Mark R Wicclair Archives - Protection of Conscience Project Library

Conscientious objection, moral integrity, and professional obligations

Mark R Wicclair

Abstract
Lauris Kaldjian defends conscientious objection against opponents who claim that there is no place for a physician’s personal moral beliefs in the practice of medicine. This essay argues that Kaldjian’s defense of conscientious objection relies on a controversial “thick” conception of conscience that opponents may justifiably question. It offers a defense that relies on a relatively “thin” conception of conscience as an agent’s core moral beliefs and that understands conscience-based refusals to provide medical services as refusals based on those core beliefs. Enabling physicians to practice medicine without compromising their moral integrity is an important pro tanto reason to accommodate physicians who conscientiously object to providing medical services. However, giving due consideration to the professional obligations of physicians requires constraints on accommodation. Accommodation should not: (1) impede a patient’s timely access to relevant information; (2) impede a patient’s timely access to referral and counselling; (3) impede a patient’s timely access to medical services that are consistent with prevailing professional standards; (4) enable physicians to practice invidious discrimination; (5) place an excessive burden on other health professionals and institutions; or (6) authorize physicians to unilaterally decide to forgo life-sustaining treatment against the wishes of patients or surrogates.

Wicclair MR. Conscientious objection, moral integrity, and professional obligations. Perspect Biol Med. 2019;62(3):543-559. Available from:

An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine

Mithya Lewis-Newby, Mark R Wicclair, Thaddeus Mason Pope, Cynda Rushton, Farr A Curlin, Douglas Diekema, Debbie Durrer, William Ehlenbach, Wanda Gibson-Scipio, Bradford Glavan, Rabbi Levi Langer, Constantine Manthous, Cecile Rose, Anthony Scardella, Hasan Shanawani, Mark D Siegel, Scott D. Halpern, Robert D Truog, Douglas B White

American Journal of Respiratory and Critical Care Medicine

Abstract
Rationale: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs.

Objectives: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting.

Methods: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law.

Main Results: The policy recommendations are based on the dual goals of protecting patients’ access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a “shield ” to protect individual clinicians’ moral integrity rather than as a “sword” to impose clinicians’ judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient’s or surrogate’s timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician’s CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting.

Conclusions: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians’ COs in the critical care setting.

Lewis-Newby M, Wicclair MR, Pope TM, Rushton C, Curlin FA, Diekema D et al.. An official American Thoracic Society policy statement: Managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med. 2015;191(2):219-227.

Managing conscientious objection in health care institutions

Mark R Wicclair

Abstract
It is argued that the primary aim of institutional management is to protect the moral integrity of health professionals without significantly compromising other important values and interests. Institutional policies are recommended as a means to promote fair, consistent, and transparent management of conscience-based refusals. It is further recommended that those policies include the following four requirements: (1) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s/surrogate’s timely access to information, counseling, and referral. (2) Conscience-based refusals will be accommodated only if a requested accommodation will not impede a patient’s timely access to health care services offered within the institution. (3) Conscience-based refusals will be accommodated only if the accommodation will not impose excessive burdens on colleagues, supervisors, department heads, other administrators, or the institution. (4) Whenever feasible, health professionals should provide advance notification to department heads or supervisors. Formal review may not be required in all cases, but when it is appropriate, several recommendations are offered about standards and the review process. A key recommendation is that when reviewing an objector’s reasons, contrary to what some have proposed, it is not appropriate to adopt an adversarial approach modelled on military review boards’ assessments of requests for conscientious objector status. According to the approach recommended, the primary function of reviews of objectors’ reasons is to engage them in a process of reflecting on the nature and depth of their objections, with the objective of facilitating moral clarity on the part of objectors rather than enabling department heads, supervisors, or ethics committees to determine whether conscientious objections are sufficiently genuine.

Wicclair MR. Managing conscientious objection in health care institutions. HEC Forum. 2014;26(3):267-283.

Positive claims of conscience and objections to immigration law

Mark R. Wicclair

American Medical Association Journal of Ethics

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.

Rights, professional obligations, and moral disapproval

Mark R Wicclair

Cambridge Quarterly of Healthcare Ethics

Extract
The claim that providing post-transplant care to Mr. C would compromise a physician’s moral integrity might have a consequentialist basis or it might rest on a conception of moral complicity. From a consequentialist perspective, it might be thought that refusing to provide post-transplant care would act as a disincentive for patients like Mr. C to go to China for organ transplants. That is, it might be thought that refusing to provide follow-up care will promote a reduction in unethical transplant practices, and transplant physicians might believe that they have an ethical obligation to do what they can to effectuate such a reduction. Alternatively, a physician might believe that to avoid moral complicity in an unethical practice, she must refrain from any direct or indirect participation in that practice, which includes providing post-transplant care.

Wicclair MR. Rights, professional obligations, and moral disapproval. Camb Q. Healthc Ethics. 2011;20(1):144-147.

Conscientious refusals by hospitals and emergency contraception

Mark R Wicclair

Journal’s Extract
Hospitals sometimes refuse to provide goods and services or honor patients’ decisions to forgo life-sustaining treatment for reasons that appear to resemble appeals to conscience. For example, based on the Ethical and Religious Directives for Catholic Health Care Services (ERD), Catholic hospitals have refused to forgo medically provided nutrition and hydration (MPNH), and Catholic hospitals have refused to provide emergency contraception (EC) and perform abortions or sterilization procedures. I consider whether it is justified to refuse to offer EC to victims of sexual assault who present at the emergency department (ED). A preliminary question, however, is whether a hospital’s refusal to provide services can be conceptualized as conscience based.

Wicclair MR. Conscientious refusals by hospitals and emergency contraception. Camb Q Healthc Ethics. 2011;20(1):130-138.

Conscience-based exemptions for medical students

Mark R Wicclair

Journal’s Extract
Just as physicians can object to providing services due to their ethical and/or religious beliefs, medical students can have conscience-based objections to participating in educational activities. In 1996, the Medical Student Section of the American Medical Association (AMA) introduced a resolution calling on the AMA to adopt a policy in support of exemptions for students with ethical or religious objections. In that report, students identified abortion, sterilization, and procedures performed on animals as examples of activities that might prompt requests for conscience-based exemptions (CBEs). In response to the student initiative, the Council on Medical Education recommended the adoption of seven “principles to guide exemption of medical students from activities based on conscience.” The House of Delegates adopted these principles in their entirety.

Wicclair MR. Conscience-based exemptions for medical students. Camb Q Healthc Ethics. 2010;19(1):38-50.

Is conscientious objection incompatible with a physician’s professional obligations?

Mark R Wicclair

Abstract
In response to physicians who refuse to provide medical services that are contrary to their ethical and/or religious beliefs, it is sometimes asserted that anyone who is not willing to provide legally and professionally permitted medical services should choose another profession. This article critically examines the underlying assumption that conscientious objection is incompatible with a physician’s professional obligations (the “incompatibility thesis”). Several accounts of the professional obligations of physicians are explored: general ethical theories (consequentialism, contractarianism, and rights-based theories), internal morality (essentialist and non-essentialist conceptions), reciprocal justice, social contract, and promising. It is argued that none of these accounts of a physician’s professional obligations unequivocally supports the incompatibility thesis.

Wicclair MR. Is conscientious objection incompatible with a physician’s professional obligations? Theor Med Bioeth. 2008;29(3):171-185.

The Moral Significance of Claims of Conscience in Healthcare (Conscience in Medicine)

Mark R Wicclair

Extract
Contrary to what Lawrence and Curlin (2007) suggest, it is not primarily disagreement about the nature of “the conscience” that underlies the controversy about whether and when health professionals should be allowed to refuse to provide services that violate their ethical beliefs. Rather, the primary source of disagreement is over the professional obligations of physicians, pharmacists and other healthcare providers and how to resolve conflicts between those obligations and healthcare professionals’ interest in maintaining their moral integrity.

Wicclair MR. The Moral Significance of Claims of Conscience in Healthcare (Conscience in Medicine). Am J Bioeth. 2007;7(1):30-31.

Reasons and Healthcare Professionals’ Claims of Conscience (Conscientious Objection and Emergency Contraception)

Mark R Wicclair

Extract
Robert Card (2007) argues against even a limited conscience based right to refuse to dispense emergency contraception (EC) on the grounds that there are no “reasonable or justified” reasons to support such claims of conscience. This line of argument raises an important question: To what extent is it appropriate to assess reasons in relation to healthcare professionals’ claims of conscience?

Wicclair MR. Reasons and Healthcare Professionals’ Claims of Conscience (Conscientious Objection and Emergency Contraception). Am J Bioeth. 2007;7(6):21-22.