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Abstract Bioethics has focused on the areas of individual ethical choices — patient care — or public policy and law. There are however, important arenas for ethical choices that have been overlooked. Health care is populated with intermediate arenas such as hospitals, nursing homes, hospices, and health care systems. This essay argues that bioethics needs to develop a language and concepts for institutional ethics. A first step in this direction is to think about institutional conscience.
Abstract Managed care organizations can produce conflicts of obligation and conflicts of interest that may lead to problems of conscience for health care professionals. This paper provides a basis for understanding the notions of conscience and conscientious objection and offers a framework for clinicians to stake out positions grounded in personal conscience as a way for them to respond to unacceptable pressures from managers to limit services.
JE Steinauer, T DePineres, AM Robert, J Westfall, P Darney
Family Planning Perspectives
Abstract The majority of residents responding to a 1995 survey of program directors and chief residents at 244 family medicine residency programs in the United States reported they had no clinical experience in cervical cap fitting, diaphragm fitting or IUD insertion and removal. For all family planning methods except oral contraceptives, no more than 24% of residents had experience with 10 or more patients. Although 29% of programs included first-trimester abortion training as either optional or routine, only 15% of chief residents had clinical experience providing first-trimester abortions. Five percent of residents stated they certainly or probably would provide abortions, while 65% of residents stated they certainly would not provide abortions. A majority (65%) of residents agreed that first-trimester abortion training should be optional within family practice residency programs. Residents were more likely to agree with inclusion of optional abortion training and with the appropriateness of providing abortions in family practice if their program offered the training.
Extract . . . In unanimous rulings last month, [United States] Chief Justice Rehnquist, writing for the court, held that there is no fundamental right to assistance in committing suicide1 and that, legally, distinguishing between refusing life saving medical treatment and requesting assistance in suicide “comports with fundamental legal principles of causation and intent.”
. . . Attempts to decriminalise assisted suicide in Britain have so far fallen well short of legislation.. . . Pressure groups in favour of voluntary euthanasia seem to accept that it will be difficult to achieve euthanasia legislation in one step but consider that assisted suicide represents a more attainable goal. From an opinion survey of Scottish doctors, the medical profession seems less resistant to assisting suicide than to practising euthanasia. . .
. . . it remains to be seen whether societal acceptance of physician assisted suicide will increase and how it will affect both social support for vulnerable and dying citizens and trust between patients and their doctors.
Extract Conclusion Tennessee Formal Ethics Opinion 96-F-140 attempts to disconnect morality from the lawyer’s work. The Board’s disregard of the lawyer’s moral and religious objections to accepting the appointment suggests either a hostility to the particular religious beliefs asserted by the inquiring lawyer or a willingness to demand lawyers accept being treated as mere means to clients’ and courts’ ends. Hostility to religious beliefs is deeply troubling when exhibited by those who are charged with providing lawyers’ guidance in discerning their professional obligations, but the second possible interpretation of the opinion is equally chilling. To the extent that the Board’s opinion represents the members’ considered judgment that lawyers are obligated to act as amoral facilitators of any action not proscribed by positive law, the power of the state is dramatically enlarged and the power of the individual and other social institutions dangerously diminished. This result cannot be tolerated under the terms of the First Amendment, nor can it be reconciled with the lawyer’s basic human rights.
Extract . . . For people with genuine morals, right and wrong do not change with popular public opinion . . . Before we congratulate our society on its social evolution over the last 50 years, we should reflect on the outcome of the society in history that practised throwing people to the lions, or perhaps the society of the 1940s that practised execution of races believed to be inferior.
[Dr. Waugh planned to respond to these letters but was unable to do so before his death on Apr. 18, 1997. In this issue, CMAJ features a tribute to Waugh (page 1524) as well as an article on issues surrounding access to abortion services (page 1545). — Ed.].
Extract We can ask ourselves: Where will we stand in 30 years if there are amendments to the Criminal Code in regard to the taking of human life, as are now being discussed? If mercy killing, physician-assisted suicide and euthanasia became legal activities — even under certain restricted guidelines — there would be inevitable progression until widespread acceptance of these practices would be accompanied by major changes in attitudes. [Dr. Waugh planned to respond to these letters but was unable to do so before his death on Apr. 18, 1997. In this issue, CMAJ features a tribute to Waugh (page 1524) as well as an article on is- sues surrounding access to abortion services (page 1545). — Ed.].
Extract When I was a medical student in the early ‘40s, and for a considerable time after that, the artificial termination of pregnancy was considered an unspeakable crime. . . . No one knew for certain how widespread the practice was, but enough patients turned up in emergency departments or in the morgue for us to know it was going on, and to arouse the ire and indignation of society’s moralists. . . . The credit for bringing the revolution about certainly belongs to Dr. Henry Morgentaler, but it is clear that Canada’s social climate had been changing slowly for several years before he defied the law by opening his first abortion clinic in Montreal . . . True, the anti-abortion campaign is not yet dead, but its force has become so attenuated the impact is limited.
