0 - Protection of Conscience Project Library

Conscientious objection to provision of legal abortion care

Brooke R. Johnson Jr., Eszter Kismödi, Monica V. Dragomana, Marleen Temmermana

International Journal of Gynecology & Obstetrics

Abstract
Despite advances in scientific evidence, technologies, and human rights rationale for providing safe abortion,a broad range of cultural, regulatory, and health system barriers that deter access to abortion continues to exist in many countries. When conscientious objection to provision of abortion becomes one of these barriers, it can create risks to women’s health and the enjoyment of their human rights. To eliminate this barrier, states should implement regulations for healthcare providers on how to invoke conscientious objection without jeopardizing women’s access to safe, legal abortion services, especially with regard to timely referral for care and in emergency cases when referral is not possible. In addition, states should take all necessary measures to ensure that all women and adolescents have the means to prevent unintended pregnancies and to obtain safe abortion.

Johnson BR, Kismödi E, Dragomana MV, Temmermana M. Conscientious objection to provision of legal abortion care. Int J Gynaecol Obstet. 2013 Dec;123 Suppl 3:S60-2. doi: 10.1016/S0020-7292(13)60004-1.

In Defense of Religious Bioethics

Judah Goldberg, Alan Jotkowitz

Extract
In the first year of a celebrated graduate program in bioethics, one of us wrote a short essay about physician-assisted suicide that claimed that murder is not only a breach of rights, but also a “grave affront to all human existence as well as to He who grants life.” Well, that last part earned me a predictable scribble on the margins of my returned paper, something to the effect of, “What if someone does not believe in a Giver of life?”

Goldberg J, Jotkowitz A. In Defense of Religious Bioethics. Am J Bioethics, December, Vol. 12, No. 12, 2012

Legal and ethical standards for protecting women’s human rights and the practice of conscientious objection in reproductive healthcare settings

Christina Zampas

Abstract
The practice of conscientious objection by healthcare workers is growing across the globe. It is most common in reproductive healthcare settings because of the religious or moral values placed on beliefs as to when life begins. It is often invoked in the context of abortion and contraceptive services, including the provision of information related to such services. Few states adequately regulate the practice, leading to denial of access to lawful reproductive healthcare services and violations of fundamental human rights. International ethical, health, and human rights standards have recently attempted to address these challenges by harmonizing the practice of conscientious objection with women’s right to sexual and reproductive health services. FIGO ethical standards have had an important role in influencing human rights development in this area. They consider regulation of the unfettered use of conscientious objection essential to the realization of sexual and reproductive rights. Under international human rights law, states have a positive obligation to act in this regard. While ethical and human rights standards regarding this issue are growing, they do not yet exhaustively cover all the situations in which women’s health and human rights are in jeopardy because of the practice. The present article sets forth existing ethical and human rights standards on the issue and illustrates the need for further development and clarity on balancing these rights and interests.

Zampas C. Legal and ethical standards for protecting women’s human rights and the practice of conscientious objection in reproductive healthcare settings. Int J Gyn Ob. 2013 Dec 10;123:S63-S65.

(Editorial) Conscientious objection to the provision of reproductive healthcare

Wendy Chavkin

Extract
Healthcare providers who cite conscientious objection as grounds for refusing to provide components of legal reproductive care highlight the tension between their right to exercise their conscience and women’s rights to receive needed care. There are also societal obligations and ramifications at stake, including the responsibility for negotiating balance between all of these competing interests. . .

. . . There are too many barriers to access to reproductive health- care. Conscience-based refusal of care may be one that we can successfully address.

Chavkin W. (Editorial) Conscientious objection to the provision of reproductive healthcare. Int J Gynec Obstet. 2013 Dec;123(SUPPL.3):s39-s40.

Conscientious objection and refusal to provide reproductive healthcare: A White Paper examining prevalence, health consequences, and policy responses

Wendy Chavkin, Liddy Leitman, Kate Polin, Global Doctors for Choice

Abstract
Background
Global Doctors for Choice—a transnational network of physician advocates for reproductive health and rights—began exploring the phenomenon of conscience-based refusal of reproductive healthcare as a result of increasing reports of harms worldwide. The present White Paper examines the prevalence and impact of such refusal and reviews policy efforts to balance individual conscience, autonomy in reproductive decision making, safeguards for health, and professional medical integrity.

Objectives and search strategy
The White Paper draws on medical, public health, legal, ethical, and social science literature published between 1998 and 2013 in English, French, German, Italian, Portuguese, and Spanish. Estimates of prevalence are difficult to obtain, as there is no consensus about criteria for refuser status and no standardized definition of the practice, and the studies have sampling and other methodologic limitations. The White Paper reviews these data and offers logical frameworks to represent the possible health and health system consequences of conscience-based refusal to provide abortion; assisted reproductive technologies; contraception; treatment in cases of maternal health risk and inevitable pregnancy loss; and prenatal diagnosis. It concludes by categorizing legal, regulatory, and other policy responses to the practice.

Conclusions
Empirical evidence is essential for varied political actors as they respond with policies or regulations to the competing concerns at stake. Further research and training in diverse geopolitical settings are required. With dual commitments toward their own conscience and their obligations to patients’ health and rights, providers and professional medical/public health societies must lead attempts to respond to conscience-based refusal and to safeguard reproductive health, medical integrity, and women’s lives.

Chavkin W, Leitman L, Polin K, for Choice GD. Conscientious objection and refusal to provide reproductive healthcare: A White Paper examining prevalence, health consequences, and policy responses. Int J Gynec Obstet. 2013 Dec 10;123(S41-S56.

Conscientious objection by Muslim students startling

Michelle McLean

Extract
I read Robert Card’s recent paper entitled ‘Is there no alternative? Conscientious objection by medical students’ with great interest.1 That Muslim students in America are able to conscientiously object (and this was entertained) to the cross-gender consultation is somewhat startling. I have just left the Middle East, where I worked as a medical educator for five-and-a-half years (2006–2011), and, to the best of my knowledge, even in the conservative, gender-segregated traditional Muslim culture of the United Arab Emirates, not once did a male or female student refuse to examine a patient of the opposite sex.

Mclean M. Conscientious objection by Muslim students startling. J Med Ethics November 2013 Vol. 39 No. 11

Rethinking Voluntary Euthanasia

Byron J. Stoyles, Sorin Costreie

Abstract
Our goal in this article is to explicate the way, and the extent to which, euthanasia can be voluntary from both the perspective of the patient and the perspective of the health care providers involved in the patient’s care. More significantly, we aim to challenge the way in which those engaged in ongoing philosophical debates regarding the morality of euthanasia draw distinctions between voluntary, involuntary, and nonvoluntary euthanasia on the grounds that drawing the distinctions in the traditional manner (1) fails to reflect what is important from the patient’s perspective and (2) fails to reflect the significance of health care providers’ interests, including their autonomy and integrity.

Stoyles BJ, Costreie S. Rethinking Voluntary Euthanasia. J Med Philos (2013) 38 (6): 674-695. doi: 10.1093/jmp/jht045

Conscientious refusal and health professionals: Does religion make a difference?

Daniel Weinstock

Abstract
Freedom of Conscience and Freedom of Religion should be taken to protect two distinct sets of moral considerations. The former protects the ability of the agent to reflect critically upon the moral and political issues that arise in her society generally, and in her professional life more specifically. The latter protects the individual’s ability to achieve secure membership in a set of practices and rituals that have as a moral function to inscribe her life in a temporally extended narrative. Once these grounds are distinguished, it becomes more difficult to grant healthcare professionals’ claims to religious exemptions on the basis of the latter than it is on the basis of the former. While both sets of considerations generate ‘internal reasons’ for rights to accommodation, the relevant ‘external’ reasons present in the case of claims of moral conscience do not possess analogues in the case of claims of religious conscience. However, the argument applies only to ‘irreducibly religious’ claims, that is to claims that cannot be translated into moral vocabulary. What’s more, there may be reasons to grant the claims of religious persons to exemptions that have to do not with the nature of the claims, but with the beneficial effects that the presence of religious persons may have in the context of the healthcare institutions of multi-faith societies.

Weinstock D. Conscientious refusal and health professionals: Does religion make a difference? Bioethics. doi: 10.1111/bioe.12059

Welcome to the wild, wild north

Conscientious Objection Policies Governing Canada’s Medical, Nursing, Pharmacy, and Dental Professions

Jacquelyn Shaw, Jocelyn Downie

Abstract
In Canada, as in many developed countries, healthcare conscientious objection is growing in visibility, if not in incidence. Yet the country’s health professional policies on conscientious objection are in disarray. The article reports the results of a comprehensive review of policies relevant to conscientious objection for four Canadian health professions: medicine, nursing, pharmacy and dentistry. Where relevant policies exist in many Canadian provinces, there is much controversy and potential for confusion, due to policy inconsistencies and terminological vagueness. Meanwhile, in Canada’s three most northerly territories with significant Aboriginal populations, whose already precarious health is influenced by funding and practitioner shortages, there are major policy gaps applicable to conscientious objection. In many parts of the country, as a result of health professionals’ conscientious refusals, access to some legal health services – including but not limited to reproductive health services such as abortion – has been seriously impeded. Although policy reform on conscientious conflicts may be difficult, and may generate strenuous opposition from some professional groups, for the sake of both patients and providers, such policy change must become an urgent priority.

Shaw J, Downie J. Welcome to the wild, wild north: Conscientious Objection Policies Governing Canada’s Medical, Nursing, Pharmacy, and Dental Professions. Bioethics. doi: 10.1111/bioe.12057

Am I my profession’s keeper?

Avery Kolers

Abstract
Conscientious refusal is distinguished by its peculiar attitude towards the obligations that the objector refuses: the objector accepts the authority of the institution in general, but claims a right of conscience to refuse some particular directive. An adequate ethics of conscientious objection will, then, require an account of the institutional obligations that the objector claims a right to refuse. Yet such an account must avoid two extremes: ‘anarchism,’ where obligations apply only insofar as they match individual conscience; and ‘totalitarianism,’ where even immoral obligations bind us. The challenge is to explain institutional obligations in such a way that an agent can be obligated to act against conscience, yet can object if the institution’s orders go too far. Standard accounts of institutional obligations rely on individual autonomy, expressed through consent. This paper rejects the Consent model; a better understanding of institutional obligations emerges from reflecting on the intersecting goods produced by institutions and the intersecting autonomy of numerous distinct agents rather than only one. The paper defends ‘Professionalism‘ as a grounding of professional obligations. The professional context can justify acting against conscience but more often that context partly shapes the professional conscience. Yet Professionalism avoids totalitarianism by distinguishing between (mere) injustice and abuse. When institutions are – or we conscientiously believe them to be – merely unjust, their directives still obligate us; when they are abusive, however, they do not. Finally, the paper applies these results to the problem of conscientious refusal in general and specifically to controversial reproduction cases.

Kolers A. Am I my profession’s keeper? Bioethics. doi: 10.1111/bioe.12056