise of tolerance, imagination and political will.”
(Article compares approach to freedom of conscience in health care in the US and Canada) Extract Advocates of compulsory referral claim that doctors who discriminate against certain practices are, whether they know it or not, also discriminating against certain people — namely, the poor, the uneducated and those in remote areas. These people already have limited access to medical services, a problem that, all sides agree, is exacerbated when their doctors refuse to present them with all their options.
Abstract BACKGROUND: For over 30 years, pharmacists have exercised the right to dispense medications in accordance with moral convictions based upon a Judeo-Christian ethic. What many of these practitioners see as an apparent shift away from this time-honored ethic has resulted in a challenge to this right.
OBJECTIVE: To review and analyze pharmacy practice standards, legal proceedings, and ethical principles behind conflicts of conscientious objection in dispensing drugs used for emergency contraception.
DATA SOURCES: We first searched the terms conscience and clause and Plan B and contraception and abortion using Google, Yahoo, and Microsoft Networks (2006-September 26, 2008). Second, we used Medscape to search professional pharmacy and other medical journals, restricting our terms to conscience, Plan B, contraceptives, and abortifacients. Finally, we employed Loislaw, an online legal archiving service, and did a global search on the phrase conscience clause to determine the status of the legal discussion.
DATA SYNTHESIS: To date, conflicts in conscientious objection have arisen when a pharmacist believes that dispensing an oral contraceptive violates his or her moral understanding for the promotion of human life. Up to this time, cases in pharmacy have involved only practitioners from orthodox Christian faith communities, primarily devout Roman Catholics. A pharmacist’s right to refuse the dispensing of abortifacients for birth control according to moral conscience over against a woman’s right to reproductive birth control has created a conflict that has yet to be reconciled by licensing agents, professional standards, or courts of law.
CONCLUSIONS: Our analysis of prominent conflicts suggests that the underlying worldviews between factions make compromise improbable. Risks and liabilities are dependent upon compliance with evolving state laws, specific disclosure of a pharmacist’s moral objections, and professionalism in the handling of volatile situations. Objecting pharmacists and their employers should have clear policies and procedures in place to minimize workplace conflicts and maximize patient care.
Abstract This chapter explores the relationship between law and bioethics and calls for a careful evaluation of the law’s contributions to bioethics. It argues that while the law contributed extensively to the development of bioethics, it introduced a language and a way of thinking that are not necessarily appropriate to handle and resolve bioethical issues, and which, in a significant portion of cases, was irrelevant and had little impact on decision-making and behavioural patterns of patients.
Abstract Objective: The aim of this study was to focus on barriers, controversy and perceived risk associated with use of emergency contraception (EC) after unprotected sexual intercourse.
Design and method: Data were extracted from the literature of the MEDLINE database service. Original articles, surveys, clinical trials and investigations are considered for this review.
Results: After the introduction of over-the-counter and advance prescription provisions for easy access to EC, the rural–urban disparity in availability of EC poses a barrier to use of EC for rural dwellers. The socio-economically weaker section of the population is unable to purchase EC because of low or no income, although there is mounting pressure by the State for prevention of unintended pregnancy by use of EC. Some healthcare providers have objected to provide EC to the patient on the grounds of their conscience and morality. Some providers and users have also expressed concerns about the possibility of increase in irresponsible sexual behaviour because of easy access to EC. There may be some truth in their apprehension because nearly 3.2 million unintended pregnancies occur annually despite various contraceptive options available in USA and the extensive use of EC is directly proportional to the volume of unprotected sexual intercourse, which is too directly proportional to the quantum of risk for contacting sexually transmitted infections (STIs)/AIDS.
Conclusions: Emergency contraception is a one-off postcoital procedure and not to be opted after every sexual intercourse. Controversy about EC may be resolved if it is used within this limit. Extensive use of EC may increase risk for contacting STIs/AIDS.
