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Triangular reflective equilibrium: A conscience-based method for bioethical deliberation

Y Michael Barilan, Margherita Brusa

Abstract
Following a discussion of some historical roots of conscience, we offer a systematized version of reflective equilibrium. Aiming at a comprehensive methodology for bioethical deliberation, we develop an expanded variant of reflective equilibrium, which we call ‘triangular reflective equilibrium’ and which incorporates insights from hermeneutics, critical theory and narrative ethics. We focus on a few distinctions, mainly between methods of justification in ethics and the social practice of bioethical deliberation, between coherence in ethical reasoning, personal integrity and consensus formation, and between political and moral deliberation. The ideal of deliberation is explicated as a sharing of conscience within a special commitment to sincerity and openness to persuasion. Personal growth in wisdom is an indirect by-product of the continuous practice of moral deliberation. This is explicated in the light of Sternberg’s balance theory of wisdom and in the context of medicine as a profession embodying altruistic responsibilities of care in democratic and pluralistic societies.

Barilan YM, Brusa M. Triangular reflective equilibrium: A conscience-based method for bioethical deliberation. Bioethics. 2011;25(6):304-319.

Process and Outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey

Yanna Van Wesemael, Joachim Cohen, Johan Bilsen, Tinne Smets, Bregje D Onwuteaka-Philipsen, Luc Deliens

Abstract
Context: Since 2002, the administration of a lethal drug by a physician at the explicit request of the patient has been legal in Belgium. The incidence of euthanasia in Belgium has been studied, but the process and outcomes of euthanasia requests have not been investigated.

Objectives: To describe which euthanasia requests were granted, withdrawn, and rejected since the enactment of the euthanasia law in terms of the characteristics of the patient, treating physician, and aspects of the consultation with a second physician.

Methods: A representative sample of 3006 Belgian physicians received a questionnaire investigating their most recent euthanasia request.

Results: The response rate was 34%. Since 2002, 39% of respondents had received a euthanasia request. Forty-eight percent of requests had been carried out, 5% had been refused, 10% had been withdrawn, and in 23%, the patient had died before euthanasia could be performed. Physicians’ characteristics associated with receiving a request were not being religious, caring for a high number of terminally ill patients, and having experience in palliative care. Patient characteristics associated with granting a request were age, having cancer, loss of dignity, having no depression, and suffering without prospect of improvement as a reason for requesting euthanasia. A positive initial position toward the request from the attending physician and positive advice from the second physician also contributed to having a request granted.

Conclusion: Under the Belgian Act on Euthanasia, about half of the requests are granted. Factors related to the reason for the request, position of the attending physician toward the request, and advice from the second physician influence whether a request is granted or not.

Wesemael YV, Cohen J, Bilsen J, Smets T, Onwuteaka-Philipsen BD, Deliens L. Process and outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey. J Pain Symptom Manage. 2011 May 16;42(5):721-733.

Would Accommodating Some Conscientious Objections by Physicians Promote Quality in Medical Care?

Douglas B White, Baruch Brody

Journal of the American Medical Association

Abstract
Conclusion
The notion that protecting physicians’ consciences benefits physicians at the expense of patients has created an overly simplistic dialogue about conscience in medicine. Viewing the issue from a societal perspective and conceptualizing medical quality as a public good allow a more robust understanding of the relationship between CBR and quality medical care. Policies that allow some CBRs while also ensuring patients’ access to the requested services may yield better overall medical quality by fostering a diverse workforce that possesses integrity, sensitivity to patients’ needs, and respect for diversity. This analysis is necessary for a genuine public discussion about how to handle moral pluralism among patients and physicians. The societal perspective should be incorporated into efforts to develop a comprehensive framework for when CBRs should and should not be accommodated.

White DB, Brody B. Would Accommodating Some Conscientious Objections by Physicians Promote Quality in Medical Care?. J Am Med Ass. 2011 May 4;305(17):1804-1805.

A matter of conscience: do conflicting beliefs and workplace demands constitute religious discrimination?

CW Von BergeN, Martin S Bressler

Journal of Behavioral Studies in Business

Abstract
Increasingly, employees maintain they should be provided an unqualified legal right to refuse work activities that violate their ethical, moral, personal, or religious convictions or beliefs-in short, their conscience. This assertion has become one of the more controversial issues confronting employers. This paper presents a brief review of conscientious objection with special attention to objection in medical related areas, followed by new discussion of freedom of conscience in the workplace.

Bergen CV, Bressler MS. A matter of conscience: do conflicting beliefs and workplace demands constitute religious discrimination? J Behavioral Studies in Business. 2011;3:1-14. Available from:

Conscientious commitment to women’s health

Bernard M Dickens, Rebecca J Cook

International Journal of Gynecology & Obstetrics

Abstract
Conscientious commitment, the reverse of conscientious objection, inspires healthcare providers to overcome barriers to delivery of reproductive services to protect and advance women’s health. History shows social reformers experiencing religious condemnation and imprisonment for promoting means of birth control, until access became popularly accepted. Voluntary sterilization generally followed this pattern to acceptance, but overcoming resistance to voluntary abortion calls for courage and remains challenging. The challenge is aggravated by religious doctrines that view treatment of ectopic pregnancy, spontaneous abortion, and emergency contraception not by reference to women’s healthcare needs, but through the lens of abortion. However, modern legal systems increasingly reject this myopic approach. Providers’ conscientious commitment is to deliver treatments directed to women’s healthcare needs, giving priority to patient care over adherence to conservative religious doctrines or religious self-interest. The development of in vitro fertilization to address childlessness further illustrates the inspiration of conscientious commitment over conservative objections.

Dickens BM, Cook RJ. Conscientious commitment to women’s health. Int J Gyn Ob. 2011;113(2):163-166.

Dishonest deed, clear conscience: when cheating leads to moral disengagement and motivated forgetting

Lisa L. Shu, Francesca Gino, Max H. Bazerman

Personality and Social Psychology Bulletin

Abstract
People routinely engage in dishonest acts without feeling guilty about their behavior. When and why does this occur? Across four studies, people justified their dishonest deeds through moral disengagement and exhibited motivated forgetting of information that might otherwise limit their dishonesty. Using hypothetical scenarios (Studies 1 and 2) and real tasks involving the opportunity to cheat (Studies 3 and 4), the authors find that one’s own dishonest behavior increased moral disengagement and motivated forgetting of moral rules. Such changes did not occur in the case of honest behavior or consideration of the dishonest behavior of others. In addition, increasing moral saliency by having participants read or sign an honor code significantly reduced unethical behavior and prevented subsequent moral disengagement. Although dishonest behavior motivated moral leniency and led to forgetting of moral rules, honest behavior motivated moral stringency and diligent recollection of moral rules.

Shu LL, Gino F, Bazerman MH. Dishonest deed, clear conscience: when cheating leads to moral disengagement and motivated forgetting. Pers Soc Psychol Bull. 2011 Mar;37(3):330-49. PubMed PMID: 2130717

What We Can’t Not Know

Revised and Expanded Edition

J. Budziszewski. What We Can’t Not Know. San Francisco: Ignatius Press, 2011, 315 pp. ISBN/UPC: 9781586174811

Publisher’s Description
In this new revised edition of his groundbreaking work, Professor J. Budziszewski questions the modern assumption that moral truths are unknowable. With clear and logical arguments he rehabilitates the natural law tradition and restores confidence in a moral code based upon human nature. What We Can’t Not Know explains the rational foundation of what we all really know to be right and wrong and shows how that foundation has been kicked out from under western society. Having gone through stages of atheism and nihilism in his own search for truth, Budziszewski understands the philosophical and personal roots of moral relativism. With wisdom born of both experience and rigorous intellectual inquiry, he offers a firm foothold to those who are attempting either to understand or to defend the reasonableness of traditional morality.

Conscientious refusals to refer: Findings from a national physician survey

Michael P Combs, Ryan M Antiel, Jon C Tilburt, Paul S Mueller, Farr A Curlin

Abstract
Background: Regarding controversial medical services, many have argued that if physicians cannot in good conscience provide a legal medical intervention for which a patient is a candidate, they should refer the requesting patient to an accommodating provider. This study examines what US physicians think a doctor is obligated to do when the doctor thinks it would be immoral to provide a referral.

Method: The authors conducted a cross-sectional survey of a random sample of 2000 US physicians from all specialties. The primary criterion variable was agreement that physicians have a professional obligation to refer patients for all legal medical services for which the patients are candidates, even if the physician believes that such a referral is immoral.

Results: Of 1895 eligible physicians, 1032 (55%) responded. 57% of physicians agreed that doctors must refer patients regardless of whether or not the doctor believes the referral itself is immoral. Holding this opinion was independently associated with being more theologically pluralistic, describing oneself as sociopolitically liberal, and indicating that respect for patient autonomy is the most important bioethical principle in one’s practice (multivariable ORs, 1.6-2.4).

Conclusions: Physicians are divided about a professional obligation to refer when the physician believes that referral itself is immoral. These data suggest there is no uncontroversial way to resolve conflicts posed when patients request interventions that their physicians cannot in good conscience provide..

Combs MP, Antiel RM, Tilburt JC, Mueller PS, Curlin FA. Conscientious refusals to refer: Findings from a national physician survey. J Med Ethics. 2011;37(7):397-401. Available from:

A Life Worth Giving? The Threshold for Permissible Withdrawal of Life Support From Disabled Newborn Infants

Dominic Wilkinson

Abstract
When is it permissible to allow a newborn infant to die on the basis of their future quality of life? The prevailing official view is that treatment may be withdrawn only if the burdens in an infant’s future life outweigh the benefits. In this paper I outline and defend an alternative view. On the Threshold View, treatment may be withdrawn from infants if their future well-being is below a threshold that is close to, but above the zero-point of well-being. I present four arguments in favor of the Threshold View, and identify and respond to several counterarguments. I conclude that it is justifiable in some circumstances for parents and doctors to decide to allow an infant to die even though the infant’s life would be worth living. The Threshold View provides a justification for treatment decisions that is more consistent, more robust, and potentially more practical than the standard view.

Wilkinson D. A Life Worth Giving? The Threshold for Permissible Withdrawal of Life Support From Disabled Newborn Infants. Am J Bioeth. 2011 Feb;11(2):20-32.

Conscientious Objection, Emergency Contraception, and Public Policy

Robert F Card

Abstract
Defenders of medical professionals’ rights to conscientious objection (CO) regarding emergency contraception (EC) draw an analogy to CO in the military. Such professionals object to EC since it has the possibility of harming zygotic life, yet if we accept this analogy and utilize jurisprudence to frame the associated public policy, those who refuse to dispense EC would not have their objection honored. Legal precedent holds that one must consistently object to all forms of the relevant activity. In the case at hand, then, I argue that these professionals must also oppose morally innocuous practices that may prevent pregnancy after fertilization. These results reveal that such objectors cannot offer a plausible and consistent objection to harming zygotic life. Additionally, there are good reasons to reject the analogy itself. In either case, these findings call into question the case supporting refusals of EC based on scruples.

Card RF. Conscientious Objection, Emergency Contraception, and Public Policy. J Med Phil. 2011;36(1):53-68.