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Healthcare personnel’s experiences of situations in municipal elderly care that generate troubled conscience

Eva Ericson-Lidman, Astrid Norberg, Birgitta Persson, Gunilla Strandberg

Abstract
Healthcare personnel may perceive troubled conscience when feeling inadequate and powerless. It is important to further explore healthcare personnel’s descriptions of situations in daily work, which generate troubled conscience to increase the awareness of such situations. This study aimed to describe health care personnel’s experiences of situations in municipal elderly care that generate troubled conscience. In this qualitative study, interviews were conducted with Registered and Enrolled nurses and nursing assistants (n = 20) working in municipal elderly care.

The interviews were tape-recorded, transcribed verbatim and analysed with content analysis. Situations that generated troubled conscience was (i) Being caught between different demands, comprising being forced to prioritize between different residents’ needs, being torn between residents’-/relatives’-/and co-workers’ needs and expectations’ and between work and private life, (ii) Being torn away from residents to other ‘must do’s’, comprising stealing time from residents’ to do housekeeping chore’ and to ‘obey’ rules and recommendations, (iii) Feeling unable to relieve suffering, comprising falling short when striving to help, lacking knowledge, advice and support and time to ease residents’ suffering and finally, (iv) Being part of providing care that is or feels wrong, comprising providing poor care and/or witnessing co-workers providing poor care, and being forced to give care that feels wrong.

These findings identify important factors that generate stress of conscience (stress caused by troubled conscience), including difficulties with balancing priorities and following rules and recommendations that seem contrary to best care, and the need for interdisciplinary teamwork. Findings point to that sharing what conscience tells in the work team opens up possibilities for healthcare personnel to constructively deal with troubled conscience. Intervention studies are needed to explore whether such measures contribute to relieve the burden of troubled conscience and increase possibilities to provide high quality care.

Ericson-Lidman E, Norberg A, Persson B, Strandberg G. Healthcare personnel’s experiences of situations in municipal elderly care that generate troubled conscience. Scand J Caring Sci. 2013 Jun;27(2):215-23. doi:
10.1111/j.1471-6712.2012.01017.x. Epub 2012 May 22. PubMed PMID: 22612532.

Freedom of Conscience in Health Care: Distinctions and Limits

Sean Murphy, Stephen Genuis

Abstract
The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the dictates of regulatory bodies and administrators. Increasing attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom.

Murphy S, Genuis S. Freedom of Conscience in Health Care: Distinctions and Limits. J Bioeth Inq. 2013 Oct;10(3):347-54. doi: 10.1007/s11673-013-9451-x. Epub 2013 Jun 21.

Whose Self-Determination? Barriers to Access to Emergency Hormonal Contraception in Italy

Emanuela Ceva, Sofia Moratti

Abstract
In Italy, Emergency Hormonal Contraception (EHC) is a prescription drug, available only in pharmacies. Evidence suggests that a number of doctors and pharmacists refuse to provide EHC, on grounds of conscience, although the exact frequency of this phenomenon is unknown. This creates a barrier to access to EHC for women, thus risking undermining their right to reproductive self-determination. In this article, we aim to offer a clearer empirical and theoretical understanding of the situation and to assess the force of doctors’ and pharmacists’ claims against providing EHC. Unlike standard discussions of the issue, we argue that the category of conscientious objection is not the most appropriate one for making sense of these claims, because they are not grounded in a conflict between two contrasting moral duties. The seemingly forced choice between protecting doctors’ and pharmacists’ professional self-determination and women’s reproductive self-determination could be prevented by distributing EHC without medical prescription and in a number of outlets (including supermarkets), thus relieving doctors and pharmacists from the legal duty to provide it.

Ceva E, Morati S. Whose Self-Determination? Barriers to Access to Emergency Hormonal Contraception in Italy. Kennedy Inst Ethics J. 2013 Jun;23(2):139-167. Available from:

Conscience Legislation, the Personhood Movement, and Access to Emergency Contraception

Jonathon F. Will

Abstract
In the medical setting, conscience legislation serves to protect health care professionals who refuse to provide certain procedures or services that would violate their consciences. The “Personhood Movement,” on the other hand, is characterized by advocates’ attempts to adopt legislation or constitutional amendments at the state and/or federal level that would extend the legal and moral protection associated with personhood to members of the human species at the earliest stages of biological development. The relationship between conscience legislation and the Personhood Movement may not be self-evident, but the connection becomes apparent when considering trends in conscience legislation. This is particularly true in the context of expanding legal protection to health care professionals who object to certain forms of birth control, such as emergency contraception (EC).

In a recent paper Professor Elizabeth Sepper noted that instead of protecting a health care provider’s conscience, a possible purpose behind broad conscience legislation is to “make abortions, family planning, and end-of-life care more difficult to obtain,” and that the true goal of such legislation is “hostility to reproductive health and patients’ interests.” Indeed, this essay will suggest that the adoption of a personhood framework could represent majoritarian approval of the very principles that cause certain people to conscientiously object to EC. While some have raised concerns that conscience legislation itself could lead to problems with access to EC (especially in rural communities), adoption of a personhood framework seems to pose a much greater risk. This essay describes the expansion of conscience legislation in the medical setting, which reflects a trend toward authorizing the refusal of a broader range of procedures and services by a broader range of health care professionals. It then draws a connection between Mississippi’s very expansive conscience legislation and the decision by a national organization, Personhood USA, to propose a personhood amendment to the Mississippi Constitution. A brief discussion of the relevant biology reveals the relationship between concepts of personhood and EC. This essay suggests that even if a personhood framework is not officially adopted, legislatures that favor the movement and the broad protection of conscience-based refusals may be less inclined to enact measures that protect a woman’s ability to obtain EC. This should be viewed as problematic given that many people, including physicians and pharmacists, may not have an accurate understanding of the reproductive biology associated with early human development and the operation of EC, which may lead such professionals to make conscientious objections based on clinically false information.

Will JF. Conscience Legislation, the Personhood Movement, and Access to Emergency Contraception. 4 Faulkner Law Review 411 (2013)

The Invention of a Human Right: Conscientious Objection at the United Nations, 1947-2-11

Jeremy K Kessler

Abstract
The right of conscientious objection to military service is the most startling of human rights. While human rights generally seek to protect individuals from state power, the right of conscientious objection radically alters the citizen-state relationship, subordinating a state’s decisions about national security to the beliefs of the individual citizen. In a world of nation-states jealous of their sovereignty, how did the human right of conscientious objection become an international legal doctrine? By answering that question, this Article both clarifies the legal pedigree of the human right of conscientious objection and sheds new light on the relationship between international human rights law and national sovereignty.

Kessler JK. The Invention of a Human Right: Conscientious Objection at the United Nations, 1947-2-11. Columbia Hum R Law R. 2013;44(753-791.

An (Un)clear Conscience Clause: The Causes and Consequences of Statutory Ambiguity in State Contraceptive Mandates

Rachel VanSickle-Ward, Amanda Hollis-Brusky

Journal of Health Politics, Policy and Law

Abstract
Since 1996, twenty-eight states have adopted legislation mandating insurance coverage of prescription contraceptives for women. Most of these policies include language that allows providers to opt out of the requirement because of religious or moral beliefs—conscience clause exemptions. There is striking variation in how these exemptions are defined. This article investigates the sources and consequences of ambiguous versus precise statutory language in conscience clauses. We find that some forms of political and institutional fragmentation (party polarization and gubernatorial appointment power) are correlated with the degree of policy specificity in state contraceptive mandates. This finding reinforces previous law and policy scholarship that has shown that greater fragmentation promotes ambiguous statutory language because broad wording acts as a vehicle for compromise when actors disagree. Interestingly, it is the more precisely worded statutes that have prompted court battles. We explain this with reference to the asymmetry of incentives and mobilizing costs between those disadvantaged by broad (primarily female employees) versus precisely worded statutes (primarily Catholic organizations). Our findings suggest that the impact of statutory ambiguity on court intervention is heavily contextualized by the resources and organization of affected stakeholders.

Vansickle-Ward R, Hollis-Brusky A. An (Un)clear Conscience Clause: The Causes and Consequences of Statutory Ambiguity in State Contraceptive Mandates. J Health Polit Policy Law. 2013 May 3. [Epub ahead of print] PubMed PMID: 23645878.

Psychometric properties concerning four instruments measuring job satisfaction, strain, and stress of conscience in a residential care context

Anneli Orrung Wallin, Anna-Karin Edberg, Ingela Beck, Ulf Jakobsson

Abstract
There are many instruments assessing the wellbeing of staff, but far from all have been psychometrically investigated. When evaluating supportive interventions directed toward nurse assistants in residential care, valid and reliable instruments are needed in order to detect possible changes. The aim of the study was to investigate validity in terms of data quality, construct validity, convergent and divergent validity and reliability in terms of the internal consistency and stability of the Job Satisfaction Questionnaire, the Psychosocial Aspects of Job Satisfaction, the Strain in Dementia Care Scale (SDCS), and the Stress of Conscience Questionnaire (SCQ) in a residential care context. The psychometric properties of the instruments were investigated in terms of data quality, construct validity, convergent and divergent validity and reliability, including test–retest reliability, in a residential care context with a sample consisting of nurse assistants (n = 114). The four instruments responded with different psychometric-related problems such as internal missing data, floor and ceiling effects, problems with construct validity and low test–retest reliability, especially when assessed on the item level. These problems were however reduced or disappeared completely when assessed for total and factor scores. From a psychometric perspective, the SDCS seemed to stand out as the best instrument. However, it should be modified in order to reduce floor effects on item level and thereby gain sensitivity. The Job Satisfaction Questionnaire seemed to have problems both with the construct validity and test–retest reliability. The final choice of instrument must, however, be made dependent on what one intends to measure.

Wallin AO, Edberg A-K, Beck I, Jakobsson u. Psychometric properties concerning four instruments measuring job satisfaction, strain, and stress of conscience in a residential care context. Arch Gerontol Geriatr. 2013 May 2. doi:pii: S0167-4943(13)00049-6. 10.1016/j.archger.2013.04.001. [Epub ahead of print]

The uneasy (and changing) relationship of health care and religion in our legal system

Robert K. Vischer

Absract
This article provides a brief introduction to the interplay between law and religion in the health care context. First, I address the extent to which the commitments of a faith tradition may be written into laws that bind all citizens, including those who do not share those commitments. Second, I discuss the law’s accommodation of the faith commitments of individual health care providers—hardly a static inquiry, as the degree of accommodation is increasingly contested. Third, I expand the discussion to include institutional health care providers, arguing that the legal system’s resistance to accommodating the morally distinct identities of institutional providers reflects a short-sighted view of the liberty of conscience. Finally, I offer some tentative thoughts about why these dynamics become even more complicated in the context of Islamic health care providers.

Vischer RK. The uneasy (and changing) relationship of health care and religion in our legal system. Theor Med Bioeth. 2013 Apr;34(2):161-70. doi: 10.1007/s11017-013-9248-2. PubMed PMID: 23546737

(Book Review) Why Tolerate Religion?

Robert Merrihew Adams

Brian Leiter. Why Tolerate Religion? Princeton, NJ: Princeton University Press, 2012, 192 pp. ISBN: 9780691153612

Extract
“Why tolerate religion?” The question is raised by someone who thinks there is something wrong about religion as such. To tolerate, Brian Leiter emphasizes, is to “put up” with beliefs or practices that one regards as “wrong, mistaken, or undesirable” (p. 8). His paradigm case of principled tolerance is one in which a “dominant group has the means at its disposal to effectively and reliably change or end [a] disfavored group’s beliefs or practices, and yet . . . acknowledges that there are moral or epistemic reasons . . . to permit the disfavored group to keep on believing and doing what it does” (p. 13). Forcibly changing or ending religious belief has commonly been extremely difficult or impossible to achieve by any means short of total extermination or banishment of the disfavored group, as history shows, and is therefore a really scary project. With his stated paradigm in mind, we might think that Leiter’s statement that “the contemporary problem, at least in the post-Enlightenment secular nations, . . . is why the state should tolerate religion as such at all” (pp. 14-15), would be ominous indeed if it were an accurate reading of political reality.

Adams RM. Why Tolerate Religion? [Internet]. Notre Dame (IN): University of Notre Dame. Notre Dame Philosophical Reviews; 2013 Jan 6.

Freedom of conscience and health care in the United States of America: The conflict between public health and religious liberty in the Patient Protection and Affordable Care Act

Peter West-Oram

Abstract
The recent confirmation of the constitutionality of the Obama administration’s Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties.

West-Oram P. Freedom of Conscience and Health Care in the United States of America: The Conflict Between Public Health and Religious Liberty in the Patient Protection and Affordable Care Act. Health Care Anal. 2013 Mar 29;21(3):237-247.