0 - Protection of Conscience Project Library

Objection to conscience. An argument against conscience exemptions in healthcare

Alberto Giubilini

Abstract
I argue that appeals to conscience do not constitute reasons for granting healthcare professionals exemptions from providing services they consider immoral (e.g. abortion). My argument is based on a comparison between a type of objection that many people think should be granted, i.e. to abortion, and one that most people think should not be granted, i.e. to antibiotics. I argue that there is no principled reason in favour of conscientious objection qua conscientious that allows to treat these two cases differently. Therefore, I conclude that there is no principled reason for granting conscientious objection qua conscientious in healthcare. What matters for the purpose of justifying exemptions is not whether an objection is ‘conscientious’, but whether it is based on the principles and values informing the profession. I provide examples of acceptable forms of objection in healthcare.

Giubilini A. Objection to conscience. An argument against conscience exemptions in healthcare. Bioethics. 2016;31(5):400-408.

Conscience and Agent-Integrity: A Defence of Conscience-Based Exemptions in the Health Care Context

Mary Neal, Sara Fovargue

Abstract
The issue of conscientious refusal by health care practitioners continues to attract attention from academics, and was the subject of a recent UK Supreme Court decision. Activism aimed at changing abortion law and the decision to devolve governance of abortion law to the Scottish Parliament both raise the prospect of altered provision for conscience in domestic law. In this article, building on earlier work, we argue that conscience is fundamentally connected to moral integrity and essential to the proper functioning of moral agency. We examine recent attempts to undermine the view of conscience as a matter of integrity and argue that these have been unsuccessful. With our view of conscience as a prerequisite for moral integrity and agency established and defended, we then take issue with the ‘incompatibility thesis’ (the claim that protection for conscience is incompatible with the professional obligations of health care practitioners). We reject each of the alternative premises on which the incompatibility thesis might rest, and challenge the assumption of a public/private divide which is entailed by all versions of the thesis. Finally, we raise concerns about the apparent blindness of the thesis to issues of power and privilege, and conclude that conscience merits robust protection.

Neal M, Fovargue S. Conscience and Agent-Integrity: A Defence of Conscience-Based Exemptions in the Health Care Context. Med Law Rev. 2016 Nov 1;24(4):544-570. doi: 10.1093/medlaw/fww023

Patient’s Autonomy, Physician’s Convictions and Euthanasia in Belgium

Raphael Cohen-Almagor

Abstract
The aim of this paper is to show the inherent contradiction in the Belgian euthanasia practice. While stressing patient’s autonomy, medical professionals exhibit paternalism in deciding the patient’s fate. First, background information is provided. Then the 2014 Belgian Society of Intensive Care Medicine Council Statement Paper will be considered. Concerns are voiced about euthanizing people who fail to find meaning in their lives, including those who underwent unsuccessful sex-change operation and blind people, euthanizing patients who did not give their consent, and euthanizing people with dementia. Finally, some suggestions designed to improve the situation are offered.

Cohen-Almagor R. Patient’s Autonomy, Physician’s Convictions and Euthanasia in Belgium. Annual Rev Law Ethics. 2016 Dec;24:343-356.

Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community

Joan Liaschenko, Elizabeth Peter

Abstract:
It may be the case that the most challenging moral problem of the twenty-first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker’s and Hilde Lindemann’s concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one’s identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing’s morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency.

Liaschenko J, Peter E. Fostering Nurses’ Moral Agency and Moral Identity: The Importance of Moral Community. The Hastings Center Report, Volume 46, Issue S1, September/October 2016, Pages S18–S21.

An Unholy Mess: Why ‘The Sanctity of Life Principle’ Should Be Jettisoned.

David Albert Jones

Abstract
The aim of this article is to present an account of an important element of medical ethics and law which is widely cited but is often confused. This element is most frequently referred to as ‘the principle of the sanctity of life’, and it is often assumed that this language has a religious provenance. However, the phrase is neither rooted in the traditions it purports to represent nor is it used consistently in contemporary discourse. Understood as the name of an established ‘principle’ the ‘sanctity of life’ is virtually an invention of the late twentieth century. The language came to prominence as the label of a position that was being rejected: it is the name of a caricature. Hence there is no locus classicus for a definition of the terms and different authors freely apply the phrase to divergent and contradictory positions. Appeal to this ‘principle’ thus serves only to perpetuate confusion. This language is best jettisoned in favour of clearer and more traditional ethical concepts.

Jones DA, An Unholy Mess: Why ‘The Sanctity of Life Principle’ Should Be Jettisoned. The New Biothics, Vol. 22, 2016, Issue 3.

Rationing conscience

Dominic Wilkinson

Abstract
Decisions about allocation of limited healthcare resources are frequently controversial. These decisions are usually based on careful analysis of medical, scientific and health economic evidence. Yet, decisions are also necessarily based on value judgements. There may be differing views among health professionals about how to allocate resources or how to evaluate existing evidence. In specific cases, professionals may have strong personal views (contrary to professional or societal norms) that treatment should or should not be provided. Could these disagreements rise to the level of a conscientious objection? If so, should conscientious objections to existing allocation decisions be accommodated? In the first part of this paper, I assess whether resource allocation could be a matter of conscience. I analyse conceptual and normative models of conscientious objection and argue that rationing could be a matter for conscience. I distinguish between negative and positive forms: conscientious non-treatment and conscientious treatment. In the second part of the paper, I identify distinctive challenges for conscientious objections to resource allocation. Such objections are almost always inappropriate.

Wilkinson D. Rationing conscience. J Med Ethics doi:10.1136/medethics-2016-103795

Further clarity on cooperation and morality

David S. Oderberg

Abstract
I explore the increasingly important issue of cooperation in immoral actions, particularly in connection with healthcare. Conscientious objection, especially as pertains to religious freedom in healthcare, has become a pressing issue in the light of the US Supreme Court judgement in Hobby Lobby. Section ‘Moral evaluation using the basic principles of cooperation’ outlines a theory of cooperation inspired by Catholic moral theologians such as those cited by the court. The theory has independent plausibility and is at least worthy of serious consideration—in part because it is an instance of double-effect reasoning, which is also independently plausible despite its association with moral theology. Section ‘Case study: Burwell v. Hobby Lobby’ examines Hobby Lobby in detail. Even if the judgement was correct in that case the reasoning was not, as it involved applying a ‘mere sincerity’ test to the cooperation question. The mere sincerity test leads to absurd consequences, whereas a reasonableness test applied using the theory of cooperation defended here would avoid absurdity. Section ‘A question of remoteness: “accommodations” and opt-outs’ explores the post-Hobby Lobby problem further, examining opt-outs and accommodations: the Little Sisters of the Poor case shows how opt-outs are misunderstood on a mere sincerity test, which the court rightly rejected. Section ‘Application to the medical field: Doogan and Wood’ discusses the UK case of Doogan and Wood, concerning participation in abortion. Again, a judicially recognised ethic of cooperation, if it were part of the fabric of legal reasoning in such cases, would have enabled the conscientious objectors in this and similar situations to have their freedom of conscience and religion respected in a way that it currently is not.

Oderberg DS, Further clarity on cooperation and morality. J Med Ethics doi:10.1136/medethics-2016-103476

Conscientious objection in healthcare, referral and the military analogy

Steve Clarke

Abstract
An analogy is sometimes drawn between the proper treatment of conscientious objectors in healthcare and in military contexts. In this paper, I consider an aspect of this analogy that has not, to my knowledge, been considered in debates about conscientious objection in healthcare. In the USA and elsewhere, tribunals have been tasked with the responsibility of recommending particular forms of alternative service for conscientious objectors. Military conscripts who have a conscientious objection to active military service, and whose objections are deemed acceptable, are required either to serve the military in a non-combat role, or assigned some form of community service that does not contribute to the effectiveness of the military. I argue that consideration of the role that military tribunals have played in determining the appropriate form of alternative service for conscripts who are conscientious objectors can help us to understand how conscientious objectors in healthcare ought to be treated. Additionally, I show that it helps us to address the vexed issue of whether or not conscientious objectors who refuse to provide a service requested by a patient should be required to refer that patient to another healthcare professional.

Clarke S. Conscientious objection in healthcare, referral and the military analogy. J Med Ethics 2016;0:1–4. doi:10.1136/medethics-2016-103777

Reasons, reasonability and establishing conscientious objector status in medicine

Robert F. Card

Abstract
This paper builds upon previous work in which I argue that we should assess a provider’s reasons for his or her objection before granting a conscientious exemption. For instance, if the medical professional’s reasoned basis involves an empirical mistake, an accommodation is not warranted. This article poses and begins to address several deep questions about the workings of what I call a reason-giving view: What standard should we use to assess reasons? What policy should we adopt in order to evaluate the reasons offered by medical practitioners in support of their objections? I argue for a reasonability standard to perform the essential function of assessing reasons, and I offer considerations in support of a policy establishing conscientious objector status in medicine.

Card RF. Reasons, reasonability and establishing conscientious objector status in medicine. J Med Ethics doi:10.1136/medethics-2016-103792

Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception

Julian Savulescu, Udo Schuklenk

Abstract
In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors’ personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: (1) removing a right to conscientious objection; (2) selecting candidates into relevant medical specialities or general practice who do not have objections; (3) demonopolizing the provision of these services away from the medical profession.

Savulescu J, Schuklenk U. (2016) Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics. doi:10.1111/bioe.12288