Protection of Conscience Project Library

Consequences for patients of health care professionals’ conscientious actions: the ban on abortions in South Australia

Leslie Cannold

Abstract
The legitimacy of the refusal of South Australian nurses to care for second trimester abortion patients on grounds of conscience is examined as a test case for a theory of permissible limits on the autonomy of health care professionals. In cases of health care professional (HCP) conscientious refusal, it is argued that a balance be struck between the HCPs’ claims to autonomous action and the consequences to them of having their autonomous action restricted, and the entitlement of patients to care and the consequences for them of being refused such care. Conscientious action that results in the disruption or termination of health care services, however, is always impermissible on two grounds. Firstly, because it is at this point that the action ‘… invades a patient’s autonomy, puts a patient at serious risk … [and] treats a patient unjustly’ (1) Secondly, because the consequences of such refusals turn them into political acts-acts of civil disobedience. It is arguable that in order for acts of civil disobedience to be legitimate, certain obligations are required of the dissenter by the community. It is concluded that the actions of the South Australian nurses, which have over the last few years both terminated and disrupted second trimester services, are morally impermissible.

Cannold L. Consequences for patients of health care professionals’ conscientious actions: the ban on abortions in South Australia. J Med Ethics. 1994 Jun;20(2):80-86.

Bioethics: Private Choice and Common Good

Daniel Callahan

Extract
There is a peculiar and disturbing feature of our times. On the one hand, biomedicine unceasingly extends its power to shape our lives and our culture. . . On the other hand, our protean selves and malleable culture are themselves more wary than ever about responding to that challenge with what might be the only means at our disposal: the search for some coherent, plausible view of what constitutes the good of human beings and their societies. In the absence of such a view, all the real power is in the hands of science, which can decisively bring about fundamental changes even without aiming deliberately to do so. Only an understanding of the self that has substance and direction can fight back, setting its own counteragenda. Choice alone cannot do that. For its part also, a society that itself lacks a compass, devoted only to fostering a minimalist civic accord, is in no less vulnerable a position. If there is no common picture of what biomedicine can do to foster a good human life-if the very question of what constitutes such a life has been banished in the name of pluralism-then that life will be pushed about in ways it is helpless to control, a frail ship that has lost its direction on a stormy, confused sea.

Callahan D. Bioethics: Private Choice and Common Good. Hastings Cent Rep. 1994 May-Jun;24(3):28-31.

(Correspondence) Methotrexate and misoprostol used in abortions

Ellen R Wiebe

Canadian Medical Association Journal, CMAJ — Canadian Medical Association Journal

Extract
Medically induced abortion rather than surgical abortion has many advantages and could improve access to abortion in Canada . . . In December 1993 I received permission from the University of British Columbia Ethics Committee to start a pilot study of abortion induced with methotrexate and misoprostol; the study is under way. I would like to hear from other physicians who may be interested in this method.

Wiebe ER. (Correspondence) Methotrexate and misoprostol used in abortions. Can Med Assoc J. 1994 May 01;150(9):1381-1382.

Toleration of moral diversity and the conscientious refusal by physicians to withdraw life-sustaining treatment

S Wear,S Lagaipa,G Louge

Abstract
The removal of life-sustaining treatment often brings physicians into conflict with patients. Because of their moral beliefs physicians often respond slowly to the request of patients or their families. People in bioethics have been quick to recommend that in cases of conflict the physician should simply sign off the case and “step aside”. This is not easily done psychologically or morally. Such a resolution also masks a number of more subtle, quite trouble some problems that conflict with the commitment to toleration and moral diversity that it is intended to support. These conflicts are detailed and evaluated.

Wear S, Lagaipa S, Louge G. Toleration of moral diversity and the conscientious refusal by physicians to withdraw life-sustaining treatment. J Med Phil. 1994 Apr;19(2):147-159.

Moral and Religious Objections by Hospitals to Withholding and Withdrawing Life-Sustaining Treatment

Anna Maria Cugliari, Tracy E Miller

Abstract
A patient’s right to decide about life-sustaining treatment may conflict with the policies of health care facilities that refuse on the basis or religious or moral convictions to honor certain decisions to forgo treatment. The New York State Task Force on Life and the Law examined the prevalence and nature of facility conscience objections to the refusal of life-sustaining treatment by conducting a survey of New York hospitals. Written questionnaires were distributed to hospitals in New York State. Fifty-eight percent of the New York State hospitals responded. Twenty-nine percent of the respondents indicated that their hospital would object on grounds of conscience either to withholding or to withdrawing life-sustaining treatment in at least one of the twelve hypothetical cases presented. Hospitals were more likely to have “no policy” for withdrawing than for withholding treatment. Only 10% of the hospitals that would object to decisions to forgo treatment on religious or moral grounds had stated the objections in writing. The patient’s medical condition and the type of life-sustaining treatment to be withdrawn or withheld are important factors in determining whether a hospital will object on grounds of conscience. The imminence of death appeared more decisive than the degree of debilitation or disability as a factor in the willingness to accept decisions to forgo life-sustaining treatment. Hospitals should establish clear, written policies about their objections to forgoing treatment so that patients and their families can evaluate whether the facility meets their needs.

Cugliari AM, Miller TE. Moral and Religious Objections by Hospitals to Withholding and Withdrawing Life-Sustaining Treatment. J. Community Health. 1994 Apr 01;19(2):87-100.

(Book Review) Medicine betrayed: the participation of doctors in human rights abuses

Christopher Howard

Extract
The reader is left with no escape from the conclusion that doctors through overwhelming pressure, cowardice, lack of peer support, lack of self-criticism or awareness and even personal conviction and relish have betrayed the principles of their profession, often in the recent past and often not far from home. . . Ultimately the question that remains tantalizingly unanswered is when is punishment not cruel, inhuman or degrading? Paradoxically, through condemning so eloquently the identified abuses of medicine, that which is not condemned seems to be given a degree of immunity for which an extension of the report’s own arguments appears to provide no justification.

Howard C. (Book Review) Medicine betrayed: the participation of doctors in human rights abuses. J Med Ethics. 1994 Mar;20(1):61-62.

A Clash at the Bedside: Patient Autonomy v. A Physician’s Professional Conscience

Judith F Daar

Extract
Conclusion
The plight of Helga Wanglie . . . focused attention on the issue of physician autonomy in the context of patient decision making. That case challenged the court, as well as our society, to consider whether a physician has an obligation to provide medical treatment he or she believes is inappropriate. . .The concept of a physician’s professional conscience will become increasingly relevant as the cost of health care rises to the point where our demands for care greatly outweigh our ability to pay for such care . . . to downplay the role a physician’s professional conscience plays in medical decision making, as both courts and policy makers traditionally have done, does not advance patient autonomy; instead, it causes doctors to be more conservative and withholding in the range of options they offer their patients. If patient autonomy is to have meaning, recognition must also be given to a physician’s moral autonomy. This Article suggests that when patients clash with their physicians over treatment choices, the principle of patient autonomy does not automatically require that the physician be forced to comply.

Daar JF. A Clash at the Bedside: Patient Autonomy v. A Physician’s Professional Conscience. Hastings Law J. 1993 Aug;44(6):1241-1289.

Conscience and Clinical Care

Leah L Curtin

Extract
If the state itself does not presume to order the consciences of its citizens, how can employers, physicians or hierarchical superiors assume such authority? For those in positions of power, it is all too easy to stifle the criticisms and consciences of subordinates by a summons to authority – or by an accusation of insubordination. The irony of it is that whether you succeed or fail in your attempts to force obedience through such tactics, you will have lost your most valuable asset – a man or woman of integrity. Within the ethical, professional and legal restraints to which all of us are subject, we can and must create a system that allows for respectful dissent and conscientious objection.

Curtin LL. Conscience and Clinical Care. Nurs Manag. 1993 Aug;24(8):26-28.

Doing what the Patient Orders: Maintaining Integrity in the Doctor-Patient Relationship

Jeffrey Blustein

Extract
Conclusion
Physicians’ appeals to conscience, understood as fear of loss of integrity, should not be taken lightly. Integrity provides the basis for a unified, whole, and unalienated life, and its moral value, while dependent on the presence of other good traits in the agent, is not reducible to them. . . a physician can consistently be concerned about his or her own integrity without claiming to know better than the patient what is in the patient’s best interests. . . . The conception of integrity I have proposed . . . allows for the possibility of integrity-preserving compromise. . . . I have also considered the common practice of patient referral from the standpoint of physician integrity, and asked whether a physician who refuses to treat a patient as a matter of conscience can consistently refer the patient to another physician for the same treatment. . . in a dispute between physicians and their patients, there may be other values and principles at stake than the ones expressed in their conflicting positions, and a physician might well decide that referral in such a case is an appropriate response to a morally complex situation.

Blustein J. Doing what the Patient Orders: Maintaining Integrity in the Doctor-Patient Relationship. Bioethics. 1993;7(4):289-314.

(Correspondence) Abortion debate continues

Linda Spano, Michael Brennan

Extract
. . . we all – including Reynolds – operate from a biased set of basic assumptions. Is it really antireligious to suggest that the antiabortion forces are largely motivated by fundamental religious views that represent fixed basic assumptions? We think not. . . . Medical intervention includes helping people achieve their potential according to their own objectives as well as many other “appropriate” activities, such as the therapeutic termination of pregnancy. . . .The abortion debate is not entirely about abortion or religion, nor is it even a debate. . . the argument is about the freedom of choice and the access of all Canadian women to safe, competent medical care and about the refusal of most Canadians to submit to the irrational demands of a vociferous minority. . .

Spano L, Brennan M. (Correspondence) Abortion debate continues. Can Med Assoc J. 1993 Jun 15;148(12):2112-2113.