Reproductive health services and the law and ethics of conscientious objection

Bernard M. Dickens

Medicine and Law

Abstract: Reproductive health services address contraception, sterilization and abortion, and new technologies such as gamete selection and manipulation, in vitro fertilization and surrogate motherhood. Artificial fertility control and medically assisted reproduction are opposed by conservative religions and philosophies, whose adherents may object to participation. Physicians’ conscientious objection to non-lifesaving interventions in pregnancy have long been accepted. Nurses’ claims are less recognized, allowing nonparticipation in abortions but not refusal of patient preparation and aftercare. Objections of others in health-related activities, such as serving meals to abortion patients and typing abortion referral letters, have been disallowed. Pharmacists may claim refusal rights over fulfilling prescriptions for emergency (post-coital) contraceptives and drugs for medical (i.e. non-surgical) abortion. This paper addresses limits to conscientious objection to participation in reproductive health services, and conditions to which rights of objection may be subject. Individuals have human rights to freedom of religious conscience, but institutions, as artificial legal persons, may not claim this right.


Dickens BM. Reproductive health services and the law and ethics of conscientious objection. Med Law. 2001;20(2):283-93.

The scope and limits of conscientious objection

Bernard M. Dickens, Rebecca J. Cook

International Journal of Gynecology & Obstetrics

Abstract: Principles of religious freedom protect physicians, nurses and others who refuse participation in medical procedures to which they hold conscientious objections. However, they cannot decline participation in procedures to save life or continuing health. Physicians who refuse to perform procedures on religious grounds must refer their patients to non-objecting practitioners. When physicians refuse to accept applicants as patients for procedures to which they object, governmental healthcare administrators must ensure that non-objecting providers are reasonably accessible. Nurses’ conscientious objections to participate directly in procedures they find religiously offensive should be accommodated, but nurses cannot object to giving patients indirect aid. Medical and nursing students cannot object to be educated about procedures in which they would not participate, but may object to having to perform them under supervision. Hospitals cannot usually claim an institutional conscientious objection, nor discriminate against potential staff applicants who would not object to participation in particular procedures.


Dickens BM, Cook RJ. The scope and limits of conscientious objection. Int J Gynaecol Obstet. 2000 Oct;71(1):71-7.

Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands

Johanna H. Groenewoud, Agnes van der Heide, Bregje D. Onwuteaka-Philipsen, Dick L. Willems, Paul J. van der Maas, Gerrit van der Wal

NEJM

Background and Methods

The characteristics and frequency of clinical problems with the performance of euthanasia and physician-assisted suicide are uncertain. We analyzed data from two studies of euthanasia and physician-assisted suicide in the Netherlands (one conducted in 1990 and 1991 and the other in 1995 and 1996), with a total of 649 cases. We categorized clinical problems as technical problems, such as difficulty inserting an intravenous line; complications, such as myoclonus or vomiting; or problems with completion, such as a longer-than-expected interval between the administration of medications and death.

Results

In 114 cases, the physician’s intention was to provide assistance with suicide, and in 535, the intention was to perform euthanasia. Problems of any type were more frequent in cases of assisted suicide than in cases of euthanasia. Complications occurred in 7 percent of cases of assisted suicide, and problems with completion (a longer-than-expected time to death, failure to induce coma, or induction of coma followed by awakening of the patient) occurred in 16 percent of the cases; complications and problems with completion occurred in 3 percent and 6 percent of cases of euthanasia, respectively. The physician decided to administer a lethal medication in 21 of the cases of assisted suicide (18 percent), which thus became cases of euthanasia. The reasons for this decision included problems with completion (in 12 cases) and the inability of the patient to take all the medications (in 5).

Conclusions

There may be clinical problems with the performance of euthanasia and physician-assisted suicide. In the Netherlands, physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient’s inability to take the medication or because of problems with the completion of physician-assisted suicide.


Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. N Engl J Med 2000; 342:551-556 February 24, 2000 DOI:10.1056/NEJM200002243420805

Some legal and ethical issues in assisted reproductive technology

Bernard M. Dickens, Rebecca J. Cook

International Journal of Gynecology & Obstetrics

Abstract: The potential and actual applications of reproductive technologies have been reviewed by many governmental committees, and laws have been enacted in several countries to accommodate, limit and regulate their use. Regulatory systems have nevertheless left some legal and ethical issues unresolved, and have caused other issues to arise. Issues that regulatory systems leave unresolved, or that systems have created, include disposal of embryos that remain after patients’ treatments are concluded, and multiple implantation and pregnancy. This may result in risks to maternal, embryonic and neonatal life and health, and the contentious relief that may be achieved by selective reduction of multiple pregnancies. A further concern arises when clinics must or choose to publicize their success rates, and they compete for favorable statistics  by questionable patient selection criteria and treatment priorities.


Dickens BM, Cook RJ. Some legal and ethical issues in assisted reproductive technology. Int J Gynaecol Obstet. 66 (1999) 55-61

Nuremberg and the Issue of Wartime Experiments on US Prisoners

The Green Committee

Jon M. Harkness

Journal of the American Medical Association

Abstract

Defense attorneys at the Nuremberg Medical Trial argued that no ethical difference existed between experiments in Nazi Concentration camps and research in U.S. prisons. Investigations that had taken place in an Illinois prison became an early focus of this argument. Andrew C. Ivy, MD, whom the American Medical Association had selected as a consultant to the Nuremeberg prosecutors, responded to courtroom crticisim of research in his home state by encouraging the Illinois governor to establish a committee to evaluate prison research. The governor names a committee and accepted Ivy’s offer to chair the panel. Late in the trial, Ivy testified – drawing on the authority of this committee – that research on Us prisoners was ethically ideal. However, the governor’s committee had never met. After the trial’s conclusion, the report was published in JAMA, where it became a source of support for experimentation on prisoners.


Harkness J. Nuremberg and the Issue of Wartime Experiments on US Prisoners: The Green Committee. JAMA. 1996;276(20):1672–1675. doi:10.1001/jama.1996.03540200058032

Freedom of conscience, professional responsibility, and access to abortion

Rebecca S. Dresser

The Journal of Law, Medicine & Ethics

Acess to abortion is becoming increasingly restricted for many women in the United States.  Besides the longstanding financial barriers facing low-income women in most states, a newer source of scar­ city has emerged. The relatively small  number of physicians willing to perform the procedure is compromising the ability of women in  certain parts of the country to obtain an abortion. Do physicians have a duty to respond to this situation? Do they have a professional responsibility  to ensure that abortions are reasonably available to the women who want to terminate their  pregnancies? Or, is abortion so morally and socially controversial as to remove any professional  obligation to provide reasonable access?


Dresser RS. Freedom of conscience, professional responsibility, and access to abortion. J Law Med Ethics 1994 Fall;22(3):280-5.