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Perceptions of conscience in relation to stress of conscience

Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin

Abstract
Every day situations arising in health care contain ethical issues influencing care providers’ conscience. How and to what extent conscience is influenced may differ according to how conscience is perceived. This study aimed to explore the relationship between perceptions of conscience and stress of conscience among care providers working in municipal housing for elderly people. A total of 166 care providers were approached, of which 146 (50 registered nurses and 96 nurses’ aides/enrolled nurses) completed a questionnaire containing the Perceptions of Conscience Questionnaire and the Stress of Conscience Questionnaire. A multivariate canonical correlation analysis was conducted. The first two functions emerging from the analysis themselves explained a noteworthy amount of the shared variance (25.6% and 17.8%). These two dimensions of the relationship were interpreted either as having to deaden one’s conscience relating to external demands in order to be able to collaborate with coworkers, or as having to deaden one’s conscience relating to internal demands in order to uphold one’s identity as a ‘good’ health care professional.

Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience in relation to stress of conscience. Nurs Ethics. 2007 May;14(3):329-343.

(Correspondence) Religion, Conscience and Controversial Clinical Practices

Lainie F Ross, Ellen W Clayton

New England Journal of Medicine, NEJM — New England Journal of Medicine

Extract
To impose the philosophy of caveat emptor is morally inadequate, given the differences in power and class between many physicians and their patients. Physicians must not be permitted to disavow responsibility on the grounds of conscientious objection; rather, such practitioners must choose careers in which their fundamental values do not interfere with the autonomy and well-being of patients. Like conscientious objectors to military service, medical conscientious objectors must bear the consequences of their beliefs.

Clayton EW. (Correspondence) Religion, Conscience and Controversial Clinical Practices. N Engl J Med. 2007 May 03;356(18):1890.

(Correspondence) Religion, Conscience and Controversial Clinical Practices

Nada L Stotland

Extract
It is unrealistic and unfair to expect patients to anticipate all conditions that may befall them, identify which ones might be problematic for their physicians, and agree either to reach a compromise or to seek care elsewhere.

Stotland NL. (Correspondence) Religion, Conscience and Controversial Clinical Practices. N Engl J Med.. 2007;356(18):1889-1890.

(Correspondence) Religion, Conscience and Controversial Clinical Practices

Victor Zarate

Extract
A health care system must establish clear criteria to allow the right balance between paternalism and the autonomy of patients in the case of medical issues that are controversial among health care professionals.

Zarate V. (Correspondence) Religion, Conscience and Controversial Clinical Practices. N Engl J Med. 2007 May 03;356(18):1890-1891.

(Correspondence) Religion, Conscience and Controversial Clinical Practices (Authors respond)

Farr A Curlin, Ryan E Lawrence, John D Lantos

Extract
Those who act conscientiously do not “disavow responsibility” and “substitute their personal values for the fundamental rights of their patients.” Rather, they are engaging in the struggle to know and do the right thing and to understand and fulfill their moral obligations in a particular situation. This task cannot be externalized or delegated. Indeed, acting conscientiously is the heart of the ethical life, and to the extent that physicians give it up, they are no longer acting as moral agents.

Curlin FA, Lawrence RE, Lantos JD. (Correspondence) Religion, Conscience and Controversial Clinical Practices (Authors respond). N. Engl. J. Med.. 2007;356(18):1891-1892.

(Correspondence) Clarification of the CMA’s position concerning induced abortion

Jeff Blackmer

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
Discussion:
CMA policy states that “a physician should not be compelled to participate in the termination of a pregnancy.” In addition, “a physician whose moral or religious beliefs prevent him or her from recommending or performing an abortion should inform the patient of this so that she may consult another physician.” You should therefore advise the patient that you do not provide abortion services. You should also indicate that because of your moral beliefs, you will not initiate a referral to another physician who is willing to provide this service (unless there is an emergency). However, you should not interfere in any way with this patient’s right to obtain the abortion. At the patient’s request, you should also indicate alternative sources where she might obtain a referral. This is in keeping with the obligation spelled out in the CMA policy: “There should be no delay in the provision of abortion services.”.

Blackmer J. (Correspondence) Clarification of the CMA’s position concerning induced abortion. Can Med Assoc J. 2007;176(9):1310.

Martin Luther at the Bedside

Nancy Berlinger

Extract
Media coverage of conscientious objection tends to cast the refusing health care provider in the role of Martin Luther at the Diet of Worms: Here I stand, I can do no other (emphasis on the “I”). Commentators also do this, parsing the rights and responsibilities (but mostly the rights) in a dyadic relationship: Providers versus patients. Paternalism versus autonomy. “I believe” versus “I want.” . . .

Conscientious objection in medicine is not merely a right to be invoked at the bedside, nor a problem to be held in check through a pro forma conscience clause. Rather, [David H] Smith reminds us, openly discussing the nature of providers’ moral objections, while keeping the needs of the suffering person
uppermost, is a “difficult and unglamorous” communal
responsibility of “morally serious people.” Amen.

Berlinger N. Martin Luther at the Bedside. Hastings Cent Rep. 2007;37(2).

Achieving transparency in implementing abortion laws

Rebecca J. Cook, Joanna N. Erdman, Bernard M. Dickens

International Journal of Gynecology & Obstetrics

Abstract
National and international courts and tribunals are increasingly ruling that although states may aim to deter unlawful abortion by criminal penalties, they bear a parallel duty to inform physicians and patients of when abortion is lawful. The fear is that women are unjustly denied safe medical procedures to which they are legally entitled, because without such information physicians are deterred from involvement. With particular attention to the European Court of Human Rights, the UN Human Rights Committee, the Constitutional Court of Colombia, the Northern Ireland Court of Appeal, and the US Supreme Court, decisions are explained that show the responsibility of states to make rights to legal abortion transparent. Litigants are persuading judges to apply rights to reproductive health and human rights to require states’ explanations of when abortion is lawful, and governments are increasingly inspired to publicize regulations or guidelines on when abortion will attract neither police nor prosecutors’ scrutiny.

Cook RJ Erdman JN, Dickens BM. Achieving transparency in implementing abortion laws. Int J Gynaecol Obstet. (2007) 99, 157-161

Health care provider refusals to treat, prescribe, refer or inform: Professionalism and conscience

R Alta Charo

Advance: Journal of the ACS Issue Groups

Extract
Conscience is a tricky business. Some interpret its personal beacon as the guide to universal truth and undoubtedly many of the health care providers who refuse to treat or refer or inform their patients do so in the sincere belief that it is in the patients’ own interests, regardless of how those patients might view the matter themselves. But the assumption that one’s own conscience is the conscience of the world is fraught with dangers. As C.S. Lewis wrote, “of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.”

Charo RA. Health care provider refusals to treat, prescribe, refer or inform: Professionalism and conscience. Advance J ACS Issue Groups. 2007 Spring 1:119-135.

From Eisenstadt to Plan B: A Discussion of Conscientious Objections to Emergency Contraception

Lynne Marie Kohm

Extract
Conclusion
Medical ethics and the practice of medicine as an act of conscience have become integral to this scientifically unsettled debate. Before medication is prescribed or dispensed, a prudent practitioner weighs carefully the risks of the medication with the potential benefits. 70 Laws that require a medical professional to perform an act against his or her best judgment violate the code of ethics of that profession to do no harm in the professional’s highest and best medical judgment. It ought to be alarming that a patient’s expectations may become the standard for professional action. Ought medical professionals prescribe and dispense what the patient wants even if it harms him or her, just because the patient’s autonomy allows a patient to live a risky life? 71 Family planning deserves a principled approach carried out with integrity that protects the parties, and that approach should be reflected in legal policy and lawmaking.

Should doctors and pharmacists be able to refuse to give out emergency contraceptives based on conscientious objections? Sexual freedom that was protected by the Supreme Court’s emancipation of sexuality from reproduction has allowed emergency contraceptives to be used for any purpose an individual desires, rather than for the best and most responsible medical purposes. Therefore, when a medical professional has concerns that an emergency contraceptive may harm the health of his or her patients or customers or their offspring, a conscientious objection provided by law seems more appropriate than a legal requirement to dispense despite objections, at least until a medical and legal consensus can be reached.

Kohm LM. From Eisenstadt to Plan B: A Discussion of Conscientious Objections to Emergency Contraception. William Mitchell Law Rev. 2007 Mar;33(3):787-805.