Ethics Archives - Page 38 of 81 - Protection of Conscience Project Library

Dispensing with conscience: A legal and ethical assessment

Jerome R Wernow, Donald G Grant

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.

Keywords:

Wernow JR, Grant DG. Dispensing with conscience: A legal and ethical assessment. Ann. Pharmacother. 2008;42(11):1669-1678. Available from:

Law and Bioethics: A Rights-Based Relationship and Its Troubling Implications

Daniel Sperling

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.

Sperling D. Law and Bioethics: A Rights-Based Relationship and Its Troubling Implications. In: Freeman M, editor. Law and Bioethics: Current Legal Issues. Oxford: Oxford University Press2008 Oct. p. 52-78.

Barriers to emergency contraception (EC): Does promoting EC increase risk for contacting sexually transmitted infections, HIV/AIDS?

NN Sarkar

International Journal of Clinical Practice

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.

Sarkar NN. Barriers to emergency contraception (EC): Does promoting EC increase risk for contacting sexually transmitted infections, HIV/AIDS? Int J Clin Pract. 2008 Oct 15;62(11):1769-1775.

Toxic Tinkering – Lethal Injection Execution and the Constitution

George J Annas

New England Journal of Medicine, NEJM — New England Journal of Medicine

Extract
Physicians should not lend their medical expertise to the state to make executions more palatable to the public, even by advising on drug protocols, doses, and routes of administration. Even physicians who support the death penalty should stay out of its execution, because the problem that the state seeks to solve by using physicians is one of the state’s own making by its refusal to abolish capital punishment and its insistence on execution by lethal injection.

Annas GJ. Toxic Tinkering – Lethal Injection Execution and the Constitution. N Engl J Med. 2008;359(14):1512-1518.

Adjudicating rights or analyzing interests: ethicists’ role in the debate over conscience in clinical practice

Armand H Matheny Antommaria

Abstract
The analysis of a dispute can focus on either interests, rights, or power. Commentators often frame the conflict over conscience in clinical practice as a dispute between a patient’s right to legally available medical treatment and a clinician’s right to refuse to provide interventions the clinician finds morally objectionable. Multiple sources of unresolvable moral disagreement make resolution in these terms unlikely. One should instead focus on the parties’ interests and the different ways in which the health care delivery system can accommodate them. In the specific case of pharmacists refusing to dispense emergency contraception, alternative systems such as advanced prescription, pharmacist provision, and over-the-counter sales may better reconcile the client’s interest in preventing unintended pregnancy and the pharmacist’s interest in not contravening his or her conscience. Within such an analysis, the ethicist’s role becomes identifying and clarifying the parties’ morally relevant interests.

Antommaria AHM. Adjudicating rights or analyzing interests: ethicists’ role in the debate over conscience in clinical practice. Theor Med Bioeth. 2008;29(3):201-212.

Shomatsu Yokoyama, a Physiologist Who Refused to Conduct Experments on Living Human Bodies

Keiko Suenaga

Nihon Ishigaku Zasshi, Journal of Japanese History of Medicine

Abstract
This article introduces the life of Shomatsu Yokoyama ( 1913-1992), a physiologist and military doctor, to the reader. During the Sino-Japanese war, Yokoyama disobeyed orders given by his superior officer to conduct inhumane medical experiments on humans. Not only in Unit 731, but also in other units, many military doctors were involved in medical crimes against residents of the areas invaded by the Japanese Army. In human living-body experiments and vivisections were widely conducted at that time. There were, however, a small number of researchers who did not follow the orders to perform human body experiments. Highlighting the life of such a rare researcher for the purpose of ascertaining the reason for his noncompliance with the order will provide us with insights on medical ethics.

Suenaga K. Shomatsu Yokoyama, a Physiologist Who Refused to Conduct Experments on Living Human Bodies. Journal of Japanese History of Medicine (Nihon Ishigaku Zasshi). 2008;54(3):239-248.

Military Medical Ethics – Physician First, Last, Always

George J Annas

Extract
The chair of the President’s Council on Bioethics, Edmund Pellegrino, has insisted that medical ethics are and must be the same for civilian and military physicians, “except in the most extreme contingencies.” There is no special medical ethics for active-duty military physicians any more than there is for Veterans Affairs physicians, National Guard physicians, public health physicians, prison physicians, or managed care physicians. The only question is whether there are “extreme contingencies” that justify physicians’ suspension of their medical–ethical obligations.

Annas GJ. Military Medical Ethics – Physician First, Last, Always. N Engl J Med. 2008;1087-1090.

The Conscience Clause in American Pharmacy: An Historical Overview

Robert A Buerki

Extract
Conscience is a tricky business. Some interpret its personal beacon as the guide to universal truth. But the assumption that one’s own conscience is the conscience of the world is fraught with dangers. As C. S. Lewis wrote, “Those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.” As nations become more ethnically and religiously diverse, and science and medicine develop new and more complex health interventions, new forms of conscientious objections are likely to emerge. Conscientious objection is not simply a matter for individual pharmacists; it is a matter that must engage the entire profession of pharmacy and society as a whole. Professional associations, boards of pharmacy, and state legislatures must work together to prevent patients from bearing the burdens of excusing pharmacists from delivering the full measure of pharmaceutical care.

Buerki RA. The Conscience Clause in American Pharmacy: An Historical Overview. Pharmacy in History. 2008;50(3):107-118.

What is conscience and why is respect for it so important?

Daniel P Sulmasy

Abstract
The literature on conscience in medicine has paid little attention to what is meant by the word ‘conscience.’ This article distinguishes between retrospective and prospective conscience, distinguishes synderesis from conscience, and argues against intuitionist views of conscience. Conscience is defined as having two interrelated parts: (1) a commitment to morality itself; to acting and choosing morally according to the best of one’s ability, and (2) the activity of judging that an act one has done or about which one is deliberating would violate that commitment. Tolerance is defined as mutual respect for conscience. A set of boundary conditions for justifiable respect for conscientious objection in medicine is proposed.

Sulmasy DP. What is conscience and why is respect for it so important? Theor Med Bioeth. 2008;29(3):135-149.

Conscientious refusal by physicians and pharmacists: Who is obligated to do what, and why?

Dan W Brock

Abstract
Some medical services have long generated deep moral controversy within the medical profession as well as in broader society and have led to conscientious refusals by some physicians to provide those services to their patients. More recently, pharmacists in a number of states have refused on grounds of conscience to fill legal prescriptions for their customers. This paper assesses these controversies. First, I offer a brief account of the basis and limits of the claim to be free to act on one’s conscience. Second, I sketch an account of the basis of the medical and pharmacy professions’ responsibilities and the process by which they are specified and change over time. Third, I then set out and defend what I call the “conventional compromise” as a reasonable accommodation to conflicts between these professions’ responsibilities and the moral integrity of their individual members. Finally, I take up and reject the complicity objection to the conventional compromise. Put together, this provides my answer to the question posed in the title of my paper: “Conscientious refusal by physicians and pharmacists: who is obligated to do what, and why?”.

Brock DW. Conscientious refusal by physicians and pharmacists: Who is obligated to do what, and why? Theor Med Bioeth. 2008;29(3):187-200.