Abstract Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses’ conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.
Abstract At the dawn of the 20th century, postmodern academics stressed the cultural differences among human beings. Philosophers predicated differing value systems based on these cultural differences, and conflicts have arisen among those who hold distinctly different religious traditions. Many people believe there can be no universal system to explain reality and thus form the basis for norms in human behavior. However, at the close of the 20th century scientists and philosophers had come full circle: physics quite literally became metaphysics, and ethical systems made sense. Rush Kidder interviewed two dozen “men and women of good conscience” from around the world and asked them if there is a single set of values that wise people use to make decisions. They answered with a resounding YES! Thus, in addition to the customary principles of beneficence, nonmalfeasance, honesty, and so forth, the author proposes a set of ethical principles based on those universal values, adapted to fit nursing administrators’ dual responsibilities. Ethical decision making and behavior, the author contends, help to reconcile perspectives and interests and to keep values and mission uppermost in one’s mind. In the process, ethical behavior establishes long-term relations of trust and cooperation, which in turn promote consistency and stability in an unstable world..
Abstract There is growing concern that rape victims are not provided with emergency contraceptives in many hospital emergency rooms, particularly in Catholic hospitals. In a small pilot study, we examined policies and practices relating to providing information, prescriptions, and pregnancy prophylaxis in emergency rooms. We held structured telephone interviews with emergency department personnel in 5K large urban hospitals, including 28 Catholic hospitals from across the United States. Our results showed that some Catholic hospitals have policies that prohibit the discussion of emergency contraceptives with rape victims, and in some of these hospitals, a victim would learn about the treatment only by asking. Such policies and practices are contrary to Catholic teaching. More seriously, they undermine a victim’s right to information about her treatment options and jeopardize physicians’ fiduciary responsibility to act in their patients’ best interests. We suggest that institutions must reevaluate their restrictive policies. If they fail to do so, we believe that state legislation requirng hospitals to meet the standard of care for treatment of rape victims is appropriate.
Extract Mifepristone, the controversial “abortion pill,” may soon be available in the US, but the distribution rules may be so strict that they “hurt access.”. . . Mifepristone has been available to women in many European countries for more than a decade. More than 500 000 women worldwide have used it, with few complications reported. When taken with misoprostol, which has already been approved in Canada, mifepristone causes abortion – in essence a miscarriage – in 95% of women who are no more than 49 days pregnant.
The purpose of this paper is to address how analysts and commentators approach the relationship between abortion law and law governing medically assisted death, discussion of which is here limited to assisted suicide and voluntary active euthanasia. The issue of involuntary euthanasia or “mercy killing” of non-consenting persons is beyond the present discussion. This paper is further limited to English language literature, and to legal experience and commentary primarily from the United States of America, Britain and Canada, although reactions to developments in the Netherlands are included. Attention will be directed initially to legal and related analysts and commentators who oppose legalization both of abortion and of medically assisted death, and who resist application of the reasoning that supported decriminalization of abortion to medically assisted death. They represent the socalled Pro-Life protagonists in the debate. Language is often employed instrumentally in the conduct of the disagreement, but the practice adopted here is to refer to protagonists by the titles they give themselves.
Second, attention will be given to adherents to the so-called pro-choice position, who favor both liberalized abortion laws and tolerance of medical means by which individuals may end their own lives when they find survival excessively painful, burdensome, or undignified. Consideration is then given to those who oppose liberal abortion laws, perhaps because of fetal vulnerability, but who consider that non-vulnerable, competent persons, such as terminal patients in unrelievable distress, should be legally entitled to assistance in dying. The reverse is then addressed, concerning those who favor women’s choice on abortion, but oppose medically assisted death because, for instance, it may be exploitive of disabled patients or violative of ethical duties that health care professionals owe patients. In conclusion, it will be proposed that reconciliation of opposing views may be approached through promotion of choice, both to continue unplanned pregnancy and burdensome life, through availability of options that individuals may be encouraged and supported, but not coerced, to adopt.
Abstract Recognition of conscientious objection seems reasonable in relation to controversial and contentious issues, such as physician assisted suicide and abortion. However, physicians also advance conscience-based objections to actions and practices that are sanctioned by established norms of medical ethics, and an account of their moral force can be more elusive in such contexts. Several possible ethical justifications for recognizing appeals to conscience in medicine are examined, and it is argued that the most promising one is respect for moral integrity. It is also argued that an appeal to conscience has significant moral weight only if the core ethical values on which it is based correspond to one or more core values in medicine. Finally, several guidelines pertaining to appeals to conscience and their ethical evaluation are presented.
Journal Extract “The question is whether we will ever be able to learn from history,” Alexander Mitscherlich said in 1947. He was a member of the German Medical Commission, who by order of the German General Medical Council witnessed the Nuremberg Trial. “I believe,” Mitscherlich continued, “that we won’t master it by just keeping our distance morally. This is doubtless easy to achieve. However, it is useless for us as soon as we think of the dark future of this century, in which situations might occur leading to a similar coldness and ignorance towards the right to live of people more defenseless and disregarded” [1]. 1
Over the ensuing decades, neither physicians nor the public faced the tiring process of reviewing and questioning history. Even the reports of the German Medical Commission met with a growing disinterest and disapproval from the physicians in post-war Germany. 2 Almost 50 percent of the German physicians were members of the NSDAP (Nazi Party), and they resumed their work after 1945 after only a brief interruption.
Thus it is understandable that it was not the physicians’ organizations nor the medical historical departments of the universities that turned towards history at the beginning of the1980s. Rather, it was their children [End Page 373] and grandchildren, who were working in the hospitals, the psychiatric institutions, and homes for persons with disabilities. They began to ask what happened 40 or 50 years ago where they were working. They were not involved personally, nor did they blame their fathers and mothers. This is the generation to which I also belong. 3
After Auschwitz and Hadamar, particularly in Germany, discussion about medical ethics and about the future of medicine are nowadays impossible without reference to history. 4 This consideration was the basis of the program entitled “Medicine and Conscience” in the German Section of International Congress of Physicians for the Prevention of Nuclear War, held in Nuremberg in October 1996. 5 As a result of this congress, on the 50th anniversary of the pronouncement of judgment in the Nuremberg Trial, 20 August 1997, the Nuremberg Code 1997 was presented. Based on the historical experiences and the fundamental ideas of the 1947 Code, the 1997 Code is designed to answer current medical questions about the application of biosciences to human beings. It discusses 10 topics, including medical experiments, reproductive medicine, genetic diagnostics and therapy, transplantation, euthanasia, and distribution of resources. (Due to the time limit and the theme of this symposium, I will focus only on the topic of medical research.) The Nuremberg Code 1997 follows the widespread practice of considering informed consent to be a prerequisite in all fields of public health care service.
The critical-historical link to the Nuremberg Code 1947 that we attempted to make with Code 1997 had to confront two fundamental issues. First, we had to determine whether the Code’s significance was only historical or universally valid. To put it differently: was the 1947 Code only to be understood from the historical context? Did it only aim at the judgment of the practices of the Nazi physicians? Or did it imply a universal validity for medical research and medicine in a civilized world?
Historical evidence, as well as a look at the text of the Code, clearly speaks for a universal validity. Telford Taylor, the chief prosecutor of Nuremberg, stated in his introduction that the trial was no mere murder trial, since the defendants were physicians who had sworn the Hippocratic oath and thus had become murderers in the execution of their profession. Logically, the judges created with the Nuremberg Code a basis for the judgment of crimes which became possible within the bounds of medicine. 6[End Page 374]
Extract Medicine depends on more than competence and expertise, essential as these are. It cannot function as an institution without good faith on the part of provider, patient and the public as a whole. The root of the public’s trust is the confidence that physicians will put patients’ welfare ahead of all other considerations, even the patients’ momentary wishes or the physicians’ monetary gain. It is the function of medicine as a profession to safeguard and promote this trust in the society at large. This point could be phrased as a maxim: “Medicine must always be treated as a public good, never as a commodity.” . . . medicine must take the lead in a public conversation about the profession’s contract with society. If it does not, that contract is likely to be redefined in terms, and in a language, quite antithetical to the core concerns of medicine.
Johanna H. Groenewoud, Agnes van der Heide, Bregje D. Onwuteaka-Philipsen, Dick L Willems, Paul J van der Maas, Gerrit van der Wal
New England Journal of Medicine
Abstract Background and Methods The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in the Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death.
Results In 114 cases, the physician’s intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5).
Conclusions There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient’s inability to take the medication or because of problems with the completion of physician-assisted suicide.
Abstract This contribution deals with the issue of the professional autonomy of the medical doctor. Worldwide, the physician’s autonomy is guaranteed and limited, first of all, by Codes of Medical Ethics. In Italy, the latest version of the national Code of Medical Ethics (Code 1998) was published in 1998 by the Federation of provincial Medical Asso- ciations (FNOMCEO). The Code 1998 acknowledges the physician’s autonomy regarding the scheduling, the choice and application of diagnostic and therapeutic means, within the principles of professional responsibility. This responsibility has to make reference to the following fundamental ethical principles: (1) the protection of human life; (2) the protection of the physical and psychological health of the human being; (3) the relief from pain; (4) the respect for the freedom and the dignity of the human person, without discrimination; (5) an up-to-date scientific qualification (Art. 5). The authors underline that autonomy is an anthropological – and consequently ethical – characteristic of the human person. Different positions on autonomy in bioethics (individualistic, evolutionistic, utilitarian and personalistic models) are explained. The relation between the professional autonomy of the physician and the autonomy of the patient and of colleagues is discussed. In fact, the medical doctor is obliged: (1) to respect the fundamental rights of the person, first of all his/her life; (2) to ensure the continuity of the care, even if he can only relieve the patient’s suffering; (3) to maintain, except under certain circumstances, professional secrecy and confidentiality regarding patients and their medical records. Moreover, the physician cannot deny the patient correct and appropriate information. He/she should not perform any diagnostic or therapeutic activity without the informed consent of the patient and the medical doctor must give up medical treatment in case of documented refusal of the individual. Furthermore, the medical doctor has the right to raise conscientious objections if he/she is requested to perform medical actions that are contrary to his/her conscience or medical opinion, unless this attitude would seriously and immediately harm the patient. Regarding the relationships with colleagues, the physician is obliged to solidarity, mutual respect, and care of sick colleagues. Finally, the authors discuss the Italian legislation affecting the physician’s professional autonomy: (1) the SSN health care Acts; (2) the so- called Charter for Public Health Care Services; (3) the Acts on privacy; (4) Good Clinical Practice.
