0 - Protection of Conscience Project Library

A Clash at the Bedside: Patient Autonomy v. A Physician’s Professional Conscience

Judith F Daar

Extract
Conclusion
The plight of Helga Wanglie . . . focused attention on the issue of physician autonomy in the context of patient decision making. That case challenged the court, as well as our society, to consider whether a physician has an obligation to provide medical treatment he or she believes is inappropriate. . .The concept of a physician’s professional conscience will become increasingly relevant as the cost of health care rises to the point where our demands for care greatly outweigh our ability to pay for such care . . . to downplay the role a physician’s professional conscience plays in medical decision making, as both courts and policy makers traditionally have done, does not advance patient autonomy; instead, it causes doctors to be more conservative and withholding in the range of options they offer their patients. If patient autonomy is to have meaning, recognition must also be given to a physician’s moral autonomy. This Article suggests that when patients clash with their physicians over treatment choices, the principle of patient autonomy does not automatically require that the physician be forced to comply.

Daar JF. A Clash at the Bedside: Patient Autonomy v. A Physician’s Professional Conscience. Hastings Law J. 1993 Aug;44(6):1241-1289.

Conscience and Clinical Care

Leah L Curtin

Extract
If the state itself does not presume to order the consciences of its citizens, how can employers, physicians or hierarchical superiors assume such authority? For those in positions of power, it is all too easy to stifle the criticisms and consciences of subordinates by a summons to authority – or by an accusation of insubordination. The irony of it is that whether you succeed or fail in your attempts to force obedience through such tactics, you will have lost your most valuable asset – a man or woman of integrity. Within the ethical, professional and legal restraints to which all of us are subject, we can and must create a system that allows for respectful dissent and conscientious objection.

Curtin LL. Conscience and Clinical Care. Nurs Manag. 1993 Aug;24(8):26-28.

Doing what the Patient Orders: Maintaining Integrity in the Doctor-Patient Relationship

Jeffrey Blustein

Extract
Conclusion
Physicians’ appeals to conscience, understood as fear of loss of integrity, should not be taken lightly. Integrity provides the basis for a unified, whole, and unalienated life, and its moral value, while dependent on the presence of other good traits in the agent, is not reducible to them. . . a physician can consistently be concerned about his or her own integrity without claiming to know better than the patient what is in the patient’s best interests. . . . The conception of integrity I have proposed . . . allows for the possibility of integrity-preserving compromise. . . . I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment. . . in a dispute between physicians and their patients, there may be other values and principles at stake than the ones expressed in their conflicting positions, and a physician might well decide that referral in such a case is an appropriate response to a morally complex situation.

Blustein J. Doing what the Patient Orders: Maintaining Integrity in the Doctor-Patient Relationship. Bioethics. 1993;7(4):289-314.

(Correspondence) Abortion debate continues

Linda Spano, Michael Brennan

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
. . . we all – including Reynolds – operate from a biased set of basic assumptions. Is it really antireligious to suggest that the antiabortion forces are largely motivated by fundamental religious views that represent fixed basic assumptions? We think not. . . . Medical intervention includes helping people achieve their potential according to their own objectives as well as many other “appropriate” activities, such as the therapeutic termination of pregnancy. . . .The abortion debate is not entirely about abortion or religion, nor is it even a debate. . . the argument is about the freedom of choice and the access of all Canadian women to safe, competent medical care and about the refusal of most Canadians to submit to the irrational demands of a vociferous minority. . .

Spano L, Brennan M. (Correspondence) Abortion debate continues. Can Med Assoc J. 1993 Jun 15;148(12):2112-2113.

(Correspondence) Physicians and abortion

Lynette E Sutherland

Extract
After I read the articles on abortion in CMAJ I began to wonder if ready access to abortion is the main issue. Are we faced with a Yes-No decision, or are we looking at a symptom of something deeper? . . . The world is overpopulated, yet more and more children are being born. Despite the efforts of many dedicated people (especially women) to take information on birth con- trol to the most afflicted parts of the world, little progress is being made. All the solutions are “Band-Aid” ones, and almost all – contraceptives, abortifacients and abortion itself – are directed toward women, whose reproductive capacity is certainly the root of so much trouble. To cure these ills, nothing short of a redirection of human nature is necessary. . . .the earth’s mad population increase will surely go on to a cataclysmic end. We can put this off temporarily if we follow the Chinese example (one-child or two-children families) worldwide, with strict supervision of female reproduction.

Sutherland LE. (Correspondence) Physicians and abortion. Can Med Assoc J. 1993;148(8):1276-1277.

(News) Allegations of Nazi past force resignation of WMA president-elect

Patrick Sullivan

Extract
the World Medical Association (WMA) . . . recently found itself caught up in the most controversial problem in WMA history. At issue was the appointment of Dr. Hans-Joachim Sewering, 76, as the WMA’s president-elect. He was to have become president in October. Angry physicians belonging to several WMA member organizations, including the CMA, demanded that the appointment be overturned because Sewering had belonged to the Schutzstaffel, the Nazi elite guard, before World War II. . . . Sewering has been heavily involved in WMA affairs for more than 20 years.

Sullivan P. Allegations of Nazi past force resignation of WMA president-elect. Can Med Assoc J. 1995;148(6):995-996.

Creating Moral Space for Nurses

Leah L Curtin

Extract
(Lengthy 1983 editorial repeated verbatim in 1993 includes the following) “No nurse should be required to give any drug if (a) she is not competent to give it or (b) she has problems of conscience with regard to its administration. If, for these reasons, a nurse refuses to give a drug, another nurse may do so. The original nurse should receive inservice and/or counseling. If she still has conscientious objections, she should not be coerced. The patient’s right to have/refuse a drug should be protected by meticulous adherence to the principles and procedures of informed consent. However, his right to the drug is not greater than another human being’s (the nurse’s) obligation to practice with integrity. Therefore, if one nurse will not give the drug – the head nurse, coordinator or supervisor should give the drug.” If none of these nurses can, in conscience, administer the drug, then the physician who ordered it must give It himself or find another physician who will do it for him.

Curtin LL. Creating Moral Space for Nurses. Nurs Manag. 1993 Mar;24(3):18-19.

(Correspondence) Clinicians who provide abortions: the thinning ranks

Denis Cavanaugh

Extract
Dr. Grimes identifies abortion as “the most divisive social issue of our time,” but he is contributing to the divisiveness by raising these issues in those of us who consider elective abortion a social evil as well as a “distasteful chore.” Abortionists don’t have all the altruism, and if elective abortion were not a billiondollar- a-year business, there would be even fewer volunteers. . .the legal entitlement of a woman to elective abortion cannot be absolute to the extent of suppressing the values and conscience of her physician, so there is no reason why a resident should have an obligation to perform such abortions.

Cavanaugh D. (Correspondence) Clinicians who provide abortions: the thinning ranks. Obst Gyn. 1993 February;81(2):318-319

Conscientious objection and abortifacient drugs

D B Brushwood

Abstract
The legal right to assert a conscientious objection is reviewed, using as an example the dispensing of abortifacient drugs by pharmacists. The three areas of law that most significantly concern the right to assert a conscientious refusal are employment law, conscience clauses, and religious discrimination law. Each of these is reviewed, with descriptions of recent cases. It is concluded that employment law protects refusals that are consistent with public policy, but does not permit an employee’s personal policy to determine how a business will be run; that conscience clauses appear to provide protection for pharmacists who object to dispensing abortifacients, but that the precise meanings of critical words and phrases in some clauses need to be defined; and that even though laws of religious discrimination require that employers accommodate religious beliefs, they may not protect a pharmacist who objects to dispensing abortifacients if the accommodation becomes unreasonably burdensome.

Brushwood DB. Conscientious objection and abortifacient drugs. Clin Therapeutics. 1993 Jan-Feb;15(1):204-212.

Has the Time Come for Doctor Death: Should Physician-Assisted Suicide Be Legalized

Wendy N Weigand

Extract
The implications of legalizing euthanasia for the medical profession and the potential for abuses are very troubling. Before public policy or legislation is formulated, the ethical issues inherent in the practice of euthanasia must be critically examined. . . It is the author’s assertion that the legalization of assisted suicide and/or physician-aid-in-dying is not the proper course of action at this time. There are too many other options available to doctors, nurses, hospitals and other health care institutions which must be exercised to their fullest extent before any form of active euthanasia is legalized.

Weigand WN. Has the Time Come for Doctor Death: Should Physician-Assisted Suicide Be Legalized. J Law Health. 1993;7(2):321-350.