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Conscience as Clinical Judgment: Medical Education and the Virtue of Prudence

Warren Kinghorn

American Medical Association Journal of Ethics

Extract
What would be the implications for medical ethics, however, if “conscience” were not some sort of external moral faculty that trafficked in “values” (rather than “facts”) but, rather, were a quite ordinary part of human decision making, inseparable from the living of everyday life and from the routine, day-to-day practice of medicine? Such a conception of conscience would render it more mundane and unremarkable but would, on the other hand, raise awareness of its quiet but important presence within the daily lives of physicians and medical practitioners. As it turns out, this more integrated conception of conscience was common in premodern moral philosophy. In this brief essay, I will outline the account of conscience given by the premodern philosopher and theologian Thomas Aquinas (~1225-1274), whose work was important in extending the thought of Aristotle into the medieval era, and will briefly suggest how Aquinas’ thirteenth-century conception of conscience might apply to modern bioethics and to the modern education of physicians.

Kinghorn W. Conscience as Clinical Judgment: Medical Education and the Virtue of Prudence. Virtual Mentor. 2013 Mar;15(3) 202-205.

Not Only the Doctor’s Dilemma: The Complexity of Conscience in Medicine

Elizabeth Sepper

Abstract
In recent years, conscience has become a national catch phrase, invoked regularly in health policy discussions. The word “conscience,” however, often stands in for refusal to deliver abortions or contraception or to remove or withhold life support.

In this talk, I argue that conscience is not so one-sided, nor medical decisionmaking so straightforward. First, medical decisions – especially those involving questions of life and death – inspire divergent moral convictions. Second, medical decisions do not simply implicate conscience for the provider. They should be thought of instead as involving, at minimum, three parties: patients, providers, and institutions. This three-sided relationship complicates moral decisionmaking, with each party asserting potentially conflicting claims.

I contend that in responding to conflicts over medical decisions, lawmakers have overlooked their complexity. As a result, existing legislation undermines conscience, risks harm to patients, and destabilizes ethical decisionmaking within medicine itself. The talk concludes with several proposals to improve the law’s approach to morality in medicine.

Sepper E. Not Only the Doctor’s Dilemma: The Complexity of Conscience in Medicine. 4 Faulkner L. Rev. 385, 406 (2013)

Positive claims of conscience and objections to immigration law

Mark R. Wicclair

Extract
If immigration laws do not provide general exemptions for health care services, should they at least provide exemptions for health care professionals who cannot in good conscience comply with the law because they believe they have an ethical obligation to treat patients without regard to their immigration status?

Wicclair MR. Positive claims of conscience and objections to immigration law. Virtual Mentor. 2013;15(3):188-192. doi: 10.1001/virtualmentor.2013.15.3.ecas1-1303.

Taking Conscience Seriously

Elizabeth Sepper

Abstract
For too long, the conventional account of morality in medicine has placed conscience firmly on one side of the moral divide. The archetypal doctor who refuses to participate in controversial treatments – most commonly end-of-life care, abortion, sterilization, and contraception – has been the lodestar of legislative efforts and scholarly accounts. In the name of institutional conscience, healthcare facilities have also been permitted to assert moral or religious objections to care and impose them on employees and affiliates of all beliefs and backgrounds. Doctors, nurses, and institutions that are willing to deliver controversial care have been virtually absent from discussions. This Article aims to reframe the debate by taking conscience seriously. Through engagement with the moral philosophical literature, it makes two inter-related arguments. First, conscience equally may compel a doctor or nurse to deliver a controversial treatment to a patient in need. Yet existing legislation meant to protect conscience, paradoxically, has undermined the consciences of these doctors and nurses. Second, endowing healthcare institutions with conscience via legislation is theoretically and practically problematic. By privileging the institutions’ rights to refuse to provide certain treatments, legislation impinges on the rights of individual providers to provide care they feel obligated by conscience to deliver. Ultimately, if legislation is to protect conscience, it must negotiate between competing claims of conscience of health providers and the facilities in which they work — regardless of whether they refuse or are willing to provide controversial care. This Article introduces a new framework for achieving a better balance between the interests of institutions, individual doctors and nurses, and the patients who depend on them for care.

Sepper E. Taking Conscience Seriously. 98 Va. L. Rv. 1501, 1532-39 (2012)

Conscientious Refusals and Reason-Giving

Jason Marsh

Abstract
Some philosophers have argued for what I call the reason-giving requirement for conscientious refusal in reproductive healthcare. According to this requirement, healthcare practitioners who conscientiously object to administering standard forms of treatment must have arguments to back up their conscience, arguments that are purely public in character. I argue that such a requirement, though attractive in some ways, faces an overlooked epistemic problem: it is either too easy or too difficult to satisfy in standard cases. I close by briefly considering whether a version of the reason-giving requirement can be salvaged despite this important difficulty.

Marsh J. Conscientious Refusals and Reason-Giving. Bioethics. 2014;28(6):313-319.

Conscientious refusals and reason-giving

Jason Marsh

Marsh J. Conscientious refusals and reason-giving. Bioethics. 2013 Feb 28. doi: 10.1111/bioe.12012. [Epub ahead of print] PubMed
PMID: 23445457

Conscience in health care and the definitions of death

Yutaka Kato

Abstract
Brain death or neurologic death has gradually become recognized as human death over the past decades worldwide. Nevertheless, in Japan, the New York State, and the State of New Jersey, one can be exempt from death determination based on neurologic criteria even in the state of brain death. In Japan, the 1997 Act on Organ Transplantation legalized brain death determination exclusively when organs were to be procured from brain-dead patients. Even after the 2009 revision, the default definition of death continued to be cardio-pulmonary criteria, despite the criticism.

The cases of Japan and the United States provide a good reference as social experiments of appreciating conscientious or religio-cultural dimensions in health care. This text theoretically examines the 1997 Act on Organ Transplantation of Japan and its 2009 revision, presenting some characteristics of Japan’s case compared to American cases and the implications its approach has for the rest of the world. This is an example in which a foreign idea that did not receive widespread support from Japanese citizens was transformed to fit the religio-cultural landscape.

Hans-Martin Sass argued for “a formula for a global Uniform Determination of Death statute, based on the ‘entire brain including brain stem’ criteria as a default position, but allowing competent adults by means of advance directives to choose other criteria for determining death during the process of dying.” These cases provide a good reference as social experiments in order to evaluate this formula.

In the text, the term “conscience” or its adjective form is chosen as a superordinate concept to moral/religious belief according to conventional usage. Conscience might appear universal whereas religio-cultural dimension differs among nations. In this text, conscience is considered to manifest itself within different societal traditions.

Kato Y. Conscience in health care and the definitions of death. Croat Med J. 2013 Feb;54(1):75-7.

Managing uncertainty: A grounded theory of stigma in transgender health care
encounters

Tonia Poteat, Danielle German, Deanna Kerrigan

Abstract
A growing body of literature supports stigma and discrimination as fundamental causes of health disparities. Stigma and discrimination experienced by transgender people have been associated with increased risk for depression, suicide, and HIV. Transgender stigma and discrimination experienced in health care influence transgender people’s health care access and utilization. Thus, understanding how stigma and discrimination manifest and function in health care encounters is critical to addressing health disparities for transgender people. A qualitative, grounded theory approach was taken to this study of stigma in health care interactions. Between January and July 2011, fifty-five transgender people and twelve medical providers participated in one-time in-depth interviews about stigma, discrimination, and health care interactions between providers and transgender patients. Due to the social and institutional stigma against transgender people, their care is excluded from medical training. Therefore, providers approach medical encounters with transgender patients with ambivalence and uncertainty. Transgender people anticipate that providers will not know how to meet their needs. This uncertainty and ambivalence in the medical encounter upsets the normal balance of power in provider-patient relationships. Interpersonal stigma functions to reinforce the power and authority of the medical provider during these interactions. Functional theories of stigma posit that we hold stigmatizing attitudes because they serve specific psychological functions. However, these theories ignore how hierarchies of power in social relationships serve to maintain and reinforce inequalities. The findings of this study suggest that interpersonal stigma also functions to reinforce medical power and authority in the face of provider uncertainty. Within functional theories of stigma, it is important to acknowledge the role of power and to understand how stigmatizing attitudes function to maintain systems of inequality that contribute to health disparities.

Poteat T, German D, Kerrigan D. Managing uncertainty: A grounded theory of stigma in transgender health care encounters. Soc Sci Med. 2013 May;84:22-9.doi: 10.1016/j.socscimed.2013.02.019

(Correspondence) Redefining Physicians’ Role in Assisted Dying

Edward Lowenstein, Marcia Angell

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

Extract
To the Editor: As two of the original petitioners to bring a Death with Dignity Act before Massachusetts voters, we are pleased that Prokopetz and Lehmann believe “there is a compelling case for legalizing assisted dying,” as they state in their Perspective article (July 12 issue).¹ However, we oppose their idea that physicians who agree that assisted dying is sometimes indicated might outsource the actual writing of the prescription to a government agency, presumably because they find that final step “incompatible with the physician’s role as healer” (in the words of the statement on the subject by the American Medical . . .

Angell M., Lowenstein E. Letter re: Redefining Physicians’ Role in Assisted Dying. N Engl J Med 2013; 368:485-486 January 31, 2013 DOI: 10.1056/NEJMc1209798

The fox and the grapes: An Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription

Cathal T. Gallagher, Alice Holton, Lisa J. McDonald, Paul J. Gallagher

Abstract
Emergency hormonal contraception (EHC) has been available from pharmacies in the UK without prescription for 11 years. In the Republic of Ireland this service was made available in 2011. In both jurisdictions the respective regulators have included conscience clauses which allow pharmacists to opt out of providing EHC on religious or moral grounds providing certain criteria are met. In effect, conscientious objectors must refer patients to other providers who are willing to supply these medicines. Inclusion of such clauses leads to a cycle of cognitive dissonance on behalf of both parties.

Objectors convince themselves of the existence of a moral difference between supply of EHC and referral to another supplier, while the regulators must feign satisfaction that a form of regulation lacking universality will not lead to adverse consequences in the long term. We contend that whichever of these two parties truly believes in that which they purport to must act to end this unsatisfactory status quo. Either the regulators must compel all pharmacists to dispense emergency contraception to all suitable patients who request it, or a pharmacist must refuse either to supply EHC or to refer the patient to an alternative supplier and challenge any subsequent sanctions imposed by their regulator.

Gallagher CT, Holton A, McDonald LJ, Gallagher PJ. The fox and the grapes: An Anglo-Irish perspective on conscientious objection to the supply of emergency hormonal contraception without prescription. J Med Ethics. 2013 Oct;39(10):638-42.doi: 10.1136/medethics-2012-100975. Epub 2013 Jan 30.