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A Most Fundamental Freedom of Choice: An International Review of Conscientious Objection to Elective Abortion

Erin Whitcomb

St. John's Journal of Legal Commentary — St. John’s Journal of Legal Commentary

Abstract
Conclusion
American President Thomas Jefferson once explained, “[t]he price of freedom is eternal vigilance.”210 He also warned, “It behooves every man who values liberty of conscience for himself, to resist invasions of it in the case of others.”211 As this Note demonstrates, even in constitutional democracies that have provided their people with broad, enumerated individual liberties, the threat of erosion of rights is ever-present. No rights, even those that seem most fundamental—like freedom of conscience—are immune. They must be avidly protected and defended. The individual choice guaranteed by statutory conscience protection demonstrates respect for the autonomy of health care providers, promotes the integrity of the medical profession,212 and protects the rights of healthcare professionals without compromising those of patients. Failure to protect individual conscience rights will be devastating to any democratic society.213

The absence of a statute compelling health care professionals’ participation in abortion is irrelevant to those in functionally equivalent circumstances, just as the cases of registered nurse Sister Charles in South Africa, American nurse Catherina Cenzon-DeCarlo, and the unnamed Canadian medical student remind us. Health care professionals who are discriminated against on the basis of their conscientious unwillingness to participate in elective abortion procedures must not be left without a remedy. South Africa and Canada should enact statutory conscience protection measures without delay. Similarly, the statutory and regulatory conscience protection established thus far in the United States must be vigilantly protected from erosion.

A matter of choice for one person should not result in a matter of compulsion for another, particularly where the matter is one of such significant moral or religious import. The “freedom to choose” so often associated with elective abortion must be extended to medical professionals who would choose to follow the dictates of their own consciences in abstaining from a practice, which, in their view, is hostile to the ethical obligations of the practice of medicine and violates the profound and inherent dignity of the human person.

Whitcomb E. A Most Fundamental Freedom of Choice: An International Review of Conscientious Objection to Elective Abortion. St. John’s J Legal Com. 2010;24(4):771-809.

Making Rules and Unmaking Choice: Federal Conscience Clauses, the Provider Conscience Regulation, and the War on Reproductive Freedom

Rachel White-Domain

Extract
Conclusion
This Comment analyzes the PCR, which is currently under review by the Obama Administration. As currently written, the PCR promises to have devastating effects on the healthcare system. . .

Commenters have predicted that the PCR will be used to discriminate against patients based on their sexual orientation. 196 And because reproductive healthcare remains so controversial in this country, women will be disproportionately disadvantaged by the PCR, which now allows almost all employees-not only the doctor, but potentially the nurse, the pharmacist, the pharmacist’s assistant, the receptionist, the ambulance driver, and the janitor-to have a say in whether she can access her chosen healthcare without interference.

The PCR brought the ongoing debate over conscience clauses into the national spotlight. . . .this Comment argues that any analysis of conscience clauses must recognize that what is at stake is access to healthcare services, and that reduction of healthcare access can be accomplished not only explicitly, for example through the explicit redefining of the term “abortion,” but also through “strategic ambiguity.” . . .

White-Domain R. Making Rules and Unmaking Choice: Federal Conscience Clauses, the Provider Conscience Regulation, and the War on Reproductive Freedom. DePaul Law Rev. 2010 Summer;59(4):1249-1281.

Religion and conscientious objection: a survey of pharmacists’ willingness to dispense medications

Laura A.Davidson, Clare T.Pettis, Amber J.Joiner, Daniel M.Cook, Craig M.Klugmand

Abstract
Some US states allow pharmacists to refuse to dispense medications to which they have moral objections, and federal rules for all health care providers are in development. This study examines whether demographics such as age, religion, gender influence 668 Nevada pharmacists’ willingness to dispense or transfer five potentially controversial medications to patients 18 years and older: emergency contraception, medical abortifacients, erectile dysfunction medications, oral contraceptives, and infertility medications. Almost 6% of pharmacists indicated that they would refuse to dispense and refuse to transfer at least one of these medications. Religious affiliation significantly predicted pharmacists’ willingness to dispense emergency contraception and medical abortifacients, while age significantly predicted pharmacists’ willingness to distribute infertility medications. Evangelical Protestants, Catholics and other-religious pharmacists were significantly more likely to refuse to dispense at least one medication in comparison to non-religious pharmacists in multinomial logistic regression analyses. Awareness of the influence of religion in the provision of pharmacy services should inform health care policies that appropriately balance the rights of patients, physicians, and pharmacists alike. The results from Nevada pharmacists may suggest similar tendencies among other health care workers, who may be given latitude to consider morality and value systems when making clinical decisions about care.

Davidson LA, Pettis CT, Joiner AJ, Cook DM, Klugman CM. Religion and conscientious objection: a survey of pharmacists’ willingness to dispense medications. Soc Sci Med. 2010 Jul;71(1):161-5. Epub 2010 Apr 13. PubMed PMID: 20447746

Perceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care

Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin

Abstract
Aim.: This paper is a report of a study of patterns of perceptions of conscience, stress of conscience and burnout in relation to occupational belonging among Registered Nurses and nursing assistants in municipal residential care of older people.

Background.: Stress and burnout among healthcare personnel and experiences of ethical difficulties are associated with troubled conscience. In elder care the experience of a troubled conscience seems to be connected to occupational role, but little is known about how Registered Nurses and nursing assistants perceive their conscience, stress of conscience and burnout.

Method.: Results of previous analyses of data collected in 2003, where 50 Registered Nurses and 96 nursing assistants completed the Perceptions of Conscience Questionnaire, Stress of Conscience Questionnaire and Maslach Burnout Inventory, led to a request for further analysis. In this study Partial Least Square Regression was used to detect statistical predictive patterns.

Result.: Perceptions of conscience and stress of conscience explained 41·9% of the variance in occupational belonging. A statistical predictive pattern for Registered Nurses was stress of conscience in relation to falling short of expectations and demands and to perception of conscience as demanding sensitivity. A statistical predictive pattern for nursing assistants was perceptions that conscience is an authority and an asset in their work. Burnout did not contribute to the explained variance in occupational belonging.

Conclusion.: Both occupational groups viewed conscience as an asset and not a burden. Registered Nurses seemed to exhibit sensitivity to expectations and demands and nursing assistants used their conscience as a source of guidance in their work. Structured group supervision with personnel from different occupations is needed so that staff can gain better understanding about their own occupational situation as well as the situation of other occupational groups.

Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care. J Adv Nurs. 2010;66(8):1708-1718.

Physician-assisted deaths under the euthanasia law in Belgium: A population-based survey

Kenneth Chambaere, Johan Bilsen, Joachim Cohen, Bregje D Onwuteaka-Philipsen, Freddy Mortier, Luc Deliens

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Abstract
Background: Legalization of euthanasia and physician-assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life-ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.

Methods: We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.

Results: The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Euthanasia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient’s explicit re quest, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.

Interpretation: Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.

Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F, Deliens L. Physician-assisted deaths under the euthanasia law in Belgium: A population-based survey. Can Med Assoc J. 2010 Jun 15;182(9):895-901.

Maryland’s conscience clause: leaving a woman’s right to a health care provider’s choice

Maria Cirincione

Extract
Conclusion
. . . Currently, ambiguities in the Maryland statute allow too much flexibility for providers in emergency rooms to refuse to provide or even inform patients about emergency contraception. This kind of state sanctioned refusal serves as the kind of government obstacle the Supreme Court has forbidden in upholding a woman’s right to bodily privacy. The Maryland legislature should act to eliminate the ambiguities in Maryland’s conscience legislation and explicitly protect a woman’s right to access emergency contraception in Maryland emergency rooms. In order to do so, the Maryland legislature should adopt the medical community’s definition for abortion that excludes emergency contraception. The new Maryland conscience statute should also provide explicit protections to patients receiving emergency room care. Physicians should be required to inform patients of emergency contraception if treatment in each particular case is medically indicated. Finally, physicians should be required to treat patients that request access to emergency contraception or to refer them to another provider who is willing to administer treatment within the effective time period of emergency contraception. . .

Cirincione M. Maryland’s conscience clause: leaving a woman’s right to a health care provider’s choice. J Health Care Law & Pol. 2010;13(1):171-202.

Professional Conscientious Objection in Medicine with Attention to Referral

Thomas A Cavanaugh

Extract
What duties accompany conscientious objection? To sum up what follows: The obligations to the patient remain unchanged, but for the denial of the contested request.

Specifically, what do these obligations entail? First, following from the very meaning of professing—and to develop a point previously mooted—full disclosure imposes the obligation to promulgate to the relevant parties one’s conscientious objection. This includes one’s prospective and current patients, colleagues, employers, and relevant institutions, for example hospitals and insurance companies. . . .

Second, conscientious objector status obliges the relevant professional to explain her reasons for her objection to those patients who request further information. . . . the patient is due the offer of an explanation. This does not, however, amount to the professional’s having a right to pontificate concerning the relevant matter. Rather, the interested patient ought to receive some answer to the question as to why the professional objects. Certainly, not all patients will be interested to know why. Those who are not interested ought not to be treated as captive audiences; those who do want to know ought to receive a considerate and considered answer. . .

Third, conscientious objector status bears exclusively on the patient’s contested request; it does not relate to the other care the physician, nurse, or pharmacist provides for the patient. If a relationship exists with the patient . . . the physician, nurse, or pharmacist must provide care to which she does not object. . .

Fourth, conscientious objector status requires the continued maintenance of confidentiality, particularly with respect to the fact that the professional objects to something the patient requests. . . .the professional must strenuously and scrupulously protect the patient’s privacy specifically concerning the patient’s request and the practitioner’s conscientious objection.

Finally, as earlier noted, while conscientious objection does not require referral to a third party who will abide by the patient’s request, it does require transfer of relevant documents, returning a prescription, and, more generally, acts which, while they may result in the act to which one objects, do not require one to aim at that act.

Cavanaugh T. Professional Conscientious Objection in Medicine with Attention to Referral. Ave Maria Law Rev. 2011;9(1):190-206.

Living Together with Disagreement: Pluralism, the Secular, and the Fair Treatment of Beliefs in Canada Today

Iain T Benson

Abstract
The Supreme Court of Canada’s decision in Chamberlain,referred to above, in how it handled the definition of “secular” and pluralism as requiring the inclusion of religion and religious viewpoints, is a model for the law and the first serious consideration of a non-atheistic/agnostic (or secularistic) “secular” in Canada. It, and the TWU decision, provide the beginning outlines of an approach to both pluralism and the secular that will be superior to the preemptively non-religious and atheistic/agnostic understandings that preceded them. The decision also correctly describes the nature of pluralism as one that encourages a diversity of beliefs and that resists the co-option of “secular” society by totalistic conceptions of liberalism that exclude diversity.

These decisions ought to lead to a reconsideration of how we view law and policies in relation to all public aspects of society, including public education. Pluralism can be and needs to be re-conceptualized within existing legal norms and the Canadian historical tradition, so as to foster a richer conception of diversity and genuine tolerance with an appropriately communitarian focus. For pluralism to be pluralism, however, it is important to rescue it from a pseudo-liberalism that hides its totalistic claims.

Benson IT, Fielding A. Living Together with Disagreement: Pluralism, the Secular, and the Fair Treatment of Beliefs in Canada Today [Internet]. Camrose, Alberta: The Ronning Centre for the Study of Religion and Public Life; 2010: 1-48.

Liberalism Unbound: Towards a More Inclusive Public Sphere

A Response to Iain T. Benson, “Living Together with Disagreement:
Pluralism, the Secular and the Fair Treatment of Beliefs
in Canada Today”

Alex Fielding

Liberalism Unbound: Towards a More Inclusive Public Sphere

Abstract
This response will be divided into three segments. First, it will respond to Benson’s analysis of pluralism, liberalism, and the “secular”. Second, it will advocate for a return to John Stuart Mill’s harm principle as a better way of reconciling competing claims when equality rights and religious freedoms collide. Third, it will apply the harm principle to the contemporary issues of same-sex marriage and the religious objections of marriage commissioners. The central idea is that by moving away from the vague, all-encompassing language of “Charter values” to the harm principle, we create a more pluralistic public sphere that gives reasons for religious and ethnic minorities to reciprocate such tolerance and participate actively in civil society.

Relationship between nurses’ organizational trust levels and their organizational citizenship behaviors

Serap Altuntas, Ulku Baykal

Abstract
Purpose: This research used a descriptive and explorative design to determine the levels of nurses’ organizational trust and organizational citizenship and to investigate relationships between the levels of organizational trust and organizational citizenship behaviors.

Design and Methods: Nurses who had completed their orientation from a total of 11 hospitals with bed capacities of 100 and located in the European district of Istanbul were included in the sample for this study. Formal, written applications and approval of the ethical committee were obtained from concerned institutions before proceeding with the data collection step. The Organizational Trust Inventory and the Organizational Citizenship Level Scale, a questionnaire form including five questions regarding nurses’ personal characteristics, were used in data collection. Data collection tools were distributed to 900 nurses in total, and usable data were obtained from 482 nurses. Number and percentage calculations and Pearson correlation analysis were used to assess research data.

Findings: The results of the present research showed that nurses had a higher than average level of trust in their managers and coworkers and they trusted more in their managers and coworkers than their institutions. The Organizational Citizenship Level Scale indicated that the behavior most frequently demonstrated by the nurses was conscientiousness, followed by courtesy and civic virtue, whereas sportsmanship was displayed to an average extent. An analysis of relationships between nurses’ level of organizational trust and their organizational citizenship behaviors revealed that nurses who trust in their managers, institutions, and coworkers demonstrated the organizational citizenship behaviors of conscientiousness, civic virtue, courtesy, and altruism more frequently.

Conclusions: The findings attained in this study indicated that the organizational trust the staff had in their institutions, managers, and coworkers influenced the organizational citizenship behaviors of conscientiousness, civic virtue, altruism, and courtesy, whereas it had no effect on sportsmanship behavior. Nurse managers should introduce studies to improve their subordinates’ organizational trust to ensure that they develop organizational citizenship behaviors, and they should support them in this process.

Clinical Relevance: These topics for nursing services will provide guidance to managers, particularly to managers of nursing services, in establishing processes to predict nurses’ organizational commitment, job satisfaction, performance, intention to leave, and other relevant issues.

Altuntas S, Baykal U. Relationship between nurses’ organizational trust levels and their organizational citizenship behaviors. J Nurs Scholarsh. 2010 Jun;42(2):186-94.