0 - Protection of Conscience Project Library

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

Mary Kathleen Deutscher Heilman, Tracy J. Trothen

Abstract
Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one’s conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.

Heilman MKD, Trothen TJ. Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada. J Med Ethics. 2020;46(2):123-127. doi:10.1136/medethics-2019-105855

(News) Woman suing two pharmacies after being denied emergency contraception

The US case brings to light concerns around conscientious objection at a time when a federal religious discrimination bill is being debated in Australia

Sheshtyn Paola

Exract
A woman has filed a lawsuit against a Thrifty White Pharmacy and a CVS Pharmacy in Minnesota in the US, alleging the two pharmacies illegally kept her from accessing emergency contraception.

Andrea Anderson, a 39-year-old mother of five, says she asked the pharmacist at her drugstore in Minnesota more than once why he couldn’t fill her prescription for emergency contraception, according to the Star Tribune.

“I then realised what was happening: he was refusing to fill my prescription for emergency contraception because he did not believe in it,” Ms Anderson said on Tuesday.

Paola S. Woman suing two pharmacies after being denied emergency contraception. Australian Pharm J [Internet]. 2019 Dec 12.

The Independence of Judicial Conscience

Barry W. Bussey

Extract
. . . Competence and character are no longer the sole criteria for evaluating a judicial nominee; candidates face a climate which demands they have the “correct” moral opinions on fundamental human rights issues. Those issues include abortion, marriage, and the euphemistically-termed Medical Assistance in Dying (MAiD). . . to disregard the judicial conscience is to compromise the dignity of the judge, the worth of her convictions, the fullness of her humanity. Even more, it undermines the very essence of what distinguishes a democratic society characterized by diversity, inclusion, and freedom.

Bussey BW. The Independence of Judicial Conscience. J Christian Legal Thought. 2019; 9(2): 34-37.

Do physicians require consent to withhold CPR that they determine to be nonbeneficial?

James Downar, Eliana Close, Robert Sibbald

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
Key Points

The Ontario Superior Court of Justice recently determined that, under both Ontario’s health care consent legislation and common law, physicians do not require consent to withhold cardiopulmonary resuscitation (CPR) that they believe to be medically inappropriate.

Physicians in Ontario need to distinguish carefully between a scenario where CPR would be outside the standard of care and should not be offered and a scenario where CPR is within the standard of care but the physician does not feel it is in the patient’s best interests; each scenario demands a different response.

Physicians still have a professional responsibility to communicate (or make reasonable efforts to communicate) honestly and compassionately about the limitations of CPR and the alternatives to aggressive care.

Downar J, Close E, Sibbald R. Do physicians require consent to withhold CPR that they determine to be nonbeneficial? CMAJ 2019 Nov 25; 191 (47) E1289-E1290; DOI: https://doi.org/10.1503/cmaj.191196.

Colorado End-of-Life Options Act

A Clash of Organizational and Individual Conscience

Matthew Wynia

Journal of the American Medical Association

Extract
The 2016 Colorado End-of-Life Options Act includes a provision unique among states with such laws, specifically privileging individual health care professionals, including physicians and pharmacists, to choose whether to write and fill prescriptions for life-ending medications, such as high-dose secobarbital or various combinations of morphine, diazepam, beta-blockers, and digoxin, without regard to the position their employer has taken on the law. This provision virtually guaranteed the Colorado law would eventually be challenged, which happened in August 2019.¹ The current legal case directly pits the conscience rights of individual health care professionals against those of religiously affiliated corporations. Because 5 of the top 10 US hospital systems by net revenue are now religiously affiliated,² and these systems often restrict medical care in a variety of ways,³ how the case is resolved could have far-reaching implications for US health care, extending well beyond the relatively rare use of aid-in-dying medications at the end of life.

Wynia M. Colorado End-of-Life Options Act: A Clash of Organizational and Individual Conscience. JAMA. 2019;322(20):1953-1954. doi:10.1001/jama.2019.16438

Colorado End-of-Life Options Act: A Clash of Organizational and Individual Conscience

Matthew Wynia

Extract
If the courts rule that the Constitution allows hospitals to exert control over individual physicians’ claims of professional conscience, it will be a victory for corporate medicine. But if the state law is upheld, the case could establish that physicians’ professional conscience claims hold or take precedence over the ethical and religious directives of religiously affiliated hospitals. It is possible that at least some religiously affiliated health systems might rather close than allow that outcome.

Wynia M. Colorado End-of-Life Options Act: A Clash of Organizational and Individual Conscience. J Am Med Ass. 2019 Oct 29;322(20):1953-1954.

In the Footsteps of Teiresias: Treatment for Gender Dysphoria in Children and the Role of the Courts

Mike O’Connor, Bill Madden

The Family Court of Australia has stepped back from a previously perceived need for involvement in the approval of stage 1 and stage 2 treatments, for children requiring gender transformation. At present those children and their families who are in agreement need not seek authorisation of the Family Court to undertake either Stage 1 (pubarche blockade with gonadotrophin-releasing hormone agonists) or Stage 2 treatment (cross-hormone therapy such as oestrogen for transgender males). Stage 1 treatment to suppress pubarche would nowadays be commenced at Tanner stage 2 which commences as early as 9.96 years in girls and 10.14 years in boys. Suppression of puberty continues until the age of 16 years when cross hormonal treatment commences. This article questions the assertion that suppression of puberty by GnRH analogues either in cases of precocious puberty or gender dysphoria is “safe and reversible” and argues that it warrants ongoing caution, despite the Family Court having broadly accepted that assertion.

O’Connor M, Madden B. In the Footsteps of Teiresias: Treatment for Gender Dysphoria in Children and the Role of the Courts. J Law Med. 2019 Oct;27(1):149-163.

Is it ever morally permissible to select for deafness in one’s child?

Jacqueline Mae Wallis

Abstract
As reproductive genetic technologies advance, families have more options to choose what sort of child they want to have. Using preimplantation genetic diagnosis (PGD), for example, allows parents to evaluate several existing embryos before selecting which to implant via in vitro fertilization (IVF). One of the traits PGD can identify is genetic deafness, and hearing embryos are now preferentially selected around the globe using this method. Importantly, some Deaf families desire a deaf child, and PGD–IVF is also an option for them. Selection for genetic deafness, however, encounters widespread disapproval in the hearing community, including mainstream philosophy and bioethics. In this paper I apply Elizabeth Barnes’ value-neutral model of disability as mere-difference to the case of selecting for deafness. I draw on evidence from Deaf Studies and Disability Studies to build an understanding of deafness, the Deaf community, and the circumstances relevant to reproductive choices that may obtain for some Deaf families. Selection for deafness, with deafness understood as mere-difference and valued for its cultural identity, need not necessitate impermissible moral harms. I thus advocate that it is sometimes morally permissible to select for deafness in one’s child.

Wallis, J.M. Is it ever morally permissible to select for deafness in one’s child?. Med Health Care and Philos 23, 3–15 (2020). https://doi.org/10.1007/s11019-019-09922-6

Professionalism eliminates religion as a proper tool for doctors rendering advice to patients

Udo Schuklenk

Abstract:Religious considerations and language do not typically belong in the professional advice rendered by a doctor to a patient. Among the rationales mounted by Greenblum and Hubbard in support of that conclusion is that religious considerations and language are incompatible with the role of doctors as public officials.1 Much as I agree with their conclusion, I take issue with this particular aspect of their analysis. It seems based on a mischaracterisation of what societal role doctors fulfil, qua doctors. What obliges doctors to communicate by means of content that is expressed in public reason-based language is not that they are public officials. Doctors as doctors are not necessarily public officials. Rather, doctors have such obligations, because they are professionals. Unlike public officials doctors are part of a profession that is to a significant extent self-governing. This holds true for all professions. The …

Responding to religious patients: why physicians have no business doing theology. Jake Greenblum Ryan K Hubbard Journal of Medical Ethics 2019; – Published Online First: 20 Jun 2019. doi: 10.1136/medethics-2019-105452

Schuklenk U. Professionalism eliminates religion as a proper tool for doctors rendering advice to patients. J Medical Ethics. 2019 Sep 12. pii: medethics-2019-105703. doi: 10.1136/medethics-2019-105703. [Epub ahead of print]

Why not common morality?

Rosamond Rhodes

Abstract
This paper challenges the leading common morality accounts of medical ethics which hold that medical ethics is nothing but the ethics of everyday life applied to today’s high-tech medicine. Using illustrative examples, the paper shows that neither the Beauchamp and Childress four-principle account of medical ethics nor the Gert et al 10-rule version is an adequate and appropriate guide for physicians’ actions. By demonstrating that medical ethics is distinctly different from the ethics of everyday life and cannot be derived from it, the paper argues that medical professionals need a touchstone other than common morality for guiding their professional decisions. That conclusion implies that a new theory of medical ethics is needed to replace common morality as the standard for understanding how medical professionals should behave and what medical professionalism entails. En route to making this argument, the paper addresses fundamental issues that require clarification: what is a profession? how is a profession different from a role? how is medical ethics related to medical professionalism? The paper concludes with a preliminary sketch for a theory of medical ethics.

Rhodes R. Why not common morality? J Med Ethics 2019;0:1–8. Published Online First: 11 September 2019. doi: 10.1136/medethics-2019-105621