Conscience Clauses, Health Care Providers, and Parents

Nancy Berlinger

Conscience Clauses, Health Care Providers, and Parents

Extract
Conscientious objection in health care always affects someone else’s health or access to care because the refusal interrupts the delivery of health services. Therefore, conscientious objection in health care always has a social dimension and cannot be framed solely as an issue of individual rights or beliefs. . . . Conscience rights are also limited by the foundational duty of care, which must be maintained through referrals and transfers so that a refusal to provide a service does not result in abandonment of a patient. . . Physicians who work in the 11 U.S. jurisdictions that permit terminally ill people, under certain conditions, to request a prescription of lethal medication with the goal of ending their lives may also have mixed emotions and intuitions about participating in medical aid-in-dying. . . Conscientious objection to providing or participating in certain activities on principle should not be used to avoid patient care that a professional finds stressful, or as a remedy for the common problem of moral distress.


Berlinger N. Conscience Clauses, Health Care Providers, and Parents [Internet]. Garrison, NY: The Hastings Center; 2022 May 31.

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada

Mary Kathleen Deutscher Heilman, Tracy J. Trothen

Journal of Medical Ethics
Journal of Medical Ethics

Abstract
Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one’s conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.


Heilman MKD, Trothen TJ. Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada. J Med Ethics. 2020;46(2):123-127. doi:10.1136/medethics-2019-105855

When Policy Produces Moral Distress: Reclaiming Conscience

Nancy Berlinger

The Hastings Center Report
The Hastings Center Report

Abstract
For too long, bioethics has followed law in reducing “conscience” to “conscientious objection,” in other words, to laws and policies permitting and protecting refusal. In “Reframing Conscientious Care: Providing Abortion Care When Law and Conscience Collide,” Mara Buchbinder and colleagues draw our attention to one dimension of the problem of reducing conscience to refusal to provide certain forms of medical care: what about the conscience problems experienced by the professionals who are attempting to provide safe, effective health care that includes services that others associate with conscientious objection? In seeking to disrupt a specific medical practice – one that is legal, desired by the patient, and conducted in accordance with medical standards – North Carolina House Bill 854, The Women’s Right to Know Act, and laws like it, appear to be designed to produce moral distress in physicians and other professionals involved in the provision of abortions. For abortion providers in North Carolina and other states, conscientious objection to the mandates of laws like HB 854 isn’t a realistic option. So what can bioethics offer to professionals bound by such laws? We can start by reclaiming the idea of “conscience” as something that can say “yes” to providing health care.


Berlinger, N. (2016), When Policy Produces Moral Distress: Reclaiming Conscience. Hastings Center Report, 46: 32–34. doi: 10.1002/hast.547

Moral distress and moral conflict in clinical ethics

C. Fourie

Bioethics
Bioethics

Abstract
Much research is currently being conducted on health care practitioners’ experiences of moral distress, especially the experience of nurses. What moral distress is, however, is not always clearly delineated and there is some debate as to how it should be defined. This article aims to help to clarify moral distress. My methodology consists primarily of a conceptual analysis, with especial focus on Andrew Jameton’s influential description of moral distress.

I will identify and aim to resolve two sources of confusion about moral distress: (1) the compound nature of a narrow definition of distress which stipulates a particular cause, i.e. moral constraint, and (2) the distinction drawn between moral dilemma (or, more accurately, moral conflict) and moral distress, which implies that the two are mutually exclusive.

In light of these concerns, I argue that the definition of moral distress should be revised so that moral constraint should not be a necessary condition of moral distress, and that moral conflict should be included as a potential cause of distress. Ultimately, I claim that moral distress should be understood as a specific psychological response to morally challenging situations such as those of moral constraint or moral conflict, or both.


Fourie C. Moral distress and moral conflict in clinical ethics. Bioethics. doi: 10.1111/bioe.12064

Comparative analysis of moral distress and values of the work organization between American and Spanish podiatric physicians

M E Losa Iglesias, R Becerro de Bengoa Vallejo, P Salvadores Fuentes

Journal of the American Podiatric Medical Association
Journal of the American Podiatric Medical Association

Abstract
Background: Moral distress is a stress symptom arising from situations that involve ethical dimensions where the health-care provider believes that he or she is unable to preserve all interests and values at stake. The aims of this study were to evaluate the impact of, and identify possible differences in, moral distress in podiatric physicians in the United States and Spain and to determine the ethical principles most closely related to moral distress.

Methods: A 2008 e-mail survey of 93 US podiatric physicians and 93 Spanish podiatric physicians (N = 186) presented statements about different ethical dilemmas, values, and goals in the workplace.

Results: Although moral distress is strongly present across the sample for all of the questions, the US sample shows higher levels of any kind of moral distress concerning questions about patients’ treatment and economic constraints, overload of paperwork, and acting against one’s conscience. In the US sample, 91.4% of physicians agreed mostly or completely with the statement that they often had to compromise their own values to cope with the demands of the workplace; 89.25% of US podiatric physicians indicated that their own professional values were congruent with the values of the organization; and a similar percentage (77.5%) reported a strong identification with the goals and framework of their work organization. The Spanish sample had similar results.


Iglesias MEL, de Bengoa Vallejo RB, Fuentes PS. Comparative analysis of moral distress and values of the work organization between American and Spanish podiatric physicians. J Am Podiatr Med Assoc. 2012 Jan;102(1):57-63.

Moral Distress, Moral Residue, and the Crescendo Effect

Elizabeth Gingell Epstein, Ann Baile Hamric

Journal of Clinical Ethics
Journal of Clinical Ethics

Extract
It is doubtful that moral distress can ever be eradicated from healthcare settings. As increasing evidence accumulates to support the damaging effects associated with this phenomenon over time, however, interventions to decrease moral distress and moral residue become more urgently -needed. The crescendo effect model focuses attention on moral distress and moral residue and the relationships between them. . . . Both providers and healthcare systems need to acknowledge the repetitive nature of morally distressing events, such as prolonged aggressive treatment at the EOL, that occur in clinical settings. The crescendo effect highlights the crushing blow to professional integrity that nurses, physicians, and other disciplines have to manage on a daily basis in settings where moral distress goes unrecognized and unaddressed. It is not appropriate to expect highly skilled, dedicated, and caring healthcare professionals to be repeatedly exposed to morally distressing situations when they have little power to change the system and little acknowledgment of these experiences as personally damaging or career compromising. As evidence for the crescendo effect and its consequences accumulates, healthcare professionals, insurers, patients, and healthcare systems must not assume that damaged moral integrity is an acceptable, natural consequence that must be borne by healthcare providers.


Epstein EG, Hamric AB. Moral Distress, Moral Residue, and the Crescendo Effect. J. Clin. Ethics. 2009 Winter;20(4):330-342

Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians

Kenneth R Stevens

The Linacre Quarterly
The Linacre Quarterly

Extract
Conclusion

Physician participation in assisted suicide or euthanasia can have a profound harmful effect on the involved physicians. Doctors must take responsibility for causing the patient’s death. There is a huge burden on conscience, tangled emotions and a large psychological toll on the participating physicians. Many physicians describe feelings of isolation. Published evidence indicates that some patients and others are pressuring and intimidating doctors to assist in suicides. Some doctors feel they have no choice but to be involved in assisted suicides. Oregon physicians are decreasingly present at the time of the assisted suicide. There is also great potential for physicians to be affected by countertransference issues in dealing with end-of-Iife care, and assisted suicide and euthanasia..


Stevens KR. Emotional and Psychological Effects of Physician-Assisted Suicide and Euthanasia On Participating Physicians. The Linacre Quarterly. 2006;73(3).