0 - Protection of Conscience Project Library

Conscience-based exemptions for medical students

Mark R Wicclair

Cambridge Quarterly of Healthcare Ethics

Journal’s Extract
Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities. In 1996, the Medical Student Section of the American Medical Association (AMA) introduced a resolution calling on the AMA to adopt a policy in support of exemptions for students with ethical or religious objections. In that report, students identified abortion, sterilization, and procedures performed on animals as examples of activities that might prompt requests for conscience-based exemptions (CBEs). In response to the student initiative, the Council on Medical Education recommended the adoption of seven “principles to guide exemption of medical students from activities based on conscience.” The House of Delegates adopted these principles in their entirety.

Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics. 2010;19(1):38-50.

Policy statement–Physician refusal to provide information or treatment on the basis of claims of conscience

American Academy of Pediatrics Committee on Bioethics

Abstract
Health care professionals may have moral objections to particular medical interventions. They may refuse to provide or cooperate in the provision of these interventions. Such objections are referred to as conscientious objections. Although it may be difficult to characterize or validate claims of conscience, respecting the individual physician’s moral integrity is important. Conflicts arise when claims of conscience impede a patient’s access to medical information or care. A physician’s conscientious objection to certain interventions or treatments may be constrained in some situations. Physicians have a duty to disclose to prospective patients treatments they refuse to perform. As part of informed consent, physicians also have a duty to inform their patients of all relevant and legally available treatment options, including options to which they object. They have a moral obligation to refer patients to other health care professionals who are willing to provide those services when failing to do so would cause harm to the patient, and they have a duty to treat patients in emergencies when referral would significantly increase the probability of mortality or serious morbidity. Conversely, the health care system should make reasonable accommodations for physicians with conscientious objections.

Committee_on_Bioethics. Policy statement–Physician refusal to provide information or treatment on the basis of claims of conscience. Pediatrics. 2009 Dec;124(6):1689-1693.

Cooperation with Securities Fraud

Ronald J Colombo

Abstract
Although “proximity” is itself an indefinite concept, we are not without tools in deciphering it. For we have at our disposal a well-developed, longtested method of analyzing proximity with an eye toward the just imposition of culpability: moral philosophy’s “principles of cooperation.” By turning to these principles, we have at our fingertips a ready-made set of factors to consider in assessing whether one’s conduct should be deemed proximate versus remote to another’s fraud. The principles of cooperation also provide a framework around which we can organize securities fraud jurisprudence in general. For the insights gleaned from the principles regarding moral culpability in many respects parallel the conclusions reached by courts and commentators construing liability under the securities laws. Perhaps, in addition to the assistance it provides us in resolving the difficult issue of proximity, this framework could serve as a useful aid in resolving other, and future, securities fraud questions..

Colombo RJ. Cooperation with Securities Fraud. Alabama University Law Review. 2009 Dec;61(1)-66.

An ethically justified practical approach to offering, recommending, performing, and referring for induced abortion and feticide

Frank A Chervenak, Laurence B McCullough

American Journal of Obstetrics & Gynecology

Abstract
We provide comprehensive, practical guidance for physicians on when to offer, recommend, perform, and refer patients for induced abortion and feticide. We precisely define terminology and articulate an ethical framework based on respecting the autonomy of the pregnant woman, the fetus as a patient, and the individual conscience of the physician. We elucidate autonomy-based and beneficence-based obligations and distinguish professional conscience from individual conscience. The obstetrician’s role should be based primarily on professional conscience, which is shaped by autonomy-based and beneficence-based obligations of the obstetrician to the pregnant and fetal patients, with important but limited constraints originating in individual conscience.

Chervenak FA, McCullough LB. An ethically justified practical approach to offering, recommending, performing, and referring for induced abortion and feticide. Am J Obstet Gynecol. 2009 Dec;201(6):560.e1-560.e6.

Ethical Distinction Between Direct and Indirect Referral for Abortion

Frank A Chervenak, Laurence B McCullough

Extract
Conclusion
The ethics of referral for abortion is autonomy based with a beneficence-based component, the clinician’s obligation to protect the woman’s health and life, similar to referral for cosmetic procedures. At a minimum, indirect referral— providing referral information but not ensuring that referral occurs—should be the clinical ethical standard of care. Direct referral for abortion is a matter of individual clinician discretion, not the clinical ethical standard of care. Conscience based objections to direct referral for termination of pregnancy have merit; conscience-based objections to indirect referral for termination of pregnancy do not.

Chervenak FA, McCullough LB. Ethical Distinction Between Direct and Indirect Referral for Abortion. The Female Patient. 2009 Dec;34:46-48

Where conscience meets desire: refusal of health care providers to honor health care proxies for sexual minorities

Shawna S Baker

Women's Rights Law Reporter — Women’s Rights Law Reporter

Baker SS. Where conscience meets desire: refusal of health care providers to honor health care proxies for sexual minorities. Women’s Rights Law Reporter. 2009-2010;31(1):1-41.

When Two Fundamental Rights Collide at the Pharmacy: The Struggle to Balance the Consumer’s Right to Access Contraception and the Pharmacist’s Right of Conscience

Suzanne Davis, Paul Lansing

Extract
Conclusion
In conclusion, we think that the marketplace of ideas should be allowed to function on this issue. So long as consumers have access to distribution channels for emergency contraception and to information regarding where the drug is available, there is no reason why the market would fail to reconcile this dilemma. However, if Wilson is correct that governments will not be able to fight the urge to take an active role in this dispute, then freedom of conscience should be the paramount fundamental right. This determination is necessary to provide the proper balance of rights because placing an affirmative duty on pharmacists to dispense a drug negates the basic premises on which our nation is built and only avoids a slight inconvenience to consumers who desire emergency contraception. Finally, it is important for governments to recognize that there are sound arguments on both sides of this legal debate and that an in depth analysis of the ethical and public policy ramifications of regulation on this issue is absolutely necessary.

Davis S, Lansing P. When Two Fundamental Rights Collide at the Pharmacy: The Struggle to Balance the Consumer’s Right to Access Contraception and the Pharmacist’s Right of Conscience. 12 Depaul J. Health Care L. 67, 89-91 (2009)

Islamic Biomedical Ethics: Principles and Application

Abdulaziz Sachedina A. Islamic Biomedical Ethics: Principles and Application. Oxford: University Press, 2009, 296 pp. Print ISBN-13: 9780195378504. DOI:10.1093/acprof:oso/9780195378504.001.0001

Author’s Abstract
This book undertakes to correlate practical ethical decisions in modern medical practice to principles and rules derived from Islamic juridical praxis and theological doctrines. This study links these rulings to the moral principles extracted from the normative religious texts and historically documented precedents. Western scholars of Islamic law have pointed out the importance of the historical approach in determining the rules and the juristic practices that were applied to the cases under consideration before the judicial opinions were issued within a specific social, economic, and political context. These decisions reflected aspects of intellectual as well as social history of the Muslim community engaged in making everyday life conform to the religious values. Ethical decisions are an important part of interpersonal relations in Islamic law. Practical guidance affecting all facets of individual and collective human life, have been provided under the general rules of “Public good” and “No harm, no harassment.” However, no judicial decision that claims to further public good is regarded authoritative without supporting documentation from the foundational sources, like the Qur‘an and the Sunna (the exemplary tradition of the Prophet). Hence, Muslim jurists, in order to infer fresh rulings about matters that were not covered by the existing precedents in the Qur‘an and the Sunna, undertook to develop rational stratagems to enable them to solve problems faced by the community. This intellectual activity led to the systematic formulation of the principles of Islamic jurisprudence, which has assumed unprecedented importance in connection with the distinct field of medical ethics in the Islamic world that shares the modern medical technology with the West. The book argues that there are distinct Islamic principles that can serve as sources for Muslim biomedical ethics that can engage in dialogue with both secular and other religiously oriented bioethics in the context of universal medical practice and research.

“Abdulaziz Sachedina is the leading Islamic thinker writing in Engish today. Thus, his Islamic Biomedical Ethics is a welcome addition to the already extensive literature in the field because of his great knowledge of the classical and modern Islamic legal and ethical sources, his authentic religious commitment to the truth of Islam, and his willingness to engage perspectives from other traditions in what is becoming a genuinely multicultural field of moral discourse.” David Novak, author of Jewish Social Ethics

Invoking conscientious objection in reproductive health care: evolving issues in Peru, Mexico and Chile

Lidia Casas

Abstract
As Latin American countries seek to guarantee sexual and reproductive health and rights, opponents of women’s rights and reproductive choice have become more strident in their opposition, and are increasingly claiming conscientious objection to providing these services. Conscientious objection must be seen in the context of the rights and interests at stake, including women’s health needs and right to self-determination. An analysis of law and policy on conscientious objection in Peru, Mexico and Chile shows that it is being used to erode women’s rights, especially where it is construed to have no limits, as in Peru. Conscientious objection must be distinguished from politically-motivated attempts to undermine the law; otherwise, the still fragile re-democratisation processes underway in Latin America may be placed at risk. True conscientious objection requires that a balance be struck between the rights of the objector and the health rights of patients, in this case women. Health care providers are entitled to their beliefs and to have those beliefs accommodated, but it is neither viable nor ethically acceptable for conscientious objectors to exercise this right without regard for the right to health care of others, or for policy and services to be rendered ineffectual because of individual objectors.

Keywords:

Casas L. Invoking conscientious objection in reproductive health care: evolving issues in Peru, Mexico and Chile. Reprod Health Matter. 2009 Nov;17(34):78-87.

Reporting of euthanasia and physician-assisted suicide in the Netherlands: Descriptive study

Hilde Buiting, Johannes Van Delden, Bregje D Onwuteaka-Philipsen, Judith Rietjens, Mette Rurup, Donald Van Tol, Joseph Gevers,Paul Van Der Maas,Agnes Van Der Heide

Abstract
Background: An important principle underlying the Dutch Euthanasia Act is physicians’ responsibility to alleviate patients’ suffering. The Dutch Act states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient’s request, the patient’s suffering (unbearable and hopeless), the information provided to the patient, the presence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians to report euthanasia to a review committee. We studied which arguments Dutch physicians use to substantiate their adherence to the criteria and which aspects attract review committees’ attention. . . .

Conclusion: Dutch physicians substantiate their adherence to the criteria in a variable way with an emphasis on physical symptoms. The information they provide is in most cases sufficient to enable adequate review. Review committees’ control seems to focus on (unbearable) suffering and on procedural issues.

Buiting H, Delden JV, Onwuteaka-Philipsen BD, Rietjens J, Rurup M, Tol DV et al. Reporting of euthanasia and physician-assisted suicide in the Netherlands: Descriptive study. BMC Medical Ethics. 2009;10(1).